Above average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Elizabeth Seton during CMS and state inspections, most recent first.
The facility failed to implement comprehensive fall prevention measures for two residents, despite physician's orders for fall mats on both sides of their beds. Observations showed only one mat in place for each resident, and care plans were not updated to reflect the necessary interventions. Staff interviews confirmed the oversight, highlighting a lack of adherence to the facility's fall prevention policy.
A facility failed to change a resident's oxygen tubing weekly as ordered by a physician. Despite documentation indicating the order was implemented, observations showed the tubing was overdue for a change. Interviews with staff confirmed the oversight and lack of documentation explaining the missed change.
The facility inaccurately coded the MDS for two residents, leading to deficiencies in their assessments. One resident's MDS incorrectly indicated the presence of an external urinary catheter and an ostomy, while another resident's MDS inaccurately recorded the date they came off skilled services. These errors were confirmed through observations, interviews, and record reviews.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, leading to deficiencies in fall prevention measures. For one resident, who was admitted with a history of stroke and severe cognitive impairment, the care plan included a physician's order for fall mats on both sides of the bed. However, observations revealed that only one fall mat was consistently placed, and there was no documentation of any refusal or rationale for the missing mat. Interviews with staff confirmed the oversight, as they acknowledged the requirement for mats on both sides but failed to implement it. Another resident, admitted with altered mental status and a recent history of falls, also had a physician's order for fall mats on both sides of the bed. Despite this, the care plan did not reflect the intervention, and observations showed only one mat in place. The resident had experienced multiple falls, including one with a major injury, yet the care plan was not updated to include the necessary fall prevention measures. Staff interviews indicated a misunderstanding or lack of follow-through on the physician's order, as only one mat was consistently used. The facility's policy on falls required the interdisciplinary team to identify and implement interventions to prevent falls, including equipment-related measures like fall mats. However, the failure to adhere to these policies and physician's orders resulted in incomplete care plans and inadequate fall prevention for the residents. The lack of documentation and communication among staff contributed to the oversight, as the necessary interventions were not consistently implemented or recorded in the residents' care plans.
Failure to Change Oxygen Tubing as Ordered
Penalty
Summary
The facility failed to provide respiratory care services in accordance with professional standards of care and the plan of care for a resident diagnosed with respiratory failure. The deficiency involved the failure to implement a physician's order to change the resident's oxygen tubing weekly. Despite the order being documented as implemented in the Treatment Administration Record (TAR) on a specified date, observations by the surveyor revealed that the oxygen tubing had not been changed as required, with the tubing still dated from a previous week. Interviews with the resident, a nurse, the unit manager, and the Director of Nursing confirmed that the oxygen tubing was overdue for a change and that the order should not have been marked as completed in the TAR. The medical record, including the TAR and progress notes, lacked any documentation explaining why the tubing was not changed as ordered. The facility's staff acknowledged the oversight and the lack of documentation for the missed change.
Inaccurate MDS Coding for Two Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for two residents, leading to deficiencies in their assessments. For one resident, who was admitted with urinary retention and a history of stroke, the MDS inaccurately indicated the presence of an external urinary catheter and an ostomy. Observations and interviews revealed that the resident only had a suprapubic urinary catheter, which was incorrectly coded as an indwelling urinary catheter. The Unit Manager and MDS Nurse confirmed that the resident never used an external urinary catheter or had an ostomy, and these were coded in error. For another resident, admitted with diagnoses including hip fracture and kidney disease, the MDS was incorrectly coded to indicate the resident had come off skilled services on a later date than actually occurred. The medical record showed the resident was discharged off skilled services a month earlier than the date coded in the MDS. The MDS coordinator acknowledged the error, confirming the incorrect coding of the discharge date.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Wellesley
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Skilled Nursing Facility At North Hill (the) | 1.4 mi | ★★★★★ | 0 | 0 |
| Care One At Newton | 1.6 mi | ★★★★★ | 8 | 0 |
| Adviniacare Newton Wellesley | 1.8 mi | ★★★★★ | 11 | 0 |
| Stone Rehabilitation And Senior Living | 2.2 mi | ★★★★★ | 5 | 0 |
| Lasell House | 2.2 mi | ★★★★★ | 1 | 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.