Above average — CMS composite of the measures below.
A standard survey is most likely before 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 Devereux Skilled Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
The facility did not prevent the use of unnecessary psychotropic medications or medications that could restrain a resident's ability to function, resulting in a deficiency related to medication management.
The facility did not provide or obtain necessary dental services for a resident, resulting in a deficiency related to unmet dental care needs.
A resident with severe cognitive impairment and an indwelling urinary catheter was not placed on enhanced barrier precautions (EBP) as required by facility policy and CDC guidance. Staff provided care using only gloves, without gowns, and there was no signage or PPE cart outside the room. Interviews revealed staff were unaware of the need for EBP for this resident, and the care plan and physician's orders did not reflect EBP requirements.
The facility failed to implement resident-centered care plans, leading to deficiencies in care. Residents at risk for pressure ulcers were not provided with Prevalon boots as required, and several residents did not receive necessary supervision during meals, despite care plans indicating the need for continual supervision due to risks such as dysphagia and aspiration. Staff interviews revealed a lack of awareness and misunderstanding of care plan requirements, contributing to these oversights.
A resident with dementia and a pressure ulcer was not properly managed due to the facility's failure to notify the Physician/Nurse Practitioner of the Wound Physician's recommendations for an X-ray. This oversight led to the resident's hospitalization for a wound infection. Interviews revealed that nurses were responsible for communicating such recommendations, but this was not done, and the care plan lacked a plan for a stage 4 pressure ulcer.
A resident with chronic respiratory failure, heart failure, and dementia was not weighed weekly as ordered by the physician, despite being on a weight gain regimen. The facility's records showed inconsistent weight monitoring over several months, and staff interviews confirmed the failure to follow the physician's order.
A resident with a stage 4 pressure ulcer on the right heel did not receive recommended X-rays on two occasions, leading to hospitalization with a wound infection. Despite the Wound Physician's recommendations, there was no documentation of the X-rays being ordered or performed, and staff interviews revealed a lack of communication and documentation. The resident's condition worsened, resulting in hospitalization.
A nurse left medications unattended on top of a medication cart during a medication pass, contrary to facility policy. The medications were accessible in the hallway with two residents and a housekeeping staff member nearby. The nurse admitted the error, and the DON confirmed that medications should not be left unattended.
Two residents with specific dietary supervision needs were observed eating without the required supervision, despite care plans indicating the necessity for continual oversight. Staff inaccurately documented that supervision was provided, as confirmed by surveyors' observations and staff interviews.
The facility failed to maintain infection control standards during medication administration. An LPN was observed not performing hand hygiene after glove removal and touching contaminated surfaces. Another LPN stacked medication cups, leading to contamination. Both acknowledged their errors, and the DON confirmed expectations for proper infection control practices.
Unnecessary Use of Psychotropic Medications
Penalty
Summary
The facility failed to prevent the use of unnecessary psychotropic medications or the use of medications that may restrain a resident's ability to function. This deficiency indicates that residents were either prescribed psychotropic drugs without a clear clinical indication or were given medications that limited their functional abilities, contrary to regulatory requirements. The report does not provide specific details about the residents involved, their medical histories, or their conditions at the time of the deficiency.
Failure to Provide or Obtain Dental Services
Penalty
Summary
The facility failed to provide or obtain necessary dental services for a resident. This deficiency was identified during the survey process, indicating that the required dental care was not arranged or delivered as needed for the resident in question. No additional details regarding the resident's medical history or specific condition at the time of the deficiency are provided in the report.
Failure to Implement Enhanced Barrier Precautions for Resident with Indwelling Catheter
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for one resident who had an indwelling urinary catheter, as required by both facility policy and CDC guidance. The resident, who had severe cognitive impairment and urinary retention, was observed multiple times without appropriate EBP measures in place. Specifically, there was no signage or precaution cart with personal protective equipment (PPE) outside the resident's room, and the resident's care plan and physician's orders did not indicate the need for EBP. Staff were observed providing care to the resident while wearing gloves but not gowns, which is inconsistent with EBP requirements for residents with indwelling devices. Interviews with staff revealed a lack of awareness and understanding regarding the need for EBP for residents with catheters. The assigned CNA stated that only gloves were necessary, and did not recognize that the resident was on precautions. A nurse and the Director of Nursing both acknowledged that residents with catheters should be on EBP, and the DON admitted she was unaware that this resident was not on EBP. These actions and inactions led to the failure to implement required infection prevention and control measures for the resident.
Failure to Implement Resident-Centered Care Plans
Penalty
Summary
The facility failed to implement resident-centered care plans for seven residents, leading to deficiencies in care. Specifically, the facility did not ensure that Prevalon boots were applied to residents at risk for pressure ulcers, as outlined in their care plans. For instance, Resident #31 and Resident #34 were observed without Prevalon boots, despite their care plans indicating the necessity of these boots to prevent pressure ulcers. Interviews with nursing staff revealed a lack of awareness regarding these care plan requirements, contributing to the oversight. Additionally, the facility failed to provide necessary supervision during meals for several residents, as required by their care plans. Residents #31, #34, #41, #6, #19, #14, and #38 were observed eating without staff supervision, despite their care plans indicating the need for continual supervision due to risks such as dysphagia and aspiration. Interviews with staff, including CNAs and nurses, confirmed that supervision was expected but not consistently provided, leading to residents being left alone during meals. The lack of adherence to care plans was further highlighted by the facility's failure to update and communicate these plans effectively to staff. For example, Resident #19's care plan required continual supervision due to aspiration risks, yet staff were not present during meals. Interviews with the Director of Nursing and other staff members indicated a misunderstanding of what continual supervision entailed, with some staff believing that periodic checks were sufficient. This miscommunication and lack of adherence to care plans resulted in significant deficiencies in resident care.
Failure to Notify Physician of Wound Care Recommendations
Penalty
Summary
The facility failed to ensure that the Physician/Nurse Practitioner was notified of recommendations made by a Wound Physician for a resident with facility-acquired pressure injuries. Specifically, the Wound Physician recommended an X-ray of the resident's right foot on two occasions, but these recommendations were not communicated to the Physician/Nurse Practitioner. As a result, the resident was hospitalized with a wound infection. The resident, who was admitted to the facility in June 2023, had diagnoses including dementia and a pressure ulcer of the right heel. The care plan did not include a plan for a stage 4 pressure ulcer of the right heel. Interviews with facility staff revealed that it was the responsibility of the nurses to notify the Physician/Nurse Practitioner of any new recommendations from the Wound Physician and to document this in the clinical record. However, the Nurse Practitioner could not recall being informed of the recommendations for an X-ray and did not document any such communication in her notes. The resident was eventually sent to the hospital for evaluation of a right heel infection, where they were treated for pressure ulcers with a superadded infection.
Failure to Implement Physician's Order for Weekly Weights
Penalty
Summary
The facility failed to implement a physician's order for a resident who was admitted with chronic respiratory failure, heart failure, and dementia. The resident was on a physician-prescribed weight gain regimen, requiring weekly weight monitoring every Monday. However, the medical records showed that weights were not consistently recorded weekly in June, July, and August 2024. Interviews with a nurse and the Director of Nurses confirmed that the resident's weights were not obtained as ordered, despite the expectation that nursing staff follow physician orders.
Failure to Implement Wound Care Recommendations
Penalty
Summary
The facility failed to follow the Wound Physician's recommendations for a resident with a facility-acquired pressure ulcer on the right heel. The Wound Physician recommended an X-ray of the resident's right foot on two separate occasions, 10/6/23 and 10/11/23, but these recommendations were not implemented. The resident's condition worsened, leading to hospitalization with a wound infection. The resident, who was admitted in June 2023, had diagnoses including dementia and a stage 4 pressure ulcer on the right heel. The care plan did not include a specific plan for the stage 4 pressure ulcer. Despite the Wound Physician's recommendations being communicated to the facility staff, there was no documentation of an X-ray being ordered or performed, and the nursing progress notes did not reflect awareness of the new wound care recommendations. Interviews with facility staff, including a nurse, the Director of Nursing, and the Nurse Practitioner, revealed a lack of communication and documentation regarding the Wound Physician's recommendations. The Nurse Practitioner could not recall being informed about the need for an X-ray, and the Director of Nursing was unable to find any documentation indicating that the recommendations were followed. Consequently, the resident was hospitalized with an infected right heel on 10/12/23.
Improper Medication Storage During Medication Pass
Penalty
Summary
The facility failed to ensure that medications were stored in accordance with State and Federal laws, as observed during a medication pass. A nurse removed medications from the medication cart and placed them on top of the cart. The nurse then left the medications unattended while walking down the hallway to obtain items from the kitchenette. During this time, the medications were accessible and unattended in the hallway, with two residents and a housekeeping staff member nearby. The nurse acknowledged that leaving the medications unattended was inappropriate, and the Director of Nursing confirmed that medications should not be left on top of the cart or unattended.
Inaccurate Documentation of Meal Supervision
Penalty
Summary
The facility failed to maintain accurate medical records for two residents, specifically regarding the level of supervision required during meals. Resident #14, who was admitted with conditions including hemiplegia, hemiparesis, dysphagia, and severe protein-calorie malnutrition, was observed eating without the required supervision or touching assistance on multiple occasions. Despite the care plan and Kardex indicating the need for continual supervision, staff had inaccurately documented that supervision was provided during all meals, contrary to the surveyors' observations. Similarly, Resident #38, diagnosed with cerebral palsy, dysphagia, and legal blindness, was also observed eating without the necessary supervision or touching assistance. The care plan and Kardex for this resident also required continual supervision, yet staff documentation inaccurately reflected that supervision was provided. Interviews with nursing staff confirmed the expectation for accurate documentation, highlighting a discrepancy between observed practices and recorded information.
Infection Control Lapses During Medication Administration
Penalty
Summary
The facility failed to ensure proper infection control practices during medication administration, as observed by surveyors. Nurse #2 was seen removing gloves and touching the contaminated gloves with her bare hand, then proceeding to touch items on the medication cart without performing hand hygiene. This occurred after administering eardrops to a resident and again after exiting a resident's room. During an interview, Nurse #2 acknowledged the mistake and stated that she should have used hand sanitizer or soap and water before and after glove removal. The Director of Nursing confirmed that staff are expected to follow infection control guidelines, including proper glove removal and hand hygiene. Additionally, Nurse #1 was observed improperly handling medication cups by stacking them, which led to contamination of the medications inside. The nurse placed the stacked cups into the medication cart drawer, further compromising infection control standards. In an interview, Nurse #1 admitted to the error, acknowledging that the top of the medication cart is contaminated. The Director of Nursing reiterated that medication cups should not be stacked to prevent contamination, and infection control measures are expected to be followed.
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Illustrative
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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 Marblehead
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lafayette Rehabilitation & Skilled Nursing | 0.1 mi | ★★★★★ | 0 | 0 |
| Salem Rehab Center | 1.5 mi | ★★★★★ | 24 | 0 |
| Abbott Skilled Nursing & Rehabilitation Center | 3 mi | ★★★★★ | 0 | 0 |
| Life Care Center Of The North Shore | 3.3 mi | ★★★★★ | 8 | 0 |
| New England Homes For The Deaf, Inc | 4.2 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.