Above average — CMS composite of the measures below.
The next survey window likely opens around April 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 Neville Center At Fresh Pond For Nursing & Rehab during CMS and state inspections, most recent first.
Kitchen food storage, food handling, and dish sanitizing practices were not maintained. Surveyors observed expired and undated food items, personal drinks stored with kitchen stock, a beard not covered in the prep area, and multiple staff handling RTE food, plates, trash lids, and utensils with bare or contaminated gloved hands without proper hand hygiene. Staff also did not consistently check or document sanitizer PPM at the 3-bay sink.
Failure to Provide Timely Podiatry Foot Care: A resident with DM, neuropathy, and abnormal toenail growth was supposed to receive routine podiatry follow-up and had long, thickened toenails that were curling inward. The resident said nursing was asked for podiatry visits but the resident was not seen when the podiatrist came to the building, and staff confirmed the resident should have been on the podiatry list but was missed.
A resident had Levothyroxine left in a medication cup on the overbed table while unsupervised, even though there was no self-administration assessment or signed form on file. Staff interviews confirmed the medication should not have been left at the bedside and that the nurse was expected to stay until the dose was taken, yet the MAR documented it as administered.
Failure to Honor Food Allergies, Intolerances, and Preferences: Two residents were served foods and beverages that did not match documented allergies, intolerances, and preferences. One cognitively intact resident with wheat and lactose issues was served French toast, bacon, a cookie containing wheat and milk, and eggs with cheese despite stated dislikes and intolerance. Another resident ordered a vegan diet and no dairy, yet was repeatedly given half and half creamers containing milk on meal trays; the resident said the creamers were unwanted and would cause diarrhea.
Kitchen equipment was not kept in safe operating condition when the grease trap in the main kitchen was observed overflowing with buildup and odor, with records showing the last service had been months earlier despite monthly service being expected. The three-bay sink also had broken drain handles that staff had propped up with toilet plungers to stop leaking, and the floor around the sink was wet while staff reported the handles had been broken for a long time and the dishwasher had been breaking down intermittently.
Two residents with a history or presence of heel pressure ulcers did not receive physician-ordered heel offloading devices while in bed, despite documentation indicating otherwise. Staff were unaware of the residents' needs and misunderstood the orders, resulting in the residents being observed without booties and with heels directly on the mattress. No refusals or clinical justifications were documented for not following the prescribed interventions.
Two residents experienced deficiencies in nutrition and hydration management when staff failed to follow protocols for significant weight loss and fluid restriction. One resident with chronic kidney disease and dysphagia had a notable weight loss without required re-weighing or notification of the RD or MD, while another with heart failure received fluids above the prescribed limit without physician notification or documentation of non-compliance.
A resident with a PICC line did not receive dressing changes as ordered by the physician, with the dressing remaining unchanged for 19 days and part of it lifting, exposing the catheter. Nursing staff documented the dressing changes as completed in the TAR when they had not been performed, and there was no documentation explaining the missed care. The facility's policy for weekly sterile dressing changes was not followed.
Surveyors found that opened insulin and IV emergency kits on two units were not properly documented or reordered from the pharmacy after use. Staff were unable to confirm when the kits were accessed or if replacements had been requested, in violation of facility policy requiring immediate reordering and documentation.
Nursing staff did not date multiple opened bottles of eye drops on a medication cart, contrary to facility policy and manufacturer guidelines. Both nursing and administrative staff confirmed that opened medications should be dated, but this was not done for several medications observed during the survey.
Two residents with orders for PICC dressing changes, heel booties, and padded side rails did not receive these interventions as ordered, yet nursing staff documented them as completed in the medical record. Observations and interviews confirmed that the interventions were not implemented, and there was no documentation of refusal or rationale for non-compliance.
A resident with an activated Health Care Proxy and signed consent for the COVID-19 vaccine did not receive the vaccine upon admission. The Unit Manager was waiting for a vaccination clinic, unaware of the facility's policy allowing immediate administration. The resident later tested positive for COVID-19, highlighting a failure in the facility's vaccination process.
The facility failed to provide a dignified dining experience for residents on the 3rd floor unit, as observed by surveyors who noted that meals were served on institutional trays during breakfast and lunch. This was confirmed by a unit manager, indicating a violation of residents' rights to a dignified existence.
A resident with multiple fall risk factors, including Parkinson's disease and orthostatic hypotension, was admitted without a baseline care plan to address their fall risk. Despite a fall risk assessment indicating moderate risk, the care plan was not created until weeks after admission, following a fall incident. The discrepancy in the care plan's creation and initiation dates was noted, with staff unable to explain the delay.
A resident admitted with malnutrition, kidney disease, and depression was found to have only two carious teeth and expressed a need for dental care, which was not addressed in their care plan. Despite being cognitively intact and having mild dysphagia due to poor dentition, the facility failed to include a dental care plan. Staff interviews confirmed the oversight and discrepancies in the admission assessment.
A resident with epilepsy was found with unpadded side rails, contrary to physician orders, after being moved to a new room. Staff were unaware of the need for padded rails, indicating a communication lapse. The DON acknowledged the oversight.
A surveyor observed a lapse in medication security on the second floor unit when an expired bottle of liquid Trazodone was left unsecured on the nursing station desk. The medication was unattended for almost 10 minutes, despite being near a common area hallway where a resident was passing by. Unit Manager acknowledged the oversight but left the medication unsecured again, indicating a failure to adhere to the facility's policy on securing medications.
The facility failed to provide timely dental care for two residents, resulting in deficiencies in oral health management. One resident with broken teeth and lost dentures did not receive a dental consultation, impacting their ability to chew and swallow. Another resident required new dentures, but the facility did not follow up on the dentist's recommendation for fabrication, despite initial consultations and communication with the resident's financial power of attorney.
The facility failed to maintain accurate medical records for two residents. One resident's dental status was inaccurately documented, leading to an incorrect MDS. Another resident's side rails were not padded as required after a room change, despite physician orders and care plans. Staff were unaware of the need for padded side rails, and the Treatment Administration Record inaccurately indicated they were padded.
Kitchen Food Storage, Hand Hygiene, and Sanitizer Monitoring Failures
Penalty
Summary
Food storage and handling practices in the kitchen were not maintained in accordance with professional standards. During the initial walkthrough, surveyors observed an open box of 15 dozen unpasteurized eggs dated 2/25/26 with a manufacturer sell-by date of 3/26/26 and 53 eggs remaining, a container of seafood salad opened and dated 4-26, an opened and undated container of coleslaw in the walk-in refrigerator, an opened box of frozen cinnamon French toast that was not frozen, an opened half-empty can of energy drink and an opened half-empty bottle of soda in the walk-in refrigerator, an opened and undated container of half and half, and an opened box of chocolate sprinkles dated opened 5/12/25 that was stored in dry storage with the top open to air. The Foodservice Director stated these items should have been dated, discarded, or not stored with kitchen stock food items. Food preparation practices also showed staff handling ready-to-eat food with contaminated hands and gloves and not using beard coverings. During lunch tray line observation, a dietary aide with a visible beard approximately one inch long was preparing fruit cups without a beard net. The same dietary aide used bare hands to move a food cart, handled the inside of fruit bowls, picked up a can of mixed fruit, held the can while scooping fruit into bowls, and touched the inside of plastic lids used to cover the fruit cups without washing hands. Another dietary aide made sandwiches with gloved hands, then touched plastic wrap, sandwiches, stickers, refrigerator doors, bowls, knives, watermelon, and other food-contact surfaces while continuing to use the same contaminated gloves. The cook and another dietary aide were also observed repeatedly touching trash can lids with bare hands, handling plates, pans, scoops, stove dials, steam tray lids, and food with bare or contaminated gloved hands without performing hand hygiene between tasks. The Foodservice Director stated staff should wash hands before putting on new gloves, after removing gloves, and should not touch food with contaminated bare hands or gloves. The facility also failed to consistently monitor and document the chemical sanitization station used for dishwashing. The manufacturer’s guidelines for the three-bay chemical sanitization station indicated the sanitizer should be used at the proper concentration and that PPM should be checked with each use. Surveyors observed kitchen staff washing dishes in the three-bay sink, but there were no documented sanitization PPM readings in the Pot Sink Log, and a kitchen staff member stated he did not check the PPM. The last documented sanitization PPM testing in the log was 6:00 P.M. on 5/10/26, and there was no indication that testing occurred after that time. The Foodservice Director stated the sanitization bays needed to be tested and documented with each use to ensure the range was appropriate for sanitizing dishes.
Failure to Provide Timely Podiatry Foot Care
Penalty
Summary
Provide appropriate foot care was not ensured for one resident with diabetes and multiple foot-related diagnoses. Resident #74 was admitted with type 2 diabetes mellitus, weakness, and age-related osteoporosis, and the most recent MDS indicated the resident was cognitively intact and required substantial to maximal assistance with personal care. The resident had consented to podiatry services, and the physician had ordered that the resident may be evaluated and treated by podiatry. The resident’s diabetic care plan included referral to a podiatrist/foot care nurse to monitor and document foot care needs and to cut long nails. The podiatry notes from prior visits documented onychomycosis, hallux valgus, diabetic peripheral neuropathy, atherosclerosis of the extremities, onychodystrophy, and a history of hyperkeratosis, with follow-up to occur as medically necessary but no sooner than 60 days. During observation and interview, the resident stated the toenails were long and needed to be cut, said the resident had asked nursing staff to be seen in April and May but was not, and reported having diabetes. The toenails were observed to be thickened and multiple nails were curling inward toward the bottoms of the feet. Facility staff confirmed the resident should have been seen by podiatry because the resident is diabetic and is seen every 60 days, but the resident was not on the list for the podiatry visit when the podiatrist was in the building and was not seen. Later, the resident again stated the toenails were sore and long and that the resident had been asking to see podiatry because the resident was not seen when the podiatrist was in the building.
Medication Left at Bedside Without Supervision
Penalty
Summary
Medications were not stored and administered as required for one resident when a medication cup containing two Levothyroxine tablets was observed left on the resident’s overbed table while the resident was unsupervised. The resident said the overnight nurse had left the pills for morning use, but the resident had not yet taken them when the surveyor observed them at the bedside. The facility policy stated staff should not leave medications unattended and should observe the resident’s consumption of medications during administration. The resident was admitted with diagnoses including vascular dementia, cognitive communication deficit, and anxiety disorder, but the most recent MDS indicated the resident was cognitively intact with a BIMS score of 15. Review of the resident’s records did not show criteria for self-administration of medications at the bedside, and staff interviews confirmed the resident did not have a self-administration assessment or signed form on file. The MAR showed the Levothyroxine was documented as administered at 6:00 A.M., while staff interviews stated the medication should not have been left at the bedside, nurses were to remain with the resident until the medication was taken, and the medication should not have been documented as given if it was not.
Failure to Honor Food Allergies, Intolerances, and Preferences
Penalty
Summary
The facility failed to consistently accommodate resident food allergies, intolerances, and preferences for two residents. The facility policy stated residents may have input into menu planning and select meals on a regular basis. Interviews with the DON and dietitian indicated that allergies, intolerances, and preferences should be followed, while the FSD stated she met with new admissions to review likes and dislikes. One resident was admitted with dysphagia, multiple sclerosis, and severe protein-calorie malnutrition, and had a cognitive score indicating intact cognition. Records listed allergies/intolerances including wheat, dairy, coffee, and lactose, along with dislikes such as no bacon, no sausage, no yogurt, no milk, no red meat, no white sugar or bread, and no pasta. During observations, the resident was served gluten free French toast and bacon despite documented dislikes, a packaged cookie that contained wheat and milk, and scrambled eggs with cheese and creamers despite lactose intolerance. The resident stated he/she did not eat bread or bacon, did not always get desired alternatives, and said cheese caused coughing and the stomach could not handle the cookie. A second resident, admitted with severe protein-calorie malnutrition, weakness, and ataxia, had orders for a vegan diet and documentation of no dairy/lactose intolerance. The tray ticket stated not to serve dairy of any kind, yet the resident was observed receiving half and half creamers containing milk on multiple occasions at breakfast and lunch. The resident stated he/she was vegan, did not want the creamers, and said using them would cause diarrhea. The FSD stated it was the facility’s practice to place creamers on all residents’ trays, including this resident’s, despite the intolerance.
Kitchen Grease Trap and Three-Bay Sink Not Maintained in Safe Operating Condition
Penalty
Summary
The facility failed to keep kitchen equipment in safe operating condition when the grease trap in the main kitchen was not maintained according to the manufacturer’s recommendations and was observed overflowing with a thick buildup and odor around the three-bay sink area. The surveyor observed the floor under and around the sink covered with a dark, thick substance extending to the pipes and coming out of the grease trap container. A kitchen staff member said the grease trap and under-sink area had looked like that for a while, and the Food Service Director stated the grease trap was supposed to be cleaned monthly by the Maintenance Director, but the last documented service was in March 2026. Record review showed the most recent grease trap service invoice documented grease, water, and sludge in the trap and recommended drain cleaning and preventative maintenance. The Board of Health grease trap maintenance log also showed the last documented service was in March 2026, with monthly service having been done up until that point. During interviews, the Food Service Director said the facility had not had the drain cleaned as recommended and did not know why the consultant company had not returned. The Administrator later stated he was not aware the grease trap had not been cleaned and said it should have been serviced and emptied monthly. The facility also failed to keep two bays of the three-bay sink in safe operating condition. The surveyor observed toilet plungers propped against the drain handles under the first wash sink bay and the third sanitize sink bay, and the floor under and around the sink was wet and appeared to be leaking. Staff said the handles had been broken for a while and water was often on the floor. The Food Service Director stated the drain stems were loose and needed replacement because they kept draining and leaking, and staff had used plungers to prop up the handles so dishes could be cleaned because the high temperature dishwasher had been breaking down intermittently.
Failure to Implement and Document Pressure Ulcer Prevention Interventions
Penalty
Summary
The facility failed to provide necessary treatment and interventions to promote healing and prevent new pressure ulcers for two residents. For one resident with a left heel pressure ulcer and severe cognitive deficits, physician orders required the use of bilateral booties and offloading of the left heel while in bed. Despite these orders, the resident was repeatedly observed in bed with heels directly on the mattress and without booties, and there was no documentation of refusal or rationale for not implementing the interventions. Staff interviews revealed a lack of awareness regarding the resident's wound and misunderstanding of the physician's orders, with some staff believing the interventions were only required during the night shift. Another resident, who had a history of a heel pressure ulcer and was dependent on staff for footwear, also had a physician order for wearing Prevelon boots while in bed. This resident was observed multiple times in bed without booties and with heels on the mattress, and no booties were visible in the room. The resident reported not being offered booties for a long time and expressed willingness to wear them if provided. Staff interviews indicated a lack of awareness and incorrect assumptions about when the interventions were required, with documentation inaccurately reflecting that the interventions were implemented every shift. In both cases, the facility's documentation on the Treatment Administration Record indicated that the prescribed interventions were carried out, but direct observation and staff interviews contradicted this. There was no evidence of resident refusal or clinical justification for not following the physician's orders, and staff were not consistently aware of the residents' needs or the specifics of the orders. The facility's failure to implement and accurately document the required interventions led to the deficiency.
Failure to Maintain Nutrition and Hydration Status for Two Residents
Penalty
Summary
The facility failed to maintain the nutrition and hydration status of two residents by not following established protocols for monitoring and responding to significant changes in weight and fluid intake. For one resident with chronic kidney disease and dysphagia, there was a significant weight loss of over 10% between two recorded weights. Despite facility policy requiring re-weighing and notification of the Registered Dietician (RD) and physician for such discrepancies, the medical record did not show that these steps were taken. The RD acknowledged that the weight discrepancy may have been overlooked due to the resident moving floors, but confirmed that follow-up was still required. For another resident with heart failure and chronic respiratory failure, the facility did not adhere to a physician's order for a 1000 ml fluid restriction per 24 hours. Documentation showed that the resident consistently received more fluids than ordered, with daily intakes ranging from 1,100 to 1,200 ml. Facility policy required that any non-compliance with fluid restrictions or changes in the resident's condition be recorded and reported to the physician, but there was no evidence in the medical record that the physician was notified of the excess fluid intake. Interviews with staff confirmed that the established protocols for monitoring and reporting significant weight changes and fluid restriction compliance were not followed. The failures included not validating significant weight loss with a re-weigh and not notifying the appropriate clinical staff, as well as not documenting or reporting fluid intake above the prescribed limit to the physician.
Failure to Perform Timely PICC Dressing Changes per Physician Order
Penalty
Summary
The facility failed to provide care and maintenance of a peripherally inserted central catheter (PICC) in accordance with professional standards and physician orders for one resident. The resident, who was admitted with diagnoses including sepsis and urinary tract infection and was cognitively intact, had a physician's order for weekly routine PICC dressing changes and as-needed changes. Despite this, the PICC dressing was observed to be 19 days old, with part of the dressing lifting and exposing the catheter to air. The resident reported that the dressing had only been changed twice since readmission, and there was no documentation in the nursing progress notes explaining why the dressing was not changed as ordered. Review of the Treatment Administration Record (TAR) showed that nurses documented the dressing change as completed on two occasions when it had not been done. Interviews with nursing staff confirmed that the dressing had not been changed according to the schedule, and staff were unable to provide a rationale for the missed care. The facility's policy required weekly sterile dressing changes using aseptic technique, but this was not followed for the resident in question.
Failure to Replace and Document Use of Emergency Medication Kits
Penalty
Summary
The facility failed to ensure pharmaceutical services met the needs of each resident by not properly managing emergency medication kits on two out of three units. During inspection, an opened insulin kit was found in the second-floor medication room refrigerator with some contents missing. There was no documentation indicating what had been removed, when it was removed, or who had removed the items. Additionally, there was no evidence that the kit had been reordered from the pharmacy for replacement. Staff interviewed were unable to confirm when the kit was accessed or if it had been reordered, despite facility policy requiring immediate reordering upon opening. A similar issue was observed on the third floor, where an intravenous (IV) emergency kit was found opened with some contents removed. Again, there was no documentation regarding the removal of items, and staff were unaware of when the kit was accessed or if it had been reordered. The facility's policy states that emergency kits should be exchanged or replenished by the pharmacy as needed, and staff interviews confirmed that kits should be reordered immediately after being opened. However, these procedures were not followed, resulting in a failure to meet the pharmaceutical needs of residents.
Failure to Date and Store Opened Medications per Policy
Penalty
Summary
Surveyors observed that nursing staff failed to ensure medications were dated upon opening and stored according to manufacturer’s guidelines, as required by facility policy and professional standards. During an inspection of a medication cart, two bottles of Lumigan eye drops, one bottle of pilocarpine eye drops, one bottle of latanoprost eye drops, and one bottle of timolol eye drops were found opened and undated. Interviews with a nurse and the Regional Director of Clinical Education and Administration confirmed that nurses are responsible for dating eye drops when opened and that this procedure was not followed in these instances.
Inaccurate Documentation and Failure to Implement Physician Orders for Pressure Injury and Safety Interventions
Penalty
Summary
The facility failed to accurately document and implement physician orders for two residents, resulting in multiple instances of inaccurate medical recordkeeping. For one resident with a history of sepsis, urinary tract infection, and diabetes, nurses documented that a peripherally inserted central catheter (PICC) dressing change was completed on two occasions when it had not been performed. Observations revealed that the PICC dressing had not been changed for 19 days, despite orders for weekly changes. The resident confirmed the dressing had only been changed twice since readmission, and staff interviews corroborated that documentation was inaccurate. Additionally, the same resident had physician orders for the use of heel booties while in bed and for padded side rails due to a seizure disorder. Despite these orders, the resident was repeatedly observed in bed without booties or offloaded heels, and the side rails were not padded. The resident stated that booties and side rail pads had not been offered or used for a long time, and staff confirmed that these interventions were not implemented as ordered. Nevertheless, nursing staff documented in the Treatment Administration Record (TAR) that these interventions were completed every shift, with no documentation of refusal or rationale for non-implementation. A second resident, with chronic kidney disease, diabetes, and severe cognitive deficits, also had physician orders for bilateral heel booties and offloading of heels while in bed. This resident was observed multiple times in bed without booties or offloaded heels, and the booties were not within reach. The resident reported not being offered the booties and experiencing discomfort from a heel wound. Staff interviews indicated a misunderstanding of the order's requirements, and the TAR reflected that the interventions were documented as completed every shift, despite not being implemented and without any record of refusal or explanation.
Failure to Administer COVID-19 Vaccine to Resident
Penalty
Summary
The facility failed to administer the COVID-19 vaccine to a resident who had an activated Health Care Proxy and had given signed consent for the vaccination upon admission. The resident, who was admitted in September 2024, had a medical history that included moderate dementia, cognitive communication deficit, and other health issues. Despite the signed consent form dated 09/03/24, the resident did not receive the vaccine and subsequently tested positive for COVID-19 on 11/06/24. The Unit Manager was aware of the signed consent but was waiting for a COVID-19 Vaccination Clinic to be scheduled at the facility to administer the vaccine. This was part of the Unit Manager's practice to hold onto consent forms until a clinic was scheduled. However, the Unit Manager was not familiar with the facility's COVID-19 Vaccination Policy and Procedures, which did not require waiting for a clinic to administer the vaccine. The Director of Nursing (DON) was informed on 11/18/24 that the resident had not received the vaccine despite the signed consent. The DON expected the Unit Manager to have obtained a physician's order, ordered the vaccine, and administered it without delay. The facility had the capability to obtain and administer the vaccine at any time, and there was no need to wait for a vaccination clinic. This oversight led to the resident not receiving the vaccine in a timely manner, increasing their risk of infection.
Lack of Dignified Dining Experience for Residents
Penalty
Summary
The facility failed to provide residents with a dignified dining experience on the 3rd floor unit. Surveyors observed that during breakfast and lunch meals on two consecutive days, residents were served on institutional trays in the dining room. This practice was confirmed during an interview with Unit Manager #1, who stated that all meals are served on trays in the dining rooms. The observations and interview indicate a lack of attention to providing a dignified dining experience for the residents, which is a violation of their rights to a dignified existence and self-determination.
Failure to Develop Timely Fall Risk Care Plan
Penalty
Summary
The facility failed to develop a baseline care plan for a resident who was at moderate risk for falls, as identified in their fall risk assessment. The resident, admitted in July 2024, had multiple diagnoses including difficulty in walking, ataxia, repeated falls, Parkinson's disease, syncope, and orthostatic hypotension. Despite these conditions, there was no baseline care plan or specific interventions documented to manage the resident's fall risk. The resident experienced a fall on July 8, 2024, but no injuries were reported. However, the absence of a care plan to address the fall risk was noted during a surveyor's review of the resident's records. The surveyor found that the falls care plan was created on July 23, 2024, although it was documented to have been initiated on the resident's admission date, July 7, 2024. The MDS Director and Unit Manager #3 were unable to explain the discrepancy in the care plan's creation and initiation dates. Unit Manager #3 stated that the fall risk assessment should have triggered the creation of a baseline falls care plan, but the goals section did not auto-populate, leading to a delay in the care plan's completion. This oversight resulted in the resident not having a comprehensive plan to address their fall risk upon admission.
Failure to Develop Dental Care Plan for Resident
Penalty
Summary
The facility failed to develop a dental care plan for a resident who was admitted with diagnoses including malnutrition, kidney disease, and depression. The resident, who was cognitively intact, was observed to have only two carious top teeth and expressed a desire to see a dentist, mentioning that their partial plates were lost during the move to the facility. Despite these observations and the resident's expressed needs, the care plan initiated shortly after admission did not include any plan for addressing dental care. Further review of the resident's records revealed that the resident had missing or broken teeth and mild dysphagia due to lack of dentition, as noted in a nutrition/hydration assessment and speech therapy evaluations. The speech therapy notes indicated that the resident was not safe for a diet texture upgrade due to the absence of a lower denture, which was not found in the resident's mouth or room. Interviews with facility staff, including a unit manager and an MDS nurse, confirmed the absence of a dental care plan and highlighted discrepancies in the admission nursing assessment.
Failure to Pad Side Rails for Resident with Seizure Disorder
Penalty
Summary
The facility failed to ensure a safe environment for a resident with a seizure disorder by not padding the side rails of the resident's bed as ordered by the physician. The resident, who has a diagnosis of epilepsy and intact cognition, was observed on multiple occasions with unpadded side rails, despite physician orders and care plan interventions requiring padded side rails to prevent injury. The resident had recently been moved to a new room, and the side rail pads were not transferred to the new bed. Certified Nurses Assistants and a nurse confirmed that they were unaware of the requirement for padded side rails, indicating a lapse in communication and adherence to physician orders. The Director of Nurses and Assistant Director of Nurses acknowledged the oversight, attributing it to the room change and the failure to move the side rail pads. This deficiency highlights a failure in following established procedures to prevent accidents for residents at risk.
Medication Security Lapse on Second Floor Unit
Penalty
Summary
The facility failed to secure medication on the second floor unit, as observed by a surveyor. During the inspection, Nurse #1 was seen removing an expired bottle of liquid Trazodone from the refrigerator in the unit's locked medication room and handing it to Unit Manager #2. The Unit Manager then placed the medication on the nursing station desk, which was located near the common area hallway. This action left the medication unsecured and unattended, as there were no staff present at the desk or in the vicinity, and a resident was observed walking past the nursing station with a rehabilitation therapist. The surveyor noted that the Trazodone remained on the desk for almost 10 minutes without supervision. When Unit Manager #2 returned to the nursing station, she acknowledged that the medication should have been secured or attended to by nursing staff. Despite this acknowledgment, the Trazodone was again left unsecured and unattended when Unit Manager #2 left the nursing station. The surveyor observed this repeated oversight, highlighting the facility's failure to adhere to its policy of securing medications, which requires that drugs and biologicals be stored in locked compartments.
Failure to Provide Timely Dental Care for Residents
Penalty
Summary
The facility failed to provide timely dental care for two residents, leading to deficiencies in their oral health management. Resident #87, who was admitted with conditions including malnutrition, kidney disease, and depression, had broken and carious teeth and lost lower dentures. Despite a consent for dental services being signed in May 2024, the resident had not received a dental consultation by July 2024. Observations and interviews revealed that the resident expressed a desire to see a dentist, and the lack of dentures was impacting their ability to chew and swallow safely, as noted in speech therapy assessments. Resident #89, admitted with cancer, heart disease, and anxiety, required new dentures as recommended by a dentist in March 2024. Although the resident's care plan included coordinating dental care, and consent for services was obtained in April 2024, the facility did not follow up on the dentist's recommendation for denture fabrication. Interviews indicated that the facility had not pursued the status of the denture refabrication, despite the dentist's initial consultation and communication with the resident's financial power of attorney regarding costs.
Inaccurate Medical Records and Equipment Oversight
Penalty
Summary
The facility failed to maintain accurate medical records for two residents, leading to deficiencies in their care. For one resident, the nursing admission assessment inaccurately documented the dental status, stating there were no oral issues, despite observations and assessments indicating missing and carious teeth. This discrepancy was confirmed by the MDS nurse, who acknowledged that the admission nursing assessment was incorrect, resulting in an inaccurate MDS. For another resident, the facility failed to document the presence of side rail pads after a room change. Despite physician orders and care plans indicating the need for padded side rails due to a seizure disorder, observations revealed that the side rails were not padded. Certified Nurses Assistants were unaware of the requirement, and the Treatment Administration Record inaccurately indicated that the side rails were padded. Interviews with facility staff, including the Director of Nurses and Assistant Director of Nurses, confirmed that the resident's medical record was not accurately documented. The staff failed to ensure the transfer of necessary equipment, such as side rail pads, during the room change, leading to inaccurate documentation in the medical records.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 1,144 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Cambridge
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sancta Maria Nursing Facility | 0.4 mi | ★★★★★ | 11 | 0 |
| Watertown Rehabilitation And Nursing Center | 1.5 mi | ★★★★★ | 19 | 0 |
| Belmont Manor Nursing Home, In | 2.3 mi | ★★★★★ | 13 | 0 |
| Cambridge Rehabilitation & Nursing Center | 2.4 mi | ★★★★★ | 4 | 0 |
| Spaulding Nursing And Therapy Center - Brighton | 2.4 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 August 2026) and official state health department websites.