Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Eliot Center For Health And Rehabilitation during CMS and state inspections, most recent first.
A resident with opioid dependence and alcohol use disorder, who was cognitively intact and had a care plan to offer AA/NA participation, was not documented as being offered or given access to AA meetings in person or virtually during the stay. The PNP noted the resident said AA had been beneficial, but the record lacked evidence of facility-facilitated recovery support, and staff gave differing accounts of who was responsible for offering the service.
Incomplete and Inaccurate Psychiatric Documentation: A resident with opioid dependence, alcohol abuse, hepatic encephalopathy, and alcoholic cirrhosis had psychiatric progress notes that were not readily accessible in the EMR and were not provided when requested. The MHC later faxed the notes after the survey and stated she had not documented the visit notes immediately and had mistakenly entered information in a psychotherapy assessment that did not match the timing of the resident’s window-jump event. The DON/Administrator stated all medical records were expected to be accurate and accessible.
A resident with dementia and behavioral disturbances, who ambulated independently and was required by the care plan to remain in the facility unless supervised, eloped from a secured unit after asking staff how to leave. Staff had observed the resident wandering and inquiring about leaving but had not initiated an elopement risk assessment or related care plan interventions. The resident was last seen at the nurse station, later found missing during clinical rounds, and ultimately located off-site at a former home address. Exit and rear doors were alarmed and code-protected, but staff had shared alarm and elevator codes with visitors, and it was presumed the resident exited by using the elevator with a visitor.
Failure to issue required Medicare non-coverage notices for two residents. Two residents with severe cognitive impairment and activated HCPs had Medicare Part A skilled services ending, but the facility did not issue SNF ABNs and could not show that paper copies of the NOMNCs were provided after phone notification of the end of skilled coverage and appeal rights.
Failure to provide scheduled group activities on resident units. Surveyors observed that posted programs such as Morning Greeting, Coffee Social, Scattergories, Seated Stretch, Balloon Pants Game, Name 5, and Group Exercise were not occurring on Units 3 and 4. Residents were seen wandering, seated without engagement, or stating there was nothing to do, while activity staff reported staffing shortages and that unit-based activity programs were not being carried out.
Medication administration errors exceeded the 5% threshold when an RN made two errors during observed med pass. A resident with HTN, anxiety, and adult failure to thrive received Amlodipine without a required BP check, and MiraLAX was signed as given even though it was not administered and was not available in the med cart. The DON’s office confirmed the nurse should have followed the order for the BP reading and should not have documented MiraLAX as given.
Infection control failures were observed involving a resident with a Foley catheter, ice handling behind the nursing station, and housekeeping cleaning practices. A resident’s urinary drainage bag was repeatedly seen on the floor next to the bed despite orders for Foley care and staff statements that it should always remain off the floor. On the Fourth Floor, a resident accessed the ice chest behind the nursing station using bare hands and without hand hygiene while staff did not redirect the resident. Housekeeping also cleaned a Contact Precaution room without a gown and then used the same mop water in other rooms, including a non-precaution room.
The facility failed to involve residents and their representatives in the care planning process, as required by policy. Quarterly care plan meetings were not conducted for several residents, and there was no evidence of invitations to these meetings. Residents with various diagnoses, including dementia and cancer, were affected, and staff confirmed the absence of required meetings and documentation.
The facility did not post daily nurse staffing information in a prominent location for three consecutive days and failed to retain 18 months of staffing records. The Administrator and VP of Operations acknowledged the requirements but could not provide the necessary documentation.
The facility failed to maintain food safety and sanitation standards, risking foodborne illness. Spoiled and unlabeled food was found in the kitchen, and unsanitary conditions were observed in the dining room. Staff mixed clean and dirty items at a drink station, and an Activities Assistant used contaminated ice for a resident's drink. The DON intervened, and interviews revealed lapses in staff training and protocol adherence.
A resident's enteral feeding pump pole was found visibly soiled with a dried, milky substance over three days, indicating a failure to maintain cleanliness. The resident, with severe cognitive impairment and dependent on enteral feeding, was observed by a surveyor, and both a CNA and the ADON acknowledged the unclean state of the equipment. The facility's policy required cleaning of visibly soiled equipment, which was not followed in this case.
A resident's communication tablet went missing, and the facility failed to resolve the grievance promptly. Despite staff awareness, the grievance was not documented or addressed according to policy. The resident, with aphasia and major depressive disorder, relied on the tablet for communication. The grievance form was incomplete, and the Administrator was unaware of the issue.
A facility failed to accurately code the MDS Assessment for a resident's dental status. The resident, with severe cognitive impairment, was observed to have significant dental issues not reflected in the assessment. The DON and MDS Nurse admitted the assessment was based on outdated information without a current examination.
Two residents dependent on staff for personal hygiene tasks did not receive necessary grooming assistance, including fingernail and facial hair care. Despite care plans indicating the need for staff assistance, observations revealed long and unkempt nails and facial hair. The DON confirmed the oversight, and CNAs admitted to not addressing these needs during routine care.
A facility failed to provide an emergency dialysis kit for a resident with Chronic Kidney Disease Stage 5, who required renal dialysis. The absence of the kit, which should have included clamps and pressure dressings, was noted during a survey. The resident had a central venous catheter, and the facility's policy required staff to be trained in handling such emergencies. However, a nurse was unaware of the resident's specific care needs, and the Director of Nursing admitted the clamp was used elsewhere and not returned.
A facility failed to implement a Consultant Pharmacist's recommendation to update a Physician's order for a resident with COPD using Budesonide. The recommendation, which was agreed upon by the physician, advised instructing the resident to rinse their mouth after use to prevent oral thrush. The Director of Nursing acknowledged the oversight during an interview.
A nurse failed to secure medications during a medication pass, leaving a cart unlocked and unattended in the hallway. This occurred while administering medications to a resident, with other residents and staff nearby. The DON expressed concerns about the safety of this practice, as it deviated from the facility's policy on medication storage.
A resident with severe cognitive impairment and dental issues did not receive requested dental services due to the facility's failure to refer them to the dental services vendor. Despite the guardian's request and multiple visits from the on-site dental service, the resident was not seen, leading to a deficiency in care.
A facility failed to adhere to infection control standards for a COVID-19 positive resident. Staff did not wear required eye protection and failed to perform hand hygiene after glove removal, despite facility policies and signage indicating necessary precautions. The DON acknowledged these lapses in protocol.
The facility failed to accurately complete PASARR screenings for two residents, resulting in missed Level II evaluations for serious mental illnesses. One resident was admitted with psychiatric diagnoses and recent psychiatric treatment, yet the PASARR indicated no SMI. Another resident's recent psychiatric treatment was not reflected in the PASARR, despite being prescribed psychotropic medications. Staff interviews revealed non-compliance with the facility's PASARR policy, leading to deficiencies in identifying and evaluating the need for specialized services.
Failure to Offer Recovery Support for Resident with SUD History
Penalty
Summary
The facility failed to ensure necessary behavioral health care and services were provided for a resident with a history of opioid dependence and alcohol use disorder. The resident was admitted with diagnoses including opioid dependence, alcohol abuse, hepatic encephalopathy, and alcoholic cirrhosis with ascites. A Substance Use Assessment documented opioid use in remission, recent alcohol use, methadone prescribed to assist with the current SUD, and active substance use within the prior 0-3 months. The resident’s SUD care plan included offering and encouraging participation in AA/NA meetings, and the resident was cognitively intact with a BIMS score of 15 out of 15. The resident’s PNP evaluation noted that the resident discussed a long history of alcohol abuse and stated that AA participation had been beneficial in recovery, with a plan to encourage ongoing participation in recovery-based supports and healthy coping skills. However, the medical record contained no documentation that the resident was offered or given an opportunity to attend AA meetings, either in person or virtually, during the stay. During interviews, the PNP and MHC stated that offering AA meetings was the facility’s responsibility, while the SW said psychiatric services were responsible and that she did not collaborate with psychiatric services regarding the resident’s care. The Administrator also stated she thought psychiatric services were responsible for offering and facilitating AA meetings.
Incomplete and Inaccurate Psychiatric Documentation
Penalty
Summary
The facility failed to ensure complete, accurate, and accessible medical records for one sampled resident when psychiatric service progress notes were not readily available and were not included in the resident’s EMR. The facility policy titled Charting and Documentation required that all services provided to the resident and progress toward care plan goals, as well as treatments or services performed, be documented in the resident’s medical record. Resident #1 was admitted with diagnoses including opioid dependence, alcohol abuse, hepatic encephalopathy, and alcoholic cirrhosis with ascites. During the survey, copies of all psychiatric progress notes were requested for Resident #1, but the Mental Health Clinician’s notes were not in the EMR and were not provided at that time. The notes were faxed to the surveyor two days after the onsite survey. Review of records showed a nursing progress note documenting that the resident eloped out of a third-floor window, and a psychotherapy assessment dated as a 05/27/26 service note stated the resident had jumped out of a second-story window and was transferred to the hospital. The Mental Health Clinician later stated she had visited the resident on 05/19/26 and 05/27/26, had not written the progress note immediately after the visit, and had mistakenly written the 05/27/26 assessment note the night before the interview, including information about the window jump before it had occurred. The Administrator stated it was her expectation that all medical records were accurate and accessible.
Failure to Supervise Resident and Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and prevent elopement for a resident on a secured unit who had a legal guardian and a care plan requiring that he/she remain in the facility unless supervised. The resident, admitted with dementia with behavioral disturbances, anxiety, major depressive disorder, and frontotemporal neurocognitive disorder, ambulated independently and required physical assistance with ADLs. The facility’s elopement policy required that residents at risk for wandering or elopement have care plan strategies and interventions to maintain safety. Despite this, the DON acknowledged that no elopement assessment or care plan interventions had been initiated for this resident prior to the incident, even after staff observed the resident asking how to leave the facility. On the day of the incident, a CNA observed the resident at the nurse station around 2:30 P.M. asking how to leave the facility. The CNA reported that the resident routinely wandered the unit but was not known to exhibit exit-seeking behavior and therefore did not believe the resident would leave. Around 2:40 P.M., a nurse saw the resident at the nursing station interacting with staff, and by approximately 3:00 P.M., during final clinical rounds, the nurse noted the resident was missing and activated an elopement code. Staff searched the interior and exterior of the facility without success, and about 45 minutes later, staff and local police located the resident at his/her former home approximately two miles away. The administrator reported that exit doors and rear doors were alarmed and required codes, and presumed the resident may have exited by entering an elevator with a visitor who had access to the code, but staff had previously shared alarm/elevator codes with visitors or outside consultants.
Failure to Issue Required Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to issue the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) and failed to provide evidence that a paper copy of the Notice of Medicare Non-Coverage (NOMNC) was given to the activated Health Care Proxy (HCP) for two residents whose Medicare Part A skilled services were ending. The report states that, for both residents, the facility initiated discharge from Medicare Part A services before benefit days were exhausted and the residents remained in the facility. Resident #33 had diagnoses including Alzheimer's disease, difficulty walking, and muscle weakness. The resident was severely cognitively impaired, with a BIMS score of 4 out of 15, was not his/her own responsible party, and had an activated HCP. Medicare Part A skilled services began on 10/1/25 and the last covered day ended on 10/23/25. The facility telephoned the activated HCP on 10/21/25 to notify them of the NOMNC, including the last covered day, the right to appeal, and the appeal deadline, but there was no evidence that a SNF ABN was issued or that a paper copy of the NOMNC was provided. Resident #78 had diagnoses including acute respiratory failure, pneumonia, non-displaced fracture of the head of the radius, and unspecified dementia. The resident was severely cognitively impaired, was not his/her own responsible party, and had an activated HCP. Medicare Part A skilled services began on 1/23/26 and the last covered day ended on 3/14/26. The facility telephoned the activated HCP on 3/12/26 to notify them of the NOMNC, including the last covered day, the right to appeal, and the appeal deadline, but there was no evidence that a SNF ABN was issued or that a paper copy of the NOMNC was provided. During interview, the MDS Nurse and Social Worker stated that the SNF ABNs had not been issued to either resident's activated HCPs and that they could not provide evidence that paper copies of the NOMNCs were provided.
Failure to Provide Scheduled Group Activities on Resident Units
Penalty
Summary
The facility failed to provide an ongoing program of group activities designed to meet the interests of and support the physical, mental, and psychological well-being of residents on Units 3 and 4. On Unit 4, the posted activity calendar showed scheduled programs including Morning Greeting, Coffee Social, Scattergories, Seated Stretch, and Balloon Pants Game, but surveyors observed that these activities were not occurring. During one observation, Activity Staff #1 was distributing the Daily Chronicle in resident rooms while six residents sat in wheelchairs parked against a wall and another resident wandered in the hallway, with no staff engaging the seven residents. A resident seated alone in the dining room said there was nothing interesting in the Daily Chronicle, there were no activities happening, and there was usually nothing to do, adding that it had been like that for a while and there were not enough staff. On Unit 3, the posted calendar showed scheduled activities including Morning Greeting, Coffee Social, Name 5, Group Exercise, Create your own puzzle, and Rhyme, Rhyme, Wrong!, but surveyors observed that these programs were not occurring. Residents were seen wandering in the hallway, including one resident attempting to access the elevator and another asking about flights out of Boston, with no staff redirecting or engaging them in group activity. Another resident was seated in the small dining room facing the wall and loudly calling out with no activity engagement, and a resident stated, "What do I do?" and "There is nothing to do." Activity Staff #1 said she had been working on her own in the Activity Department until the current Activity Director started, and that there were not enough activity staff to do programs on each unit. The Administrator and Activities Director reported that there were no activity programs occurring on the units and that the only activities offered on the units were one-to-one visits, nail care, room visits, and music therapy due to staffing challenges.
Medication Administration Errors Exceeded 5 Percent
Penalty
Summary
The facility failed to ensure it was free of a medication error rate of five percent or greater when one of two nurses observed made two errors out of 34 opportunities, resulting in a 5.88% medication error rate and affecting one resident. The errors involved a resident admitted in September 2025 with diagnoses including hypertension, anxiety, and adult failure to thrive. The resident had physician orders in April 2026 for Amlodipine 10 mg daily for hypertension, to be held for systolic blood pressure less than 100, and MiraLAX 17 grams daily for constipation, to be held for loose stools. During medication administration observation, the nurse gave Amlodipine without obtaining a blood pressure reading first and did not administer MiraLAX, yet electronically signed the MAR as if both medications had been given. The nurse stated she did not obtain the blood pressure because the previous shift usually obtained vital signs, and she signed the MAR for MiraLAX so she could continue to the next resident even though the medication was not available in the medication cart. The ADON stated the nurse should have followed the physician order for the blood pressure check before giving Amlodipine and should not have signed off MiraLAX as administered when it was not available.
Infection Control Failures With Foley Care, Ice Handling, and Housekeeping Practices
Penalty
Summary
The facility failed to keep Resident #14’s Foley catheter drainage bag off the floor. Resident #14 was admitted with diagnoses including hydronephrosis with renal and ureteral calculus obstruction, retention of urine, and acute kidney failure, unspecified, and had physician’s orders for Foley catheter care every shift with monitoring for hematuria and placement. The treatment administration record showed the resident was receiving Foley catheter care as ordered. On multiple observations, the urinary drainage bag was seen laying on the floor next to the resident’s bed, including while the resident was asleep and again as a nurse exited the room. The District Coordinator of Education and the DON both stated the bag should never be on the floor and should be kept off the floor to prevent infection. The facility also failed to ensure sanitary handling of ice on the Fourth Floor Unit. A resident was observed behind the nursing station accessing an ice chest, using a scoop with bare hands, removing ice from the scoop with bare hands, placing ice into two cups, and picking up ice that fell onto the ice cart and putting it into the cups. The resident was not observed sanitizing hands during the observation. Two staff members walked by while the resident was accessing the ice chest and did not redirect the resident or assist with obtaining the ice. The ADNS and DON stated residents should not be behind the nursing station accessing the ice chest on their own and that staff should redirect them. Housekeeping staff also failed to follow infection control practices when cleaning consecutive rooms on the Fourth Floor Unit. HSK #2 was observed mopping a room with a Contact Precaution sign outside the door without wearing a gown, then moved to another room and continued mopping with the same water, and then continued to another non-precaution room with that same water. The room under Contact Precautions was identified by the IP as a resident diagnosed with C-DIFF. HSK #2 stated she cleaned three rooms and changed the water, and the Housekeeping Manager stated contaminated rooms should be cleaned last and not with the same water used in another room.
Failure to Involve Residents in Care Planning Process
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were provided the right to participate in the care planning process, as required by their policies. Specifically, the facility did not conduct quarterly care plan meetings for four residents, nor did they invite the residents or their representatives to participate in these meetings. The facility's policy mandates that the Interdisciplinary Team (IDT) should include the resident or their representative and that care plan meetings should be held at a convenient time for them. However, there was no documented evidence of such meetings or invitations for the residents in question. Resident #40, admitted with Adjustment Disorder and Dementia, had no documented evidence of care plan reviews by the IDT following MDS assessments in May and September 2024. The MDS Nurse confirmed the absence of care plan meetings involving the resident or their representative. Similarly, Resident #89, with diagnoses including Malignant Neoplasm of the Prostate and Dementia, had no evidence of IDT care plan meetings following the November 2024 MDS assessment, despite being listed on the facility's care plan meeting schedule. Resident #57, with conditions such as COPD and Diabetes Mellitus, reported never attending care plan meetings, and there was no evidence of such meetings following the August 2024 MDS assessment. Lastly, Resident #22, with Malignant Neoplasm of the Brain and Multiple Sclerosis, had no documented participation in care plan meetings scheduled for April and July 2024. The resident's Health Care Proxy confirmed not being invited to these meetings. The MDS Nurse and Regional MDS Nurse acknowledged the lack of evidence for the required meetings and invitations.
Failure to Post and Retain Nurse Staffing Information
Penalty
Summary
The facility failed to comply with the requirement to post daily nurse staffing information in a prominent and accessible location for residents and visitors. During a recertification survey, it was observed that the facility did not have the required nurse staffing information posted on three consecutive days. The Administrator acknowledged the requirement but was unable to provide evidence of the postings for the specified dates. Additionally, the facility did not maintain 18 months of daily nurse staffing records as required. The Vice President of Operations confirmed the location where the staffing information should be posted but admitted that the facility did not have the necessary records retained for the required duration.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards of food safety and sanitation, leading to potential foodborne illness risks for residents. During an inspection, surveyors observed spoiled and improperly labeled food items in the facility's kitchen. Specifically, cucumbers with a moldy film and ground beef past its use-by date were found in the walk-in and reach-in refrigerators, respectively. Additionally, sandwiches were stored without proper labeling or dating. Dietary staff acknowledged that these items should have been discarded or properly labeled, as per the facility's food safety policies. In the main dining room, surveyors noted unsanitary conditions during meal service. A drink station was set up with clean and dirty items improperly mixed. Nursing staff served drinks from this station, where dirty cups and utensils were placed alongside clean ones. An Activities Assistant was observed using a clean cup to scoop ice from a contaminated container, which was then served to a resident. The Director of Nursing intervened to prevent the resident from consuming the contaminated drink and educated the staff member on proper procedures. Interviews with the Corporate Food Service Director and the Director of Nursing revealed lapses in staff training and adherence to food safety protocols. The Corporate FSD confirmed that dirty items should not have been on the same table as clean items, and that staff should not have used contaminated ice. The DON expressed uncertainty about whether the staff member involved had received adequate training in safe food handling practices.
Failure to Maintain Cleanliness of Enteral Feeding Equipment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for a resident who was dependent on enteral feeding. The deficiency was identified when a surveyor observed the resident's enteral feeding pump pole, which was visibly soiled with a dried, milky-colored substance at the base. This observation was made over three consecutive days, indicating a lack of timely cleaning and maintenance of the equipment. The facility's policy required that enteral feeding poles be cleaned if visibly soiled and routinely, but this was not adhered to in this instance. The resident involved had been admitted to the facility with diagnoses including dysphagia and gastrostomy status, and had severely impaired cognitive skills, rarely understanding or being understood by others. During an interview, a CNA acknowledged that the base of the pole was dirty and should have been cleaned immediately after the spill occurred. The CNA noted that the nursing staff responsible for the spill should have wiped it up, as they had access to wipes for cleaning. The Assistant Director of Nurses also confirmed the pole was dirty and stated that both housekeeping and nursing staff were responsible for maintaining cleanliness, emphasizing the importance of immediate spill cleanup to prevent pest attraction and maintain a proper environment.
Failure to Resolve Grievance for Missing Communication Device
Penalty
Summary
The facility failed to ensure prompt efforts to resolve a grievance for a resident who had a communication device reported missing. The resident, who was admitted with conditions including aphasia and major depressive disorder, relied on an electronic communication tablet to communicate with staff. The grievance policy of the facility mandates that grievances be addressed promptly, but in this case, the grievance regarding the missing tablet was not resolved in a timely manner. The resident's communication tablet, which was essential for making needs known, was reported missing by nursing staff. Despite the awareness of the missing device by various staff members, including a Certified Nurses Aide and the Speech Therapist, the grievance was not properly documented or addressed. The grievance form, completed by a supervising nurse, was found incomplete with no evidence of action taken, responsible person, or follow-up documented. The form was located in the binder of a contracted social worker who was no longer with the facility. Interviews with staff revealed that the grievance process was not followed as required. The Administrator, who was the Grievance Officer, was unaware of the missing device and had not received a grievance form related to it. The Assistant Director of Nurses acknowledged that the grievance had been discussed in staff meetings but was unsure of any subsequent actions. The failure to address the grievance promptly and effectively highlights a breakdown in the facility's grievance resolution process.
Inaccurate MDS Assessment Coding for Dental Status
Penalty
Summary
The facility failed to ensure the accurate coding of the Minimum Data Set (MDS) Assessment for a resident, specifically regarding dental status. The resident, admitted in November 2023 with diagnoses including Unspecified Dementia, Insomnia, Anxiety, and high cholesterol, was found to have discrepancies in the MDS Assessment completed on November 8, 2024. The assessment inaccurately indicated no dental issues, despite observations by the surveyor and the Director of Nursing (DON) revealing that the resident had no teeth on the top gum line and three teeth on the bottom gum line, two of which were dark in color and broken. During interviews, it was revealed that the MDS coding for the resident's dental status was not based on a current examination. The DON admitted that the assessment was completed by an off-site MDS Nurse, and there was no evidence that any staff member or the MDS Nurse had examined the resident's mouth for dental status. The MDS Nurse confirmed that the responses for dental status were carried over from a previous assessment completed on November 13, 2023, without verification, leading to the inaccurate coding.
Failure to Provide Grooming Assistance to Dependent Residents
Penalty
Summary
The facility failed to provide necessary grooming assistance to two residents who were dependent on staff for personal hygiene tasks. Resident #15, who was admitted with multiple diagnoses including unspecified dementia and major depressive disorder, was observed on two occasions with long facial hair and fingernails with debris, despite being dependent on staff for these grooming tasks. The resident's care plan indicated a need for assistance with personal hygiene, yet the Certified Nurses Aides (CNAs) responsible for the resident's care did not provide the required grooming services during morning and evening care. Similarly, Resident #57, who was admitted with conditions such as chronic obstructive pulmonary disease and diabetes mellitus, was observed with long and jagged fingernails on two separate occasions. The resident's care plan required staff assistance for personal hygiene, including fingernail care, but the CNAs failed to provide this care during scheduled grooming times. The resident expressed a need for fingernail trimming, yet the care was not provided until later in the day after the deficiency was noted by the surveyor. The Director of Nursing (DON) acknowledged the oversight in both cases, confirming that the grooming tasks were part of the residents' care plans and should have been addressed during routine care. The CNAs involved admitted to not noticing or addressing the grooming needs during their shifts, resulting in the residents not receiving the necessary personal hygiene care as outlined in their care plans.
Failure to Provide Emergency Dialysis Kit for Resident
Penalty
Summary
The facility failed to provide care and services consistent with professional standards of practice for a resident requiring renal dialysis. Specifically, the facility did not ensure that an emergency kit, including clamps and pressure dressings, was kept with the resident and at the resident's bedside as ordered. This deficiency was observed during a survey when the surveyor, along with the resident's family member, noted the absence of the emergency kit in the resident's room. The resident, who was admitted with Chronic Kidney Disease Stage 5 and dependent on renal dialysis, had a central venous catheter in the chest, necessitating the availability of the emergency kit. Further investigation revealed that the facility's policy required staff to be trained in recognizing and intervening in medical emergencies related to dialysis care. However, during an interview, a nurse was unaware of the resident's specific care needs and the location of the venous catheter access site. The Director of Nursing acknowledged that the clamp should have been at the resident's bedside but was used for another resident's wound care and not returned. This oversight highlights a lapse in adherence to the facility's policy and the physician's orders for the resident's care.
Failure to Implement Pharmacist's Recommendation for Medication Management
Penalty
Summary
The facility failed to act upon a recommendation made by the Consultant Pharmacist during a monthly Medication Regimen Review for a resident diagnosed with Chronic Obstructive Pulmonary Disease (COPD). The resident was prescribed Budesonide, an inhaled steroid medication, and the Consultant Pharmacist recommended updating the Physician's order to include instructions for the resident to rinse their mouth after use to prevent oral thrush. This recommendation was reviewed and agreed upon by the resident's physician but was not implemented in the resident's Physician's orders. During an interview, the Director of Nursing (DON) acknowledged that the recommendation should have been added to the resident's Physician's orders to prevent the development of thrush, but it had not been done. The facility's policy indicates that consultants provide written, dated, and signed reports of each consultation visit, which include recommendations and plans for implementation. However, the facility did not follow through with the Consultant Pharmacist's recommendation, leading to a deficiency in ensuring proper medication management for the resident.
Medication Storage Deficiency During Medication Pass
Penalty
Summary
The facility failed to ensure that medications were stored securely and in accordance with accepted professional standards during a medication pass for a resident. Nurse #1 prepared medications on top of a medication cart in the hallway outside the resident's room. The medications included oral medications, a nasal spray, and an inhalation medication. Nurse #1 left the medication cart unattended and unlocked in the hallway multiple times while administering medications to the resident in their room. This left the medications accessible to unauthorized staff and residents present in the hallway. During the medication pass, Nurse #1 repeatedly left the medication cart unlocked and unattended, with medications on top of the cart, while entering the resident's room to administer the medications. The Director of Nursing expressed concerns about the safety of leaving medication carts unlocked and unattended, emphasizing that medications should be secured and carts locked when not in use or unattended. Nurse #1 admitted to leaving the cart unlocked for convenience, indicating a deviation from the facility's policy on medication storage.
Failure to Provide Dental Services
Penalty
Summary
The facility failed to provide necessary dental services for a resident, despite a request from the resident's guardian. The resident, who was admitted with diagnoses including unspecified dementia, insomnia, anxiety, and high cholesterol, did not have any dental care problems, goals, or interventions included in their care plan. The facility's policy stated that routine and emergency dental services were available through a contract with a licensed dentist. However, the resident's guardian requested dental services in July 2024, and the resident was not referred to the dental services vendor, even though the on-site dental service had visited the facility multiple times since the request. Observations and interviews revealed that the resident had no teeth on the top gum line and three teeth on the bottom gum line, two of which were dark in color and broken. The resident mentioned that their other teeth were at home and expressed that their teeth did not hurt. The Director of Nursing (DON) acknowledged that the resident should have been referred for dental services as requested but was not. This oversight resulted in the resident not receiving the necessary dental care, despite the facility's policy and the guardian's request.
Infection Control Deficiency in COVID-19 Positive Resident's Care
Penalty
Summary
The facility failed to adhere to infection control standards for a resident who tested positive for COVID-19. The resident, admitted in April 2004 with a diagnosis of Paranoid Schizophrenia, was placed under contact and droplet precautions due to a positive COVID-19 test. The facility's policy required staff to wear appropriate PPE, including gloves, gowns, masks, and eye protection, and to perform hand hygiene after removing gloves. However, observations revealed that staff did not consistently follow these protocols. On two separate occasions, staff members entered the resident's room without wearing the required eye protection, despite signage indicating the need for such precautions. A housekeeper was observed cleaning the room without goggles and failed to perform hand hygiene after removing gloves. Similarly, a CNA entered the room without eye protection, citing unavailability, although goggles were present in the PPE bin. The Director of Nursing confirmed that both staff members should have worn eye protection and that the housekeeper should have performed hand hygiene after glove removal.
Failure to Complete Accurate PASARR Screenings for Residents
Penalty
Summary
The facility failed to accurately complete Level I Preadmission Screening and Resident Review (PASARR) for two residents, leading to deficiencies in identifying and evaluating serious mental illnesses (SMI) or intellectual disabilities (ID/DD). For one resident, the PASARR indicated no SMI, despite the resident being admitted with diagnoses of Major Depressive Disorder, Unspecified Psychosis, PTSD, and Anxiety, and having received psychiatric services during a recent hospitalization. The facility did not complete a Level II PASARR Evaluation as required, which should have been triggered by the resident's psychiatric diagnoses and recent psychiatric treatment. Another resident was admitted with diagnoses of PTSD and Major Depressive Disorder. The PASARR Level I Screening failed to acknowledge the resident's recent psychiatric treatment during hospitalization, which included agitation, mood lability, and pseudobulbar affect symptoms. Despite being prescribed Zyprexa and Prozac for these symptoms, the PASARR did not reflect the need for a Level II evaluation, which would have determined the necessity for specialized services for SMI. Interviews with facility staff revealed a lack of adherence to the facility's PASARR policy, which mandates accurate screening and reporting of psychiatric diagnoses upon admission. The MDS Nurse and Director of Nursing acknowledged the oversight in the PASARR process for the first resident, while the Admissions Liaison and Social Worker recognized the need for a Level II evaluation for the second resident based on the hospital discharge summary. These failures resulted in the residents not receiving the necessary evaluations and potential specialized services for their mental health conditions.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,024 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Natick
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Beaumont Rehab & Skilled Nursing Ctr - Natick | 1.9 mi | ★★★★★ | 6 | 0 |
| Mary Ann Morse Nursing & Rehabilitation | 2.2 mi | ★★★★★ | 1 | 0 |
| Casa De Ramana Rehabilitation Center | 2.6 mi | ★★★★★ | 3 | 0 |
| Royal Wayland Rehabilitation And Nursing Center | 2.6 mi | ★★★★★ | 0 | 0 |
| Bethany Skilled Nursing Facility | 2.8 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 August 2026) and official state health department websites.