Above average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Laurel Ridge Rehab And Skilled Care Center during CMS and state inspections, most recent first.
The facility failed to provide necessary assistance with meals for four residents, despite care plans indicating the need for staff support. Residents with cognitive impairments and conditions like dysphagia and Parkinson's disease were observed without assistance, leading to potential risks. Staff interviews confirmed the expectation to follow care plans, yet assistance was not provided as required.
The facility failed to adhere to physician's orders for three residents requiring dialysis, by taking blood pressure on the arm with the dialysis shunt, contrary to the facility's policy. This involved residents with end-stage renal disease and other conditions, where blood pressure was repeatedly measured on the restricted arm, as confirmed by staff interviews.
The facility failed to store medications securely and properly, as observed by surveyors. Medications were left unattended at a nursing station, and medication carts on two units were found unlocked and unclean. Staff interviews confirmed that these practices were against facility policy.
The facility failed to ensure dignified feeding practices for residents dependent on staff assistance. Observations revealed staff standing over residents while feeding, contrary to the facility's policy requiring staff to sit at eye level. Interviews with management confirmed the expectation for staff to be at eye level, highlighting a breach in the dignity policy.
A facility failed to assess and document the use of pillows tucked under a fitted sheet as a potential restraint for a resident with severe cognitive impairment. The resident was observed with pillows on both sides of the bed, used to prevent falls, but there was no documentation or assessment in the care plan or medical records. Interviews with staff revealed a lack of awareness and assessment regarding the use of pillows as a restraint, constituting a deficiency in compliance with the facility's restraint policy.
The facility failed to accurately complete MDS assessments for three residents, leading to deficiencies in reflecting their health status. One resident's MDS did not document a fall with a major injury, another's inaccurately indicated adequate vision despite severe impairments, and a third's incorrectly coded antibiotic use and omitted wound care documentation. The inaccuracies were confirmed by the DON and MDS Nurse during interviews.
The facility failed to develop a care plan for a resident's vision impairment and did not implement a wander guard for another resident at high risk for elopement. Despite severe cognitive impairments and specific diagnoses, the care plans and assessments did not reflect these needs. Observations showed the absence of necessary interventions, and staff interviews confirmed the lack of adherence to care protocols.
A resident with severe cognitive impairment and high risk for pressure ulcers did not have a physician's order to off-load heels implemented. Despite the order to float heels on a pillow, observations showed the resident's heels were on the mattress. Staff interviews confirmed the expectation to follow such orders, but documentation did not indicate any refusal by the resident, indicating a lapse in care.
A resident's pharmacist recommendations for medication adjustments were not acknowledged by the physician for about five months, despite the facility's policy for timely acknowledgment. Staff interviews revealed issues with the pharmacy recommendation system after switching pharmacists, leading to delays in addressing recommendations.
Two residents in a LTC facility were found with inaccessible call lights, contrary to facility policy and care plans. One resident with severe cognitive impairment and dependency on daily activities had the call light clipped out of reach, while another resident with Alzheimer's had the call light wrapped behind the bed. Staff interviews confirmed the deficiency.
The facility failed to post daily nurse staffing information at the start of each shift, as required. Observations showed outdated and incomplete staffing data, lacking total numbers and hours for RNs, LPNs, and CNAs. Staff interviews revealed a lack of awareness of posting requirements, with the Unit Coordinator and scheduler not fully understanding the need for detailed staffing information. Both the DON and Administrator acknowledged the requirement for proper posting.
Failure to Assist Residents with Meals
Penalty
Summary
The facility failed to provide necessary assistance with Activities of Daily Living (ADLs), specifically with meals, for four residents. Resident #39, who has severe cognitive impairment and is dependent on staff for ADLs, was repeatedly observed with meal trays set up without staff assistance, despite the care plan indicating a need for physical assistance and adaptive feeding equipment. Observations over several days showed the resident not initiating self-feeding, and staff interviews confirmed the expectation that assistance should be provided according to the care plan. Resident #163, with moderate cognitive impairment and a history of severe protein-calorie malnutrition, was also observed without staff assistance during meals. Despite calling out for help, the resident did not receive the required assistance as per the care plan, which indicated the need for staff participation in eating. Staff interviews reiterated the necessity of following the care plan, yet the resident was left without the needed support. Resident #32, with severe cognitive impairment and dysphagia, was observed attempting to feed themselves without staff assistance, resulting in food spillage and potential aspiration risks. The care plan clearly stated the need for total assistance with eating, which was not provided. Similarly, Resident #100, with severe cognitive impairment and Parkinson's disease, was left unsupervised during meals, contrary to the care plan's requirement for supervision due to aspiration precautions. Staff interviews highlighted inconsistencies in following care plans, leading to these deficiencies.
Failure to Follow Dialysis Care Protocols
Penalty
Summary
The facility failed to provide dialysis care consistent with professional standards for three residents who required dialysis. The deficiency involved not adhering to physician's orders regarding the measurement of blood pressure on the arm with a dialysis shunt. The facility's policy clearly stated that blood pressure should not be taken on the arm with the dialysis access site, yet this was not followed for the residents involved. Resident #44, who was admitted with end-stage renal disease and heart failure, had multiple instances where blood pressure was taken on the right arm, which was the arm with the dialysis access site. This was despite clear physician's orders and care plan interventions indicating that no blood pressure or blood draws should be performed on that arm. Similarly, Resident #263, also with end-stage renal disease, had blood pressure readings taken on the right arm, contrary to the physician's orders and care plan instructions. Resident #51, admitted with end-stage renal disease, diabetes, and chronic heart failure, had a sign above their bed indicating that blood pressure should not be taken on the left arm. However, the facility's records showed multiple instances where blood pressure was taken on the left arm, against the physician's orders. Interviews with nursing staff and the Director of Nursing confirmed that the orders were not followed, leading to the deficiency in care for these residents.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in accordance with accepted professional standards of practice. On the first-floor nursing station, medications including rhopressa eye drops and a brown paper bag containing various ophthalmic solutions were left unattended. This was observed by the surveyor over a period of time during which multiple staff members, including Certified Nursing Assistants, the Maintenance Director, and therapists, walked near the unattended medications. Interviews with Nurse #2, Unit Manager #1, and the Director of Nursing confirmed that medications should not be left unattended at the nursing station. Additionally, the facility did not properly secure medication carts on two of three units. On the third-floor unit, a nurse left the medication cart unlocked and unattended, which was only addressed after the surveyor's intervention. On the second-floor unit, the medication cart was found to contain a medication cup with applesauce, a dirty plastic spoon, and cups filled with a clear liquid, indicating a lack of cleanliness and proper storage. The Assistant Director of Nurses confirmed that the medication cart should be locked when unattended and that it should not contain non-medication items. The Director of Nurses also stated that medication carts should be locked and kept clean.
Failure to Ensure Dignified Feeding Practices
Penalty
Summary
The facility failed to ensure that staff treated residents in a dignified manner during meal times, particularly for those residents who were dependent on staff for assistance with feeding. The facility's policy on dignity, dated 6/6/22, mandates that each resident should be cared for in a way that promotes their well-being and self-esteem, prohibiting demeaning practices. However, observations by the surveyor on multiple occasions revealed that staff members were standing over residents while feeding them, rather than sitting at eye level as required by the policy. This was observed in the third-floor dining room and in residents' rooms, where staff were seen standing while feeding residents in bed. Interviews with Unit Manager #3 and the Director of Nursing confirmed that staff should be sitting at eye level with residents during feeding. Despite this, the surveyor noted several instances where staff did not adhere to this practice, including leaving a resident with food on their face and chest after feeding. These observations indicate a failure to uphold the facility's dignity policy, compromising the residents' right to a dignified dining experience.
Failure to Assess and Document Use of Pillows as Restraint
Penalty
Summary
The facility failed to identify and assess the use of pillows tucked underneath a fitted sheet below the side rails on both sides of the bed as a potential restraint for Resident #97. The facility's policy on the use of restraints, revised in April 2017, clearly defines physical restraints and outlines the conditions under which they may be used. However, the staff did not follow these guidelines, as the use of pillows was not documented or assessed as a restraint, despite the fact that Resident #97 could not remove them easily. Resident #97, who was admitted to the facility in March 2023, has severe cognitive impairment with a BIMS score of 0 out of 15, indicating a high level of dependency on staff for mobility. The resident was observed multiple times with pillows tucked under the fitted sheet on both sides of the bed, which were used to prevent the resident from falling. Despite these observations, there was no documentation in the resident's care plan, medical record, or physician's orders to support the use of these pillows as a restraint. Interviews with facility staff, including a CNA, a nurse, a unit manager, the ADON, and the DON, revealed a lack of awareness and assessment regarding the use of pillows as a potential restraint. The unit manager and the DON acknowledged that a restraint assessment should have been completed, but it was not. The facility's failure to assess and document the use of pillows as a restraint for Resident #97 constitutes a deficiency in compliance with their own restraint policy.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) assessments for three residents, leading to deficiencies in reflecting their true health status. For one resident, the MDS assessment did not document a fall with a major injury, despite progress notes and a facility report indicating that the resident sustained a fracture from a fall. The Director of Nurses and the MDS Nurse acknowledged the inaccuracy during interviews, confirming that the MDS should have reflected the fall with a major injury. Another resident's MDS assessment inaccurately indicated adequate vision, despite a visit note from contracted vision services diagnosing severe vision impairments, including legal blindness. The resident confirmed during an interview that they could only see shadows. Both the Director of Nurses and the MDS Nurse admitted the MDS was inaccurately coded and should have indicated vision impairment. For the third resident, the MDS assessment incorrectly coded the use of an antibiotic, when in fact, the resident was on Tamiflu, an antiviral medication. Additionally, the MDS failed to document a non-pressure wound and its treatment, despite documentation from a wound care consultant and physician's orders indicating daily wound care. The MDS Nurse and the Director of Nurses confirmed the inaccuracies in the MDS coding during interviews.
Deficiencies in Care Planning for Vision Impairment and Elopement Risk
Penalty
Summary
The facility failed to develop and implement a comprehensive and person-centered care plan for two residents, leading to deficiencies in their care. For one resident, who was admitted with diagnoses including dementia, diabetes, and hypertension, the facility did not create a care plan addressing the resident's vision impairment. Despite observations indicating the resident's inability to see their meals and a diagnosis of legal blindness, the resident's care plan, MDS assessment, and CNA Kardex did not reflect this impairment. Interviews with staff confirmed the lack of a care plan for the resident's vision loss, despite recommendations from contracted vision services. Another resident, admitted with diagnoses such as bipolar disorder, anxiety disorder, and amnesia, was identified as having a high risk for elopement. The resident's care plan included the use of a wander guard, but observations revealed that the device was not in place during multiple instances. The resident's TAR inaccurately indicated the presence of the wander guard, and staff interviews confirmed the absence of the device, despite a physician's order requiring its use. The facility's policy on elopement risk was not followed, as the resident's care plan did not ensure the consistent use of the wander guard. These deficiencies highlight the facility's failure to adhere to its policies and procedures, resulting in inadequate care planning and implementation for residents with specific needs. The lack of a care plan for vision impairment and the failure to ensure the use of a wander guard for a high-risk resident demonstrate significant oversights in the facility's care management practices.
Failure to Implement Physician's Order for Heel Off-Loading
Penalty
Summary
The facility failed to implement a physician's order for a resident, identified as Resident #35, who was admitted with diagnoses including dementia, Parkinson's disease, and type 2 diabetes. The resident was at high risk for developing pressure ulcers, as indicated by a Norton Scale score of 7. Despite a physician's order dated December 23, 2023, to float the resident's bilateral heels on a pillow while in bed every shift, observations on multiple occasions from June 11 to June 13, 2024, revealed that the resident's heels were directly on the mattress. This was confirmed by Nurse #3 during an observation on June 13, 2024. Interviews with facility staff, including a CNA, the Infection Control Nurse, and the Director of Nurses, indicated that the expectation was for nurses to follow the physician's orders and care plans, which included off-loading the resident's heels. However, the nursing progress notes from June 3 to June 13, 2024, did not document any refusal by the resident to have their heels offloaded, suggesting a failure in adhering to the prescribed care plan. This deficiency highlights a lapse in the facility's adherence to professional standards of quality care for Resident #35.
Delayed Acknowledgment of Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure that recommendations from the Monthly Medication Review conducted by the pharmacist were addressed and acknowledged by the physician in a timely manner for a resident. The resident, who was admitted to the facility with diagnoses including intervertebral disc degeneration and personality disorder, had a Brief Interview for Mental Status score indicating cognitive intactness. The pharmacist recommended a decrease in Omeprazole and a Narcan order over several months, but these recommendations were not acknowledged by the physician until approximately five months later. Interviews with facility staff revealed that the pharmacy recommendation system had been ineffective since the facility began using a different pharmacist. The Unit Manager stated that recommendations typically get acknowledged within one week, but this was not the case for the resident in question. The Director of Nursing acknowledged that the system was broken and that recommendations had not been followed up as timely as they should have been, leading to the delay in addressing the pharmacist's recommendations for the resident.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to ensure that the call lights were accessible for two residents, leading to a deficiency in providing adequate means for residents to call for assistance. Resident #5, who was admitted with diagnoses including unspecified dementia, polyarthritis, and age-related osteoporosis, was observed multiple times with the call light clipped to the top of the wire where it comes out of the wall, making it unreachable. This resident had a severe cognitive impairment and was dependent on all activities of daily living, as indicated by their Minimum Data Set Assessment. The facility's policy and the resident's care plan both emphasized the importance of keeping the call light within reach, yet this was not adhered to. Similarly, Resident #64, diagnosed with Alzheimer's disease and unspecified dementia, was also found with the call light inaccessible, wrapped up and hanging behind the headboard of the bed. This resident also had severe cognitive impairment and required assistance with activities of daily living. Observations confirmed that the call light was not within reach, despite the care plan's instructions to ensure accessibility. Interviews with the Unit Manager and the Director of Nursing corroborated the surveyor's findings, acknowledging that the call lights were not accessible as required by the facility's policy.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post daily nurse staffing information at the start of each shift, as required by regulations. Observations by surveyors on multiple occasions revealed that the posted staffing information was outdated and incomplete. Specifically, the staffing data did not include the total number and hours for Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Certified Nurse Aides (CNAs). On June 11, 2024, the posted staffing information was dated June 8, 2024, and lacked the required details. Similar deficiencies were noted on June 12 and June 13, 2024. Interviews with facility staff revealed a lack of awareness and understanding of the requirements for posting nurse staffing information. The Unit Coordinator, responsible for posting the staffing data, indicated that the scheduler prepares the staffing sheet. The scheduler admitted to being unaware of the need to separate RNs and LPNs and to include total hours worked. Both the Director of Nursing and the Administrator acknowledged that the staffing information should be posted as required, indicating a systemic issue in ensuring compliance with staffing posting regulations.
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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) |
|---|---|---|---|---|
| Benjamin Healthcare Center | 1.5 mi | ★★★★★ | 1 | 0 |
| Armenian Nursing & Rehabilitation Center | 1.5 mi | ★★★★★ | 2 | 0 |
| Sherrill House | 1.5 mi | ★★★★★ | 9 | 0 |
| Recuperative Services Unit-hebrew Rehab Center | 1.6 mi | ★★★★★ | 1 | 0 |
| St Joseph Rehab & Nursing Care Center | 2.4 mi | ★★★★★ | 5 | 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.