Above average — CMS composite of the measures below.
The next survey window likely opens around October 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 Leonard Florence Center For Living during CMS and state inspections, most recent first.
Medication administration errors exceeded the allowed rate after an LPN made 4 errors in 38 opportunities, affecting two newly admitted residents. One resident received carvedilol and an inhaler before breakfast, despite the carvedilol order requiring food and the inhaler needing priming per manufacturer guidance. Another resident received carvedilol and metformin before breakfast, even though both were ordered with food or meals; the DON stated physician orders should be followed.
Opened medications were found undated and not stored according to manufacturer guidance in the medication room and in a resident’s room. A vial of Acetylcysteine Solution was open and undated in the refrigerator, two vials of Ipratropium Bromide and Albuterol Sulfate Inhalation Solution were opened and removed from the foil pouch, and additional opened vials of the same medication plus an open bottle of iron supplement liquid were found in a resident’s room. Facility policy required opened containers to be dated, and an RN and the DON stated the medications should have been dated when opened.
A resident with quadriplegia and ventilator dependence, who was alert and able to communicate, was verbally abused by a CNA who forcefully told the resident to "shut up" when the resident attempted to ask a question. This disrespectful interaction was witnessed by another CNA and confirmed through interviews, violating the resident's right to dignity and respect.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure it was free from a medication error rate greater than 5% after one nurse made 4 errors out of 38 opportunities, resulting in a 10.53% medication error rate. The errors affected two residents, Resident #102 and Resident #98, during medication administration observations conducted by the surveyor. The facility policy required medications to be administered in accordance with orders, within one hour of the prescribed time unless otherwise specified, and documented in PCC. Resident #102 was newly admitted with diagnoses including type 2 diabetes mellitus, congestive heart failure, atherosclerotic heart disease, hypertension, and dyspnea. During observation, Nurse #1 administered carvedilol 25 mg and fluticasone-salmeterol inhalations. Resident #102 had not eaten breakfast before or during the medication pass and stated breakfast had not yet been ordered. The physician’s order for carvedilol directed that it be given with breakfast and dinner. The inhaler manufacturer’s instructions also required priming before first use or after prolonged nonuse, but the nurse stated he did not prime the inhaler and did not know whether it had been primed. Resident #98 was also newly admitted and had diagnoses including type 2 diabetes mellitus, thrombocytopenia, atherosclerotic heart disease, hypertension, and acute on chronic diastolic congestive heart failure. During observation, Nurse #1 administered carvedilol 25 mg and metformin 500 mg tablets. Resident #98 had not eaten breakfast before or during the medication pass and was later observed still without a breakfast meal. The physician’s orders directed carvedilol to be given with food and metformin to be taken with meals. The nurse stated he should have administered the medications with food, and the DON stated physician orders should be followed and medications should be administered with food as indicated.
Opened Medications Found Undated and Improperly Stored
Penalty
Summary
Medications and biologicals were not labeled in accordance with accepted professional principles, and several opened medications were found undated during observations in the facility’s medication storage room and in a resident’s room. On 11/19/25 at 8:29 A.M., the surveyor and Nurse #2 observed one 30 mL vial of Acetylcysteine Solution, USP, open and undated in the refrigerator, with clear liquid still present inside. The manufacturer’s instructions stated that opened containers should be discarded after 96 hours and stored in the refrigerator after opening. The same observation found two 3 mL vials of Ipratropium Bromide and Albuterol Sulfate Inhalation Solution, USP, opened, undated, and removed from the foil pouch, although the manufacturer’s instructions stated that unit dose vials should remain in the protective foil pouch and, once removed, should be used within one week. Later that morning, the surveyor and Nurse #2 observed medications in Resident #16’s room, including five 3 mL vials of Ipratropium Bromide and Albuterol Sulfate Inhalation Solution, USP, that were opened, undated, and removed from the foil pouch, along with one 16 fl. oz. bottle of Iron Supplement Liquid, Ferrous Sulfate 220 mg/5 mL, that was open and undated. Facility policy stated that when opening a multi-dose container, the date opened shall be recorded on the container, and Nurse #2 stated the open and used medications should have been dated when opened. The DON later stated he would expect the medications to be dated when opened.
Resident Subjected to Verbal Abuse by CNA
Penalty
Summary
A deficiency occurred when a certified nurse aide (CNA) interacted with a resident in a manner that was not respectful or dignified. The resident, who was alert, oriented, and able to communicate needs, reported that the CNA told them to "shut up" in a forceful and rude manner while the resident was attempting to ask a question. This interaction was witnessed by another CNA, who confirmed that the statement was made in a disrespectful tone. The resident expressed feeling disrespected and upset by the CNA's behavior. The facility's internal investigation corroborated the resident's account, with the witness stating that the CNA was dismissive and verbally abusive toward the resident. The resident involved had significant medical needs, including quadriplegia, chronic respiratory failure, a tracheostomy, and ventilator dependence, and required staff assistance for care. Despite these vulnerabilities, the staff member failed to uphold the facility's policy requiring all employees to treat residents with kindness, respect, and dignity. Multiple interviews with staff and the resident confirmed that the CNA's conduct was inappropriate and constituted verbal abuse, violating the resident's right to be treated with respect and dignity.
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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 Chelsea
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Katzman Family Center For Living | 1 mi | ★★★★★ | 5 | 0 |
| Highland Park Rehabilitation And Healthcare Center | 1 mi | ★★★★★ | 21 | 0 |
| The Massachusetts Veterans Home At Chelsea | 1 mi | ★★★★★ | 3 | 0 |
| Rehabilitation & Nursing Center At Everett (the) | 1.8 mi | ★★★★★ | 12 | 0 |
| The Center At Advocate | 2 mi | ★★★★★ | 3 | 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.