Average — CMS composite of the measures below.
The next survey window likely opens 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 Hancock Park Rehabiliation And Nursing Center during CMS and state inspections, most recent first.
Infection Control Program and Surveillance Failures: A resident on MRSA precautions was observed with staff entering and exiting the room without PPE, using contaminated hands and gloves, and failing to perform hand hygiene while touching surfaces, equipment, and another room. The facility also lacked an ongoing infection surveillance system, and its line listings did not include current infections such as MRSA, C. difficile, or an active eye infection; the IP stated she only reviewed antibiotic reports at month end and did not track signs, symptoms, or trends unless antibiotics were prescribed.
Cold Dining Room Temperatures: The third-floor East Dining Room was observed at 60 to 67 degrees, and multiple residents reported feeling cold, with one resident leaving to get a winter coat because it was “freezing.” The Assistant Maintenance Director stated the dining room vents were turned off and the switches had been removed, preventing heat from blowing into the room, while a nearby dining room with open vents measured 71 to 76 degrees.
A resident with a hx of stroke, aphasia, and severe cognitive impairment had a fall care plan directing staff to keep the call light within reach, but surveyors observed the call light out of reach and inaccessible on multiple occasions. An RN said the resident uses the call light and it should be within reach, and the DON stated resident call lights should be within reach and accessible.
Failure to Provide Meal Assistance and Supervision: A resident with severely impaired cognition, adult failure to thrive, weight loss, GERD, and vascular dementia was dependent for self-feeding and required assistance per the care plan. Surveyors observed the resident eating breakfast in bed without staff supervision or assistance, eating less than half of the meal, and coughing while eating, with no staff stopping to check on or assist. The record also did not show a refusal of assistance.
A resident with dementia, legal blindness, and a hand contracture did not receive the ordered ROM support and hand orthotic use identified by OT. Staff gave conflicting accounts about who was responsible for placing the hand carrot, the physician’s orders did not include it, and the care plan did not address the contracture or ROM monitoring. The resident was observed with the hand fisted, and OT said staff were expected to follow the discharge education for ROM and orthotic use.
A facility failed to keep accurate medical records for two residents. One resident with severe cognitive impairment had new skin areas observed on the left lower leg, including an open area and two additional similar open areas, but the weekly skin checks, care plan, and progress notes did not accurately document them. Another resident with dementia and legal blindness had a contracture diagnosis listed as present on admission even though the admission paperwork did not show it, while OT documentation identified the onset of a right-hand contracture and splint intolerance.
A resident with PAD, DM, anemia, and recent vascular surgery had discharge orders for vascular follow-up and staple removal by the surgeon, but the facility transcribed the order as staple removal every shift. An RN removed the staples before the follow-up visit, bleeding occurred, steri-strips were applied, and the wound later dehisced. The NP and ED documented that the staples had been removed prematurely and the resident was sent for ED evaluation.
A resident with a complex medical history, including diabetes and pressure ulcers, did not receive diabetic foot care and skin checks as ordered by the physician. Despite being at high risk for skin breakdown, the facility failed to administer diabetic foot care on multiple occasions and did not complete weekly skin checks. Interviews revealed that the care was not performed as ordered, leading to the development of new heel ulcers.
The facility failed to provide a varied menu for residents on a renal diet, resulting in complaints about repetitive meals, particularly fish. Despite policies requiring menu reviews, the renal diet menu included fish four times in one week. Residents expressed dissatisfaction, and staff acknowledged the oversight, noting the issue had not been addressed despite being raised in committee meetings.
The facility did not maintain clean ice machines on three floors, with observations of black speckles and brown slimy substances inside the machines. Interviews revealed confusion over cleaning schedules, with the last preventative maintenance occurring seven months prior, leading to unsanitary conditions.
A facility failed to properly manage a resident's peripheral IV and IJ sites, leading to deficiencies in care. The peripheral IV was not replaced or rotated after 96 hours, and no order was obtained for extended dwell time, resulting in its use beyond the maximum dwell time. The IJ site lacked treatment orders for post-removal care. The resident, with multiple diagnoses, reported that the IV and dressings had not been changed since the hospital stay. Interviews revealed a lack of communication and documentation regarding IV site management.
The facility failed to provide appropriate dialysis care for two residents. One resident did not have their physician notified or orders obtained after an AV fistula revision, and their condition was not documented post-surgery. Another resident's pressure dressing was not removed as ordered after dialysis sessions. Staff interviews confirmed lapses in following protocols, highlighting deficiencies in adherence to dialysis guidelines.
A resident with COPD and cognitive communication deficit was found to have an unsecured Albuterol inhaler in their room, contrary to facility policy. The resident, who was cognitively intact, kept the inhaler on a bedside table and on their lap, expressing a need for immediate access. Staff interviews confirmed the policy was not followed, as the inhaler should have been secured.
A facility failed to ensure proper coordination of hospice services for a resident with severe cognitive impairment, resulting in a reduction of hospice aide visits without proper communication or documentation. The facility's social worker and DON were unaware of the changes, and the resident's family was not informed, leading to a deficiency in hospice service provision.
Infection Control Program and Surveillance Failures
Penalty
Summary
The facility failed to maintain an infection prevention and control program designed to prevent the development and transmission of communicable diseases and infections. Resident #48 had diagnoses including dementia, muscle weakness, morbid obesity, and repeated falls, and had a physician order for MRSA precautions. On 12/4/25, a surveyor observed a precaution bin outside the resident’s room containing PPE, and a contact precaution sign was posted on the door. Housekeeping Staff #1 entered the room without PPE, touched items on the overbed table with bare hands, exited, handled gloves on the housekeeping cart with a contaminated bare hand, and re-entered the room without additional PPE. The same staff member was then observed using contaminated gloved hands to touch items in the room, the bathroom door handle, and the housekeeping cart. She removed contaminated gloves by touching the outside of the gloves with bare hands and then walked across the hall into another room without performing hand hygiene. She was also observed touching the bathroom door handle and items in the bathroom with contaminated hands, returning to Resident #48’s room without PPE, and continuing to touch the bathroom door handle, housekeeping cart items, spray bottles, a mop, and surfaces in the room without hand hygiene. During interview, the staff member acknowledged she should have worn PPE because the resident was on precautions and said she should not have entered the room without it. The facility also failed to implement an infection control surveillance plan for identifying, tracking, monitoring, and reporting infections, communicable diseases, and outbreaks among residents and staff. The facility’s surveillance policy required tracking of healthcare-associated infections, running logs of residents with positive MRSA and C. difficile, and routine audits of hand hygiene and PPE adherence. However, the facility’s infection control line listings did not show monitoring, tracking, or analysis of current infections, and the December 2025 line listing did not include a resident with confirmed MRSA, a resident with confirmed C. difficile infection, or a case of active eye infection. The Infection Preventionist stated she reviewed line listings at the end of the month and did not track clinical signs, symptoms, or infection trends unless antibiotics were prescribed, and she was unable to provide documentation of ongoing surveillance or actions taken.
Cold Dining Room Temperatures
Penalty
Summary
The facility failed to maintain comfortable and safe temperature levels in the third-floor East Dining Room. During observations, two of four residents reported feeling cold and one resident was wearing a jacket; later, three of five residents reported feeling cold and one resident was wearing a jacket. One resident stated, “I need to go get my coat, it’s freezing,” then wheeled out of the dining room and returned wearing a winter coat. During the surveyor’s observation with the Assistant Maintenance Director, thermal readings in the third-floor dining room ranged from 60 degrees to 67 degrees, and temperatures did not rise above 67 degrees during the observation. The Assistant Maintenance Director stated the two vents in the dining room were turned off and the switches had been removed over two years earlier so residents would not adjust airflow. He also stated the fourth-floor thermostat controlled heat to the third-floor dining room, but heat would not blow in if the vents were closed. By comparison, the fourth-floor dining room had open vents and thermal readings between 71 degrees and 76 degrees.
Call Light Not Kept Within Reach
Penalty
Summary
The facility failed to implement Resident #121’s plan of care by not keeping the resident’s call light within reach and accessible as required by the fall care plan. Resident #121 was admitted in March 2022 with diagnoses including cerebral infarction (stroke) and aphasia, and the 9/3/25 MDS indicated severe cognitive impairment with a BIMS score of 0 out of 15. The fall care plan dated 3/6/22 identified the resident as at risk for falls and directed staff to ensure the call light was within reach and to encourage use for assistance. On 12/3/25, the surveyor observed the resident in bed with the call light out of reach on the bedside table. On 12/4/25, the surveyor again observed the call light on the floor and inaccessible, and the resident was unable to engage in further conversation when asked how help was requested. During interview, Nurse #1 stated the resident does use the call light and it should be within reach, and the DON stated resident call lights should be within reach and accessible.
Failure to Provide Meal Assistance and Supervision
Penalty
Summary
The facility failed to ensure nursing staff provided assistance with ADLs for one resident, specifically with meals, as required by the plan of care. Resident #15 was admitted with diagnoses including adult failure to thrive, unintentional weight loss, gastro-esophageal reflux, and vascular dementia. The MDS dated 9/10/25 indicated the resident had severely impaired cognition and was dependent for all self-care activities, requiring substantial/maximal assistance for self-feeding. The facility policy stated residents unable to perform ADLs independently would receive services necessary to maintain good nutrition, including support and assistance with dining. On 12/2/25 and 12/3/25, the surveyor observed Resident #15 seated upright in bed eating breakfast without staff supervision or assistance. The resident was not visible from the hallway, ate less than 50% of breakfast, and was observed coughing while eating. No staff passed by or stopped to check on or assist the resident during these observations. The care plan indicated the resident was dependent on one person for meals and included monitoring and documenting signs and symptoms of dysphagia such as pocketing, choking, coughing, drooling, holding food in the mouth, and several attempts at swallowing. During interview, nursing staff stated the resident was set up for meals and checked on if assistance was needed, while the DON stated the resident should receive the level of assistance and/or supervision indicated on the care plan and refusals should be documented; the record review did not show that the resident refused assistance.
Failure to Implement ROM and Hand Orthotic Plan
Penalty
Summary
The facility failed to ensure a resident with limited ROM received appropriate treatment and services to prevent further decrease in ROM. Resident #43, admitted in February 2022 with unspecified dementia and legal blindness, was cognitively impaired, dependent on staff for all ADLs, and later had a diagnosis of contracture, unspecified joint added to the diagnosis list on 6/5/25. On 12/2/25, the resident was observed asleep in bed with the right hand balled into a fisted position, and a hand carrot was seen on the nightstand. The resident’s OT discharge summary stated that the resident had made gains with skilled OT services, including orthotic use and a ROM program, and could tolerate the carrot orthotic up to 5 hours per day to prevent further loss of ROM and maintain skin integrity. The summary also documented that staff were educated on ROM during care and on using the carrot orthotic as tolerated throughout the day. However, the physician’s orders did not include the use of a hand carrot, and the care plan did not indicate the contracture or methods for staff to monitor the resident’s hand contracture. During interviews, CNA #1 was unsure how long the hand had been contracted and said rehab was responsible for placing the carrot in the resident’s hand; when she attempted ROM, the resident grimaced in pain and pulled the hand away. Nurse #1 said rehab had ended the use of the carrot, while CNA #2 said the resident wears the hand carrot every day. OT #1 said staff were expected to follow the education provided, obtain physician’s orders, and update the care plan, and stated he had spoken with nursing about using the hand carrot and performing ROM. The DON and Regional Nurse #1 later stated that residents with contractures should have a care plan for contracture management and ROM monitoring, and acknowledged that the resident was missed and that the interventions related to the hand carrot and ROM as tolerated were not implemented upon discharge from rehab services.
Inaccurate Documentation of Skin Findings and Contracture Onset
Penalty
Summary
The facility failed to maintain accurate medical records for two residents. For one resident with vascular dementia, major depressive disorder, and severe cognitive impairment, the record did not accurately reflect newly identified skin areas found during weekly skin evaluations. The resident was observed with a raised purple/black area on the left lateral lower leg, and later with an open area on that leg plus two additional similar open areas on the front and upper part of the left leg. The weekly skin assessments documented a hematoma on the right side of the head on one date, but a later assessment failed to note any skin issues, and another assessment completed after the surveyor’s observation did not document the left lower leg injury. The care plan and progress notes also did not document the open areas or skin injuries. During interviews, the CNA assigned to the resident said she would notify the nurse if she noticed new skin areas, redness, scratches, or bruises during care, but she did not notice the open area during morning care. The nurse said CNAs should report new areas during ADL care and that new areas should be accurately documented in the skin assessment. The DON stated that CNAs are expected to report new skin concerns, nurses are expected to assess new areas, and nurses are expected to accurately document findings on weekly skin assessments and notify the physician. For the second resident, who had unspecified dementia, legal blindness, and dependence on staff for all ADLs, the record did not accurately document the onset of a contracture. Although a diagnosis of unspecified joint contracture was added to the diagnosis list and was listed as present on admission, the admission paperwork did not show a contracture at admission. An OT discharge summary documented onset of a contracture to the resident’s right hand and inability to tolerate a splint. The DON stated that medical records are expected to be accurately documented.
Premature Removal of Surgical Staples
Penalty
Summary
Nursing failed to ensure services met professional standards of practice when a resident’s surgical staples were removed before the ordered follow-up with the vascular surgeon. The resident had been admitted with diagnoses including status post left iliac angioplasty, PTA stent placement, right femoral-popliteal bypass, PAD, DM, and anemia. The hospital discharge summary and vascular surgeon note both indicated the resident was to return in 2 weeks for reassessment of the surgical site and staple removal, but the facility transcribed the order as staples to be removed every shift and monitor the surgical site every shift. The record did not show that nursing clarified the order with the physician before entering it into the electronic record, despite the facility policy requiring clarification when an order is unclear. Nursing Supervisor #1 stated she entered the order to indicate the resident had a surgical wound with staples and did not intend for the staples to be removed at that time, and she acknowledged she should have clarified the treatment order with the physician. Nurse #1 later saw the order, noted prior shifts had not removed the staples, and removed them during the evening shift, applying pressure and steri-strips when bleeding occurred. After the staples were removed, the resident’s NP documented that the staples had been removed by nursing even though post-op orders called for vascular follow-up in 2 weeks for staple removal and wound reassessment. The wound had bleeding and dehiscence, the vascular surgeon was notified, and the resident was sent to the Hospital ED. The ED note stated the staples had been removed prematurely, there was significant drainage and bleeding, and the surgical wound at the medial aspect of the left thigh was partially dehisced.
Failure to Provide Diabetic Foot Care and Skin Checks
Penalty
Summary
The facility failed to provide necessary treatment and services for a resident with pressure ulcers, consistent with professional standards of practice, to promote healing and prevent new ulcers from developing. The resident, who was admitted with a complex medical history including diabetes mellitus with neuropathy, foot ulcer, toe amputations, and pressure ulcer, did not receive diabetic foot care treatments and skin checks as ordered by the physician. The facility's policies required regular skin assessments and diabetic foot care, but these were not consistently performed. The resident was at high risk for skin breakdown, as indicated by a score of 10 on the Norton Plus Pressure Ulcer Risk Scale. Despite the care plan's instructions to administer treatments as ordered and follow facility protocols for skin breakdown prevention, diabetic foot care was not administered on multiple occasions, and weekly skin checks were not completed as required. The Treatment Administration Record showed that diabetic foot care was not administered 18 out of 23 opportunities in August and 13 out of 17 opportunities in September, with no documentation of refusal by the resident. Interviews with the resident and staff revealed that diabetic foot care was not performed as ordered, and skin checks were not routinely conducted. The Director of Nurses acknowledged the lack of documentation and adherence to physician orders, and the resident confirmed that diabetic foot care was not provided. The resident developed new bilateral heel ulcers, indicating a failure in the facility's care processes to prevent further skin breakdown.
Repetitive Meals for Renal Diet Residents
Penalty
Summary
The facility failed to provide a varied menu for residents on a renal diet, leading to complaints about repetitive meals. The facility's policy required menus to meet nutritional needs and be reviewed by a registered dietitian, but the renal diet menu included fish as the main meal four times in one week. This lack of variety was noted in Resident Dining Committee Meeting Minutes, and residents expressed dissatisfaction with the repetitive meals, particularly the frequent serving of fish. Interviews with residents and staff revealed that the issue had not been addressed despite being raised in committee meetings. The Registered Dietitian and Food Service Director acknowledged the oversight, with the dietitian noting that the repetition was not noticed until after the meals were prepared. Residents on the renal diet reported dissatisfaction, with some refusing meals due to the lack of variety and not being offered substitutes. The facility had been using a four-week cycle menu for the Spring/Summer season, which had not been updated to address these concerns.
Failure to Maintain Clean Ice Machines
Penalty
Summary
The facility failed to adhere to professional standards of practice for food safety and sanitation, specifically in maintaining clean and safe ice machines across three floors. Observations revealed that the ice machines on the 5-East and 5-West units, as well as other units, contained black speckles, brown slimy substances, and brown films inside the machines, which were full of ice. These conditions were noted during a surveyor's inspection and were confirmed by the Food Service Director and the Director of Maintenance. Interviews with the Food Service Director and the Director of Maintenance revealed a lack of clarity and oversight regarding the cleaning schedule and maintenance of the ice machines. The Director of Maintenance stated that the machines were cleaned every two weeks and that a vendor was responsible for quarterly maintenance. However, the last preventative maintenance was conducted seven months prior, in March 2024, indicating a lapse in the scheduled cleaning and maintenance routine. This oversight contributed to the unsanitary conditions observed in the ice machines.
Failure to Properly Manage IV and IJ Sites
Penalty
Summary
The facility failed to ensure the proper care and treatment of a peripherally inserted intravenous (IV) line device and an internal jugular (IJ) venous access site for a resident. The peripheral IV site was not managed according to professional standards, as the dressing was not changed, the line was not replaced or rotated after 96 hours, and no order was obtained for an extended dwell time. The line was used beyond the maximum dwell time of seven days. Additionally, the IJ site was not properly managed post-removal, as there were no treatment orders to remove, change, or apply a dressing, nor to monitor the site for signs of infection or bleeding. The resident involved was readmitted to the facility with multiple diagnoses, including bacteremia, end-stage renal disease on hemodialysis, diabetes mellitus, and pressure ulcers. Observations revealed that the resident had a peripheral IV in the right forearm with a dressing dated 9/21/24, and a loose dressing on the neck dated 9/25/24. The resident reported that the IV and dressings had not been changed since the hospital stay, and the dressing on the neck was from a previous IV catheter insertion site. Interviews with the resident and staff indicated a lack of communication and proper documentation regarding the management of the IV sites. The re-admission assessment did not include an evaluation of the IV sites, and the comprehensive care plan for IV antibiotic use was not developed until 10/2/24. The Director of Nurses confirmed that the peripheral IV should not have been in use beyond four days without an order for extended dwell time, and there were no orders related to the IJ site. The facility's failure to adhere to professional standards and policies resulted in the deficiency.
Deficiencies in Dialysis Care for Two Residents
Penalty
Summary
The facility failed to provide appropriate dialysis care and services for two residents, leading to deficiencies in their treatment. For Resident #47, the facility did not notify the physician or obtain necessary orders following a revision of the resident's left arteriovenous (AV) fistula. Additionally, there was no documentation of the resident's condition upon returning to the facility post-surgery. The resident was admitted with diagnoses including end-stage renal disease and diabetes mellitus, and the facility's records did not reflect any assessment or new orders for the care of the AV fistula post-revision. Observations over several days indicated that the resident's dressing was not properly managed, and the comprehensive care plan lacked a specific plan for the AV fistula revision. For Resident #32, the facility failed to remove the pressure dressing applied by the dialysis center to the fistula in the left arm, as ordered by the physician and recommended by the dialysis center. The resident, who was also diagnosed with end-stage renal disease, had a physician's order to remove the dressing after dialysis sessions on specific days. However, observations revealed that the dressing was not removed as required, and the resident reported that the facility staff sometimes forgot to remove it. The facility's communication book consistently noted the need to remove the dressing after four hours, but this was not adhered to. Interviews with facility staff, including nurses and unit managers, confirmed the lapses in following the prescribed protocols for both residents. The staff acknowledged the failure to assess Resident #47 post-surgery and to communicate and execute the necessary care for Resident #32's dialysis access site. These deficiencies highlight a lack of adherence to the facility's own dialysis guidelines and the Massachusetts Board of Registration in Nursing's standards of practice.
Unsecured Medication Storage for Resident
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored securely, as required by their policy. Specifically, for one resident, an Albuterol Inhalation Aerosol Solution was left unsecured and unattended in the resident's room. The resident, who was admitted with diagnoses including acute pulmonary edema, COPD, and a cognitive communication deficit, was found to be cognitively intact according to a recent assessment. However, there was no documentation in the resident's care plans or assessments indicating that the resident was able to self-administer medication. During multiple observations, the resident was seen keeping the inhaler unsecured on a bedside table and on their lap while in a wheelchair. The resident expressed a preference for keeping the inhaler nearby for immediate use. Interviews with staff, including the Unit Manager and the Director of Nurses, revealed that the facility's policy was not being followed, as the medication should have been secured in a lock box or the nurse's medication cart if the resident was not assessed to self-administer medication.
Failure to Ensure Proper Hospice Service Coordination
Penalty
Summary
The facility failed to ensure that hospice services were provided in accordance with the agreement between the hospice and the facility for a resident with severe cognitive impairment and other medical conditions. The resident was admitted with diagnoses including cerebrovascular disease and dementia. The facility's policy required collaboration between the facility, hospice, and family to ensure continuity of care, but this was not achieved. The hospice aide schedule was reduced without proper communication or documentation, leading to a lack of awareness among the facility staff and the resident's family. The hospice care services agreement required the hospice to coordinate the implementation of the plan of care and communicate with the facility to ensure coordination of patient care services. However, the facility's social worker and director of nursing were not informed about the decrease in hospice aide visits from 3-4 times per week to 1-3 times per week. The family member of the resident expressed concerns about the lack of communication and was unaware of the reduction in services until after it occurred. Interviews with facility staff and hospice personnel revealed a lack of communication and documentation regarding the changes in the hospice aide schedule. The hospice staff indicated that they usually work with the resident and sign in and out, but the facility was not informed of the schedule changes. The hospice visit log showed inconsistencies in the frequency of visits, and there was no documentation in the hospice binder or electronic medical record to reflect the changes. This lack of collaboration and communication led to a deficiency in the provision of hospice services for the resident.
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Illustrative
What surveyors actually found near you
We read the 1,013 citations issued within 25 miles in the last 12 months — including the 3 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Quincy
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Regalcare At Quincy | 0.6 mi | ★★★★★ | 0 | 0 |
| South Cove Manor Nursing & Rehabilitation Center | 0.7 mi | ★★★★★ | 2 | 0 |
| John Scott House Nursing & Rehabilitation Center | 1.9 mi | ★★★★★ | 2 | 0 |
| Royal Braintree Nursing And Rehabilitation Center | 2.3 mi | ★★★★★ | 18 | 0 |
| Pope Nursing Home | 2.6 mi | ★★★★★ | 0 | 0 |
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