Average — CMS composite of the measures below.
The next survey window likely opens around October 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 Village At West Roxbury during CMS and state inspections, most recent first.
Incomplete Pacemaker Care Plans: Two residents with pacemakers did not have resident-centered, personalized care plans that included key pacemaker details such as the cardiologist, pacemaker type, implant date, paced rate, or check frequency. One resident’s chart also lacked pacemaker-related progress notes, monitoring orders, and a scheduled pacemaker check, while staff interviews showed uncertainty about the paced rate and check schedule.
Dignified Dining Experience Not Provided: A resident with severe cognitive impairment, Parkinson's disease, and substantial/maximal eating assistance needs was observed twice with staff standing over them in bed during breakfast assistance. Facility policy required residents to be treated with dignity and respect, and both a CNA and the DON stated staff should be seated next to residents rather than standing over them while helping with meals.
A resident with cerebral infarction and MDD was observed in a motorized wheelchair with a seatbelt buckled around the abdomen and thighs, and staff said the belt was used whenever the resident was up in the chair and could not be applied or removed independently. The chart lacked a restraint/device assessment, MD order, care plan entry, or progress note documentation for the seat belt, and the UDA device assessments only addressed side rails. The DON stated staff should have reported the seat belt use so a restraint assessment could be completed.
A resident with major depressive disorder, visual hallucinations, and severe cognitive impairment received routine quetiapine without a documented GDR attempt or documentation that GDR was clinically contraindicated. The record showed the same dose since admission, no behavioral health visits, and the DON acknowledged that a GDR had not been attempted even though it should have been addressed.
Failure to complete baseline AIMS assessment for a resident on antipsychotic medication. A resident with Parkinson's disease, severe cognitive impairment, and hallucinations was receiving quetiapine, but the record did not show an AIMS assessment on admission or at initiation of the antipsychotic. A pharmacist later recommended AIMS testing, and when it was finally completed, the score was 2, showing tardive dyskinesia movements had been identified but were not severe enough for interventions.
Failure to Develop Person-Centered PTSD Care Plans: Two residents with PTSD had care plans that did not identify their specific trauma histories, triggers, or signs and symptoms of trauma. Record review showed one resident had nightmares, flashbacks, sexual assault history, and domestic violence concerns, while the other had extensive trauma including childhood abuse, foster care, physical assault, and family loss. The SW and DON stated PTSD care plans should be person centered, and the COO could not locate a trauma informed assessment for either resident.
Failure to provide behavioral health services for a resident with anxiety, depression, dementia, and psychosis who was receiving antipsychotic and antidepressant medications. The care plan called for psych consults and psych services as needed, and the record included an order for psych to see the resident as needed, but there was no documentation that behavioral health actually evaluated the resident after admission. The DON confirmed the resident had not been seen by psych, and the SW stated residents with consent and psychotropic meds should receive psych or behavioral health services.
Pharmacy review recommendations were not implemented for two residents. One resident with Parkinson's disease and severe cognitive impairment had delayed AIMS testing after a pharmacist recommendation, no documented GDR review for quetiapine, and PRN bowel medication orders that lacked frequency details. Another resident with dementia had a PRN Fleet enema order that did not include dose or frequency, despite the pharmacist requesting clarification. The DON said recommendations should be addressed right away, but staff were unsure who handled them.
Medications were not consistently stored in locked compartments or kept accessible only to authorized staff. A surveyor observed an open med cart that could be opened without interference while residents and staff were in the hall, and later observed 2 capsules in a medication cup on a resident's bedside table while the resident was asleep and the roommate was awake. An LPN stated that meds should not be left at bedside and med carts should not be left open.
A resident with hypothyroidism was observed self-administering thyroid medication without a proper assessment for their ability to do so safely. The facility's policy requires an interdisciplinary team assessment and a physician's order for self-administration, which was not followed. Nursing staff confirmed the resident should have been supervised while taking medication, but this was not consistently done.
A resident's MDS assessment inaccurately coded a pressure ulcer as stage 2, despite documentation of granulation tissue, which is inconsistent with stage 2 ulcers. Interviews with staff confirmed the error, and the importance of using the RAI manual for accurate coding was emphasized.
The facility failed to follow physician orders for two residents. One resident's urinary catheter drainage bag was not changed as prescribed, with discrepancies in the schedule and documentation. Another resident did not have offloading boots applied as ordered, despite records indicating compliance. Staff interviews revealed lapses in adherence to care plans and documentation.
A facility failed to provide appropriate respiratory care for a resident with obstructive sleep apnea by not consistently applying the physician-ordered CPAP machine at bedtime. Observations showed the CPAP was not in use, and staff interviews confirmed it was not applied. The resident's care plan lacked CPAP use instructions, and there were no cleaning orders, contrary to facility policy.
The facility failed to create individualized PTSD care plans for two residents. One resident, admitted in 2020, had no PTSD care plan despite an active diagnosis. Another resident, admitted in 2023, had a PTSD diagnosis but lacked a care plan identifying triggers, as confirmed by the DON.
A resident with moderate cognitive impairment and multiple diagnoses was observed with bed rails positioned incorrectly, contrary to the physician's order and assessment. The facility's policy requires bed rails to be used as mobility aids, not restraints, and mandates proper assessment and informed consent. However, staff interviews and observations revealed that the rails were consistently positioned in the middle of the bed, not in the upper 1/4 as required, indicating a failure to adhere to guidelines and orders.
A facility failed to address a consultant pharmacist's recommendations to clarify conflicting Tylenol PRN orders for a resident with moderate cognitive impairment. Despite repeated recommendations, both orders were administered without clarification, and the DON acknowledged the oversight.
A facility failed to properly store medications on a nursing unit, leaving vials of an IV antibiotic unlocked and unattended at the nurses' station. Staff interviews confirmed the medications were for a specific resident, and the DON acknowledged the oversight, which violated the facility's medication storage policy.
The facility failed to date and dispose of expired refrigerated foods as required by its policy. During a kitchen inspection, a surveyor found undated containers and an expired pan of caramel sauce in the refrigerator. The Food Service Director acknowledged that all refrigerated foods should have expiration dates and that expired items must be discarded.
The facility failed to maintain accurate medical records for two residents, leading to deficiencies in care. A resident with dementia did not receive documented steri strip treatment, while another resident with diabetes had incomplete wound descriptions in assessments. Staff interviews revealed inconsistencies in following facility policies on skin audits and pressure ulcer prevention.
The facility failed to maintain a clean and homelike environment in the shower rooms of two resident units. Observations revealed dirty tile grout, missing floor tiles, a missing drain cover, and the presence of dead and live insects. Staff interviews confirmed the need for repairs and cleaning to uphold the facility's policy of providing a safe and comfortable environment.
A facility failed to support a resident's right to self-determination by permanently revoking their smoking privileges after multiple incidents of possessing smoking paraphernalia. Despite the resident's requests to resume smoking under supervision, the facility maintained the revocation due to non-compliance with its smoking policy.
A resident with a history of PTSD and other conditions was restrained by staff during the confiscation of a vape pen, leading to a deficiency. The resident reported being attacked, and the facility's investigation confirmed that staff held the resident down to remove the vape pen, which was hidden under their clothing. The actions were considered overly aggressive, violating the facility's policy on physical restraints.
A resident with a complex medical history alleged assault by staff during a vape pen confiscation. Despite being informed of the resident's intention to report the incident to the police, a nurse failed to notify the Administrator immediately, leading to a delay in addressing the allegations. The Administrator only learned of the situation when police arrived hours later.
A severely cognitively impaired resident was involved in a verbal altercation with a CNA, during which profane language was used by both parties. The incident was witnessed by two nurses, leading to the termination of the CNA after an internal investigation.
Incomplete Pacemaker Care Plans
Penalty
Summary
The facility failed to ensure resident-centered, personalized care plans were developed for two residents with pacemakers. Resident #46 was admitted with diagnoses including Parkinson's disease, adult failure to thrive, bradycardia, and presence of a cardiac pacemaker. His/her MDS dated 9/11/25 showed severe cognitive impairment. The care plan initiated 5/7/25 stated the resident had a pacemaker related to bradycardia, palpitations, and HTN, with interventions for cardiology follow-up as needed, pacemaker checks as needed, vital signs as ordered and as needed, and reporting abnormalities to the MD if noted. However, the care plan did not include comprehensive pacemaker information such as the cardiologist's name, the type of pacemaker, implant date, or paced rate. Progress notes did not include pacemaker details or appointments for pacemaker checks, physician orders did not include monitoring orders or specific pacemaker settings, and the unit appointment book did not show a scheduled pacemaker check since admission through the end of the year. Resident #59 was readmitted with diagnoses including hemiplegia and hemiparesis, cerebral infarction, heart failure, and aphasia, and the MDS dated 7/4/25 indicated severe cognitive impairment. A physician order dated 9/15/25 directed staff to check the pacemaker monitor at bedside for functioning every shift, and hospital discharge paperwork from 1/11/21 identified the pacemaker mode as DDD. The pacemaker care plan did not include the paced rate, cardiologist information, frequency of checks, or cardiologist information. Medical doctor and nurse practitioner progress notes since admission in 2021 did not indicate the resident had a pacemaker or any details about it. During interviews, Nurse #2 stated she did not know the paced rate or the schedule for pacemaker checks, and the DON stated he expected a comprehensive care plan and physician orders for pacemaker management, including monitoring the paced rate.
Dignified Dining Experience Not Provided
Penalty
Summary
The facility failed to provide a dignified dining experience for one resident. Facility policy titled Dignity/Quality of Life, revised 12/6/21, stated that residents are to be treated with dignity and respect, that dignity means assisting residents in maintaining and enhancing self-esteem and self-worth, and that demeaning practices that compromise dignity are prohibited. The resident involved was admitted in March 2025 with diagnoses including Parkinson's disease, adult failure to thrive, bradycardia, and presence of a cardiac pacemaker. The most recent MDS, dated 9/11/25, showed a BIMS score of 2 out of 15, indicating severe cognitive impairment, and indicated the resident required substantial/maximal assistance with eating. On 9/22/25 at 8:30 A.M. and again on 9/24/25 at 8:26 A.M., the surveyor observed a staff member standing over the resident in bed while assisting with the breakfast meal. During an interview on 9/25/25 at 8:12 A.M., CNA #1 stated that when assisting a resident with eating, staff should be seated next to the resident and should not stand over them, whether the resident is in a chair or in bed. During an interview on 9/25/25 at 9:56 A.M., the DON stated that staff should be sitting with residents and making them feel comfortable while assisting with meals to provide a dignified dining experience.
Failure to Assess Wheelchair Seat Belt as Potential Restraint
Penalty
Summary
The facility failed to assess the use of a seat belt as a potential physical restraint for one resident. The facility policy stated that all potentially restraining devices require assessment to determine whether the device constitutes a restraint, and if so, restraint procedures are to be used. Resident #17 was admitted with diagnoses including cerebral infarction and major depressive disorder, and the most recent MDS showed a BIMS score of 15 out of 15, indicating the resident was cognitively intact. The MDS did not indicate that any restraint was used. Surveyors observed the resident seated in a motorized wheelchair with a seatbelt buckled around the abdomen, and later observed the resident with a seat buckle around the abdomen and across the thighs. The resident stated that both belts were used when up in the chair, that the resident had left-sided weakness and could not keep the legs in the chair without the buckle, and that assistance was needed to apply and remove the buckles. The medical record did not show a restraint or device assessment for the seat belt, physician orders for the seat belt, or a care plan addressing its use. Progress notes also did not mention the seat belt or any restraint, and the device assessments in the UDA packet only addressed side rails. CNA #2 stated the seatbelt was in place at all times when the resident was in the wheelchair and could not be removed or applied independently, while the DON stated staff should have reported the seat belt use so a restraint assessment could be completed and said there should have been a physician order and care plan.
Unnecessary Antipsychotic Use Without GDR Evaluation
Penalty
Summary
The facility failed to ensure that one resident’s drug regimen was free from unnecessary antipsychotic medication use. Resident #46, admitted with diagnoses including major depressive disorder and visual hallucinations, had a BIMS score of 2 out of 15 on the most recent MDS, indicating severe cognitive impairment. The MDS also showed routine daily antipsychotic and antidepressant use, with no Gradual Dose Reduction (GDR) attempted and no physician documentation that a GDR was clinically contraindicated. Review of the medical record showed the resident had been receiving quetiapine since admission at the same dose, ordered for hallucinations. The care plan stated the resident was taking psychotropic medication and included interventions to use the lowest dose possible and review the need for the medication quarterly and as needed. However, physician and NP progress notes did not show that a GDR was attempted or documented as contraindicated, and the record did not show any behavioral health visits since admission. During interview, the DON stated behavioral health services manage GDRs in the facility and acknowledged that the resident had not been seen by behavioral health services since admission and that a GDR had not been attempted, though it should have been attempted or documented as contraindicated.
Failure to Complete Baseline AIMS Assessment for Resident on Antipsychotic Medication
Penalty
Summary
The facility failed to complete a baseline AIMS assessment for one resident with severe cognitive impairment and multiple medical diagnoses, including Parkinson's disease, adult failure to thrive, bradycardia, and a cardiac pacemaker. The resident was admitted in March 2025 and had a BIMS score of 2 out of 15 on the most recent MDS, with use of antipsychotic and antidepressant medications and routine daily antipsychotic administration documented. Physician orders showed quetiapine was prescribed for hallucinations beginning at admission, indicating antipsychotic therapy was initiated without a documented AIMS assessment at that time. The medical record did not show an AIMS assessment completed before the one performed on 5/27/25, which was 81 days after admission and initiation of the antipsychotic medication and 40 days after the consultant pharmacist recommended that AIMS testing be performed. The pharmacist's medication regimen review specifically noted that the resident was receiving quetiapine and recommended AIMS testing now and every 6 months to monitor for tardive dyskinesia. When the AIMS was eventually completed, the score was 2, indicating tardive dyskinesia movements had been identified but were not severe enough for interventions and did not interfere with ADLs.
Failure to Develop Person-Centered PTSD Care Plans
Penalty
Summary
The facility failed to develop person-centered trauma informed care plans for two residents with PTSD by not accounting for their individual trauma histories, preferences, and triggers. The deficiency was identified through record review and interviews, and the facility policy stated that residents who are trauma survivors should receive culturally competent, trauma informed care that accounts for experiences and preferences to help eliminate or mitigate triggers that may cause re-traumatization. The policy also stated that upon admission, residents should be assessed with a PTSD screen and traumatic events checklist, with the information used to identify trauma and triggers. One resident was admitted with a diagnosis including PTSD and had a BIMS score of 15 out of 15, indicating intact cognition. Behavioral health notes documented ongoing PTSD symptoms including nightmares and flashbacks related to past trauma, inability to live with a spouse due to a question of domestic violence, and other trauma/loss including sexual assault and miscarriage at 20 weeks. The care plan initiated for this resident included a PTSD care plan, but it did not identify the resident’s specific trauma, specific triggers, or signs and symptoms of trauma to avoid re-traumatization. A second resident was admitted with a diagnosis including PTSD and had a BIMS score of 13 out of 15. Behavioral health notes and hospital discharge psychiatry paperwork documented extensive trauma history, including finding the mother overdosing at age five and performing CPR, foster care placement, physical assault, being locked in a cupboard for three days, childhood abuse, physical abuse by an ex-husband, and the murder of a daughter. The care plan initiated for this resident also included a PTSD care plan, but it did not identify the resident’s specific trauma, specific triggers, or signs and symptoms of trauma to avoid re-traumatization. During interviews, the Social Worker and DON stated that PTSD care plans should be person centered and identify specific trauma and triggers, and the COO stated the interdisciplinary team could not locate any trauma informed assessment completed for either resident.
Failure to Provide Behavioral Health Services
Penalty
Summary
The facility failed to provide behavioral health services for one resident who had diagnoses including anxiety disorder, dementia, major depressive disorder, and unspecified psychosis not due to a substance or known physiologic disturbance. The resident’s MDS showed a BIMS score of 2 out of 15, indicating severe cognitive impairment, and the record showed use of antipsychotic and antidepressant medications, including quetiapine for hallucinations, mirtazapine for depression, and sertraline for major depressive disorder. The resident’s care plan identified psychotropic medication use related to depression and anxiety and included requests for psych consults and psych services as needed. The medical record showed a physician order allowing the resident to be seen by psych as needed, and progress notes stated that psychiatry would follow along and that the resident was followed by psychiatry. However, review of the record failed to show that the resident had actually been evaluated by behavioral health services since admission. A signed request for counseling or behavioral health services was present in the record, but it was dated two months after admission. During interviews, the DON stated the resident had not been seen by psych services but should have been, and the Social Worker stated that residents with signed consent and psychotropic medications should receive psych or behavioral health services.
Pharmacy Review Recommendations Not Implemented
Penalty
Summary
The facility failed to ensure that monthly pharmacy medication regimen review recommendations were implemented in accordance with physician or nurse practitioner response for two residents. The report states that a licensed pharmacist was to perform monthly drug regimen reviews, including the medical chart, and that the facility did not follow its own psychotropic medication policy regarding medication review and gradual dose reduction (GDR) considerations. For one resident admitted with Parkinson's disease, adult failure to thrive, bradycardia, and a cardiac pacemaker, the most recent MDS showed severe cognitive impairment, use of antipsychotic and antidepressant medications, routine daily antipsychotic administration, and no attempted GDR or physician documentation that a GDR was clinically contraindicated. The consultant pharmacist recommended AIMS testing for quetiapine, but the medical record did not show the AIMS assessment was completed until 81 days after admission and 40 days after the recommendation. The completed AIMS score was 2, indicating tardive dyskinesia movements had been identified but were not severe enough for interventions and did not interfere with ADLs. The pharmacist also noted PRN orders for milk of magnesia, bisacodyl suppository, and Fleet enema needed clarification of frequency, but the physician orders did not include a frequency. In addition, the pharmacist did not recommend a GDR for the antipsychotic medication, and provider progress notes did not show a GDR review or documentation that it was clinically contraindicated. For another resident with dementia, persistent mood disorder, and lower back pain, the MDS showed moderate cognitive impairment. The pharmacist’s monthly medication regimen review included a recommendation to clarify the strength and frequency of a PRN Fleet enema order, but the active physician order did not include a dose or frequency for administration. During interviews, nursing staff and the DON stated that pharmacy recommendations were not consistently brought to floor staff, that the DON usually addressed them, and that the orders should have been addressed right away.
Medications Left Unsecured and Accessible
Penalty
Summary
Drugs and biologicals were not stored in locked compartments and only authorized personnel were not consistently limited access to medications on one of two units. The facility policy titled "storage of Medications" stated that medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access. On 9/22/25 at 6:56 A.M., a surveyor observed a medication cart open and was able to open the drawer without interference while several residents and staff members were in the hall. Later that morning at 8:28 A.M., the surveyor observed 2 capsules in a medication cup on a resident's bedside table while the resident was asleep in bed and the roommate was awake. During an interview on 9/25/25 at 7:57 A.M., Nurse #1 stated that medications should not be left at bedside and medication carts should not be left open.
Failure to Assess Resident for Safe Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident did not self-administer medications without a proper assessment. The resident, who was admitted with a diagnosis of hypothyroidism, was observed self-administering a thyroid medication without having been assessed for the ability to do so safely. The facility's policy requires an interdisciplinary team assessment and a physician's order for residents who wish to self-administer medications, but this process was not followed for the resident in question. The resident was observed with a medication cup containing a pill, which they identified as their morning thyroid medication. The resident stated that the nurse usually leaves the medication for them to take independently. However, the resident's medical records indicated that the medication was to be administered by nursing staff, and there was no documentation of an assessment for self-administration. Interviews with nursing staff confirmed that the resident should have been supervised while taking their medication, but this was not consistently done.
Inaccurate MDS Assessment for Pressure Ulcer Staging
Penalty
Summary
The facility failed to ensure an accurate Minimum Data Set (MDS) assessment for a resident, specifically in coding the correct stage of a pressure ulcer. The resident, who was admitted with diagnoses including diabetes and nutritional anemia, had a pressure ulcer on the coccyx documented in the hospital discharge summary. The MDS assessment inaccurately coded the ulcer as a stage 2, despite documentation indicating the presence of granulation tissue, which is not characteristic of a stage 2 ulcer. Interviews with facility staff, including a nurse and the Director of Nursing, confirmed the presence of granulation tissue in the pressure ulcer, which should have precluded a stage 2 classification. The MDS Nurse acknowledged the error, stating that the MDS was not completed accurately. The Director of Nursing emphasized the importance of using the Resident Assessment Instrument (RAI) manual for accurate coding, highlighting a lapse in following proper assessment protocols.
Failure to Implement Physician Orders for Catheter Care and Offloading Boots
Penalty
Summary
The facility failed to ensure that nursing services were provided in accordance with the comprehensive care plan and professional standards of quality for two residents. For Resident #217, the facility did not implement the physician's order to change the urinary catheter drainage bag as prescribed. The physician's order specified that the catheter bag should be changed weekly on Mondays and Thursdays during the night shift. However, the nursing staff only scheduled the change for Thursdays, and the surveyor observed that the catheter bag had not been changed since 10/20/24, despite a record indicating it was changed on 10/24/24. Nurse #5 could not recall changing the bag on the specified date, and the Director of Nursing confirmed that the order should have been followed. For Resident #62, the facility failed to follow the physician's orders to apply offloading booties to the resident's heels while in bed. The physician's order required the boots to be worn at all times, but the surveyor observed the resident lying in bed with heels directly on the mattress on multiple occasions. The Treatment Administration Record inaccurately indicated that the boots were worn during these times, with only three documented refusals. Nurse #1 acknowledged the responsibility to ensure the boots were on and to document any refusals, while the Director of Nursing noted that the resident often kicked the boots off.
Failure to Implement CPAP Orders for Resident
Penalty
Summary
The facility failed to provide respiratory care services in accordance with professional standards of practice for a resident diagnosed with obstructive sleep apnea, heart failure, and shortness of breath. The resident was admitted to the facility with a physician's order for a continuous positive airway pressure (CPAP) machine to be used at nighttime. However, observations and interviews revealed that the CPAP machine was not consistently applied at bedtime as ordered. The CPAP was often found wrapped in a plastic bag on the nightstand with a dry water chamber, indicating it was not in use. The resident reported that staff did not offer or apply the CPAP at bedtime, and the Treatment Administration Record inaccurately documented the application of the CPAP. Interviews with staff, including a Certified Nurse Assistant and a nurse working the overnight shift, confirmed that the resident did not wear the CPAP at night. The Director of Nursing acknowledged that nursing staff should follow the physician's orders and apply the CPAP, and noted that the resident was aware of their needs. Additionally, the resident's care plan did not include the use of the CPAP, and there were no orders for cleaning the machine, which are required as per the facility's policy.
Failure to Develop PTSD Care Plans for Residents
Penalty
Summary
The facility failed to develop individualized care plans for residents diagnosed with post-traumatic stress disorder (PTSD). Resident #17, admitted in August 2020, had an active diagnosis of PTSD as indicated in their quarterly behavioral assessment and Minimum Data Set (MDS) assessment. However, a review of their medical records revealed that a PTSD care plan had not been developed. During an interview, the MDS Nurse confirmed that a care plan should have been created for this diagnosis. Similarly, Resident #29, admitted in November 2023, also had a diagnosis of PTSD. Their MDS assessment showed they were cognitively intact, scoring 15 out of 15 on the Brief Interview for Mental Status (BIMS). Despite this, their plan of care did not include a personalized PTSD care plan identifying any triggers. The Director of Nursing acknowledged that the PTSD care plan was integrated with the psychotropics plan of care but should have specifically identified triggers that could exacerbate symptoms.
Improper Implementation of Bed Rails for Resident
Penalty
Summary
The facility failed to ensure that bed rails were implemented in accordance with the bed rail assessment and physician's order for a resident with moderate cognitive impairment and multiple diagnoses, including hemiplegia and diabetes. The resident was observed multiple times with bilateral side rails positioned in the middle of the bed, contrary to the physician's order and assessment, which specified the use of 1/4 bedrails for mobility and transfers. The facility's policy on the use of side rails emphasizes their use as mobility aids rather than restraints and requires a thorough assessment and informed consent. Despite the policy, the resident's bed rails were not positioned as assessed and ordered, leading to a discrepancy between the intended use and actual implementation. Interviews with staff, including a CNA and a nurse, confirmed that the side rails were consistently positioned in the middle of the bed. The Director of Nursing and Director of Operations also observed the incorrect positioning, noting that the rails were not in the upper 1/4 of the bed as required. This inconsistency highlights a failure in adhering to the facility's guidelines and the physician's order, potentially impacting the resident's safety and care.
Failure to Address Pharmacist Recommendations for Medication Orders
Penalty
Summary
The facility failed to address recommendations from the Monthly Medication Reviews (MMRs) conducted by the consultant pharmacist in a timely manner for a resident. The facility's policy requires that the consultant pharmacist's observations and recommendations regarding residents' medication therapies be communicated and responded to appropriately and timely. However, for a resident with moderate cognitive impairment and multiple diagnoses, including hemiplegia and diabetes, the recommendations to clarify two conflicting Tylenol as needed (PRN) pain orders were not acted upon. The pharmacist's notes from September and October indicated the need to clarify which Tylenol order should remain active to avoid medication errors. Despite the consultant pharmacist's recommendations being documented and communicated to the Director of Nursing (DON) and Medical Director, the facility did not act on these recommendations. The resident's Medication Administration Record (MAR) showed that both Tylenol orders were administered on multiple occasions in September and October, without clarification or discontinuation of one of the orders. During an interview, the DON acknowledged that the recommendations were not acted upon as they should have been, indicating a lapse in the facility's process for addressing pharmacist recommendations.
Improper Storage of Medications on Nursing Unit
Penalty
Summary
The facility failed to ensure that all medications were stored in accordance with accepted professional principles of practice. Specifically, on the [NAME] Unit, a plastic container containing vials of ampicillin sulbactam, an intravenous antibiotic medication, was observed to be unlocked and unattended at the nurses' station. This occurred on multiple occasions over two days, as noted by the surveyor's observations. Interviews with nursing staff revealed that the medications in the plastic container were intended for a specific resident, Resident #62. Despite this, the medications were not properly secured, as confirmed by the Director of Nursing, who acknowledged that the IV antibiotics should not have been left unlocked and unattended. This oversight indicates a failure to adhere to the facility's policy on the safe and secure storage of medications.
Failure to Date and Dispose of Expired Refrigerated Foods
Penalty
Summary
The facility failed to adhere to its policy on food storage and labeling, as observed during a surveyor's inspection of the kitchen. The inspection revealed three undated plastic containers in the refrigerator, one labeled as pasta sauce, and two unlabeled containers with a reddish-brown liquid and an opaque liquid, respectively. Additionally, a pan labeled as caramel sauce was found with an expired date. During an interview, the Food Service Director confirmed that all refrigerated foods should have a written expiration date and that expired foods must be removed and discarded, indicating a lapse in following these procedures.
Documentation Failures in Resident Care
Penalty
Summary
The facility failed to maintain complete and accurate documentation in the medical records for two residents, leading to deficiencies in care. For Resident #47, who was admitted with diagnoses including psychosis and dementia, the facility did not accurately document the treatment involving steri strips on the resident's right forearm. Although the Treatment Administration Record indicated that the steri strip treatment was completed, an observation revealed no steri strips present, and Nurse #8 admitted to signing off on the treatment without actually performing it, as the wound had healed. For Resident #25, who was admitted with diagnoses including diabetes and nutritional anemia, the facility failed to ensure a complete wound description was documented during the admission assessment and weekly skin checks. The resident had a stage 2 pressure ulcer on the coccyx, noted in the hospital discharge summary and nursing notes, but the admission assessment and subsequent skin checks lacked detailed descriptions of the wound. Nurse #1, who completed the assessments, acknowledged the omission and expressed difficulty recalling the wound's appearance due to the time elapsed since admission. Interviews with nursing staff, including the Director of Nursing, highlighted the importance of completing the description section in skin assessments, which was not consistently done. The MDS Nurse also noted that skin assessments were not always accurately completed, impacting the review process for MDS completion. These documentation failures indicate a lack of adherence to the facility's policies on skin audits and pressure ulcer prevention, which require detailed assessments and documentation to ensure proper care and monitoring of residents' skin conditions.
Facility Fails to Maintain Clean and Homelike Shower Rooms
Penalty
Summary
The facility failed to maintain a clean and homelike environment in the shower rooms of two resident units, as observed during a survey. On one unit, the shower room had dirty tile grout, missing floor tiles around the drain, and a missing drain cover, which was replaced with a metal mesh sink strainer. Additionally, there were several dead and live small winged insects present in the shower room. On the other unit, the shower room also had dark colored stains in the grout on the tiled shower walls. Interviews with facility staff confirmed the deficiencies. The Regional Maintenance Director acknowledged the need for repairs to the grout, drain cover, and tiles in the affected shower room. The Director of Nurses (DON) also stated that the shower rooms should be kept clean, and the tiles and drain cover should be replaced, with the insects removed. These observations and interviews indicate a failure to uphold the facility's policy of providing a safe, clean, comfortable, and homelike environment for residents.
Facility Fails to Support Resident's Right to Self-Determination in Smoking Policy
Penalty
Summary
The facility failed to uphold a resident's right to self-determination by permanently revoking their smoking privileges. The resident, who was admitted with conditions including post-traumatic stress disorder, anxiety disorder, opioid dependence, and hemiplegia, had a care plan that allowed smoking under supervision during designated times. Despite this, the facility revoked the resident's smoking privileges after they were found with a vape pen in their bed, following previous incidents of possessing smoking paraphernalia. The facility's smoking policy required residents to smoke only under staff supervision and prohibited possession of smoking materials. The resident's privileges were initially suspended after two incidents of possessing paraphernalia, and permanently revoked after a third incident. Despite the resident's repeated requests to resume smoking, the facility maintained the revocation, citing non-compliance with the smoking policy. Interviews with facility staff confirmed the resident's ongoing requests to participate in supervised smoking times.
Resident Restrained During Vape Pen Confiscation
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraint, as required by their policy, which led to a deficiency. The incident involved a resident who was alert, oriented, and able to make their needs known. The resident had a history of post-traumatic stress disorder, anxiety disorder, opioid dependence, major depressive disorder, and other conditions. On the morning of the incident, Nurse #1, along with CNA #1 and CNA #2, used physical force to confiscate a vape pen from the resident, which was hidden under their clothing. The facility's policy defines restraint as any manual method or device that restricts a resident's freedom of movement and is not easily removed by the resident. The incident was reported by the resident, who claimed that the staff attacked them in bed while trying to take the vape pen. The facility's internal investigation and a report to the Disabled Persons Protection Commission confirmed that the staff held the resident down to remove the vape pen. Interviews with the involved staff revealed that Nurse #1 enlisted the help of CNA #1 and CNA #2 to assist in taking the vape pen, during which the CNAs held the resident's hands to allow Nurse #1 to retrieve the item. The actions of the staff were deemed overly aggressive, leading to the deficiency finding.
Failure to Report Alleged Resident Assault Promptly
Penalty
Summary
The facility failed to adhere to its Abuse Prohibition Policy when a cognitively intact resident alleged that they were assaulted by staff members during an incident involving the confiscation of a vape pen. The incident occurred early in the morning, and the resident reported the alleged assault to a Certified Nurse Aide (CNA), who then informed a nurse. However, the nurse did not immediately report the allegation to the facility's Administrator as required by the policy. Consequently, the Administrator only became aware of the situation when police officers arrived at the facility in response to the resident's call, more than five hours after the incident. The resident involved had a complex medical history, including post-traumatic stress disorder, anxiety disorder, opioid dependence, major depressive disorder, and other conditions. The resident was non-ambulatory, used a wheelchair, and had intact cognitive patterns. The staff members involved in the incident included two CNAs and a nurse, who admitted to confiscating a vape pen from the resident's incontinence brief. Despite being informed of the resident's intention to report the alleged assault to the police, the nurse failed to notify the Administrator promptly, leading to a delay in addressing the resident's allegations.
Verbal Altercation Between CNA and Resident
Penalty
Summary
The Facility failed to ensure staff treated a severely cognitively impaired resident with dignity and respect. The incident involved a verbal altercation between a Certified Nurse Aide (CNA) and the resident, during which profane language was used. The resident, who had severe cognitive impairment due to conditions such as stroke, schizoaffective disorder, and paranoid personality disorder, was admitted to the Facility in October 2022. On the morning of 04/29/24, the resident was heard yelling profanities at CNA #1, who responded with similar profane language. This was witnessed by two nurses who reported the incident. The Facility's policy on Resident Rights, revised in December 2021, mandates that residents be treated with respect and dignity. Despite this, CNA #1 engaged in a verbal altercation with the resident, which was corroborated by multiple staff members through written witness statements. The Director of Nursing (DON) and the Administrator were informed of the incident, and following an internal investigation, CNA #1 was terminated based on the testimonies of the witnesses.
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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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Nursing homes near West Roxbury
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| German Center For Extended Care | 0.7 mi | ★★★★★ | 6 | 0 |
| Care Village At Parkway | 1.4 mi | ★★★★★ | 14 | 0 |
| Newbridge On The Charles Skilled Nursing Facility | 2.3 mi | ★★★★★ | 1 | 0 |
| Recuperative Services Unit-hebrew Rehab Center | 2.5 mi | ★★★★★ | 1 | 0 |
| Brush Hill Care Center | 2.7 mi | ★★★★★ | 6 | 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.