Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Hunt Nursing & Rehab Center during CMS and state inspections, most recent first.
A resident with cerebral palsy, dysphagia, and cognitive communication disorder developed a new open area on the buttock/coccyx, but the wound was not seen by the wound MD until about 12 days later. Nursing documented the open area and used a dressing initially, yet no initial treatment orders were implemented before the wound MD visit. Staff interviews confirmed that initial wound orders are normally used until the wound MD sees the resident, but they did not know why this resident was not seen sooner or why orders were not started.
Failure to implement optometry recommendations for a resident with intact cognition and corrective lenses. The resident reported being told cataract surgery was recommended for the left eye, but no ophthalmology appt had been made and the resident was worried vision was worsening. The record showed repeated optometry recommendations for cataract surgery consult, IOP monitoring, and glaucoma testing, but no evidence the referrals were carried out; the UM and DON said they expected the recommendations to be followed.
Failure to implement wound treatment orders for a resident with a right heel DTI. A resident with severe cognitive impairment and neurocognitive disorder with Lewy bodies and Parkinson’s disease had a Wound MD order for Betadine plus ABD pad, gauze roll, and tape for an unstageable right medial heel DTI, but the MAR/TAR reflected skin prep and NS cleansing instead, with the Betadine order not entered until weeks later. Staff interviews showed the MD deferred to the Wound MD, the UM said wound recommendations were entered into the EHR, the Wound Nurse was unaware the Betadine treatment was not implemented, and the DON cited transcription issues.
The facility failed to date inhalers once opened, as required by regulations. Surveyors observed six medication carts with various inhalers, such as Fluticasone Propionate and Advair Diskus, that were opened and undated. Interviews with nursing staff confirmed the expectation to date inhalers upon opening, but this was not followed. The Unit Manager and DON acknowledged the deficiency.
A resident with severe cognitive impairments had a MOLST form indicating DNR status, but the facility's records showed a Full Code status. Interviews revealed that the inconsistency was overlooked, and the social worker admitted the MOLST form was missed, confirming the resident should have been a DNR.
The facility failed to develop and implement comprehensive care plans for two residents. One resident's care plan lacked essential pacemaker information, while another resident's care plan directives for foot elevation and the use of Darco shoes were not followed. Interviews confirmed these deficiencies, highlighting a lack of adherence to care plans and physician orders.
A resident with polyneuropathy and chronic pain syndrome was not provided with the necessary services to maintain their ability to perform activities of daily living. Despite being discharged from PT with a functional maintenance program for walking, the resident only used a wheelchair due to the facility's failure to implement the program. Staff interviews revealed a lack of awareness and follow-through on the PT recommendations.
A facility failed to maintain professional standards in managing a resident's urinary catheter. The resident, with severe cognitive impairment and multiple medical conditions, had their catheter bag improperly positioned above the knee while in bed, contrary to care protocols. Observations and interviews confirmed the deficiency, with no documentation of resident refusal to comply with correct positioning.
A resident with a history of falls was assessed as being at risk and had a care plan intervention for a fall mat beside their bed. However, the mat was not in place when the resident fell out of bed. The DON observed the resident earlier but could not recall if the mat was present, and later confirmed its absence after the fall.
A facility did not ensure staff followed the care plan for a resident at risk for falls due to impulsivity and decreased strength. The care plan required assistance from two staff members for toileting and transfers. However, the Director of Rehabilitation (DOR) left the resident unattended, resulting in a fall and a fractured elbow. The facility's investigation confirmed the resident's need for assistance and supervision during toileting, which was not provided. Both the DOR and the Director of Nurses (DON) acknowledged the lapse in following the care plan interventions.
A resident known to be impulsive and at high risk for falls was left unsupervised by the Director of Rehabilitation, leading to a fall and a fractured elbow. The resident's care plan required standby assistance, which was not provided, resulting in the injury.
Delayed wound assessment and missing initial treatment orders
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards for one resident with an open skin area. Resident #35, who had diagnoses including cerebral palsy, dysphagia, and cognitive communication disorder and was mildly cognitively impaired, was observed resting on an air mattress and stated that he/she had a new wound on the buttock that nurses were caring for daily. The resident’s care plan identified high risk for pressure ulcer development related to bowel and bladder incontinence and physical limitations, with interventions to report pink, red, or open areas to the nurse and to update the physician of new skin conditions and obtain orders. On 12/3/25, nursing documented that after a large bowel movement an open area around the coccyx was noticed, cleaned with normal saline, and covered with border foam. The next day, nursing noted an open area to the coccyx and that the resident would be seen by the wound MD. Risk meeting notes later documented that the resident had a new open area and would be seen by the wound MD on 12/8/25, then again noted on 12/12/25 that the resident had not yet been seen and would be seen on 12/15/25. The wound physician’s note on 12/15/25 described a full-thickness non-pressure wound to the left buttock measuring 2 cm by 3 cm by 0.1 cm with moderate sero-sanguinous drainage and grimacing noted. The clinical record showed that Resident #35 was not seen by the wound physician until 12/15/25, approximately 12 days after the area was identified, and there were no treatment orders implemented for the open area before that date. The facility’s Skin Integrity Management policy stated that when skin breakdown is identified, it should be reported timely, wound treatment orders obtained, and referral made to the wound consultant. During interviews, the physician stated that initial treatment orders are implemented until the resident can be seen by the wound physician, while the unit manager, wound nurse, and DON each stated they did not know why the resident did not receive initial treatment orders or why the wound physician did not see the resident sooner.
Failure to Implement Optometrist Recommendations for Ophthalmology Services
Penalty
Summary
The facility failed to implement an optometrist’s recommendation for Resident #26, who was admitted with diagnoses including spina bifida, colostomy, hypertension, major depressive disorder, and anxiety. The resident’s most recent MDS indicated a BIMS score of 15 out of 15, showing cognitive intactness, and also noted dependence on staff for activities of daily living and use of corrective lenses. During an interview, the resident stated he/she had been seen by the eye doctor a few months earlier and was told cataract surgery was recommended for the left eye, but he/she had not been informed that an appointment had been made and was worried the vision was getting worse. The medical record showed a consent for ophthalmology services was signed, and the resident was seen by the optometrist on 5/15/25 and 10/24/25. Those visits documented recommendations for cataract surgery with an ophthalmology consult, further testing for IOP monitoring, OCT/VF testing, and glaucoma testing, with instructions to make the next available ophthalmology appointment. Review of the record failed to show that the optometrist’s recommendations from either visit were implemented. The Unit Manager stated the expectation was to follow the doctor’s recommendations and was unaware that an appointment had not been made, and the DON stated recommendations were reviewed and, if the resident agreed, the appointment would be made.
Failure to Implement Wound Physician Orders for Heel DTI
Penalty
Summary
The facility failed to implement the Wound Physician’s treatment orders for one resident with a right heel deep tissue injury. The resident was admitted in August 2025 with diagnoses including neurocognitive disorder with Lewy bodies and Parkinson’s disease, and the Minimum Data Set assessment dated 11/18/25 indicated the resident was unable to participate in the Brief Interview for Mental Status Exam and was severely cognitively impaired. On 2/10/26, the resident was observed resting on an air mattress and was unable to participate in the interview process. The resident’s care plan identified a suspected DTI with interventions to provide treatment per physician’s order and refer to a wound specialist if indicated or ordered. The Wound Physician’s note dated 12/15/25 identified an unstageable DTI of the right medial heel and ordered Betadine once daily and as needed, along with ABD pad, gauze roll, and paper tape. Subsequent Wound Physician notes dated 12/22/25, 12/29/25, 1/5/26, 1/12/26, and 1/19/26 continued the same Betadine-based treatment plan. However, the physician orders and treatment administration records for December 2025 and January 2026 showed Skin Prep Wipes and cleansing with normal saline, skin prep, ABD pads, gauze roll, and tape, with the Betadine order not entered until 1/27/26, approximately 43 days after the Wound Physician initially recommended it. During interviews, the physician stated he deferred to the Wound Physician for skin injury treatment orders, the Unit Manager stated the Wound Nurse rounds with the Wound Physician and enters recommendations into the electronic record, the Wound Nurse said she was not aware the Betadine treatment was not implemented, and the DON stated there had been issues with transcription of orders and that she was not aware the Betadine orders were not implemented.
Failure to Date Opened Inhalers in Medication Carts
Penalty
Summary
The facility failed to ensure that medications were dated once opened, as required by State and Federal regulations. During observations, surveyors found that six medication carts contained inhalers that were opened and in use but not dated. This was contrary to the facility's policy, which mandates that medications and biologicals be stored safely and properly, following the manufacturer's recommendations. The surveyor's observations included various inhalers such as Fluticasone Propionate, Advair Diskus, Breo Ellipta, Combivent Respimat, Albuterol Sulfate, Budesonide-Formoterol Fumarate, Spiriva Respimat, Trelegy Ellipta, Anoro Ellipta, Ventolin, Incruse Ellipta, and Stiolto Respimat, all of which were found undated. Interviews with the nursing staff, including Nurses #3, #4, #5, #6, #1, and #7, revealed that the expectation was for the nurse who opens the inhalers to date them to ensure proper tracking of expiration after opening. However, this practice was not followed, as evidenced by the undated inhalers. Both the Unit Manager and the Director of Nursing confirmed the expectation that all inhalers should be labeled with the date when opened, acknowledging the deficiency in practice observed by the surveyors.
Inconsistent Documentation of Advance Directives
Penalty
Summary
The facility failed to ensure that Advance Directives were consistently documented in the medical record for a resident with severe cognitive impairments. The resident, who was admitted with conditions including hemiplegia, aphasia, dysphagia, dementia, and epilepsy, had a MOLST form indicating a Do Not Resuscitate (DNR) status. However, the resident's physician order and care plan indicated a Full Code status, which was inconsistent with the MOLST form. This discrepancy was noted during a review of the resident's medical records and interviews with facility staff. Interviews with the facility's nurse and unit manager revealed that the expectation was for nurses to follow the MOLST form, but the inconsistency between the MOLST and the physician order was overlooked. The social worker acknowledged that the resident's guardian had the right to make the resident a DNR and admitted that the MOLST form from 2018 was missed. The resident had been in the facility since 2017, and the social worker confirmed that the resident should have been a DNR, not a Full Code, as indicated in the medical records.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive resident-centered care plan for two residents, leading to deficiencies in their care. For Resident #48, who was admitted with a cardiac pacemaker among other diagnoses, the facility did not include essential pacemaker information in the care plan. This information should have included the paced rate, serial number, frequency of pacemaker checks, and cardiologist details. Interviews with the Unit Manager and Director of Nursing confirmed that such details were expected to be part of the care plan upon admission. For Resident #95, the facility did not implement the care plan directives related to foot elevation and the use of Darco shoes. Despite physician orders to elevate the resident's feet while in bed and to use Darco shoes when ambulating, observations showed that the resident's feet were not elevated, and the resident was not wearing the prescribed shoes. Interviews with the Unit Manager and Director of Nursing confirmed that these orders were not followed, despite the resident's history of foot surgeries and balance issues. The deficiencies highlight a lack of adherence to care plans and physician orders, which are crucial for addressing the specific medical needs of residents. The facility's failure to include necessary pacemaker information and to implement prescribed interventions for foot care and ambulation contributed to the identified deficiencies.
Failure to Maintain Functional Maintenance Program for Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident #40, was provided with the appropriate treatment and services to maintain their ability to perform activities of daily living. Resident #40, who was admitted with diagnoses including polyneuropathy, polyarthritis, and chronic pain syndrome, had previously been discharged from physical therapy with a functional maintenance program (FMP) in place for walking with a walker and staff assistance. However, the facility did not maintain this program, resulting in the resident only using a wheelchair for mobility. Observations and interviews revealed that Resident #40 had a rolling walker in their room but was not using it, as they had stopped participating in therapy due to back pain. The resident expressed willingness to try physical therapy again, but no one had approached them about it. The Director of Rehab confirmed that the resident had not been seen by physical therapy in 2024 or 2025 and was unable to provide documentation of the FMP, indicating uncertainty about whether it was ever implemented. Interviews with staff, including a CNA and the Unit Manager, indicated a lack of awareness and follow-through regarding the resident's FMP. The Director of Nursing acknowledged that physical therapy recommendations should be communicated to nursing staff and followed, but this did not occur in Resident #40's case. As a result, the resident's ability to perform activities of daily living was not maintained as recommended by physical therapy.
Improper Management of Urinary Catheter Devices
Penalty
Summary
The facility failed to maintain professional standards in the management and care of urinary catheter devices for a resident with severe cognitive impairment and multiple medical conditions, including end-stage renal disease and dementia. The deficiency was identified when a surveyor observed that the resident's urinary catheter bag was consistently strapped to the resident's leg above the knee, rather than being positioned below the bladder level while the resident was in bed. This improper positioning was observed on multiple occasions, and there was no documentation indicating that the resident refused to have the catheter bag positioned correctly. Interviews with the Unit Manager and the Director of Nursing confirmed that the catheter bag should be hanging from the bed to prevent urinary backflow and tube kinking. The facility's records, including the resident's care plan and physician's orders, indicated the need for proper catheter care, but there was no evidence of staff documenting any refusal by the resident to comply with the correct positioning of the catheter bag. This oversight in catheter management represents a failure to adhere to established care protocols for residents with indwelling catheters.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to consistently implement and follow the care plan for a resident with a history of falls. The resident, who was admitted in June 2024 and diagnosed with dementia and a history of falls, was assessed as being at risk for falls. The comprehensive care plan included an intervention for a fall mat to be placed on the floor beside the resident's bed. However, on October 21, 2024, the resident was found on the floor after falling out of bed, and it was noted that the fall mat was not in place as required by the care plan. The Director of Nurses (DON) observed the resident sleeping in bed earlier that morning but could not recall if the fall mat was present. Later, the DON was informed that the resident had fallen and observed that the fall mat was not in the room. This oversight was confirmed by the facility's corrective measures narrative, which identified the absence of the fall mat at the time of the fall. The facility's policy on care planning mandates the development and implementation of a comprehensive person-centered care plan with measurable objectives and timeframes, which was not adhered to in this instance.
Failure to Implement Care Plan Leads to Resident Fall and Injury
Penalty
Summary
The deficiency reported by surveyors involved a failure by the facility to ensure staff implemented and followed interventions identified in the care plan of Resident #1, who was at risk for falls due to impulsivity and decreased strength. Despite the care plan indicating that Resident #1 required assistance from two staff members for toileting and transfers, on 02/26/24, the Director of Rehabilitation (DOR) left Resident #1 in his/her room to take himself/herself to the bathroom without informing any other staff. As a result, Resident #1 fell and later complained of left elbow pain, which was diagnosed as a fractured elbow. The facility's investigation revealed that Resident #1 was known to be impulsive, required assistance with all transfers, and staff were supposed to stay outside his/her bathroom door when he/she was on the toilet. The facility's Care Planning policy required the development and implementation of a comprehensive person-centered care plan for each resident, consistent with their identified needs. Resident #1, admitted with diagnoses including spinal stenosis, left sided hemiplegia, left foot drop, history of falls, and anxiety, had a Falls Care Plan indicating the need for reminders to use the call bell for assistance and for staff to provide supervision during toileting. Despite this, the DOR failed to assist Resident #1 to the bathroom when requested, leading to the fall and subsequent injury. The DOR acknowledged knowing Resident #1's history of falls and impulsivity but still left him/her unattended. During interviews, both the DOR and the Director of Nurses (DON) admitted that the DOR should have assisted Resident #1 or asked another staff member to help him/her to the bathroom but failed to do so. The DON mentioned that the Rehabilitation Department staff had helped develop Resident #1's Care Plan, emphasizing the importance of staff following the interventions outlined in the plan.
Failure to Provide Adequate Supervision for High-Risk Resident
Penalty
Summary
The Facility failed to ensure adequate supervision and assistance for a resident known to be impulsive and at high risk for falls. On the day of the incident, the Director of Rehabilitation (DOR) left the resident alone to use the bathroom without informing other staff members, despite the resident's care plan indicating the need for standby assistance. The resident attempted to transfer themselves, fell, and sustained a skin tear and a fractured elbow diagnosed the following day. The resident had a history of falls and required assistance with all transfers, as documented in their care plan and therapy evaluations. The care plan specifically required staff to stay outside the bathroom door to provide supervision while the resident was on the toilet. Despite this, the DOR asked the resident if they could manage alone and left them unsupervised, leading to the fall. Interviews with the DOR and the Director of Nurses confirmed that the DOR was aware of the resident's needs but failed to follow the care plan. The incident report and nurse progress notes corroborated the sequence of events, highlighting the lack of communication and adherence to the resident's care plan, which ultimately resulted in the resident's injury.
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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 Danvers
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Twin Oaks Center | 0.4 mi | ★★★★★ | 0 | 0 |
| Brentwood Rehabilitation And Healthcare Ctr (the) | 1.4 mi | ★★★★★ | 6 | 0 |
| Hathorne Hill Rehabilitation And Healthcare Center | 1.5 mi | ★★★★★ | 14 | 0 |
| Care One At Peabody | 1.8 mi | ★★★★★ | 10 | 0 |
| Continuing Care At Brooksby Village | 2.1 mi | ★★★★★ | 12 | 0 |
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