Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Care One At Weymouth during CMS and state inspections, most recent first.
A resident admitted for subacute care with multiple diagnoses, including UTI and diabetes, had physician progress notes documenting plans for a repeat UA/CS and initiation of low-dose Lantus insulin, but these intended orders were never transcribed into the electronic physician order system or reflected on the MAR. Review of the record showed no active orders or administration for the repeat UA/CS or Lantus, and no nursing documentation of contacting the physician to clarify the progress note entries. Interviews with the physician, unit manager, nursing supervisor, and DON confirmed that the physician typically enters orders directly into PCC or gives verbal orders to nursing, that the physician likely missed entering these specific orders, and that leadership was unaware that the intended treatments documented in the progress notes had not been converted into active orders or carried out.
A resident with a history of UTI, fall, DM, and depression had multiple physician-ordered interventions, including vital signs each evening, daily diabetic foot care at bedtime, behavior tracking for depression each shift, and pain evaluations each shift. Review of the MAR and TAR showed numerous dates where documentation for these ordered vital signs, foot care, behavior tracking, and pain assessments was left blank. Facility leadership, including a supervisor, unit manager, and DON, confirmed that nursing staff are expected to document on the MAR/TAR as care is provided but could not account for the missing entries.
A resident with osteomyelitis, MRSA, and a foot abscess received duplicate antibiotic therapy when oral Doxycycline and Amoxicillin/Clavulanate were administered while IV Daptomycin and Ceftriaxone were still being given. The MAR showed five doses of the oral antibiotics were given before the later start date reflected in the orders, and staff confirmed the oral antibiotics should not have been administered until the IV course was completed.
Infection control practices were not followed when a nurse used shared equipment, including a vital signs machine and glucometer, without cleaning and disinfecting it between residents or after use. Staff also failed to follow Contact Plus Precautions for a resident with C. diff when a CNA and a nurse entered the room without proper hand hygiene and PPE, and staff did not wash hands with soap and water when exiting the room. A nurse also carried a cup of water from the resident's room to another resident's room.
A resident receiving IV antibiotics for osteomyelitis, MRSA, and a foot abscess was given five doses of two oral antibiotics that were not intended to be administered. The Unit Manager identified the medication error and clarified the order with the consulting physician’s office, but the resident’s Physician or NP was not notified, and the NP later stated she was unaware of the error.
A resident receiving IV antibiotics through a PICC line had the dressing left in place beyond the required interval. Surveyors observed split gauze under a transparent dressing at the insertion site, and the nurse confirmed the dressing had last been changed the prior week. The DON stated that when gauze covers the PICC site, it must be changed every 48 hours because the site cannot be assessed while covered.
Failure to support discharge planning for a cognitively intact resident with ESRD. The resident repeatedly asked Social Services about returning to the community to live with a significant other, but notes did not document discharge discussions, community supports, or referrals to outside agencies. Staff interviews showed the SW team was unfamiliar with the resident’s current wishes, no referral had been documented, and a scheduled care plan meeting did not occur.
Incorrect Antiseizure Medication Dose Administered: An RN administered levetiracetam 500 mg to a resident with epilepsy after misreading the order and believing it called for one-half tablet instead of 1.5 tablets. The resident’s physician order required levetiracetam 1000 mg, 1.5 tablets PO q12h, and the RN later acknowledged the resident received the wrong dose; the DON stated meds should be given as ordered.
Incomplete Weight Documentation in Resident Record: The facility failed to maintain complete and accurate medical records for a resident with bacteremia and sepsis when weight checks were signed off as obtained but the actual results were not entered in the EMR. Staff, including the Unit Manager and DON, confirmed that weights should be documented in the medical record, but the resident's chart showed missing weight values despite ordered weekly monitoring.
A resident’s PHI was placed in another resident’s discharge paperwork when a provider progress note was entered into the wrong medical record. The note included the resident’s name, diagnoses, hospital stay details, exam findings, code status, clinical status, vital signs, labs, and meds. The error was only identified after the discharged resident’s family member noticed another resident’s information and called the facility. Staff, including the Unit Manager, ADON, and DON, were unaware of the issue until after discharge.
Missing Baseline Care Plans for Newly Admitted Residents: The Facility failed to develop and implement baseline care plans within 48 hours for two newly admitted residents. One resident had respiratory failure, pneumonia, COPD, oxygen dependence, an open coccyx area, and other acute needs; the other had acute respiratory failure with hypoxia, COPD-related oxygen dependence, CHF, frequent falls, and constipation. Staff interviews showed the UM, ADON, and DON were unaware the baseline care plans had not been completed.
Nursing staff did not obtain physician's orders for the use of bilateral side rails for two residents who had been assessed and recommended for side rail use. Both residents, with complex medical histories including metastatic cancer, ALS, and recent fractures, had signed informed consent forms, but documentation of physician authorization was missing. Staff interviews revealed confusion about the requirement for a physician's order, and the DON was unaware of the oversight.
The facility failed to provide a dignified dining experience for residents, as meals were served on trays with trash left on tables, and staff were not adequately supervising or assisting during mealtimes. Observations in multiple dining areas revealed staff engaging in personal activities rather than focusing on resident care, and improper storage of equipment in dining spaces.
The facility failed to address grievances from residents, including one who reported long call light wait times and another who had an issue with a CNA. Both residents felt their concerns were not taken seriously, and grievances were not documented or resolved. Additionally, residents lacked access to grievance forms, hindering their ability to file complaints anonymously. The DON acknowledged that forms were not accessible as required.
The facility failed to properly store and dispose of medications, with loose pills found in medication carts and a non-affixed controlled substance box in a refrigerator. Nurses acknowledged the improper storage, and the DON confirmed the need for immediate disposal of loose pills and secure storage of controlled substances.
The facility failed to follow professional standards for food safety and sanitation, risking foodborne illness. Dietary staff did not adhere to proper hand hygiene, handling ready-to-eat food without changing gloves or washing hands after potential contamination. Additionally, food products in nourishment kitchenettes were not properly labeled or dated, and equipment was not maintained clean, with visible residue and splatter.
The facility failed to inform residents about binding arbitration agreements, as required by policy. The agreements were not fully explained, and residents were not provided copies for review. Interviews revealed that residents were unaware of signing these agreements, which were included in the admission packet and signed electronically. The Administrator acknowledged the oversight, indicating a need for correction.
The facility failed to implement its pneumococcal vaccination policies, resulting in deficiencies for five residents. The facility did not ensure proper screening, education, or administration of vaccines. Residents were not provided with information on the benefits and side effects of the vaccine, and there was a lack of documentation for informed consent. The Director of Nursing admitted that the vaccine status of residents had not been reviewed per CDC guidelines.
The facility failed to provide two residents with summaries of their baseline care plan meetings within 48 hours of admission, as required by policy. Both residents, who were cognitively intact, reported not receiving the summaries, which would have helped them understand their care goals. Interviews with staff revealed no established process for providing these summaries unless requested, and the Director of Nurses acknowledged the lack of documentation.
A resident with a post-surgical wound infection did not have their surgeon notified as recommended by the wound physician. The Unit Manager, responsible for implementing the wound physician's recommendations, admitted to only focusing on the continuation of the antibiotic Keflex and failed to inform the surgeon. The Director of Nursing expected the UM to follow through with all recommendations, including notifying the surgeon.
The facility's walk-in freezer in the main kitchen was not maintained in a safe operating condition, with significant frost and ice buildup observed on food items and broken internal temperature monitoring. The Regional FSD acknowledged the issue, noting that dietary staff are required to check temperatures twice daily.
The facility did not notify the State Agency of a change in Administrator. The previous Administrator was no longer in position as of late August, but the new Administrator did not inform the State Agency until early October, despite the change being effective in early September.
Failure to Transcribe and Implement Physician Orders for Insulin and Laboratory Testing
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a newly admitted resident received treatment and care in accordance with professional standards and physician orders. Facility policy required that all medication and treatment orders be written, dated, signed by an authorized prescriber, and recorded on the physician’s order sheet, with medications administered only upon such written orders. The resident, admitted with diagnoses including urinary tract infection, status post fall, diabetes mellitus, and asthma, had a physician progress note dated 11/28/25 indicating a plan for a repeat urinalysis with culture and sensitivity (UA/CS) and to restart glargine (Lantus) insulin at a lower dose. Review of the medical record from 11/28/25 through 12/23/25, including physician orders, MAR, and nursing notes, showed no documentation of an order for the repeat UA/CS or for Lantus at a lower dose, and no documentation that nursing contacted the physician to clarify these intended orders. A subsequent physician progress note dated 12/23/25 directed administration of low-dose Lantus 6 units every morning subcutaneously. Review of the MAR from 12/23/25 through 12/29/25 (the date of transfer/discharge) revealed no physician orders for Lantus 6 units every morning subcutaneously and no documentation that nursing sought clarification of this order. Interviews with nursing leadership and the physician established that physicians typically enter orders directly into the electronic medical record (PCC), or, if unable, provide verbal orders to nursing for entry. The physician stated he usually enters orders into PCC and must have missed entering the intended orders for this resident, and the DON reported she was unaware of the unacted-upon intended orders documented only in the progress notes. As a result, the intended treatments documented in the physician’s progress notes were not transcribed into active physician orders or implemented.
Incomplete MAR/TAR Documentation for Ordered Assessments and Treatments
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical and treatment records for one sampled resident. Facility policy on charting and documentation, last revised in July 2017, requires that all services provided, progress toward care plan goals, and any changes in a resident’s condition be documented in the medical record, and that medication administration and treatments be recorded on the MAR and TAR upon completion. Resident #2, admitted in November 2025 with diagnoses including urinary tract infection, status post fall, diabetes mellitus, and depression, had physician orders from 12/01/25 through 12/29/25 for vital signs every evening shift, daily diabetic foot care at bedtime, behavior tracking for depression every shift, and pain evaluation every shift. Review of the resident’s MAR and TAR for that period showed multiple omissions where required documentation was left blank. Vital signs on the evening shift were not documented on several specific dates in December. Diabetic foot care entries were omitted on multiple consecutive and nonconsecutive dates. Behavior tracking for depression and pain evaluations on the evening shift were also left blank on several dates. In interviews, a supervisor, a unit manager, and the DON each stated that nursing staff are expected to document daily on residents, complete the MAR and TAR as care is provided, and enter documentation upon completion of medications and treatments, but they could not explain why this resident’s records contained missing documentation.
Unnecessary Duplicate Antibiotic Therapy
Penalty
Summary
The facility failed to ensure one resident’s drug regimen was free from unnecessary drugs when oral antibiotics were administered in addition to ongoing IV antibiotics. The resident was admitted with acute osteomyelitis of the left ankle and foot, MRSA, and a cutaneous abscess of the left foot, and was cognitively intact with a BIMS score of 15 out of 15 while receiving IV antibiotics. The hospital discharge summary indicated Daptomycin and Ceftriaxone were to continue through 1/9/26, followed by a 14-day course of Doxycycline and Amoxicillin/Clavulanate beginning 1/10/26. However, the physician’s orders later reflected the oral antibiotics starting on 1/24/26, and the discontinued orders showed the earlier oral antibiotic orders were stopped on 1/12/26 after being active from 1/10/26. The MAR showed five doses of Doxycycline and Amoxicillin/Clavulanate were administered while the resident was also receiving IV antibiotics. Staff interviews confirmed the resident received duplicate antibiotic therapy because the oral antibiotic orders that were intended to start later had not been discontinued.
Infection Control Failures With Shared Equipment and Contact Precautions
Penalty
Summary
The facility failed to follow infection prevention and control practices related to cleaning shared resident-care equipment. The facility policy required reusable items and durable medical equipment to be cleaned and disinfected between residents, and CDC guidance stated reusable medical equipment such as blood pressure cuffs should be reprocessed prior to use on another patient or when soiled. During observations, Nurse #5 exited multiple resident rooms with the vital signs machine without cleaning and disinfecting it, used the same machine for more than one resident in the same room without disinfecting it between residents, and returned a shared glucometer to the medication cart without cleaning or disinfecting it after use. During interview, Nurse #5 stated that shared equipment must be wiped cleaned and disinfected between residents or after use for a resident, and acknowledged she had not wiped down the vital signs machine between residents or the glucometer after checking a resident's blood glucose level. The DON and Infection Preventionist later stated that all shared equipment, including the vital sign machine and glucometer, needed to be wiped down prior to use and between residents to prevent the spread of infection. The facility also failed to follow hand hygiene and PPE practices for a resident on Contact Plus Precautions for C. diff. The resident had physician orders for Contact Plus Precautions, and the precaution sign outside the room directed staff to clean hands before entering, wear a gown and gloves, and wash hands with soap and water before exiting. Observations showed CNA #2 entered the room wearing a gown but without gloves, CNA #3 entered without hand hygiene or PPE and later exited without washing hands with soap and water, and Nurse #5 entered the room without hand hygiene or PPE while carrying cups of water, gave one cup to the resident, exited without washing hands with soap and water, and then entered another resident's room with the second cup of water without performing hand hygiene.
Failure to Notify Provider of Medication Error
Penalty
Summary
The facility failed to notify the resident’s Physician or Nurse Practitioner after a medication error involving Resident #56, who was cognitively intact and receiving IV antibiotics for acute osteomyelitis of the left ankle and foot, MRSA, and a cutaneous abscess of the left foot. The facility’s policy required prompt notification of the provider for any significant medication error or adverse consequence, and the resident’s orders indicated IV ceftriaxone and daptomycin for osteomyelitis. After a follow-up visit, oral doxycycline and amoxicillin-pot clavulanate were entered and then discontinued, but the January MAR showed that five doses of both oral antibiotics were administered before the error was identified. The Unit Manager said she discovered the error and clarified the order with the consulting physician’s office, but she did not notify the resident’s Physician or NP. The NP stated she was not aware the resident had received the oral antibiotics, and the DON stated the Physician or NP should have been notified when the medication error was identified.
PICC Dressing Not Changed Per Required Frequency
Penalty
Summary
The facility failed to provide care and maintenance of a PICC line for one resident receiving IV antibiotics for acute osteomyelitis of the left ankle and foot, MRSA, and a cutaneous abscess of the left foot. The resident was cognitively intact, had a central line, and was receiving IV antibiotics through the PICC line twice daily. The facility’s policy and external guidance stated that transparent dressings are to be changed at least every 7 days, while gauze dressings are to be changed every 48 hours. Resident #56’s PICC dressing was last documented as changed on 1/9/26, and the surveyor observed on 1/12/26 and 1/13/26 that the PICC site had a 2 cm x 2 cm split gauze covered by a transparent dressing. The resident stated the dressing had last been changed the prior week. The record did not show any as-needed dressing changes. During interview, the nurse said she had last changed the dressing on 1/9/26 and was unsure whether dressing frequency differed when gauze was used. The DON stated that if gauze covered the PICC insertion site, it needed to be changed every 48 hours because the site could not be assessed while covered.
Failure to Support Resident Discharge Planning
Penalty
Summary
The facility failed to provide medically-related social services to help Resident #18 achieve the highest practicable physical, mental, and psychosocial well-being by not assisting with the resident’s request for discharge planning. Resident #18 was admitted with end stage renal disease and had a BIMS score of 15 out of 15, indicating cognitive intactness. The resident’s health care proxy was not invoked, and the resident remained responsible for decision making. The facility’s records showed no active discharge plan for return to the community, and the resident’s clinical record indicated that questions about returning to the community were only addressed during comprehensive assessments. Resident #18 told surveyors that he/she had been asking Social Services for about four months about the process to return to the community and live with a significant other. The resident reported leaving voicemail messages that were not regularly checked, giving information to someone believed to be a Social Work intern without follow-up, and being told by a Social Worker that a referral to Elder Services would be made, although the resident was unsure whether it had occurred. Review of Social Services notes did not show discussion of the resident’s desire to return to the community, the intended discharge location, community supports, or any referrals to local agencies to determine feasibility of discharge. Psychotherapy notes documented repeated discussions about relocating, including plans to leave the facility with a significant other, marry, and move out of state, while also expressing mixed emotions about leaving family. Interviews with Social Work staff and the Director of Social Services showed that staff were unfamiliar with the resident’s current discharge wishes, had no documentation of referrals, and had not met with the resident about the missed care plan meeting. The former Social Worker stated she had discussed the resident’s desire to return to the community but had not referred the resident to community agencies and was unsure why those discussions were not documented. The Administrator stated the discussions should have been documented and that the resident had not been referred to community agencies for assistance or eligibility determination.
Incorrect Antiseizure Medication Dose Administered
Penalty
Summary
The facility failed to ensure a resident with a history of epilepsy received the correct dose of an anticonvulsant medication. During a medication pass observation, Nurse #1 prepared and administered levetiracetam 500 mg to Resident #66 and stated the electronic medication administration order indicated 1,000 mg with one-half tablet, which she believed equaled 500 mg and therefore gave one tablet. However, the resident’s physician’s order specified levetiracetam 1000 mg, give 1.5 tablet by mouth every 12 hours, dated 1/21/25. During a later interview, Nurse #1 said she thought the order said 0.5 tablet instead of 1.5 tablets and acknowledged that Resident #66 received the wrong dose. Nurse #1 stated the resident needed two more tablets of levetiracetam 500 mg. The DON stated medications should be administered as ordered and physician’s orders should be followed.
Incomplete Weight Documentation in Resident Record
Penalty
Summary
The facility failed to ensure staff maintained complete and accurate medical records for one resident out of a sample of 28. For Resident #153, the medical record did not include weight results even though the resident had physician's orders for weight monitoring every Monday for three weeks starting 12/22/25. The facility's policy titled Weight Assessment and Intervention stated that weights are recorded in each individual's medical record. Record review showed the resident was admitted in December 2025 with diagnoses including bacteremia and sepsis. The MDS dated 12/23/25 listed the resident as 71 inches tall, weighing 155 pounds, with no weight loss or gain. The December 2025 TAR and Documentation Survey Report showed weights were signed off or documented as obtained on 12/22/25, 12/24/25, 12/29/25, 12/31/25, and 1/5/26, but the actual results were not indicated. The Weight and Vitals Summary later listed weights of 145.6 pounds on 1/7/26 and 146.6 pounds on 1/13/26. Staff interviews confirmed that weights should be obtained on Mondays and recorded in the electronic medical record, and the Unit Manager and DON acknowledged that the resident's weights were not documented in the record.
PHI Included in Wrong Resident’s Discharge Paperwork
Penalty
Summary
The Facility failed to maintain a resident’s right to privacy and confidentiality of Protected Health Information when a provider progress note for one resident was placed in another resident’s discharge paperwork. The misplaced note contained the other resident’s name and included medical diagnoses, hospital stay information, physical exam findings, code status, current clinical and medical status, vital signs, laboratory results, and medications. The error was discovered only after the discharged resident’s family member reviewed the paperwork at home and called the Facility to report that another resident’s information had been included. The resident whose information was disclosed had been admitted in 9/2025 with diagnoses including a fall from a ladder with subsequent falls, rib fractures, a left clavicle fracture, and alcohol use disorder. The discharged resident had been admitted in 9/2025 with diagnoses including respiratory failure, pneumonia, chronic obstructive pulmonary disease, and oxygen dependence. Interviews showed staff were unaware of the incorrect documentation until after discharge, and the Unit Manager, ADON, and DON each stated they did not recall being informed of the breach at the time it occurred.
Missing Baseline Care Plans for Newly Admitted Residents
Penalty
Summary
The Facility failed to ensure that baseline care plans were developed and implemented within 48 hours of admission to address residents’ immediate health and safety needs. The Facility policy stated that a baseline plan of care is to be developed for each resident within 48 hours of admission and must include the minimum healthcare information necessary to properly care for the resident. For one resident admitted in 9/2025 with diagnoses including respiratory failure, pneumonia, COPD, and oxygen dependence, the hospital discharge summary identified immediate needs including acute on chronic respiratory failure with 4 liters of oxygen, AVAPS use at night, pneumonia with antibiotic use, acute heart failure, and subcutaneous anticoagulation. The resident’s admission evaluation also noted an open area to the coccyx requiring treatment, but the medical record did not support that a baseline care plan was developed and implemented for these concerns within 48 hours of admission. A second resident admitted in 11/2025 with diagnoses including acute respiratory failure with hypoxia, oxygen dependence related to COPD, and CHF also had immediate needs identified on the hospital discharge summary, including chronic respiratory failure with 2 liters of oxygen, frequent falls, and constipation. The medical record did not support that baseline care plans were developed and implemented, or that comprehensive care plans addressing these concerns were in place within 48 hours of admission. During interviews, the Unit Manager said she was not aware the first resident did not have a completed baseline care plan and stated it was her responsibility to complete them. The ADON said she was unaware that either resident’s baseline care plan had not been completed, and the DON said she was not aware the residents were missing baseline care plans upon admission.
Failure to Obtain Physician's Orders for Side Rail Use
Penalty
Summary
Nursing staff failed to obtain physician's orders for the use of bilateral side rails for two residents who had been assessed and recommended for side rail use upon admission. For the first resident, who had diagnoses including metastatic colon cancer, history of falls, change in mental status, pulmonary emboli, and ascites requiring a pleurx-drain, the informed consent form for bed rail use was signed, but the section indicating a physician's order had been obtained was left blank. Review of the resident's physician's orders confirmed that no order for side rail use was documented during the relevant period. For the second resident, who had a history of a fall with a right lower leg fracture, anxiety, depression, chronic pain, and ALS, the informed consent form was signed and the box indicating a physician's order had been checked. However, review of the physician's orders revealed no documentation of an order for bilateral side rail use. Interviews with nursing staff indicated a lack of understanding regarding the requirement for a physician's order, with one nurse believing the consent form itself served as the order and another unaware that the order was missing. The Director of Nursing was also unaware that the required orders had not been obtained.
Failure to Provide Dignified Dining Experience
Penalty
Summary
The facility failed to ensure a dignified and homelike dining experience for residents in three of four dining areas. Observations revealed that residents were served meals on trays at tables, with trash such as milk cartons and coffee mug covers left on the tables. In the [NAME] Unit dining room, staff members were observed sitting in the back corner, with one on their phone, and a diathermy machine was improperly stored in the dining area. Similar issues were noted on subsequent days, with residents eating on trays and trash left on tables, and staff not providing adequate supervision or assistance during mealtimes. In the Clover Unit dining room, residents were observed eating on trays with trash left on tables, and no staff were present during mealtimes. In the Ivy Unit dining room, staff were observed engaging in casual conversations and eating, rather than supervising residents. Interviews with staff, including a CNA, Unit Manager, and the DON, confirmed that meals should be served off trays and onto tables, and staff should supervise residents during mealtimes. However, the observations indicated a lack of adherence to these protocols, leading to the deficiency in providing a dignified dining experience.
Failure to Address Resident Grievances and Provide Access to Grievance Forms
Penalty
Summary
The facility failed to ensure residents had the right to voice grievances and have them addressed promptly, as evidenced by the experiences of two residents. One resident, admitted for short-term rehabilitation, repeatedly voiced concerns about long call light wait times and other issues, but felt unheard and received no resolution. Despite attempts to communicate these grievances to staff and management, including the Director of Nursing (DON), the resident's concerns were not formally documented or investigated as required by the facility's grievance policy. The resident's family member also attempted to address these issues with the DON but felt dismissed, leading to a public complaint via a Google review. Another resident reported an issue with a Certified Nurse Aide (CNA) to a staff member, but no grievance was documented or resolved. The resident expressed skepticism about whether their complaint was taken seriously or recorded. The facility's Grievance Book did not reflect any action taken regarding this resident's concern, and the DON and Administrator were unaware of the issue until prompted by a surveyor. A Unit Manager later claimed to have completed a grievance form but admitted the process was incomplete and not communicated to the resident. Additionally, the facility did not ensure residents had access to grievance forms, hindering their ability to file complaints anonymously. During a Resident Council meeting, residents expressed confusion about the location of grievance forms, with some unaware of their existence. Observations confirmed that forms were not readily available on all floors, and staff were inconsistent in their knowledge of where forms could be found. The DON acknowledged that forms were not accessible to residents as they should have been, contributing to the facility's failure to uphold residents' rights to voice grievances.
Medication Storage and Disposal Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and disposal of medications in accordance with accepted professional principles. During a survey, it was observed that two of the five medication carts contained loose oral medication tablets and capsules that were not stored in their original dispensing systems. Nurse #6 and Nurse #7 acknowledged the presence of loose pills in the drawers and admitted that they should have been disposed of immediately. The Director of Nursing confirmed that any pills that fall out of their packaging should be destroyed immediately. Additionally, the facility did not provide a permanently affixed compartment for storing a Schedule IV controlled substance in one of the medication room refrigerators. A controlled substance metal storage box was found on a shelf inside the refrigerator, which was not locked, and the box itself was not permanently affixed. The Unit Manager and Nurse #7 were unaware of the requirement for the box to be permanently affixed. The Director of Nursing later confirmed that the box should have been secured inside the refrigerator.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to adhere to professional standards of food safety and sanitation, which could potentially lead to foodborne illnesses among residents. Observations revealed that dietary staff did not follow proper hand hygiene practices. For instance, dietary aides and a cook were seen handling ready-to-eat food with gloved hands but did not change gloves between tasks or after touching potentially contaminated surfaces. Additionally, staff members were observed returning to the food service line without washing their hands after performing tasks that could lead to cross-contamination, such as touching their face or picking up items from the floor. The facility also failed to properly label and date food products and maintain clean equipment in the nourishment kitchenettes. Observations in various unit kitchenettes showed unlabeled and undated food items, such as yogurt and non-dairy beverages, which were not identified with resident names. Furthermore, the kitchenettes had equipment with visible food residue and splatter, such as microwaves with orange and brown residue and freezers with hard ice build-up and brown residue. Interviews with the Regional Food Service Director confirmed that dietary staff are responsible for ensuring that items in the refrigerators and freezers are appropriately labeled and dated. The director also stated that the maintenance department is responsible for cleaning and maintaining equipment in the kitchenettes. However, the facility does not supply certain food products found in the kitchenettes, indicating a lack of control over items brought in from outside the facility.
Failure to Properly Inform Residents About Arbitration Agreements
Penalty
Summary
The facility failed to properly inform residents or their representatives about binding arbitration agreements, as required by their policy. The policy mandates that residents be informed about the nature and implications of arbitration agreements, ensuring they understand that signing such agreements is voluntary and not a condition for admission or care. However, interviews and document reviews revealed that the facility did not adhere to these requirements for three residents, all of whom were cognitively intact and admitted for short-term rehabilitation. The Director of Nurses indicated that arbitration agreements are included in the admission packet, and residents have the option to opt out. However, the Admissions Director, who is responsible for these agreements, was not involved in explaining them to residents. Instead, this task was delegated to a Unit Secretary, who admitted to not fully reviewing or reading the agreements to residents. The agreements were signed electronically, and residents were not provided with copies for review, contrary to the facility's policy. Interviews with the three residents revealed that they were unaware of having signed arbitration agreements, as these were not explained to them, nor were they given the opportunity to review the documents. One resident, who had experience with arbitration agreements, expressed a desire to rescind the agreement upon learning of its existence. Another resident stated they would have consulted with an attorney or family before signing if they had been aware of the agreement. The facility's Administrator acknowledged the oversight and indicated that residents should have received copies of their signed agreements, which was not the case.
Failure to Implement Pneumococcal Vaccination Policies
Penalty
Summary
The facility failed to implement its policies and procedures for pneumococcal vaccinations, resulting in deficiencies in screening, education, and administration of vaccines for five residents. The facility's policy required that residents be assessed for eligibility to receive the pneumococcal vaccine series upon admission and be offered the vaccine within 30 days unless contraindicated or previously vaccinated. However, the facility did not ensure that residents were properly screened for eligibility, nor did it provide education on the benefits and potential side effects of the vaccine to residents or their representatives. For Resident #117, the facility did not document that the resident received information or education regarding the pneumococcal vaccine, despite having refused the PCV13 and PPSV23 vaccines. Similarly, Resident #25's medical record lacked a completed consent and tracking form, and there was no evidence of follow-up screening or education. Resident #113 also refused the vaccines, but there was no documentation of informed consent or education provided. Resident #388's record showed a refusal of the vaccines without documentation of education, and the resident did not receive the recommended follow-up vaccine per CDC guidelines. Resident #1, a long-term resident, did not have a completed consent and tracking form, and there was no evidence of follow-up screening or education. The Director of Nursing, who also served as the Infection Preventionist, acknowledged the difficulty in managing the pneumococcal vaccine schedule and admitted that the vaccine status of residents had not been reviewed according to CDC guidelines. This lack of adherence to policy and CDC recommendations led to the failure in offering and administering the pneumococcal vaccines appropriately.
Failure to Provide Baseline Care Plan Summaries
Penalty
Summary
The facility failed to provide two residents with a summary of their baseline care plan meetings within 48 hours of admission, as required by their policy. Resident #238, admitted with conditions including acidosis and multiple sclerosis, was cognitively intact but reported not receiving a summary of the care plan meeting or understanding what a care plan was. Similarly, Resident #237, admitted with conditions such as hypertensive emergency and COPD, also did not receive a summary of their care plan, which they expressed would have been helpful for understanding their care goals and asking relevant questions. Interviews with facility staff, including social workers and the Director of Nurses, revealed that there was no established process for providing residents with a written summary of their baseline care plans unless specifically requested. The Director of Nurses acknowledged the lack of documentation or evidence that the residents were provided with such summaries, attributing it to the absence of the case manager and a lapse in the social worker's responsibilities. The case manager confirmed that while notes were made in the system, no summaries were provided to the residents, and she was unaware of this being a regulatory requirement.
Failure to Notify Surgeon of Post-Operative Site Infection
Penalty
Summary
The facility failed to meet professional standards of practice for a resident with a post-operative site infection. The resident, who was admitted with a coronary bypass, Type II Diabetes, and a post-surgical wound on the left medial calf, had a wound evaluation that recommended continuing the antibiotic Keflex and notifying the surgeon about the site infection. However, the nursing progress notes did not indicate that the surgeon was informed of the infection, as recommended by the wound physician. Interviews revealed that the Unit Manager (UM) was responsible for rounding with the wound physician and implementing his recommendations. The UM admitted to only focusing on the continuation of Keflex and failing to notify the surgeon about the infection. The Nurse Practitioner (NP) was also not informed about the need to notify the surgeon. The Director of Nursing (DON) stated that the UM should have followed through with all recommendations, including notifying the surgeon and documenting the notification.
Walk-in Freezer Temperature Control Issues
Penalty
Summary
The facility failed to maintain the walk-in freezer in the main kitchen in a safe operating condition, as observed by the surveyor on two separate occasions. On the first observation, the outside thermometer on the freezer door showed a temperature range between -36 to -48 Fahrenheit, but there was no internal thermometer to verify this temperature. Significant frost and ice buildup were noted on various food items, including chocolate and vanilla ice cream cups, and cheese omelets, indicating potential temperature control issues. Ice buildup was also observed on the storage racks inside the freezer. During a follow-up observation, the outside thermometer registered a temperature range between -6 to -40 Fahrenheit, and the internal thermometer was found broken, failing to register any temperature. Additional frost and ice buildup were noted on various food items, including pork loin, beverage mix cartons, and Lactaid Vanilla Ice Cream cups. The Regional Food Service Director acknowledged the freezer was not maintaining appropriate temperatures and noted that dietary staff are required to check freezer temperatures twice daily. However, the presence of a broken thermometer hindered accurate temperature monitoring.
Failure to Notify State Agency of Administrator Change
Penalty
Summary
The facility failed to provide written notice to the State Agency regarding a change in the facility's Administrator. According to the Health Care Facility Reporting System (HCFRS), the previous Administrator was no longer the Administrator of record as of 8/30/24. However, there was no indication that the State Agency was notified of the new Administrator. During an interview, the current Administrator stated he was unaware that the previous Administrator's leave had been reported to the State Agency and admitted he had not notified the State Agency of his effective date as Administrator. The change in Administrator was effective 9/1/24, but the State Agency was only informed on 10/8/24.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Weymouth
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Linden Ponds | 1.6 mi | ★★★★★ | 4 | 0 |
| Pope Nursing Home | 2.1 mi | ★★★★★ | 0 | 0 |
| Royal Braintree Nursing And Rehabilitation Center | 2.3 mi | ★★★★★ | 18 | 0 |
| Queen Anne Nursing Home, Inc | 2.4 mi | ★★★★★ | 0 | 0 |
| Alliance Health At Braintree | 2.4 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.