Above average — CMS composite of the measures below.
The next survey window likely opens around December 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 Mary Ann Morse Nursing & Rehabilitation during CMS and state inspections, most recent first.
Failure to Prevent Resident Elopement: A resident with dementia and moderately impaired cognition was last seen in bed during the overnight shift, then exited the unit and facility undetected and was found on a nearby loading dock by police. Interviews and observations showed the resident likely left through an employee service door and exterior door with alarms that were only locally audible and stopped once the doors closed; the DON/Administrator reported the doors were not properly secured.
A facility failed to allow a resident, capable of making their own medical decisions, to review and sign important medical documents, including Advanced Directives and medication consents. Instead, these were signed by the resident's representative, despite the Health Care Proxy not being invoked. The facility did not address the resident's decision-making capabilities, and the required review and documentation of the MOLST form were not completed.
The facility failed to maintain accurate and accessible Advance Directives for two residents. One resident's MOLST form was not part of the active medical record, leading to a discrepancy with the physician's orders. Another resident's MOLST did not match the physician's orders, causing inconsistencies in documented treatment preferences.
A resident developed multiple Stage 2 pressure ulcers due to the facility's failure to conduct timely skin assessments and implement a recommended therapeutic air mattress. Despite a CNA noting redness on the resident's buttocks, a licensed nurse did not complete a follow-up assessment, and the resident continued to use a standard mattress, contrary to a physician's recommendation.
A facility failed to provide appropriate care for residents with dementia, leading to unmet needs and distress. One resident made undignified comments towards another without staff intervention. Another resident expressed a desire to leave an activity and requested bathroom use, but staff did not respond promptly. A third resident attempted to stand multiple times, indicating a need to move, but staff did not engage appropriately to determine their needs.
A resident with ESRD did not receive Sevelamer medication as required during the medication pass process. The medication, intended to be taken with meals, was administered without food by a nurse who was unaware of the proper administration instructions. The nurse admitted to not reading the medication instructions, and the unit manager acknowledged the oversight.
A facility failed to maintain accurate medical records for a resident, particularly in documenting advanced directives and code status. The resident's Health Care Proxy was invoked temporarily, but the facility did not follow up, and the MOLST form was improperly signed. The Dialysis Transition of Care Form showed inconsistent code status entries, alternating between DNR, Full Code, and being left blank, leading to potential confusion during dialysis.
The facility failed to adhere to infection control standards on the Cedar and Birch Units. On the Cedar Unit, a resident on Enhanced Barrier Precautions was not attended to with the required PPE by staff. On the Birch Unit, a nurse did not properly disinfect a glucometer between uses, using alcohol wipes instead of the facility-approved bleach wipes, potentially contaminating the carrying case and medication cart.
The facility failed to offer updated pneumococcal vaccinations to three residents who were eligible and not up-to-date with their vaccinations. Despite the facility's policy requiring assessment and offering of vaccines within 30 days of admission, these residents were not provided with the necessary vaccinations. The Infection Preventionist confirmed the oversight and could not provide evidence of vaccination offers for these residents.
The facility failed to provide education on the benefits and risks of COVID-19 vaccines to three residents before administration, as required by policy. The Infection Preventionist admitted to not having evidence of providing necessary education, resulting in a deficiency in the vaccination process.
The facility inaccurately coded MDS assessments for several residents, indicating outdated Pneumococcal Vaccinations as current and incorrectly documenting catheter types due to errors in record transfer and review.
Failure to Prevent Resident Elopement
Penalty
Summary
The Facility failed to ensure adequate supervision to prevent elopement for a resident with moderately impaired cognition. The resident had diagnoses including diabetes mellitus, new onset atrial fibrillation, a pancreatic head lesion, and dementia, and the Health Care Proxy had been invoked. The resident was last observed in bed by the Nursing Supervisor during the overnight shift, but later exited the unit and the Facility undetected and was found on the loading dock of a neighboring Facility about 150 yards away, after having been located by police and transported to the Hospital ED for evaluation. The Facility’s Missing Persons Policy stated that unit clinical staff are required to know the location of each resident at all times and that the unit charge nurse is responsible for assuring each resident’s location is known and accounted for through formal communications and data systems. Despite this, the Nursing Supervisor reported no awareness of how the resident left the building and stated she never heard any alarms indicating someone had left. The report also indicated that the resident had been seen walking in the hallway earlier in the night and was escorted back to bed after asking the time and being asked whether he/she knew where he/she was. Survey observations and interviews identified that the resident likely exited through an employee service door leading to a stairwell and then to an exterior door. The Environmental Service Director stated the security surveillance footage had identified the exit door used, but the footage was not saved and could not be retrieved. During observation, the surveyor found that the alarmed doors sounded only locally and were not hard-wired to a system audible in other parts of the building, and the alarm stopped once the door closed. The Administrator stated the doors were not properly secured and the alarms could only be heard if someone was nearby when the doors were opened.
Failure to Allow Resident to Sign Medical Documents
Penalty
Summary
The facility failed to ensure that a resident, who was capable of making their own medical decisions, was given the opportunity to review and sign important medical documents. These documents included Advanced Directives, side rail consent, self-administration of medication consent, and consent for the use of psychotropic medications. Despite the resident being identified as their own decision-maker, the facility allowed the resident's representative to sign these documents instead. The resident's clinical record showed that the Health Care Proxy was not invoked, indicating that the resident was capable of making their own decisions. However, the facility did not address the resident's medical decision-making capabilities, as confirmed by a social worker. The facility's policy required an initial review and discussion about the MOLST form with the resident, which was not completed or documented in the medical record.
Inaccurate and Inaccessible Advance Directives
Penalty
Summary
The facility failed to ensure that Advance Directives were accurate and accessible for two residents. For one resident, the facility did not maintain a completed MOLST form as part of the active medical record, which was necessary for staff to access in case of a change in the resident's condition. This resident, who was cognitively intact, had a completed MOLST form indicating specific treatment preferences, but it was found in an old chart and not accessible to staff. The resident's current physician's orders did not reflect the MOLST form, leading to a discrepancy in the resident's documented treatment preferences. For another resident, the facility failed to ensure that the physician's orders matched the resident's current MOLST. The resident's MOLST indicated a DNR and DNI status, with some sections left blank, while the physician's orders included instructions that were not aligned with the MOLST, such as allowing hospital transport and the use of non-invasive ventilation. This inconsistency between the MOLST and the physician's orders could lead to confusion regarding the resident's treatment preferences.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for a resident, leading to the development of pressure ulcers. The resident, who was admitted with no pressure ulcers but was at risk due to conditions such as COPD, chronic kidney disease, and diabetes, had a CNA document redness on the buttocks. However, a licensed nurse did not complete a necessary skin assessment following this observation, and the assessment was not re-attempted after being initially refused by the resident. This lack of timely assessment and intervention resulted in the development of multiple Stage 2 pressure ulcers on the resident's buttocks and coccyx. Additionally, the facility did not follow through on a community physician's recommendation for a therapeutic air mattress to prevent pressure ulcers. The recommendation was not reviewed with the facility physician, and the resident continued to use a standard mattress. This oversight occurred despite the resident's history of pressure ulcers and inability to frequently change positions, which increased the risk of skin breakdown. The facility's failure to adhere to its own policies for skin assessment and to implement recommended preventative measures contributed to the resident's development of pressure ulcers. The lack of communication and follow-up regarding the community physician's recommendation for an air mattress further exemplifies the deficiencies in care provided to the resident.
Failure to Provide Appropriate Dementia Care
Penalty
Summary
The facility failed to provide appropriate treatment and interventions for three residents diagnosed with dementia, impacting their physical, mental, and psychosocial well-being. Resident #72, who had dementia with behavioral disturbance and Alzheimer's disease, was observed making undignified statements towards Resident #63. Despite having a care plan that required staff to modify the environment and intervene before agitation escalated, staff did not take action to guide Resident #72 away from the source of distress or engage them in a calming activity. Resident #63, diagnosed with dementia with behavioral disturbance and agitation, expressed a desire to disengage from an activity and requested to use the bathroom, but staff did not respond promptly. The resident's care plan required staff to anticipate and meet their needs, yet during a group activity, the resident repeatedly called out and expressed distress without staff offering to remove them from the situation or provide an alternative activity. Additionally, when the resident requested to use the bathroom, staff present in the room did not respond, leaving the resident to continue expressing their need without assistance. Resident #94, with dementia and Parkinson's disease, attempted to stand from their wheelchair multiple times, indicating a need to move or use the bathroom. Despite staff being aware that standing often meant the resident wanted to move, they did not make eye contact or ask questions to determine the resident's needs. The resident's care plan required staff to use simple, directive sentences and ask yes/no questions, but these interventions were not offered timely, resulting in the resident being left without appropriate assistance.
Medication Administration Error for Resident with ESRD
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors during the medication pass process. Specifically, for one resident with End Stage Renal Disease (ESRD) and dependence on renal dialysis, the staff did not administer Sevelamer, a phosphate binder, as required. The medication was supposed to be given with meals to control high blood phosphorus levels, but it was administered without food, contrary to the physician's orders and the facility's medication administration policy. During an observation, a nurse administered the Sevelamer medication to the resident without ensuring it was taken with food, despite the resident's indication that it should be taken with meals. The nurse was unaware of the requirement to administer the medication with food and admitted to not reading the medication instructions. The unit manager confirmed that the nurse should have reviewed the medication instructions and listened to the resident's input.
Inaccurate Documentation of Advanced Directives and Code Status
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, specifically regarding the documentation of advanced directives and code status. The resident, who was admitted with diagnoses including altered mental status, malignant neoplasm of the prostate, and hypertensive chronic kidney disease, had a Health Care Proxy (HCP) invoked temporarily due to moderate incapacity for medical decision-making. However, the facility did not follow up on the invocation, and the MOLST form was signed by the HCP without proper authorization. Additionally, the facility's Dialysis Transition of Care Form, which serves as a communication tool between the facility and the dialysis center, contained inconsistent and inaccurate documentation of the resident's code status. The form showed discrepancies in the resident's code status over several dates, with entries alternating between DNR, Full Code, and being left blank. This inconsistency in documentation could lead to confusion regarding the appropriate response in the event of a cardiac emergency during dialysis.
Infection Control Deficiencies on Cedar and Birch Units
Penalty
Summary
The facility failed to adhere to infection control standards on two units, Birch and Cedar, leading to potential transmission of communicable diseases. On the Cedar Unit, a resident on Enhanced Barrier Precautions (EBP) was not properly attended to by staff using the required Personal Protective Equipment (PPE). During a wound observation, the Unit Manager did not wear gloves or a gown while handling the resident, despite the care plan indicating the necessity of such precautions. The Infection Preventionist confirmed that the expectation was for staff to wear a gown and gloves during such care activities. On the Birch Unit, the facility did not ensure proper disinfection of glucometers between uses on multiple residents. During a medication administration observation, a nurse failed to sanitize the glucometer after use, placing it back in the carrying case without cleaning it with the facility-approved disinfecting bleach wipes. The Director of Nursing later confirmed that the nurse should have used bleach wipes instead of alcohol wipes, as the latter were not the approved method for disinfecting the glucometer, potentially contaminating the carrying case and medication cart.
Failure to Offer Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that pneumococcal vaccinations were offered to three residents who were eligible and not up-to-date with their vaccinations. This deficiency was identified during a survey where it was found that the facility did not adhere to its own policy, which required assessing residents for vaccination eligibility upon admission and offering the vaccine within 30 days unless contraindicated or already vaccinated. The policy also mandated that vaccination status be assessed within seven working days of admission. Resident #72, admitted in December 2023 with dementia, had not been offered an updated pneumococcal vaccine despite being eligible, as their last PPSV23 vaccination was in 2005. The Infection Preventionist (IP) confirmed that the resident's vaccination was not up-to-date and could not provide evidence that an updated vaccination had been offered. Similarly, Resident #33, admitted in April 2023 with a cerebrovascular accident, had not been offered an updated pneumococcal vaccine after receiving PCV13 in 2019. The IP was unaware of this resident's vaccination status. Resident #2, admitted in June 2023 with dementia, also had not been offered an updated pneumococcal vaccine after receiving PCV13 in 2014. The IP acknowledged that this resident's vaccination was not up-to-date and could not provide evidence of an offer for an updated vaccination. The facility did not provide any additional evidence to the survey team regarding the vaccination status of these residents at the time of the survey exit.
Failure to Educate Residents on COVID-19 Vaccine Risks and Benefits
Penalty
Summary
The facility failed to provide education regarding the benefits and potential risks associated with COVID-19 vaccines for three residents, leading to a deficiency in their vaccination process. Specifically, the facility did not provide education on the risks, benefits, and potential side effects of the COVID-19 vaccine to three residents prior to vaccine administration. Resident #33, who was admitted with a diagnosis of cerebrovascular accident, received COVID-19 vaccinations without documented evidence of prior education. Similarly, Resident #2, diagnosed with dementia, was administered a COVID-19 vaccination without documented education on the associated risks and benefits. Resident #81, admitted with a lower leg fracture, was not provided with education on the risks and benefits of additional COVID-19 vaccination doses, despite being offered an updated booster. The facility's policy requires that residents or their legal representatives be informed about the benefits and potential side effects of vaccinations before administration, and that this education be documented in the resident's medical record. However, interviews with the Infection Preventionist (IP) revealed that the facility did not have a process for using consent forms and relied on verbal consent, which was not documented. The IP admitted to the lack of evidence for providing the necessary education to the residents or their representatives, resulting in a failure to comply with the facility's vaccination policy. The survey team did not receive any additional evidence from the facility to support that the required education was provided to the residents involved.
Inaccurate MDS Coding for Vaccinations and Catheter Use
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) assessments for four residents, leading to deficiencies in the documentation of their health status. For three residents, the MDS assessments inaccurately indicated that their Pneumococcal Vaccinations were up to date, despite records showing that the vaccinations were outdated. Specifically, one resident's last vaccination was in 2005, another in 2019, and the third in 2014. These inaccuracies were identified during interviews with the Infection Preventionist and the MDS Coordinator, who acknowledged the errors and noted that the information was auto-populated from the immunization documentation in the residents' records. Additionally, the facility failed to accurately document the type of urinary catheter in use for another resident. The MDS assessment incorrectly marked the presence of both an indwelling and an external catheter due to an error made by a CNA during the look-back period. This error was transferred to the MDS without proper review and correction before submission. The MDS Coordinator confirmed the mistake during a follow-up interview, highlighting the need for thorough review of documentation before finalizing assessments.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,282 citations issued within 25 miles in the last 12 months — including the 4 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Natick
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Riverbend Of South Natick | 1.5 mi | ★★★★★ | 3 | 0 |
| Beaumont Rehab & Skilled Nursing Ctr - Natick | 1.7 mi | ★★★★★ | 1 | 0 |
| Eliot Center For Health And Rehabilitation | 2.2 mi | ★★★★★ | 1 | 0 |
| Adviniacare Newton Wellesley | 2.5 mi | ★★★★★ | 11 | 0 |
| Royal Wayland Rehabilitation And Nursing Center | 2.8 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Mary Ann Morse Nursing & Rehabilitation.
100% money-back within 48 hours.
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.