Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 New England Homes For The Deaf, Inc during CMS and state inspections, most recent first.
Surveyors observed improper food storage in facility refrigerators, including multiple unlabeled and undated food and beverage items, as well as expired products. Additionally, a staff member was seen handling residents' food and dinnerware with bare hands in the dining room, such as touching dinner rolls and straws directly. Both the DON and Foodservice Director confirmed these practices did not meet professional standards.
Staff did not maintain resident dignity during feeding, as a staff member was observed standing over a resident in a Broda chair and in bed while assisting with meals, contrary to facility policy and confirmed expectations by the unit manager and DON.
A resident with severe cognitive impairment was prescribed Seroquel, an antipsychotic, and the invoked Health Care Proxy was provided with an informed consent form that incorrectly listed the risks and benefits for an antidepressant rather than an antipsychotic. Nursing staff confirmed the error, resulting in the HCP not being fully informed about the medication's actual risks and benefits.
A resident with severe cognitive impairment and high fall risk was observed with foam wedges used as a fall intervention, but staff did not complete a restraint assessment for their use. Facility staff confirmed the absence of a restraint assessment and could not provide a restraint policy.
A resident with a cardiac pacemaker did not have a comprehensive, individualized care plan addressing their device, as required by facility policy. The medical record lacked essential pacemaker details such as the serial number, device type, paced rate, and cardiologist contact information. Staff interviews confirmed the omission of this information from the care plan and medical record.
Two residents did not receive care according to professional standards: one did not have a nurse practitioner's order for Zofran implemented after experiencing nausea and vomiting, and another had an air mattress in use without physician orders specifying the required settings, despite being at high risk for pressure ulcers. Nursing staff and management confirmed these omissions.
Two residents did not receive care in accordance with provider recommendations and professional standards: one did not receive a recommended oral antibiotic after IV therapy for osteomyelitis due to lack of communication between nursing staff and providers, and another did not have a urine specimen collected or provider notified after repeated failed attempts, resulting in transfer to the ER for acute cystitis.
A resident with multiple respiratory diagnoses was repeatedly observed receiving supplemental oxygen therapy without a physician's order, contrary to facility policy and professional standards. Nursing staff and leadership confirmed that an order is required, but none was found in the resident's records, care plan, or administration logs.
The facility failed to regularly inspect bed frames for potential entrapment risks, specifically in Zone 7, for all residents' beds. A resident with severe cognitive impairment was found with an inadequate bed bolster, creating a visible gap and entrapment risk. The facility's documentation of bed inspections was outdated, and staff confirmed that checks were only conducted annually.
A resident with multiple diagnoses, including deafness, blindness, and psychosis, had an incomplete MOLST form lacking the required provider's signature in section H, rendering the form invalid despite the resident's elected DNR status.
A facility failed to follow privacy and confidentiality policies when a Unit Manager used a personal cell phone to photograph a resident's wound. The incident was reported by a Social Worker and confirmed by multiple staff members, but no photo was found on the unit cell phone, raising concerns about the use of personal devices for clinical photography.
The facility failed to develop a care plan for a resident with PTSD and did not implement the falls care plan for another resident with severe cognitive impairment. The PTSD care plan was missing, and fall mats were not placed as required, leading to deficiencies in care.
The facility failed to ensure a resident's oxygen concentrator filter was free of significant dust. The resident, with asthma and congestive heart failure, had a care plan that did not reference their asthma or oxygen therapy. The Unit Manager and facility staff were unaware of the dusty filter, relying on a vendor for maintenance, and lacked a policy for filter maintenance.
A resident's wheelchair was found to be in disrepair, with missing and broken parts, despite the resident reporting the issue to staff months prior. Interviews revealed a lack of communication and responsibility among staff regarding the maintenance of the wheelchair.
Failure to Follow Food Storage and Handling Standards
Penalty
Summary
The facility failed to adhere to proper food storage and handling practices as observed during a survey. In the kitchen, multiple food and beverage items were found in both the walk-in and reach-in refrigerators without labels or dates, including carafes of liquids, containers of juice, milk, soy milk, Lactaid milk, thickened juice, soda, chocolate whipped cream, and various prepared foods such as tuna salad, coleslaw, and baked beans. Some containers were labeled but had use-by dates that had already passed. The Foodservice Director confirmed that all opened food and drink containers should be labeled with their contents and date, and discarded after three days. In the second-floor dining room, a staff member was observed handling residents' food and dinnerware with bare hands. Specifically, the staff member touched dinner rolls with bare hands while spreading butter and opened straws by touching the area where residents would place their mouths. Both the Director of Nursing and the Foodservice Director stated that staff should not directly touch residents' food or dinnerware with bare hands. These actions were directly observed by the surveyor and confirmed as not in accordance with professional standards of food service safety.
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
Staff failed to treat a resident with dignity during mealtimes by not sitting at eye level while assisting with feeding. Observations showed a staff member standing over a resident in a Broda chair during lunch and again standing over the same resident while feeding them in bed at breakfast. The facility's policy requires residents to be treated with dignity and respect at all times. Both the unit manager and the Director of Nursing confirmed in interviews that staff should not be standing over residents when providing feeding assistance.
Failure to Provide Accurate Informed Consent for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that the Health Care Proxy (HCP) for one resident with severe cognitive impairment was provided with accurate information regarding the risks and benefits of an antipsychotic medication. The resident, who had diagnoses including dementia, deafness, cognitive communication deficit, and major depressive disorder, was determined to lack capacity to make health care decisions, and the HCP was invoked. The resident was prescribed Seroquel, an antipsychotic, for symptoms such as agitation and delusional thinking. Upon review, the informed consent form signed by the HCP listed the purpose of the medication as treatment for major depressive disorder and included risks and benefits associated with antidepressant medications, not antipsychotics. Interviews with nursing staff confirmed that Seroquel is an antipsychotic and that the consent form contained incorrect information regarding the medication's risks and benefits. This error resulted in the HCP not being fully informed about the specific risks and benefits of the antipsychotic medication being administered.
Failure to Assess Foam Wedges as Potential Restraint
Penalty
Summary
The facility failed to assess the use of foam wedges as a potential physical restraint for a resident with severe cognitive impairment, dementia, legal blindness, deafness, and schizophrenia. The resident was identified as a high fall risk, with a history of attempting to crawl out of bed and tossing legs over the side. Observations showed the resident in bed with foam wedges on both sides, and documentation indicated the wedges were used as a fall intervention. However, there was no evidence in the resident's assessments that a restraint assessment had been completed for the use of these foam wedges. Interviews with nursing staff, the unit manager, and the DON confirmed that the foam wedges were used as a fall prevention measure, but staff had not conducted a restraint assessment for their use. Additionally, the facility was unable to provide a policy related to restraints. The lack of a restraint assessment and policy for the use of foam wedges constituted the deficiency identified during the survey.
Failure to Develop Comprehensive Care Plan for Resident with Pacemaker
Penalty
Summary
The facility failed to develop and implement a comprehensive, resident-centered care plan for a resident with a cardiac pacemaker. According to the facility's own policy, specific information regarding the pacemaker—including the cardiologist's contact information, type of pacemaker, type of leads, manufacturer and model, serial number, date of implant, and paced rate—should be documented in the medical record and on a pacemaker identification card upon admission. However, a review of the resident's electronic and paper medical records, as well as physician's orders and care plans, revealed that none of this required information was present. The resident had a history of acute and chronic respiratory failure with hypoxia, pneumonia, chronic obstructive pulmonary disease, and the presence of a cardiac pacemaker, and was assessed as having intact cognition. Interviews with facility staff, including a nurse, unit manager, and the Director of Nursing, confirmed that the resident's medical record lacked essential pacemaker-related information. Staff acknowledged that the care plan should have included details such as the serial number, type of device, paced rate, cardiologist information, and a method for monitoring and transmitting pacemaker data to the appropriate physician. The absence of this information constituted a failure to meet the facility's policy and regulatory requirements for comprehensive care planning for residents with pacemakers.
Failure to Implement Medication Orders and Specify Air Mattress Settings
Penalty
Summary
The facility failed to follow professional standards of nursing practice for two residents. For one resident with dementia and dysphagia, a nurse practitioner documented an as-needed order for Zofran to address nausea and vomiting. However, review of the physician's orders and medication administration record showed that the order for Zofran was not implemented. Nursing staff did not enter the order, and the unit manager was unaware of the nurse practitioner's note. The resident subsequently experienced further gastrointestinal symptoms, including diarrhea and emesis, without the ordered medication being available. For another resident with chronic obstructive pulmonary disease, reduced mobility, and severe cognitive impairment, the facility did not specify the required settings for the resident's air mattress in the physician's order, despite the resident being at high risk for pressure ulcers. Observations showed the air mattress was set to certain firmness and cycle time levels, but the physician's order and care plan only indicated the need for an air mattress without detailing the appropriate settings. Interviews with nursing staff and management confirmed that the order should have specified the mattress settings to ensure proper care.
Failure to Communicate Provider Recommendations and Obtain Timely Specimens
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards for two residents. For one resident with a history of extradural and subdural abscess, osteomyelitis, and sepsis, the infectious disease provider recommended discontinuing IV antibiotics and starting an oral antibiotic regimen. However, after the resident returned from the appointment, nursing staff did not notify the medical doctor or nurse practitioner of the new medication recommendation. As a result, no new order for the oral antibiotic was initiated, and the resident did not receive the recommended medication. Multiple staff interviews confirmed that the recommendation was not communicated, and the resident was not on any antibiotics at the time of the survey. For another resident with mild cognitive impairment, heart failure, and sensory deficits, a care plan meeting was held after a fall and increased confusion, leading to an order for a urine analysis with culture and sensitivity to test for a possible urinary tract infection. The order was documented in the paper record, but the urine specimen was not obtained over several days, as the resident remained in bed or was otherwise unavailable. Nursing notes repeatedly indicated the inability to collect the specimen, but there was no documentation that the nurse practitioner or physician was notified of the failure to obtain the sample. The resident subsequently experienced another fall, was sent to the emergency department for evaluation of mental status changes, and was treated for acute cystitis. Staff interviews confirmed that the lack of timely notification to the provider about the uncollected urine specimen was a deviation from expected practice. Both the unit manager and DON acknowledged that the provider should have been informed after a few days of unsuccessful attempts to collect the specimen, which might have prevented the resident's transfer to the emergency department.
Oxygen Therapy Administered Without Physician Order
Penalty
Summary
The facility failed to provide respiratory care services in accordance with professional standards of practice for one resident who was observed receiving supplemental oxygen therapy without a physician's order. The resident, admitted with acute and chronic respiratory failure with hypoxia, pneumonia, chronic obstructive pulmonary disease, and a cardiac pacemaker, was noted multiple times over two days to be receiving oxygen via nasal cannula at varying flow rates. Despite these observations, there was no active physician's order for oxygen therapy in the resident's medical record, Kardex, or medication and treatment administration records. Facility policy requires verification of a physician's order prior to administering oxygen, and this was confirmed by interviews with nursing staff and facility leadership, all of whom acknowledged that an order is necessary. The resident's care plan referenced oxygen therapy as ordered, but no such order was present. Nursing progress notes documented the administration of oxygen, but this was not supported by a corresponding physician's order, indicating a failure to follow established protocols for respiratory care.
Failure to Regularly Inspect Bed Frames for Entrapment Risks
Penalty
Summary
The facility failed to regularly inspect bed frames to identify areas of potential entrapment, specifically in Zone 7 (the space between the mattress and the foot of the bed) for all 27 residents' beds. This deficiency was evidenced by the inadequate bed bolster provided for a resident with a traumatic brain injury and severe cognitive impairment. Observations revealed a visible gap between the bolster and the mattress, creating a potential entrapment risk. The resident's bed rail assessment and care plan did not address this entrapment zone, and the facility's documentation of bed inspections was outdated, with the most recent records from 2021. Interviews with the Maintenance Director and Unit Manager confirmed that bed entrapment checks were only conducted annually, and there was no recent documentation of these inspections. The Unit Manager acknowledged the inadequacy of the bolster and the entrapment risk it posed. The Administrator was unable to explain why the entrapment zone sheets had not been updated since 2021. This lack of regular inspection and documentation led to the failure to identify and mitigate the entrapment risk for the resident.
Incomplete MOLST Form for Resident
Penalty
Summary
The facility failed to accurately complete a Medical Orders for Life Sustaining Treatment (MOLST) form for a resident with diagnoses including deafness, blindness, and psychosis. The resident, represented by a legal guardian, had elected Do Not Resuscitate (DNR) status, along with Do Not Intubate or Ventilate, and Do Not Hospitalize. However, the MOLST form was found to be invalid as it lacked the required provider's signature in section H, which is necessary to verify the information accurately reflects the discussion with the guardian. This deficiency was identified during a review of the resident's medical records and confirmed in an interview with the Unit Manager.
Violation of Privacy and Confidentiality Policies
Penalty
Summary
The facility failed to ensure staff implemented policies and procedures related to personal privacy and confidentiality for one resident. Specifically, a Unit Manager used a personal cell phone to take a picture of the resident's wound, which is against the facility's Clinical Photography Policy. The policy states that clinical photography should only be done with a completed Photography Consent Form and should not be taken on personal devices. The resident's health care proxy had consented to clinical photography, but the use of a personal phone was a clear violation of the policy. During a clinical meeting, the Unit Manager showed the photo of the resident's wound to the Director of Nursing (DON) and offered to show it to the Administrator, who declined. The Unit Manager made a joke about her husband not liking to see such photos, which was witnessed by the Social Worker and other staff members. The Social Worker reported the incident to Human Resources (HR), who then brought it to the attention of the Administrator and the DON. Despite reviewing the unit cell phone, no photos of the wound were found, raising concerns about the use of personal devices for clinical photography. Interviews with various staff members, including the Social Worker, HR Staff Person, DON, Rehab Director, and the Administrator, confirmed the incident. The Unit Manager denied taking the photo on her personal phone and claimed she was joking about her husband. However, the Rehab Director and Social Worker believed the photo was on a personal phone, as the phone used was white, unlike the facility's black phones. The Administrator and DON assumed the photo was taken on the unit cell phone but could not find any evidence of it. The incident highlights a breach of the facility's policy and the need for strict adherence to privacy and confidentiality protocols.
Failure to Develop and Implement Care Plans
Penalty
Summary
The facility failed to develop and implement a care plan for two residents, leading to deficiencies in their care. For Resident #81, who was admitted in May 2021 with a diagnosis of post-traumatic stress disorder (PTSD), the facility did not develop a care plan addressing this diagnosis. Despite the resident's Minimum Data Set (MDS) assessment indicating an active diagnosis of PTSD, no written care plan was created. This was confirmed during an interview with Unit Manager #1, who acknowledged that a care plan should have been developed for the PTSD diagnosis. For Resident #3, who has severe cognitive impairment and is dependent on staff for all activities of daily living (ADLs), the facility failed to implement the falls care plan. The resident's care plan and Kardex indicated the need for fall mats on each side of the bed due to a history of rolling out of bed and lack of safety awareness. However, observations on multiple occasions revealed that fall mats were not present in the resident's room. Interviews with staff, including a Certified Nursing Assistant and Unit Manager #1, revealed that the fall mats were forgotten during a recent room change, and the care plan interventions were not followed.
Failure to Maintain Clean Oxygen Concentrator Filter
Penalty
Summary
The facility failed to ensure the oxygen concentrator filter for a resident with asthma and congestive heart failure was free of significant dust. The resident, who was admitted in May 2021, had a care plan that did not reference their asthma or intermittent use of oxygen therapy. The resident's active physician orders required oxygen therapy to maintain blood oxygen saturation above 88%. The oxygen concentrator was last used on 3/4/24 for shortness of breath, and the resident had been hospitalized twice for shortness of breath in the past two months. On two separate occasions, the surveyor observed the resident's oxygen concentrator filter covered in dust. The Unit Manager was unaware of the dusty filter and stated that facility staff do not change or clean these filters, relying instead on a respiratory equipment vendor who visits weekly. The Administrator and Director of Nursing confirmed that the facility does not have a policy for oxygen concentrator filter maintenance and relies on the vendor for this task. They were unable to confirm the last time the filter was changed.
Failure to Maintain Safe Wheelchair for Resident
Penalty
Summary
The facility failed to ensure that Resident #18's wheelchair was in safe operating condition. Resident #18, who has diagnoses including deafness, blindness, and psychosis, reported the wheelchair's poor condition to nursing staff and the Maintenance Director two to three months prior to the survey. The wheelchair was observed to be missing the upper left chair handle, had exposed metal edges, a broken and loosely attached right armrest, and a stretched and scratched sling back fabric. Despite these reports, no action was taken to repair or replace the wheelchair, causing discomfort to the resident. Interviews with the Unit Manager, Rehabilitation Director, and Maintenance Director revealed a lack of communication and responsibility regarding the maintenance of the wheelchair. The Unit Manager was unaware of the wheelchair's condition, and the Rehabilitation Director stated that it was the responsibility of the staff who were informed or observed the issue to report it to the Maintenance Director. The Maintenance Director confirmed that he had not been informed about the wheelchair's condition and had not made any repairs. The Rehabilitation Director assessed the wheelchair and determined it needed to be replaced due to its broken components and age.
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What surveyors actually found near you
We read the 1,060 citations issued within 25 miles in the last 12 months — including the 2 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
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Danvers
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brentwood Rehabilitation And Healthcare Ctr (the) | 1.3 mi | ★★★★★ | 6 | 0 |
| Care One At Peabody | 1.6 mi | ★★★★★ | 10 | 0 |
| Pilgrim Rehabilitation & Skilled Nursing Center | 2.1 mi | ★★★★★ | 5 | 0 |
| Twin Oaks Center | 2.1 mi | ★★★★★ | 0 | 0 |
| Hunt Nursing & Rehab Center | 2.4 mi | ★★★★★ | 21 | 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.