Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Masconomet Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
Improper food storage and contaminated glove use during meal service were observed in the kitchen and nourishment areas. Surveyors found moldy onions, raw bacon stored above milk, uncovered and undated food items, expired tea packets, and opened milk and thickened juice without opened dates. During breakfast prep, a cook touched equipment and raw eggs with gloved hands and then used the same gloves to handle ready-to-eat quiche, toast, and pancakes for resident plates.
Hand Roll Not Maintained as Ordered: A resident with hemiplegia, impaired cognition, and upper-extremity contractures had a physician order for a left-hand roll to be in place at all times except during ADLs, but repeated observations found the device absent. The care plan did not include the hand roll intervention, the resident said staff only applied it when asked, and CNA and nursing interviews showed inconsistent awareness and documentation of the order.
A resident with dementia, severely impaired cognition, repeated falls, and total ADL dependence had a physician order for safety floor mats beside the bed while in bed. Surveyors observed the mats not in place on multiple occasions, with both mats leaning against a wall at one point and one mat folded up at another. Staff and the DON confirmed the mats should be in place whenever the resident was in bed, and the resident had previously had an unwitnessed fall in the room.
Oxygen therapy and nebulizer equipment were not managed as ordered for two residents. One resident with pulmonary fibrosis, pneumonia, and acute respiratory failure with hypoxia was observed receiving O2 above the ordered 2 L/min, and another resident with chronic respiratory failure with hypoxia was also observed on 3 L/min instead of 2 L/min. For the second resident, nebulizer tubing was undated and the mask was stored outside the respiratory bag, contrary to staff-described infection control practices and the resident’s orders.
Opened medications were found undated in a medication cart, including inhalers, a nasal solution, and a liquid protein supplement. An RN, a unit manager, and the DON all stated the medications should have been dated when opened, but they were observed without dates in the Gould unit cart.
Failure to Use Enhanced Barrier Precautions for Chronic Wound Care: A resident with dementia and a chronic stage 3 heel pressure ulcer did not have EBP reflected in the order or care plan, and surveyors observed no precaution sign or cart at the doorway. A CNA provided morning care and an RN and UM performed wound care without precaution gowns, while the CNA, RN, UM, DON, and infection control nurse stated they were unaware chronic wounds required EBP.
A resident with dementia and moderate cognitive impairment had a court-appointed Conservator responsible for managing finances. The facility failed to send required quarterly financial statements to the Conservator, instead sending them to a family member not legally responsible for the resident's finances.
A resident with anxiety and dementia was prescribed Valproic Acid, a psychotropic medication, but the facility did not create a care plan addressing its use, monitoring, or potential adverse effects. Nursing staff and management acknowledged the absence of such a care plan and gaps in staff knowledge regarding monitoring for adverse effects.
The facility did not follow physician orders for weekly skin checks for a resident at high risk for pressure ulcers, resulting in a missed assessment and subsequent identification of a new pressure wound. Additionally, physician orders for air mattress settings were not followed for two other residents.
A resident's oxygen concentrator and filter were found with visible dust and powder, despite facility policy and physician orders requiring weekly cleaning and tubing changes. Documentation indicated the tasks were completed, but direct observation by surveyors and confirmation from the unit manager and DON revealed the equipment was not properly maintained.
A resident with an anxiety disorder was receiving PRN psychotropic medications, and the consultant pharmacist recommended a 14-day re-evaluation for one of the medications. Although the physician agreed and requested the re-evaluation, the order was not updated in the medical record as required by facility policy. Interviews confirmed that such recommendations should be implemented promptly, but this was not done.
The facility failed to follow professional standards for weight management by not conducting reweights for a resident with significant weight changes. Despite the resident's notable weight fluctuations and medical conditions, required reweights were not documented, hindering clinical decision-making.
Improper food storage and contaminated glove use during meal service
Penalty
Summary
The facility failed to store, label, date, and handle food in accordance with professional food service standards. In the main kitchen walk-in refrigerator, surveyors observed two bins of onions on the bottom shelf with multiple yellow onions covered in a green and white substance resembling mold, a case of raw bacon stored on a middle shelf above a case of milk, an opened blue bag of hard-boiled eggs loosely secured with plastic wrap and exposed to air, and eight loaves of baked sweet bread on a sheet pan that were undated and exposed to air. In the dry storage area, surveyors also found a case of nectar-thick tea packets with a use-by date of 10/23/25. Additional observations showed improperly dated and stored ready-to-eat foods and beverages. In a reach-in refrigerator, surveyors found a container of egg salad that was halfway full and dated 3/2/26, and a container of chicken salad that was halfway full and dated 3/7/26. In the first-floor nourishment kitchen refrigerator, surveyors observed an opened carton of Lactaid milk that was halfway full with a best-by date of 1/26/26 and no opened date, and an opened bottle of Thick and Easy nectar-thick apple juice that was halfway full with a best-by date of 1/22/26 and no opened date. The Food Service Director stated that all food and beverage items should be marked with received and opened dates, that moldy or rotten items should be discarded immediately, and that opened or prepared foods should be discarded after two days. The facility also failed to prevent contaminated glove use during food preparation and service. During breakfast service, a cook touched an oven handle with gloved hands, removed a whole quiche by flipping it into his gloved hands, sliced it, and placed the pieces on resident plates. Using the same gloves, he then handled ready-to-eat toast and placed it on resident plates. On another observation, the cook grabbed shelled eggs with gloved hands, cracked them into a pan, touched the pan handle, then touched the steamer handle to retrieve ready-to-eat pancakes, and continued using the same gloves to handle pancakes for resident plates. The Food Service Director stated that staff should use a utensil or glove when touching ready-to-eat food and should change gloves when contaminated, such as after touching equipment handles or raw eggs.
Hand Roll Not Maintained as Ordered
Penalty
Summary
The facility failed to ensure Resident #91’s ordered hand roll was in place as prescribed by the physician. Resident #91 was admitted in November 2024 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left dominant side. The most recent MDS indicated moderately impaired cognition, functional limitations in range of motion in both upper extremities, and dependence on staff for ADLs. The active physician’s order directed that a hand roll be placed in the left hand at all times, with removal allowed for ADLs and skin inspection every shift, starting 4/1/25. Review of the care plans showed ADL and chronic pain plans, but no intervention addressing the hand roll, including refusal or removal of the device. Therapy documentation noted severe contracture to the left upper extremity and right lower extremity, and the quarterly assessment documented pain during movement and care due to contractures. During multiple observations on 3/10/26, 3/11/26, and 3/12/26, the resident was seen in bed without the hand roll in place or nearby. The resident stated staff did not put the hand roll in unless asked and that he/she often forgot to ask. CNA #2 said she was not aware of the hand roll order, Nurse #5 stated the hand roll should be in place at all times except during care, and the DON stated the hand roll should be in place and refusals should be documented.
Failure to Keep Ordered Fall Mats in Place
Penalty
Summary
A resident with dementia, anxiety disorder, repeated falls, severely impaired cognition, and dependence on staff for ADLs had a physician’s order for safety floor mats next to the bed while in bed, with placement to be checked every shift. The resident’s falls care plan and Kardex also identified fall mats at the bedside as an intervention. The resident had an unwitnessed fall in the room and was found on the fall mat beside the bed during the investigation. During later survey observations, the resident was seen in bed with the fall mats not in place as ordered: on one occasion both mats were leaning against a wall, and on another occasion one mat was in place while the other was folded up and leaning against a wall. Staff interviews confirmed that the mats should be in place whenever the resident was in bed and that if staff moved them during care or feeding, they were expected to return them afterward. The DON also stated that the fall mats should be in place whenever the resident was in bed.
Oxygen Therapy and Nebulizer Equipment Not Managed as Ordered
Penalty
Summary
Respiratory care was not provided in accordance with physician orders for two residents who were receiving oxygen therapy. The facility’s policy required verification of a physician order for oxygen administration and observation of the resident to ensure oxygen was being tolerated. For Resident #67, who was admitted with idiopathic pulmonary fibrosis, pneumonia, and acute respiratory failure with hypoxia and was cognitively intact, the record showed an order for continuous oxygen via nasal cannula at 2 liters per minute. During multiple observations, the oxygen concentrator was found set above the ordered rate, including 3 liters per minute and later 2.5 liters per minute, while the resident stated the baseline setting was 2 liters per minute and that staff had decreased it after the resident thought 3 liters was too high. Nursing staff and the DON stated the oxygen should have been set at the ordered 2 liters per minute. For Resident #112, who was admitted with chronic respiratory failure with hypoxia and was also cognitively intact, the record showed an order for oxygen via nasal cannula at 2 liters per minute as needed to keep oxygen saturation above 90%. During observations, the oxygen concentrator was set at 3 liters per minute, and the resident stated he/she should be on 2 liters of oxygen and did not adjust the settings. A nebulizer machine was observed on top of the resident’s drawer, with undated tubing and the nebulizer mask stored next to a plastic food container, a glass vase, and a box of gloves. The resident was also observed inhaling medication via the nebulizer mask while the oxygen concentrator remained set at 3 liters per minute. The resident’s orders also included ipratropium-albuterol nebulizer treatments and a respiratory bag change order requiring the bag to be changed and dated. Staff interviews confirmed that oxygen should be administered as ordered, nebulizer tubing should be changed weekly and dated, and nebulizer masks should be stored in respiratory bags. The DON stated that oxygen should be administered at the ordered setting and that using the wrong oxygen setting could lead to carbon dioxide retention.
Opened medications were left undated in a medication cart
Penalty
Summary
Drugs and biologicals were not stored in accordance with State and Federal laws because medications that had been opened were not dated according to manufacturer guidelines in one of three medication carts observed. During an observation of the Gould unit medication cart, the surveyor and Nurse #1 found one opened and undated Fluticasone Furoate inhaler, one opened and undated Spiriva Handihaler inhaler, one opened and undated Ipratropium Bromide nasal solution, and one opened and undated liquid protein supplement. The facility policy titled "Medication Labeling and Storage" stated that labeling of medications and biologicals dispensed by the pharmacy must be consistent with applicable federal and state requirements and currently accepted pharmaceutical practices, and that multi-dose vials not opened or accessed are discarded according to the manufacturer's expiration. During interviews, Nurse #1, Unit Manager #1, and the DON each stated that medications should have been dated when opened.
Failure to Use Enhanced Barrier Precautions for Chronic Wound Care
Penalty
Summary
The facility failed to ensure transmission-based precautions were followed for a resident with a chronic stage 3 pressure ulcer. The resident was admitted in February 2024 with diagnoses including malnutrition and dementia, and the most recent MDS dated 1/14/26 showed a BIMS score of 4 out of 15 and a stage 3 pressure ulcer. The medical record identified a left heel pressure ulcer, stage 3, with an onset date of 8/4/25, indicating the wound had been present for more than seven months. The resident’s physician’s order and plan of care for 3/1/26-3/12/26 did not indicate enhanced barrier precautions. Surveyors observed no precaution sign or precaution cart at the resident’s doorway on multiple occasions. On 3/11/26, a CNA assisted the resident with morning care without wearing a precaution gown, and on 3/12/26, a nurse and unit manager removed a soiled wound dressing and applied a new dressing to the resident’s left heel without wearing precaution gowns. During interviews, the CNA, nurse, unit manager, DON, and infection control nurse stated they were unaware that chronic wounds required enhanced barrier precautions, and the infection control nurse stated the resident should have had enhanced barrier precautions implemented but did not.
Failure to Provide Quarterly Financial Statements to Resident's Conservator
Penalty
Summary
The facility failed to provide required quarterly financial statements to the legally appointed Conservator of a resident with a Personal Needs Account (PNA). The resident, who was admitted in April 2023 and has a diagnosis of dementia with moderate cognitive impairment, was assigned a Conservator by court decree on 12/21/23. Despite this legal appointment, the facility's Business Office Manager continued to send the resident's quarterly financial statements to a family member who was not legally responsible for the resident's finances. During interviews, the Business Office Manager acknowledged that the statements should have been sent to the Conservator, as she was legally responsible for the resident's financial affairs. The Conservator confirmed that she had not received any quarterly statements from the facility since her appointment. This failure to provide the required financial information to the appropriate legal representative constituted the deficiency identified during the survey.
Failure to Develop Care Plan for Psychotropic Medication Use
Penalty
Summary
The facility failed to develop and implement a comprehensive, resident-centered care plan for one resident who was prescribed a psychotropic medication, specifically Valproic Acid, for anxiety and dementia. Physician orders indicated the use of this mood stabilizer, but the resident's care plan did not include any focus, goals, or interventions related to the medication. Interviews with nursing staff revealed a lack of knowledge regarding monitoring for adverse effects of psychotropic medications, and it was acknowledged by both nursing staff and management that a care plan addressing psychotropic medication use and its potential adverse effects was absent.
Failure to Follow Physician Orders for Skin Checks and Air Mattress Settings
Penalty
Summary
The facility failed to follow professional standards of practice for three residents by not adhering to physician orders. For one resident with diagnoses including osteoarthritis and failure to thrive, the facility did not complete a weekly skin check as ordered by the physician. The resident was identified as high risk for developing pressure ulcers, and documentation showed that skin checks were performed on two dates in July, but there was no record of a skin check for the week in between. The absence of this documentation was confirmed by both the medical record and nursing progress notes. Additionally, the same resident was later found to have developed a left heel pressure wound, which was documented during the next recorded skin check. The unit manager confirmed the missing skin check and was unable to locate any related documentation in the nursing progress notes. The report also notes that the facility failed to follow physician orders for air mattress settings for two other residents, but specific details for those cases are not included in the provided excerpt.
Failure to Maintain Clean Respiratory Equipment
Penalty
Summary
The facility failed to maintain respiratory equipment according to professional standards of practice for one resident who required oxygen therapy. Observations by the surveyor revealed that the oxygen concentrator and its filter had a visible layer of gray dust and powder, indicating they were not cleaned as required. The facility's policy and the resident's physician order both specified that the oxygen concentrator, including the filter, should be cleaned and the tubing changed weekly. Despite documentation on the Treatment Administration Record indicating that these tasks were completed, direct observation showed that the equipment remained dirty. Both the unit manager and the Director of Nursing confirmed that the equipment should have been cleaned weekly, but it was not done as required.
Failure to Implement Pharmacy Recommendation for PRN Psychotropic Medication
Penalty
Summary
Facility staff failed to implement a pharmacy recommendation for a resident who was admitted with an anxiety disorder. The facility's policy requires staff to act upon all recommendations from the consultant pharmacist regarding medication regimen review irregularities. The consultant pharmacist identified that the resident was receiving PRN psychotropic medications, specifically Trazadone and Clonazepam, and recommended that if therapy was to continue beyond 14 days, a medical justification and a specified duration for the PRN order should be documented in the progress note. The physician responded in agreement and requested a new order to include a 14-day re-evaluation for Clonazepam. However, review of the medical record did not show that a 14-day re-evaluation for Clonazepam was added to the physician order as recommended. Interviews with the unit manager and the DON confirmed that pharmacy recommendations should be implemented promptly, typically within 24-48 hours after the physician addresses them. Despite this, the required re-evaluation was not documented, resulting in non-compliance with the facility's medication regimen review policy.
Failure to Conduct Reweights for Significant Weight Changes
Penalty
Summary
The facility failed to follow professional standards for weight management for one resident. Specifically, the facility did not conduct reweights for weights outside of acceptable parameters as per their policy. The policy required reweights to be conducted within 24 hours if a resident's weight changed by three or more pounds from the prior weight. However, for Resident #101, reweights were not obtained on multiple occasions when significant weight changes were noted. This resident had a history of Type 2 diabetes mellitus, sepsis, and dysphagia, and was cognitively intact with a BIMS score of 15 out of 15. The resident experienced notable weight fluctuations, but the required reweights were not documented in the medical record on several dates, including 1/27/24, 2/10/24, 2/20/24, 3/6/24, 3/19/24, and 4/2/24. The Registered Dietician and the Director of Nursing (DON) confirmed that the facility's policy was not followed. The Registered Dietician stated that she relies on accurate weight records to make clinical decisions and interventions. The DON also emphasized that weights should be done on admission, weekly for the first four weeks, and reweights should be conducted and recorded if there is a weight change of three pounds or more. The failure to document reweights and include risk notes in the medical record hindered the ability to make informed clinical decisions for Resident #101, who was experiencing weight loss despite consuming a significant portion of meals and snacks.
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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 Topsfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hunt Nursing & Rehab Center | 4 mi | ★★★★★ | 21 | 0 |
| Hathorne Hill Rehabilitation And Healthcare Center | 4 mi | ★★★★★ | 14 | 0 |
| Twin Oaks Center | 4.1 mi | ★★★★★ | 0 | 0 |
| Brentwood Rehabilitation And Healthcare Ctr (the) | 4.8 mi | ★★★★★ | 6 | 0 |
| Ledgewood Rehabilitation And Nursing Center | 5.5 mi | ★★★★★ | 0 | 0 |
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