Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 North End Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
Medication administration errors exceeded the allowed rate when two residents received several scheduled meds late. An LPN gave multiple 8:00 A.M. meds after the ordered time, including gabapentin, diltiazem, clopidogrel, Colace, and brimonidine, and another nurse gave Eliquis and torsemide late as well. Both nurses acknowledged the meds were not given within the required 1-hour window, and the DON confirmed meds must be administered within one hour of the ordered time.
Failure to Document Ordered Blood Sugar Monitoring: A resident with DM2, dementia, and an amputation had physician-ordered FSBS checks twice daily, but the eMAR showed multiple blank 6:00 A.M. entries over the review period. An RN stated he obtained the blood sugars but did not always enter them in the clinical record, and the ADON said the results were expected to be documented in the eMAR for provider review.
Failure to Identify and Document Bruise After Resident Fall: A resident with COPD and dementia, who had severe cognitive impairment and needed assistance with ADLs, was found on the floor after a fall. Surveyors later observed a large bruise on the right forehead/temple that staff had not identified or documented in the clinical record, and the nurse stated no one had reported the area to her. The DON said staff were expected to identify and report new bruises, but there was no documentation that the bruise had been recognized.
A resident with a suprapubic catheter, chronic urinary retention, and severely impaired cognition had catheter care that did not match the urology plan. Surveyors observed urine odor, a dark purple tube, and debris on the collection bag, while the record showed no documented catheter exchange for over 5 months despite an order for monthly and PRN changes. Staff and the DON stated the facility was not changing suprapubic catheters and there was confusion about where the exchange was supposed to occur.
A nurse with an expired CPR certification failed to immediately start CPR on a full code resident found unresponsive and pulseless, instead leaving the resident with a CNA while calling 911 and retrieving emergency equipment. The CNA did not begin CPR, resulting in a delay of life-saving measures, contrary to facility policy and AHA guidelines.
A nurse assigned to a full code resident was not current in CPR certification and had not completed the required annual CPR competency. When the resident was found unresponsive, the nurse initiated CPR and called 911, but emergency responders determined the resident may have expired about an hour earlier. The DON was unaware of the expired certification, and no mock code drills had been conducted in the past year. An audit during survey also found another nurse with an expired CPR certification.
Nursing staff did not consistently label and date enteral free water administration bags and tube feeding bottles, and in several cases, the amount of tube feeding administered did not match physician orders. Multiple residents with conditions such as malnutrition, dysphagia, and ventilator dependence were affected, with observations showing unlabeled bags and bottles and discrepancies in administered volumes. Facility policies lacked clear instructions on labeling, and the DON confirmed that proper labeling and adherence to orders were expected.
Two residents with cardiac pacemakers did not have individualized, comprehensive care plans that included required details such as device information, implant date, paced rate, frequency of checks, or cardiologist contact information. Nursing staff were unclear about the need to include these specifics, and the DON confirmed these omissions did not meet facility policy.
Two residents requiring ventilator or tracheostomy care did not receive respiratory tubing changes in accordance with physician orders or facility policy. Tubing was observed to be in use beyond the recommended interval, and staff interviews revealed inconsistent adherence to established protocols for changing respiratory equipment.
Staff failed to secure medication and treatment carts, leaving them unlocked and unattended on a unit. The surveyor was able to access these carts multiple times without staff intervention, despite staff walking by or being nearby. Facility policy and interviews confirmed that carts should be locked at all times when not in use.
Two residents experienced inaccurate medical record documentation: one had ventilator tubing changes recorded that did not occur, and another had conflicting tube feeding orders with nurses signing for both time frames. The DON confirmed that documentation did not accurately reflect care provided.
A resident with multiple comorbidities and severely impaired cognition, who was a full code, was found unresponsive and later pronounced deceased. The nurse who responded had an expired CPR certification and delayed initiating CPR while calling 911 and retrieving the crash cart. The DON was unaware of the expired certification and did not investigate the incident or complete required code documentation. The facility's process for reviewing unexpected deaths was not followed, and a subsequent audit revealed another staff member with an expired CPR certification.
The facility failed to identify and assess the use of pillows underneath a fitted sheet as a potential restraint for a resident with severe cognitive impairment. The resident was observed multiple times with pillows tucked under the fitted sheet to prevent rolling out of bed, but no restraint assessment was documented. The ADON and DON confirmed that this practice could be considered a restraint and that no assessment had been conducted.
The facility failed to develop and implement a care plan for a resident with an implantable cardioverter defibrillator (ICD). The resident's clinical record lacked information about the ICD, and the ADON was unaware of its presence, indicating a lapse in communication and documentation.
The facility failed to address suicide threats for a resident with severe cognitive impairment and did not follow a physiatrist's recommendations for therapy evaluations for another resident with Alzheimer's and a history of falling. These lapses indicate a failure to meet professional standards of nursing practice.
The facility failed to maintain accurate medical records for a resident with severe cognitive impairment, inaccurately documenting the replacement of a suprapubic catheter. The Director of Nurses confirmed that the facility staff do not perform these changes, and the resident goes to urology for the procedure.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure medications were administered in accordance with physician orders without errors for two of three residents observed receiving medications, resulting in a medication error rate of 28%. The facility policy stated medications are to be administered in accordance with prescribed orders and within one hour of the prescribed time unless otherwise specified. During observation on 4/29/26, surveyors watched two nurses administer 25 medication opportunities and found 7 medications were not given in accordance with the physician's orders. For one resident with orders for gabapentin 600 mg three times daily for neuropathy, diltiazem ER 300 mg daily for hypertension, clopidogrel 75 mg daily for cerebral infarction, Colace 100 mg twice daily for constipation, and brimonidine tartrate ophthalmic solution 0.2% twice daily, Nurse #1 administered medications that were scheduled for 8:00 A.M. later than ordered and acknowledged they were late. For another resident with orders for Eliquis 2.5 mg twice daily and torsemide 5 mg twice daily, Nurse #2 administered medications that were scheduled for 8:00 A.M. later than ordered and acknowledged they were late. Both nurses stated medications are required to be given within one hour of the prescribed time, and the DON stated nursing staff are required to administer medications within one hour of the physician's ordered time.
Failure to Document Ordered Blood Sugar Monitoring
Penalty
Summary
The nursing facility failed to provide standards of quality nursing practice for one resident with diabetes mellitus by not obtaining and recording blood sugar checks in accordance with the physician’s orders. Resident #69 was admitted in August 2024 and had diagnoses including dementia, acquired right leg amputation, and type 2 diabetes mellitus. The resident’s MDS indicated a Brief Interview for Mental Status score of 14 out of 15, showing the resident was cognitively intact, and also showed insulin had been administered during the last seven days. The resident was observed sitting in a wheelchair with the left leg wrapped in a dressing and the right leg amputated. The physician ordered finger stick blood sugar checks two times a day, and the MAR for 4/1/26 through 4/29/26 showed the 6:00 A.M. FSBS checks were blank on 9 of 29 days, including 4/6/26, 4/7/26, 4/19/26, 4/21/26, 4/22/26, 4/25/26, 4/27/26, and 4/28/26. During interview, Nurse #3 stated he obtained the 6:00 A.M. blood sugars and passed the results to the oncoming nurse, but did not always enter the results in the clinical record, and said that if blood sugars are not on the MAR, the monitoring cannot be validated. The ADON stated blood sugar results were expected to be in the electronic MAR and available for the nurse practitioner and doctor to review, and that the night nurse was responsible for the 6:00 A.M. checks.
Failure to Identify and Document Bruise After Resident Fall
Penalty
Summary
The facility failed to provide quality nursing care for one resident by not identifying a large bruise on the resident’s right forehead/temple after a fall. Resident #10 had diagnoses including COPD and unspecified dementia, and the most recent MDS indicated severe cognitive impairment and need for partial to moderate assistance with daily care. The facility’s Falls-Clinical Protocol stated staff, with physician guidance, would follow up on falls with associated injury until the resident was stable and delayed complications such as late fracture or subdural hematoma had been ruled out or resolved. Resident #10 was found on the floor near the closet after yelling for help, and the clinical record documented a fall with a skin tear to the left outer elbow. During multiple observations over several days, surveyors saw a dark purple/blue/yellowish discolored area on the right forehead/temple that was approximately the size of a silver dollar, and the resident stated he/she had fallen. The progress notes from the days after the fall did not identify the forehead discoloration, the physician’s orders did not include monitoring of the area, and Nurse #2 stated no staff had brought the bruise to her attention and she had not noticed it until the surveyor pointed it out. The DON stated she expected staff to identify and report new areas such as bruises and noted there was no documentation that staff identified the bruise on the resident’s right temple.
Failure to Change Suprapubic Catheter as Ordered
Penalty
Summary
The facility failed to ensure appropriate catheter care and to follow the urology medical plan for one resident with a suprapubic catheter. The resident was admitted in March 2022 with diagnoses including other obstructive and reflux uropathy and benign prostatic hyperplasia with lower urinary tract symptoms, and the most recent MDS indicated severely impaired cognition and use of an indwelling catheter. The care plan identified a suprapubic urinary catheter due to chronic urinary retention and stated the catheter was to be changed as clinically indicated and as ordered. The physician’s order called for replacement of the 14 Fr suprapubic catheter with a 10 cc balloon monthly and as needed, and a prior progress note documented the catheter being changed on 11/23/25 with a return in 4 to 6 weeks for the next change. Survey observations found the resident with a urine collection bag covered under the wheelchair, a stale odor of urine, a dark purple catheter tube, and white/brown substance and debris on the top of the collection bag. Review of the record showed no provider progress notes or TAR documentation indicating the suprapubic catheter had been changed after 11/23/25, and the catheter had not been changed in over 5 months. A urology note dated 4/1/26 described the urine in the bag and tubing as extremely cloudy and dark and stated the suprapubic catheter gets exchanged at the nursing facility. During interviews, nursing staff and the DON stated the facility was not currently changing suprapubic catheters and that the resident would need to go out to a clinic, urology, or interventional radiology for exchange; the DON also stated there was confusion regarding the urology provider’s note and could not explain why there was an order for catheter changes when the facility did not have a policy to provide that treatment.
Delayed CPR Initiation Due to Nurse's Actions and Lapsed Certification
Penalty
Summary
A deficiency occurred when a nurse failed to immediately initiate cardiopulmonary resuscitation (CPR) for a resident who was a full code and found unresponsive with no pulse. The nurse, whose CPR certification had expired, discovered the resident without signs of breathing or a pulse during a routine check. Instead of starting CPR right away, the nurse left the resident with a CNA, who was not instructed to begin CPR, while he went to call 911, page a code blue, and retrieve the crash cart. This sequence of actions resulted in a delay in the initiation of life-saving measures. Facility policy and American Heart Association guidelines require that CPR be started immediately upon finding an unresponsive individual with no pulse, unless a do-not-resuscitate (DNR) order is in place. The nurse did not follow these protocols, as he prioritized calling for help and gathering equipment over starting chest compressions. The CNA present did not begin CPR and was told to wait for the nurse to return. The Director of Nursing confirmed that the expectation was for the nurse to start CPR while the CNA called for help and retrieved equipment, but this did not occur. The resident involved had significant medical conditions, including chronic kidney disease, hypertension, and type 2 diabetes, and was documented as having severely impaired cognition. The resident was last seen alive a few hours before being found unresponsive. Emergency medical services arrived to find the resident with signs of prolonged downtime and pronounced the resident deceased. The nurse renewed his CPR certification approximately one month after the incident.
Failure to Ensure Nurse CPR Competency and Certification
Penalty
Summary
The facility failed to ensure that a nurse assigned to care for a resident with full code status was competent and certified to perform Cardiopulmonary Resuscitation (CPR) at the time of an emergency. The resident, who had severely impaired cognition and was unable to participate in a mental status exam, was found unresponsive and without a pulse. The nurse on duty initiated CPR and called 911, but it was later determined by emergency responders that the resident may have expired about an hour prior to their arrival. Review of records showed that the nurse's CPR certification had expired six months before the incident, and there was no documentation of completion of the required annual CPR competency. Interviews revealed that the Director of Nursing (DON) was unaware of the nurse's expired certification and acknowledged that the facility had not conducted any mock code drills in the past year, contrary to their stated policy. The DON also indicated that responsibility for tracking staff competencies and CPR recertification had lapsed due to recent staff departures in both the staff development and human resources departments. An audit conducted during the survey identified another nurse with an expired CPR certification. The Medical Director stated that it is expected for both the facility and individual nurses to ensure timely renewal of CPR certifications.
Failure to Label and Administer Enteral Feedings per Physician Orders
Penalty
Summary
Nursing staff failed to adhere to professional standards of practice for the administration of free water flushes and enteral tube feeding for six out of seven residents observed with tube feeds. Specifically, staff did not consistently label and date enteral free water administration bags and tube feeding bottles, as required for safe administration and monitoring. In several cases, the amount of tube feeding administered did not match the physician's orders, indicating a lack of compliance with prescribed nutritional regimens. For example, one resident with protein-calorie malnutrition, ventilator dependence, and muscle wasting had a water bag for free water flushes that was not labeled with the date hung. Another resident, also with protein-calorie malnutrition and ventilator dependence, had both an unlabeled water administration bag and discrepancies between the amount of tube feeding administered and the physician's order. Additional residents with diagnoses such as dysphagia, Alzheimer's disease, Guillain-Barre Syndrome, and amyotrophic lateral sclerosis were observed with either unlabeled tube feeding bottles, unlabeled free water administration bags, or both. In multiple instances, the volume of tube feeding delivered did not correspond to the prescribed rate and duration, as evidenced by the remaining volume in the bottles and the time elapsed since they were hung. The facility's policies on enteral nutrition and safety precautions did not specify requirements for labeling and dating tube feeding and free water administration bags, contributing to inconsistent practices among staff. During interviews, the DON confirmed that all enteral free water administration bags and tube feeding bottles should be labeled with the date, time hung, and prescribed rate of flow, and that nurses are responsible for ensuring the correct amount is administered as ordered. The observed deficiencies were based on direct observations, record reviews, and staff interviews.
Failure to Develop Comprehensive Pacemaker Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, individualized care plans for two residents with cardiac pacemakers. For one resident with chronic obstructive pulmonary disease and a pacemaker, the care plan did not include essential pacemaker information such as the make, model, serial number, implant date, paced rate, frequency of pacemaker checks, or cardiologist contact details. The resident was dependent on staff for daily activities and had an active diagnosis of a cardiac pacemaker, but the care plan lacked the required documentation and monitoring details as outlined in the facility's own policy. Similarly, another resident with an atrioventricular block and a pacemaker did not have a care plan that included the cardiologist's information, paced rate, or frequency of pacemaker checks. Interviews with nursing staff revealed uncertainty about the need to include specific pacemaker information in care plans, and the DON confirmed that such details should be present. The facility's failure to document and plan for the monitoring and care of residents with pacemakers was identified through record review and staff interviews.
Failure to Adhere to Respiratory Tubing Change Protocols
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care in accordance with professional standards of practice for two residents who required ventilator or tracheostomy care. For one resident with severe cognitive impairment and total dependence for activities of daily living, the tracheostomy tubing in use was observed to be dated more than three weeks prior, despite facility policy requiring tubing changes every seven days or as needed. There was no physician's order specifying the frequency of tubing changes for this resident, and staff interviews confirmed that tubing was changed on a set weekly schedule, not necessarily aligned with policy or physician orders. For another resident, also severely cognitively impaired and dependent on staff, ventilator tubing was observed to be in use beyond the weekly change interval specified in the physician's order. The care plan for this resident directed staff to keep respiratory equipment clean and change disposable equipment per facility policy, but the observed practice did not align with these directives. Interviews with staff and the DON confirmed that respiratory tubing should be changed per physician order or, if absent, per facility policy, but this was not consistently followed.
Unattended and Unlocked Medication and Treatment Carts
Penalty
Summary
Facility staff failed to store drugs and biologicals in accordance with State and Federal requirements, as well as the facility's own policy. Multiple observations were made on the fourth floor where medication and treatment carts were left unlocked and unattended. Specifically, a medication cart was found unlocked in the hallway without a nurse present, and the surveyor was able to access its drawers for four minutes without staff intervention. During this time, other staff members, including a certified nurse's aide and another staff member, passed by without addressing the unsecured cart. Additionally, several treatment carts were observed unlocked and unattended near the nurse's station and in the hallway. The surveyor was able to access these carts without interference, and staff, including the Admissions Director, walked by the unlocked carts multiple times without securing them. Interviews with nursing staff and the Director of Nursing confirmed that only authorized personnel should have access to these carts and that they are required to be locked at all times when not in use.
Inaccurate Medical Record Documentation for Respiratory and Enteral Care
Penalty
Summary
The facility failed to maintain accurate medical records for two residents. For one resident with severe cognitive impairment and ventilator dependence, the respiratory administration record indicated that ventilator tubing was changed on specific dates, but observation revealed the tubing had not been changed as documented. The respiratory therapist stated that tubing changes occurred weekly on Sundays, which did not align with the documentation. The Director of Nursing confirmed that documentation should only reflect actual changes performed according to physician orders. For another resident who was cognitively intact and dependent on staff for all activities of daily living, there were conflicting physician orders for enteral feeding times. The medication administration record showed that nurses signed off on both conflicting orders over several days, indicating inaccurate recordkeeping regarding the timing of tube feedings. The Director of Nursing acknowledged that only one time frame should have been documented, and the presence of conflicting orders led to inaccurate documentation.
Failure to Investigate and Monitor Adverse Event Following Resident Death
Penalty
Summary
The facility failed to implement effective adverse event monitoring and investigation processes, specifically in the case of a resident with chronic kidney disease, hypertension, and type 2 diabetes who was a full code. The resident, who had severely impaired cognition and could not participate in mental status exams, was found unresponsive and pulseless. The nurse on duty, whose CPR certification had expired six months prior, left the resident with a certified nursing aide to call 911, initiate a code blue, and retrieve the crash cart before starting CPR. Emergency responders later determined the resident may have expired about an hour before being found. The Director of Nursing (DON) was unaware that the nurse's CPR certification was expired and stated that responsibility for tracking certifications belonged to the Staff Development Coordinator and Human Resources, both of whom had recently left the facility. The DON had assumed their duties but had not yet filled the positions. Although a code sheet system was reportedly implemented to document code events, the sheet was not completed for this incident, and the DON did not conduct an investigation, stating that nothing in the medical record warranted further review. The DON was also unaware that CPR was not initiated immediately. The Administrator confirmed that the facility's process for unexpected deaths of full code residents included completing a code sheet and review by the DON and physician, but this was not done in this case. The Medical Director expected all staff to be recertified in CPR every two years and was notified of the incident, noting the death was not expected as the resident was not on hospice. During a facility-wide audit conducted during the survey, another staff member was found to have an expired CPR certification.
Failure to Assess Use of Pillows as Potential Restraint
Penalty
Summary
The facility failed to identify and assess the use of pillows underneath a fitted sheet as a potential restraint for a resident with severe cognitive impairment. The resident, who was admitted with diagnoses including dementia, spinal stenosis, and anxiety disorder, was observed multiple times with pillows tucked under the fitted sheet on both sides of the bed. This practice was intended to prevent the resident from rolling out of bed, as noted by a Certified Nursing Assistant (CNA). However, there was no documentation in the resident's medical record or plan of care indicating that a restraint assessment had been completed for this intervention. During interviews, the Assistant Director of Nurses (ADON) and the Director of Nurses (DON) confirmed that the use of pillows in this manner could be considered a restraint and that no assessment had been conducted. The facility's policy on the use of restraints requires a pre-restraining assessment and review to determine the need for restraints, which was not followed in this case. The DON also stated that staff had not been instructed to use pillows in this way for the resident.
Failure to Develop and Implement Care Plan for Resident with ICD
Penalty
Summary
The facility failed to develop and implement a care plan for a resident with an implantable cardioverter defibrillator (ICD). The resident, who was admitted with diagnoses including end-stage renal disease and chronic systolic heart failure, had an ICD placed prior to admission. However, the clinical record did not include any information related to the ICD, nor did it contain a care plan with individualized interventions or methods for staff to monitor or identify the ICD. During an interview, the Assistant Director of Nursing (ADON) acknowledged that all information related to internal defibrillators should be included in the resident's record. The ADON was unaware that the resident had an internal defibrillator, indicating a lapse in communication and documentation within the facility. This oversight led to the deficiency noted in the report.
Failure to Address Suicide Threats and Follow Therapy Recommendations
Penalty
Summary
The facility failed to meet professional standards of nursing practice for two residents. For Resident #18, who was admitted with diagnoses including major depressive disorder and psychotic disorder with delusions, the facility did not address suicide threats in a timely manner. The resident, who had a severe cognitive impairment, expressed suicidal intentions to the surveyor. Despite the facility's policy requiring immediate action, the Unit Manager dismissed the threats and did not inform the Director of Nurses or other relevant staff. This failure to act appropriately was confirmed during interviews with the Director of Nurses and other staff members, who stated that the resident should have been placed under one-to-one supervision and assessed by a Psychiatric Nurse Practitioner immediately after the threats were made. For Resident #3, who was admitted with diagnoses including Alzheimer's disease and a history of falling, the facility failed to follow the recommendations from a physiatrist for physical therapy and occupational therapy evaluations. The physiatrist had recommended these evaluations due to the resident's ongoing functional decline. However, the medical record showed that the recommendations were not communicated to the rehabilitation staff, and the resident was not receiving the necessary rehabilitation services. The Director of Nurses confirmed that the request for therapy evaluations was not acted upon, indicating a lapse in communication and follow-through on critical medical recommendations.
Inaccurate Documentation of Suprapubic Catheter Changes
Penalty
Summary
The facility failed to maintain accurate medical records for a resident with severe cognitive impairment who had a suprapubic catheter. The resident's medical records inaccurately documented the replacement of the suprapubic catheter, indicating it was changed 23 times in February and three times in March, which was not the case. The Director of Nurses confirmed that the facility staff do not perform suprapubic catheter changes and that the resident goes to urology for these procedures. The resident was admitted with diagnoses including muscle wasting, benign prostate hyperplasia, and urinary retention. The resident's care plan and physician's orders specified monthly catheter changes, but the documentation did not reflect the actual practice. The discrepancy was noted during a surveyor's observation and subsequent review of the resident's records and progress notes, which indicated that the catheter was changed at an external urology appointment, not by the facility staff as documented.
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 1,258 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 Boston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Marian Manor | 1.9 mi | — | 0 | 0 |
| Leonard Florence Center For Living | 2 mi | ★★★★★ | 2 | 0 |
| Highland Park Rehabilitation And Healthcare Center | 2.3 mi | ★★★★★ | 21 | 0 |
| Katzman Family Center For Living | 2.8 mi | ★★★★★ | 5 | 0 |
| The Massachusetts Veterans Home At Chelsea | 3 mi | ★★★★★ | 3 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for North End Rehabilitation And Healthcare Center.
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.