Above average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at German Center For Extended Care during CMS and state inspections, most recent first.
A resident with a Stage II pressure ulcer did not receive recommended nutritional interventions due to a lack of communication and follow-up by the facility's staff. The RD's recommendations for vitamins and minerals to promote wound healing were not documented or acted upon by nursing staff, and key personnel were unaware of the oversight.
A resident with significant cognitive impairment did not receive the flu vaccine for over three months after admission, despite consent from their Health Care Agent. The facility's staff, including the Unit Manager and ADON, were unaware of the consent, and the issue was only discovered during an audit and Care Plan meeting. The facility's process required ordering the vaccine through the pharmacy, which was not done promptly.
A resident with significant cognitive impairment was not administered the COVID-19 vaccine for over three months despite consent from their Health Care Agent upon admission. Facility staff were unaware of the signed consent, leading to a delay in vaccination until it was discovered during a facility-wide audit.
A resident with moderate cognitive impairment complained about staff speaking a different language, but the facility failed to document the grievance as it was resolved verbally within seven days. The facility's policy only required documentation if complaints remained unresolved for more than seven days, leading to a lack of written records for this and similar grievances.
The facility failed to comply with professional standards for food service safety, as observed during a survey. Food items were improperly stored directly on the floor and lacked proper labeling and dating in the kitchen's roll-in refrigerator. Additionally, a dented can of blueberry filling was found on the can rack, contrary to the facility's policy of setting aside such items for return. Interviews with the Food Service Director and staff revealed a lack of adherence to the facility's food handling policy.
A resident with dementia and a psychotic disorder, who was hospitalized for a trimalleolar fracture, frequently removed their soft cast upon returning to the facility. Despite this behavior, the care plan was not updated for over a month. Staff interviews confirmed the resident's actions, and the DON was unaware of the lack of timely updates to the care plan.
A resident with a foot ulcer did not receive a physician-ordered dressing change as per their care plan. The dressing was observed to be dated two days prior, and the nurse's initials did not match the nurse assigned for the missed date. The resident, who was cognitively intact, confirmed the missed dressing change, and the facility's documentation inaccurately reflected that the change had been completed.
A resident with a history of heart failure and atrial fibrillation did not receive proper monitoring for their anticoagulation therapy. Despite high INR levels, the facility failed to follow up on necessary lab tests and warfarin dosing for almost a week. Nursing staff recognized the lack of orders but did not take action, leading to a low INR level. The facility had discontinued using a coumadin tracking log, contributing to the oversight.
The facility failed to notify the Physician/Nurse Practitioner when a resident consistently refused medication and when the resident's weights were not obtained as ordered. The resident, who had significant weight loss and was at risk for malnutrition, did not have their weight recorded as required, and the Physician/Nurse Practitioner was not informed of these issues, leading to a deficiency in care.
Failure to Implement Nutritional Interventions for Wound Healing
Penalty
Summary
The facility failed to ensure that nursing staff provided care and services that met professional standards of practice for a resident admitted with a Stage II pressure ulcer. Upon admission, the resident was assessed with a pressure ulcer on the right buttocks and multiple skin tears. The Registered Dietician (RD) recommended nutritional interventions, including the administration of specific vitamins and minerals to promote wound healing. However, there was no documentation indicating that nursing staff obtained physician's orders for these recommendations, nor were the vitamins administered as part of the resident's care plan. Interviews with facility staff revealed a lack of awareness and communication regarding the RD's recommendations. The RD did not ensure that the recommendations were communicated to the nursing staff, and the Unit Manager and Director of Nurses were unaware that the recommendations had not been followed. This oversight resulted in a failure to implement necessary nutritional interventions to support the resident's skin integrity and wound healing, as recommended by the RD.
Failure to Administer Flu Vaccine Timely
Penalty
Summary
The facility failed to administer the influenza vaccine to a resident whose Health Care Proxy had been invoked, despite the Health Care Agent (HCA) providing consent upon admission. The resident, admitted in November 2024 with conditions including a fall with a left humeral fracture, anemia, a Stage II pressure ulcer, and dementia, did not receive the flu vaccine until more than three months later. The facility's policy required offering the vaccine between October 1st and March 3rd, but there was no documentation of the vaccine being administered until February 2025. Interviews revealed that the Unit Manager and Assistant Director of Nurses (ADON) were unaware of the signed consent for the vaccine. The HCA had to reiterate her consent multiple times, and the issue was only identified during a facility audit and a Care Plan meeting. The Director of Nurses (DON) was informed of the oversight by the Social Worker, who initiated an investigation. The facility's process required the nurse to inform the physician and order the vaccine through the pharmacy, but this was not done in a timely manner, leading to the delay in vaccination.
Failure to Administer COVID-19 Vaccine Timely
Penalty
Summary
The facility failed to administer the COVID-19 vaccine to a resident whose Health Care Agent (HCA) had signed a consent form for vaccination upon admission. The resident, who was admitted in November 2024 with diagnoses including a fall with a left humeral fracture, anemia, Stage II pressure ulcer, and dementia, did not receive the vaccine until more than three months later. Despite the HCA's consent and request for vaccination, the facility did not ensure the vaccine was administered in a timely manner. Interviews with facility staff revealed a lack of awareness and communication regarding the signed consent form. The Unit Manager did not recall seeing the consent form, and the Assistant Director of Nurses (ADON) discovered the oversight during a facility-wide vaccine audit. The Director of Nurses (DON) was unaware of the signed consent until the day of the survey. The facility's expectation was that the nurse obtaining consent should inform the physician and obtain an order to administer the vaccine, which did not occur in this case.
Failure to Document and Maintain Grievance Records
Penalty
Summary
The facility failed to ensure that all written grievance decisions included necessary details such as the date the grievance was received, a summary of the grievance, steps taken to investigate, findings, confirmation status, corrective actions, and the date the decision was issued. Additionally, the facility did not maintain evidence of grievance results for at least three years. This deficiency was identified during a review of the facility's grievance policy and interviews with staff and a resident. The facility's grievance policy was found to be undated and did not fully comply with the Department of Public Health's regulation 483.10 regarding grievances. A resident with moderate cognitive impairment, diagnosed with Parkinson's Disease, voiced a complaint about staff speaking a different language in front of them. The complaint was not documented in the facility's grievance binder as it was resolved verbally within seven days, according to the Unit Manager and Administrator. The facility's practice was to only document complaints as grievances if they remained unresolved for more than seven days. This practice led to the absence of written documentation for the resident's complaint, which was resolved verbally and not escalated to a formal grievance.
Deficiencies in Food Storage and Labeling Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey. The surveyor noted several deficiencies in the storage and labeling of food items in the facility's kitchen. Specifically, food items such as bananas and a container of unlabeled and undated brown food were stored directly on the floor in the roll-in refrigerator, which is against FDA food code requirements. Additionally, several food items, including cottage cheese, sandwiches, jelly donuts, canned fruit, tomato juice, and cups of red liquid, were found to be opened, undated, and unlabeled in the refrigerator. The facility's policy requires that all prepared and opened foods be labeled, dated, and discarded after three days, which was not followed in these instances. Further observations revealed a can of blueberry filling with a significant dent on the rim stored on the can rack in the upstairs kitchen. The Food Service Director (FSD) acknowledged that dented cans should be set aside for return and not stored for use. The FSD admitted to not having seen the dented can, which was intended for serving residents. Interviews with the FSD and food service employees confirmed the lack of adherence to the facility's food handling policy, as they were unaware of the dates when certain food items were opened or prepared.
Failure to Update Care Plan for Resident with Behavioral Issues
Penalty
Summary
The facility failed to review and revise the care plan for a resident who was admitted with dementia and a psychotic disorder. The resident, who was severely cognitively impaired and dependent on staff for daily activities, was hospitalized after a fall and diagnosed with a trimalleolar fracture of the right ankle. Upon returning to the facility, the resident was placed in a soft cast and exhibited behaviors of attempting to remove the cast, which was not addressed in the care plan until over a month later. The care plan was not updated to include these behaviors until 8/22/24, despite a Significant Change MDS being completed on 7/19/24. Interviews with staff revealed that the resident frequently removed the soft cast, and staff had to reapply it. The Director of Nursing was unaware that the care plans were not updated to address the resident's behavior of removing the leg cast, which had been ongoing since the resident's re-admission in July 2024. The facility's policy required care plans to be reviewed and updated when there was a significant change in the resident's condition, but this was not done in a timely manner for this resident.
Failure to Implement Physician-Ordered Dressing Change
Penalty
Summary
The facility failed to ensure that nursing services were provided in accordance with the comprehensive care plan for a resident with a foot ulcer. Specifically, the nursing staff did not implement a physician's ordered dressing change for the resident's left foot. The resident, who was cognitively intact, reported that the dressing was not changed on the specified date as required by the care plan. The dressing observed on the resident's foot was dated two days prior, indicating that the dressing change was not performed as scheduled. The facility's policy required that dressings be dated and initialed by the nurse performing the change. However, the initials on the dressing did not match those of the nurse who was supposed to perform the change on the missed date. Interviews with the nurse and the unit manager confirmed that the dressing change was not completed as ordered, and the Director of Nursing acknowledged the oversight. The resident's treatment administration record inaccurately indicated that the dressing change had been completed, highlighting a discrepancy between documentation and actual care provided.
Failure to Monitor Anticoagulation Therapy
Penalty
Summary
The facility failed to provide care and treatment in accordance with professional standards of practice for a resident who was on anticoagulation therapy. The resident, who had a history of heart failure, atrial fibrillation, and pulmonary embolism, was admitted with a requirement for careful monitoring of their anticoagulant medication, warfarin. Despite having a plan of care that included administering anticoagulation as ordered and checking INR levels as ordered, the facility did not follow through with these requirements. The resident's INR levels were found to be high on several occasions, prompting a physician's order to hold the warfarin and recheck the INR the following day. However, due to a lab error, the INR test was not completed, and the resident's warfarin was held without further INR monitoring for almost a week. During this period, the nursing staff failed to obtain new orders for INR testing or warfarin dosing, despite recognizing the absence of such orders and the need for further monitoring. Interviews with the nursing staff and the Director of Nursing revealed a lack of communication and follow-up regarding the resident's anticoagulation management. The facility had previously used a coumadin tracking log but had discontinued its use, contributing to the oversight. The resident's INR eventually dropped to a low level due to the lack of anticoagulation, highlighting the facility's failure to adhere to its own anticoagulation protocol and ensure proper monitoring and treatment of the resident.
Failure to Notify Physician of Medication Refusal and Missed Weights
Penalty
Summary
The facility failed to ensure nursing staff notified the Physician/Nurse Practitioner when a resident consistently refused to take prescribed medication and when the resident's weights were not obtained as ordered. The resident, who had diagnoses including Heart Failure and was prescribed Jardiance and Lasix, refused the medication on five occasions over 18 days without the Physician/Nurse Practitioner being informed. Additionally, the resident's weights were not recorded weekly as ordered, and there was no documentation to support that the Physician/Nurse Practitioner was notified of the missed weights or the reasons for the missed weights. The resident was admitted with a significant weight loss and was at risk for malnutrition. Despite this, the facility did not obtain the resident's weight as ordered on multiple occasions. The resident's Medication Administration Record (MAR) and Progress Notes indicated poor appetite and fluid intake, but there was no documentation that the Physician/Nurse Practitioner was informed of these issues. The Nurse Practitioner confirmed that he was not aware of the medication refusals or the missed weights, which were critical for managing the resident's heart failure and overall health. Interviews with nursing staff and the Director of Nursing (DON) revealed that the facility's policies required notification of the Physician/Nurse Practitioner in cases of medication refusal and missed weights. However, these policies were not followed, leading to a lack of necessary medical intervention for the resident. The DON emphasized the importance of following Physician orders and documenting any refusals or missed weights, but this was not done in the case of the resident, resulting in a deficiency in care.
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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 Boston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Care Village At Parkway | 0.7 mi | ★★★★★ | 14 | 0 |
| Care Village At West Roxbury | 0.7 mi | ★★★★★ | 9 | 0 |
| Newbridge On The Charles Skilled Nursing Facility | 2 mi | ★★★★★ | 1 | 0 |
| Recuperative Services Unit-hebrew Rehab Center | 2.1 mi | ★★★★★ | 1 | 0 |
| Armenian Nursing & Rehabilitation Center | 2.8 mi | ★★★★★ | 2 | 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.