Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 John Scott House Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with a history of subdural hematoma, craniotomy, Parkinson’s disease, and anticoagulation, and with an invoked HCP, was found on the floor by one nurse, who then sought assistance from another nurse. After the resident was assessed and returned to bed, neither nurse completed required fall documentation or notified the physician or HCA, each assuming the other would do so. The fall was not reported to clinical leadership until later, and the physician was not documented as being notified until several days after the event. A family member later observed a bruise near the resident’s eye during a visit and reported that no one from the facility had informed her of the fall.
A resident with a history of subdural hematoma, craniotomy, Parkinson’s disease, and anticoagulation use was found on the floor next to the bed after an unwitnessed fall. Two nurses assisted the resident back to bed, but no immediate VS, neuro checks, or fall, skin, or pain assessments were completed, and no incident report, physician/family notification, or timely nursing note was done as required by facility policy. Each nurse assumed the other would complete the necessary documentation and notifications, and the event was not reported to management the same day, resulting in a failure to provide and document post-fall care in accordance with professional standards.
Surveyors found that the facility did not ensure a clean, comfortable, and homelike environment, with multiple areas in disrepair such as broken heaters, peeling molding, wall cracks, and water damage in resident rooms and common areas. Residents reported a lack of visible maintenance activity, and incomplete work orders were discovered. Additionally, a window air conditioner was found with visible black spots and a dust-laden filter, indicating poor maintenance practices.
A resident who was cognitively intact and dependent on staff for personal hygiene expressed a clear wish to grow a handlebar mustache and not have it trimmed. Despite this, staff continued to trim the mustache against the resident's wishes, and the care plan did not reflect the resident's preference. Staff interviews confirmed that the resident's requests were disregarded, resulting in a failure to respect the resident's dignity and self-determination.
A resident with dementia and oropharyngeal dysphagia required supervision and verbal cues for safe swallowing during meals, as outlined in the care plan and recommended by the SLP. Surveyors observed the resident eating alone in bed or in the day room without consistent staff supervision or cueing, and staff interviews revealed a lack of understanding and implementation of the required interventions. This failure to follow the care plan and SLP recommendations resulted in a deficiency.
A resident was not seen by a physician or NP at the required 60-day intervals, with gaps of 76 and 114 days between visits, and no documentation of a provider visit for 158 days. The deficiency was due to missed visits and incomplete documentation following a change in the physician's record-keeping system.
Surveyors found that the facility did not maintain the main kitchen floor and walls in a sanitary condition, with cracked and receded grout, debris, water accumulation, and damaged wall coverings behind the three-bay sink. The FSD and Administrator confirmed that these areas should be intact and easily cleanable to meet food safety standards.
Handrails on one unit were found to be loose and easily moved in several areas, while residents were observed walking in the affected hallway. The DON confirmed that handrails should be securely attached for resident use, and the Administrator noted there was no specific process for identifying and reporting broken handrails, depending on staff to inform maintenance when issues arise.
A resident with severe cognitive impairment and multiple health issues experienced a significant decline in condition, requiring new medical orders. The facility failed to promptly notify the resident's Health Care Agent (HCA) of these changes, as required by policy. The HCA was only informed two days later, despite the facility's expectation for timely communication.
The facility failed to provide education, assess eligibility, and offer Pneumococcal Vaccinations per CDC recommendations and facility policy for three residents. The residents were not offered the PCV 20 vaccine as required, and staff interviews revealed a lack of clarity and responsibility in ensuring vaccinations were administered. The Infection Prevention Nurse and Director of Nurses acknowledged the deficiencies and the need for improvement.
The facility failed to develop person-centered care plans that included trauma-informed approaches and identified triggers for two residents with a history of trauma and PTSD. Incomplete assessments and care plans, along with a lack of staff awareness, led to deficiencies in providing appropriate care.
The facility failed to follow Enhanced Barrier Precautions (EBP) guidelines while performing wound care for a resident with Bullous Pemphigoid and colonized with ESBL bacteria. Nurse #1 did not wear a protective gown during the procedure, despite clear signage and physician's orders. The ADON and DON confirmed that gown and gloves were required for high-contact care activities for residents on EBP precautions.
Failure to Notify Physician and Health Care Agent After Resident Fall
Penalty
Summary
Staff failed to promptly notify a resident’s physician and Health Care Agent (HCA) after the resident experienced a significant change in status related to a fall. The resident had been admitted with diagnoses including status post fall with a subdural hematoma requiring a right craniotomy, Parkinson’s disease, and anticoagulation use, and had an invoked Health Care Proxy. Facility policy required prompt notification of the resident, physician, and resident representative of changes in medical or mental condition, including accidents or incidents. On the morning in question, one nurse (Nurse #2) found the resident on the floor next to the bed and obtained the assigned nurse (Nurse #1) to assist. After assessing the resident for injury and returning the resident to bed, neither nurse completed the required fall documentation or made the required notifications to the physician or HCA at that time. Nurse #1 stated that at the end of her shift she had not completed any documentation related to the fall and assumed Nurse #2 would do so, and confirmed she did not notify the physician or HCA. Nurse #2 stated she assumed Nurse #1 would complete the documentation and notifications and did not verify that this occurred, and did not report the fall to anyone until the following morning during nurse-to-nurse report; she later entered a late note about the incident. Review of the medical record showed no documentation that the unwitnessed fall was reported to the physician until several days later. The Staff Development Coordinator and DON both reported they were unaware of the fall until the DON began an investigation into a bruise of unknown origin near the resident’s right eye, which had been identified by the resident’s HCA during a visit. A family member reported discovering the bruise during a visit and being told by a nurse that the resident had likely fallen the previous day, and also reported that no one from the facility had notified her of the fall.
Failure to Assess and Document Care After Unwitnessed Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing services met professional standards of quality following an unwitnessed fall. A resident with a history of a fall resulting in a subdural hematoma requiring a right craniotomy, Parkinson’s disease, and anticoagulation use was admitted in 10/2025. On 10/27/25 at approximately 7:15 A.M., the resident was found on the floor next to the bed by one nurse (Nurse #2), who then notified the assigned nurse (Nurse #1). Both nurses assisted the resident back into bed. Facility policy required that any fall, including unwitnessed falls, be followed by physician and family notification, completion of a fall incident report and fall investigation, monitoring of vital signs, and neurological checks. Nurse #1 reported that, because it was the end of her shift and Nurse #2 told her not to worry about the documentation, she did not obtain vital signs, did not perform neurological checks, and did not complete any fall, skin, or pain assessments, incident report, or timely nursing progress note for the event, only entering a late note on 11/04/25. Nurse #2 stated she assumed Nurse #1 would complete the required documentation and did not follow up or report the incident to anyone that day, only mentioning it the following morning in report. The Staff Development Coordinator and DON both stated they were not aware the resident had been found on the floor on 10/27/25 until a bruise of unknown origin was identified by the resident’s health care proxy on 10/28/25, and both confirmed that the facility’s expectation is that the responding nurse immediately assess the resident and complete all required assessments, vital signs, neurological checks, and notifications after any witnessed or unwitnessed fall.
Failure to Maintain Clean, Homelike, and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by multiple observations of disrepair and lack of cleanliness across two of four units. Specific issues included a baseboard heater in pieces on the floor, peeling and damaged molding, cracks and holes in walls, chipped paint, and scratched walls in resident rooms and common areas. Residents reported that maintenance staff were rarely seen performing repairs or preventative maintenance, and some stated that visible damage had been present since before their admission. Review of work order slips revealed incomplete and unsigned requests, indicating lapses in the maintenance process. Further deficiencies were observed in the Whirlpool tub room and an adjacent resident room, where there was evidence of water damage such as brown discoloration, bubbling and chipped paint, and bowed or cracked plaster on ceilings and walls. Maintenance staff acknowledged that these issues were related to recurring water leaks from an upstairs tub room and that previous patching and painting had not resolved the problem. The administrator was unaware of the ongoing water leakage and the extent of the damage until it was pointed out during the survey. Additionally, a window air conditioner in a resident room was found to be in poor condition, with visible black spots on the vents and a filter heavily laden with dust. The maintenance director confirmed that air conditioners are typically cleaned before storage, but if a resident requests year-round use, housekeeping is expected to notify maintenance for cleaning. In this case, the air conditioner had not been properly maintained, as evidenced by the accumulation of dust and debris.
Failure to Honor Resident's Personal Grooming Preferences
Penalty
Summary
The facility failed to honor a resident's right to dignity and self-determination by not respecting the resident's expressed wish to grow a handlebar mustache. The resident, who was cognitively intact with a BIMS score of 14 and dependent on staff for personal hygiene due to hemiplegia following a stroke, repeatedly communicated to staff that he did not want his mustache trimmed. Despite these clear wishes, staff continued to trim his mustache against his instructions. The care plan did not document the resident's preference regarding his mustache, and staff interviews confirmed that they trimmed the mustache even when the resident objected. Observations showed the resident's mustache was initially long and curling into his mouth, but later had been trimmed without his consent. The resident reported that staff ignored his requests and trimmed his mustache anyway, leaving him feeling disregarded. Staff interviews corroborated that the resident did not want his mustache touched, but they proceeded to trim it, sometimes justifying it as necessary for hygiene. The facility's own policy emphasized the importance of respecting resident rights and preferences, but this was not followed in the resident's care.
Failure to Implement Safe Swallowing Interventions for Resident with Dysphagia
Penalty
Summary
The facility failed to implement the person-centered care plan interventions for a resident with oropharyngeal dysphagia, resulting in a lack of adherence to safe swallowing strategies. The resident, who had dementia and dysphagia, was assessed as having moderate cognitive impairment and required a mechanically altered diet with supervision for eating. The care plan and dining needs list indicated the resident was independent with eating but required 1:8 supervision and intermittent cues. Speech therapy notes documented the need for the resident to be upright and out of bed for meals, to alternate solids and liquids, and to receive verbal cues to promote safe swallowing. Despite repeated education to nursing staff by the SLP, the resident was frequently observed eating alone in bed, not always upright, and without consistent staff supervision or cueing as recommended. Observations by the surveyor showed the resident eating meals alone in bed on multiple occasions, with visual aids present but not always followed, and without staff providing the necessary verbal cues to alternate solids and liquids. On one occasion, the resident was observed in the day room for breakfast but did not receive staff cues to alternate solids and liquids, and the visual aids were not present. Staff interviews revealed inconsistent understanding and implementation of the care plan interventions, with some staff unaware of the specific cues required or the importance of supervision during meals. Staff also reported challenges with the resident refusing assistance and the need for multiple staff to assist with getting the resident out of bed, which sometimes resulted in the resident remaining in bed for meals. The SLP confirmed that the resident required intermittent supervision and verbal cues to use safe swallowing strategies, and that staff had been educated on these needs. However, the care plan lacked specific details on the cues required, and staff did not consistently provide the recommended supervision or cueing during meals. The failure to implement the care plan interventions as recommended by the SLP and documented in the resident's care plan led to the deficiency identified during the survey.
Failure to Ensure Timely Physician/NP Visits and Documentation
Penalty
Summary
The facility failed to ensure that a resident was seen by a physician or nurse practitioner (NP) at the required intervals as outlined in both facility policy and regulatory requirements. According to the facility's policy, residents must be reassessed and have an updated medical care plan at least every 30 days for the first 90 days after admission, and every 60 days thereafter. Record review showed that the resident was seen by a physician on 4/16/24 and by an NP on 7/2/24, resulting in a 76-day gap between visits, which exceeds the required 60-day interval. Further review indicated that after the NP's visit on 7/2/24, the next documented provider visit was not until 10/25/24, a gap of 114 days, and there was no documentation of any provider visit for 158 days following the 10/25/24 visit. Interviews with the Clinical Nurse Consultant confirmed that the physician and NP were expected to visit the facility weekly, but documentation showed that the resident had not been seen by a provider since October 2024. The physician was unable to provide additional documentation of visits due to a transition to new documentation software, which contributed to the lack of timely and complete records. The deficiency was attributed to an oversight in both the scheduling of visits and the maintenance of proper documentation.
Failure to Maintain Sanitary Kitchen Surfaces
Penalty
Summary
Surveyors observed that the facility failed to maintain the main kitchen floor and ceiling in a sanitary and safe condition, as required by professional standards for food safety and sanitation. Specifically, there were multiple instances of cracked, crumbled, and receded floor grout throughout the kitchen, including at the floor-wall joint and inside the walk-in refrigerator. These areas contained settled debris and water. Additionally, the wall covering behind the three-bay sink was uneven and missing in places, with visible openings in the wall. These conditions were directly observed by surveyors during their inspection. Interviews with the Food Service Director (FSD) confirmed that most of the kitchen flooring and grouting was original to the building and had not been fully repaired, except for some small areas. The FSD acknowledged that the kitchen walls should not have holes or protruding coverings and that the flooring should be easily cleanable and free from debris or moisture. The Administrator also stated that the kitchen walls and flooring should be in good condition, without holes or compromised areas that could harbor debris or moisture, and that the kitchen should be maintained in a safe and sanitary condition.
Handrails Not Securely Affixed in Hallway
Penalty
Summary
The facility failed to ensure that handrails on the East 2 unit were securely affixed to the wall. During an observation, a surveyor was able to move three separate pieces of handrails with minimal effort in different areas of the unit, indicating that the handrails had come loose from the wall. Residents were observed walking in the hallway where the loose handrails were present. The DON confirmed that all handrails should be securely attached, as they are used by residents. The Administrator acknowledged the concern and stated that there was no specific process in place for identifying broken handrails, relying instead on staff to report issues to the maintenance department.
Failure to Notify Health Care Agent of Resident's Condition Change
Penalty
Summary
The facility failed to promptly notify the Health Care Agent (HCA) of a resident who experienced a significant decline in condition, which necessitated new physician's orders and changes in the treatment plan. The resident, who was admitted in February 2023, had a history of Alzheimer's type dementia, acquired hypothyroidism, a left parotid mass, dysphagia, and chronic stage three kidney disease. The Health Care Proxy (HCP) for the resident had been invoked, indicating that the HCA should be informed of any significant changes in the resident's condition. On March 18, 2024, the resident exhibited signs of a decline, including a fever of 102.1 degrees Fahrenheit, lethargy, and low oxygen saturation levels, which required the administration of oxygen and other medical interventions. Despite these significant changes, there was no documentation to support that the nursing staff notified the HCA of the resident's condition on March 18 and March 19, 2024. The HCA was only informed on March 20, 2024, which was the first time she was made aware of the resident's medical decline and the need for oxygen. Interviews with the nursing staff, including a nurse, the Unit Manager, the Assistant Director of Nurses (ADON), and the Director of Nurses (DON), revealed that the facility's policy required prompt notification of the HCA in such situations. However, the staff could not confirm that the HCA was informed in a timely manner, as expected by the facility's policy. The lack of timely communication with the HCA regarding the resident's significant change in condition constituted a deficiency in the facility's adherence to its notification policy.
Failure to Provide Pneumococcal Vaccinations per CDC Recommendations
Penalty
Summary
The facility failed to provide education, assess eligibility, and offer Pneumococcal Vaccinations per CDC recommendations and facility policy for three residents. The facility's policy required offering the Pneumococcal conjugate vaccine (PCV 13, PCV 15, or PCV 20) based on availability and previous vaccination history, and ensuring informed consent with the most current literature on the risks and benefits. However, the facility did not adhere to these guidelines, resulting in residents not being offered the PCV 20 vaccine as recommended by the CDC for adults 65 and over who had not received prior pneumococcal vaccines or had received them more than five years ago. Resident #9, admitted in May 2022, had received PPSV 23 in 2014 but was never offered the PCV 20 vaccine since admission. The resident, who is cognitively intact, expressed interest in receiving the vaccine but was unaware of its availability. Resident #67, admitted in March 2021, had received PPSV 23 and PCV 13 in November 2021, but there was no evidence that the PCV 20 vaccine was ever offered to the resident or their healthcare proxy. Resident #52, admitted in January 2024, had no information regarding pneumococcal vaccinations in their immunization record, and the consent form was incomplete, with no follow-up to readdress the vaccinations. Interviews with staff revealed a lack of clarity and responsibility in ensuring residents received the necessary vaccinations. The Unit Managers and nurses indicated that immunization consents were completed upon admission, but there was no process for re-offering vaccinations or ensuring follow-up. The Infection Prevention Nurse acknowledged the deficiencies and the need for improvement in the vaccination process, while the Director of Nurses admitted that the facility's policy was not being followed as it should be.
Failure to Provide Trauma-Informed Care
Penalty
Summary
The facility failed to develop a person-centered plan of care that included trauma-informed approaches and identified triggers to avoid potential re-traumatization for two residents. For one resident with a history of PTSD, the facility did not identify specific triggers related to their trauma, despite the resident's active diagnosis and ongoing psychotherapy sessions. The resident's care plan and assessments were incomplete and did not reflect the necessary information to prevent re-traumatization. Interviews with staff revealed a lack of awareness of the resident's specific triggers, and the Director of Social Services acknowledged the deficiencies in the assessments and care plan documentation. For another resident, the facility did not complete a trauma assessment, resulting in a failure to provide trauma-informed care. The resident, who had multiple diagnoses including a traumatic amputation and cerebral palsy, was not assessed for past trauma upon admission. The social worker admitted that a comprehensive psychosocial assessment was not completed, and the resident confirmed that they had not been asked about past traumas or triggers. The resident had experienced significant traumatic events, but this information was not documented or communicated to the facility staff. The facility's policy on trauma-informed care and PTSD was not followed, as evidenced by the incomplete assessments and care plans for both residents. The policy required interdisciplinary assessment and the development of care plans that included potential triggers and interventions to avoid re-traumatization. However, the facility failed to gather and document the necessary information to provide appropriate care for residents with a history of trauma and PTSD.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to follow Enhanced Barrier Precautions (EBP) guidelines while performing wound care for a resident diagnosed with Bullous Pemphigoid and colonized with Extended Spectrum Beta-Lactamase (ESBL) bacteria in the urine. The facility's policy required the use of gown and gloves during high-contact care activities, including wound care, for residents on EBP precautions. However, during an observation, Nurse #1 did not don a protective gown while providing wound care to the resident's bilateral breast wounds, despite the clear signage on the resident's door and the physician's orders indicating the need for EBP precautions. During interviews, Nurse #1 acknowledged the failure to wear a protective gown, and both the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed that the expectation was for staff to wear a gown and gloves during high-contact care activities for residents on EBP precautions. The ADON and DON reiterated that the resident was on EBP precautions due to an MDRO infection, and gown and gloves were required for wound care, even though the wounds were not draining any fluid.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 1,011 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 Braintree
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Royal Braintree Nursing And Rehabilitation Center | 1 mi | ★★★★★ | 18 | 0 |
| Regalcare At Quincy | 1.4 mi | ★★★★★ | 0 | 0 |
| Affinity Healthcare | 1.5 mi | ★★★★★ | 22 | 0 |
| Pope Nursing Home | 1.6 mi | ★★★★★ | 0 | 0 |
| Alliance Health At Braintree | 1.7 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 July 2026) and official state health department websites.