Average — CMS composite of the measures below.
The next survey window likely opens around January 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 Oak Knoll Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A nurse used a BGM and a wrist BP cuff on multiple residents without cleaning or disinfecting either device between uses. The nurse placed the cuff in her pocket after use, then set it on the med cart, and returned the BGM to its supply basket without disinfection. The nurse said she forgot to clean the equipment after each resident, and the UM confirmed the devices should have been disinfected between uses.
A resident with dysphagia and a history of choking episodes was not provided with direct supervision during meals, despite repeated recommendations from an SLP and multiple incidents requiring the Heimlich Maneuver. The care plan was not updated to reflect the need for direct supervision, and the resident continued to experience choking episodes, ultimately resulting in death.
A resident with dysphagia, dementia, and a history of choking incidents was not provided with direct supervision during meals as recommended by the SLP. Despite multiple episodes requiring the Heimlich Maneuver, staff only provided distant or informal supervision, and the care plan was not updated to reflect the need for direct oversight. This lack of direct supervision led to another choking event during a meal, resulting in the resident's death.
A facility failed to execute a valid MOLST form for a resident with dementia, as the form was signed by the HCP before the resident was deemed incapacitated by a physician. The HCP activation occurred after the MOLST signing, and the form was not re-addressed upon the resident's admission, leading to the deficiency.
A resident with severe dementia and a history of falls was found using wedge cushions as a restraint instead of the ordered scoop mattress. The facility failed to assess the use of these cushions properly, did not obtain informed consent, and did not review the risks and benefits with the resident's representative. Observations confirmed that the cushions acted as a restraint, preventing the resident from exiting the bed.
The facility failed to transmit MDS assessments within the required 14 days for 17 residents. Comprehensive and non-comprehensive assessments were submitted late due to the absence of the regular MDS Coordinator, with the Corporate MDS Coordinator acknowledging the delay.
A facility failed to complete a PASRR Level I screening before admitting a resident with Major Depressive Disorder and Psychotic Disorder. The screening, which assesses for serious mental illness or developmental disabilities, was conducted after the resident's admission. This was confirmed by a social worker during an interview.
A facility failed to notify the State Mental Health Authority for a Resident Review after a resident with severe dementia and other mental health diagnoses experienced a significant change in condition. The resident was involved in a behavioral incident leading to a psychiatric evaluation at a hospital, but the required PASRR Level II screen was not completed upon their return to the facility.
A facility failed to notify a physician or NP about a resident's high blood sugar levels, despite having orders for regular monitoring and insulin administration. The resident, who was cognitively intact and diagnosed with Diabetes Type II, experienced multiple instances of elevated blood glucose without appropriate medical notification, leading to discomfort and symptoms associated with hyperglycemia. The DON admitted the lack of a specific policy for hyperglycemia and the failure to notify medical staff when levels exceeded 450 mg/dL.
The facility failed to maintain respiratory equipment for two residents, leading to deficiencies in care. One resident's oxygen concentrator filter was not cleaned as required, risking impaired oxygen delivery. Another resident's nebulizer equipment lacked proper maintenance and storage, with no physician's order for care. These oversights highlight failures in adhering to professional standards and infection control practices.
A facility failed to provide appropriate dialysis care for a resident with ESRD, resulting in inadequate monitoring of fluid intake and failure to provide food before dialysis. The resident, on a fluid restriction, experienced inconsistent documentation of fluid intake, with several days below 1000 ml and some days undocumented. The resident also reported not receiving food from staff before dialysis, relying on family-provided snacks. Staff interviews revealed a lack of awareness and communication regarding the resident's care needs.
A facility failed to conduct timely AIMS assessments for a resident receiving antipsychotic medication, as required by their policy. The resident, with diagnoses including Alzheimer's and Major Depressive Disorder, was on Seroquel, but their clinical record lacked an AIMS assessment within the last six months. Interviews confirmed the oversight, highlighting a lapse in monitoring for adverse effects like Tardive Dyskinesia.
A facility failed to follow infection control standards during wound care and G-tube medication administration for a resident with a Stage Four Pressure ulcer. The nurse did not perform hand hygiene after removing gloves and before donning new ones, and did not wear a gown as required by Enhanced Barrier Precautions. The resident had multiple medical conditions, including severe cognitive impairment and dependence on staff for daily activities.
Failure to Disinfect Shared Monitoring Equipment Between Residents
Penalty
Summary
The facility failed to adhere to infection control and prevention standards for multi-resident medical equipment use on the Sub Acute unit. The deficiency involved a blood glucose monitor (BGM) and a wrist blood pressure cuff that were used on multiple residents without being cleaned and disinfected between uses, contrary to facility policy requiring reusable resident-care equipment to be decontaminated between residents and blood glucose meters to be disinfected after each use. During a medication administration observation, Nurse #2 used a wrist blood pressure cuff on a resident on Enhanced Barrier Precautions and placed the cuff in her pocket after obtaining the blood pressure reading without cleaning or disinfecting it. After leaving the room, she removed the cuff from her pocket and placed it on top of her medication administration cart before documenting the reading. The nurse then used the same cuff on a second resident and again placed it in her pocket without cleaning or disinfecting it, then returned it to the medication cart after exiting the room. The nurse later used the wrist blood pressure cuff on a third resident and again did not clean or disinfect it before or after use. She also used a BGM on the same resident and placed the BGM back in the basket with the BGM supplies without cleaning or disinfecting it. The surveyor observed the contaminated cuff and BGM placed on the medication cart. During interview, Nurse #2 stated she forgot to clean the BGM and wrist blood pressure machine after each resident use, and Unit Manager #2 stated the BGM should have been disinfected after each resident use and the wrist blood pressure cuff should have been cleaned after each resident use.
Failure to Revise Dysphagia Care Plan After Repeated Choking Incidents
Penalty
Summary
A deficiency occurred when the facility failed to review and revise a resident's dysphagia care plan in response to repeated choking episodes and recommendations from a Speech Language Pathologist (SLP). The resident, who had a history of dysphagia, dementia, and right-side hemiplegia following a stroke, experienced multiple choking incidents that required staff to perform the Heimlich Maneuver. Despite these events and the SLP's recommendation for direct supervision during meals, the care plan was not updated to include this intervention, and the resident continued to be supervised only from a distance. The resident's care plan was initially updated after a choking episode to downgrade the diet and provide education on safe eating practices. However, after subsequent choking incidents, including those where the resident expelled large pieces of unchewed food, the only intervention added was re-education on taking small bites and alternating with sips. The SLP evaluation specifically recommended direct supervision with oral intake, but this was not incorporated into the care plan, nor was it implemented in practice. Staff interviews confirmed that no one was assigned to provide direct supervision during meals, and documentation of education or further SLP referrals was lacking. The failure to revise the care plan and implement direct supervision as recommended by the SLP persisted despite ongoing choking episodes. Ultimately, the resident choked during a meal, was found unresponsive, and died despite staff intervention. The facility's own investigation and staff interviews confirmed that the SLP's recommendations were not added to the care plan, and no new interventions were implemented following repeated incidents.
Failure to Provide Direct Supervision During Meals for Resident with Dysphagia
Penalty
Summary
A deficiency occurred when a facility failed to provide adequate supervision to a resident with a history of dysphagia, dementia, and right-sided hemiplegia, who was at increased risk for aspiration and had experienced multiple choking episodes. Despite repeated incidents where the resident choked on food and required the Heimlich Maneuver, staff did not implement the Speech Language Pathologist's (SLP) recommendation for direct supervision during meals. The resident's care plan and documentation did not reflect any changes or additional interventions after the SLP evaluation, which specifically called for direct supervision with all oral intake. Staff interviews and record reviews revealed that although the resident was seated at the Nurses Station during meals, no specific staff member was assigned to provide direct, continuous supervision as recommended. Instead, supervision was informal and staff were often engaged in other tasks such as passing meal trays or administering medications. Multiple staff members, including nurses and CNAs, confirmed that there was no formal assignment for direct supervision, and the resident was only monitored from a distance or within earshot. The lack of direct supervision persisted even after several documented choking incidents, with no evidence that the SLP's recommendations were incorporated into the resident's care plan or daily routine. Ultimately, the resident experienced another choking episode during a meal, which resulted in death despite staff attempts to perform the Heimlich Maneuver. The facility's failure to ensure direct supervision as recommended by the SLP and required by the resident's condition led to the deficiency.
Failure to Execute Valid Advance Directives
Penalty
Summary
The facility failed to accurately execute Advance Directives for a resident, specifically concerning the Massachusetts Medical Order for Life-Sustaining Treatment (MOLST) form. The deficiency involved the MOLST form being signed by the resident's Health Care Proxy (HCP) before the resident was deemed incapacitated by a physician, which rendered the form invalid. The facility's policy requires that a determination of a patient's lack of capacity must be made by a physician in writing before a healthcare proxy can be activated. The resident, who was admitted to the facility with a diagnosis of dementia, had a MOLST form signed by the HCP prior to admission. However, the HCP activation form was dated after the MOLST form was signed, indicating that the HCP was not yet officially activated at the time of signing. There was no evidence that the MOLST form had been re-addressed with the HCP after the resident's admission, and this issue was only identified when brought to the facility's attention by a surveyor. The social worker confirmed that a new MOLST form should have been completed upon the resident's admission, but it was not.
Failure to Ensure Resident is Free from Physical Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints, as required by their policy. The resident, who was admitted with severe dementia, agitation, adjustment disorder with anxiety, and muscle weakness, was observed using wedge cushions as a restraint instead of the ordered scoop mattress. The facility did not appropriately assess or re-assess the use of these wedge cushions, which were used to prevent the resident from exiting the bed and potentially falling. The facility's policy mandates that any device with the potential to act as a restraint must be preceded by a comprehensive assessment, including obtaining informed consent and reviewing the risks and benefits with the resident's representative. However, in this case, the facility did not obtain informed consent for the use of wedge cushions, nor did they review the risks and benefits with the resident's representative. The wedge cushions were placed under the fitted bottom sheet, adjacent to the side rails, leaving no space for the resident to exit the bed, effectively acting as a restraint. Observations by the surveyor and interviews with facility staff, including a CNA, a nurse, the unit manager, and the DON, confirmed that the wedge cushions were used to prevent the resident from falling out of bed. The staff acknowledged that the wedge cushions were not easily removable by the resident and were considered a restraint. Despite this, there was no physician's order for the use of wedge cushions, and the necessary assessments and consents were not completed, leading to the deficiency.
Delayed Submission of MDS Assessments
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were transmitted within the required 14 days after the completion date for 17 residents out of a sample of 23. Specifically, comprehensive MDS assessments for seven residents and non-comprehensive MDS assessments for ten residents were submitted late. The comprehensive assessments, which include the completion of both the MDS Assessment and the Care Area Assessment (CAA) process, were not transmitted within the mandated timeframe. Similarly, non-comprehensive assessments, which do not require the completion of the CAA process, were also delayed in submission. The issue arose during a period when the regular MDS Coordinator was on leave, and the Corporate MDS Coordinator was responsible for overseeing the completion and submission of the facility's MDS assessments. The Corporate MDS Coordinator acknowledged that the assessments for the 17 residents were submitted late according to the standards outlined in the Centers for Medicare and Medicaid (CMS) MDS 3.0 Resident Assessment Instrument (RAI) Manual. The delay in submission was confirmed through a review of the Facility's MDS 3.0 Final Validation Report.
Failure to Complete PASRR Level I Screening Prior to Admission
Penalty
Summary
The facility failed to ensure that a Preadmission and Resident Review Level I (PASRR Level I) screening was completed prior to the admission of a resident with serious mental illness to the nursing facility. The resident, who was admitted in April 2023, had diagnoses including Major Depressive Disorder and Psychotic Disorder. The PASRR Level I screening, which is intended to assess for serious mental illness or developmental disabilities before admission, was completed after the resident's admission. This oversight was confirmed during an interview with a social worker, who acknowledged that the screening should have been completed prior to the resident's admission.
Failure to Notify State Mental Health Authority After Resident's Significant Change in Condition
Penalty
Summary
The facility failed to notify the State Mental Health Authority for a Resident Review after a significant change in mental condition occurred for a resident. This resident, who was admitted with diagnoses including severe dementia with agitation, adjustment disorder with anxiety, and major depressive disorder, experienced a significant behavioral incident. The resident punched a CNA in the face during care and subsequently grabbed the CNA's hand, causing scratches. Following this incident, the resident was sent to the hospital for a psychiatric evaluation under Section 12, which allows for involuntary evaluation and admission to a psychiatric unit. Despite the resident's transfer to the hospital for psychiatric evaluation and subsequent readmission to the facility, there was no documented evidence that a PASRR Level II screen was completed. This screen is necessary to determine if the resident requires additional specialized support services due to a change or decline in condition. During interviews, the facility's social worker acknowledged that the PASRR Level II review was not submitted following the resident's hospitalization for psychiatric evaluation.
Failure to Notify Physician of High Blood Sugar Levels in Diabetic Resident
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident with Diabetes Type II, as per the physician's orders and professional standards of practice. The resident, who was cognitively intact and diagnosed with Diabetes Mellitus, had physician orders for blood glucose monitoring four times a day and insulin administration. Despite these orders, the facility did not notify the physician or nurse practitioner of the resident's consistently high blood glucose levels, which were recorded on multiple occasions. The facility's policy required notification of high blood sugar levels, but there was no evidence that this was done. The Director of Nursing acknowledged that the facility lacked a specific policy for hyperglycemia and that the nursing staff did not notify the physician or nurse practitioner when the resident's blood sugar levels exceeded 450 mg/dL. The resident reported experiencing symptoms associated with high blood sugar, such as dry mouth, sweet-smelling breath, and frequent urination, and recalled a previous hospitalization due to elevated blood sugar levels. The physician confirmed that the order for high blood sugar levels was not documented with a specific numerical value for notification, and there was no record of the nurse practitioner being contacted regarding the resident's elevated blood sugar levels.
Deficiencies in Respiratory Care and Equipment Maintenance
Penalty
Summary
The facility failed to provide adequate respiratory care for two residents, leading to deficiencies in equipment maintenance and infection control. For one resident with chronic obstructive pulmonary disease and chronic respiratory failure, the facility did not maintain the oxygen concentrator's air intake gross particle filter according to physician orders and manufacturer guidelines. Despite documentation indicating the filter was cleaned, observations revealed it was covered in a thick layer of gray dust, suggesting it had not been properly maintained. This oversight placed the resident at risk for equipment malfunction and impaired oxygen delivery. Another resident, admitted with pneumonia and acute respiratory failure, did not have an active physician's order for the care and maintenance of nebulizer equipment. Observations showed the nebulizer tubing and face mask were not stored properly, lacking a storage bag and date label, and were left directly on the nightstand. The resident reported using the nebulizer equipment without it being changed, contrary to the facility's policy of weekly changes. The nurse confirmed the equipment had not been changed as required, and the Director of Nursing acknowledged the absence of a physician's order for nebulizer maintenance. These deficiencies highlight the facility's failure to adhere to its own policies and professional standards of practice for respiratory care. The lack of proper equipment maintenance and infection control measures for both residents could lead to significant health risks, including contamination and impaired respiratory function. The facility's documentation practices also came into question, as records did not accurately reflect the care provided.
Inadequate Dialysis Care and Fluid Monitoring for Resident
Penalty
Summary
The facility failed to provide appropriate dialysis care and services for a resident with End Stage Renal Disease (ESRD) who required hemodialysis. The resident, who was cognitively intact and required assistance for eating, was on a physician-ordered fluid restriction of 1500 milliliters per day. However, the facility did not adequately monitor and assess the resident's fluid intake, as evidenced by inconsistent documentation and failure to maintain accurate records of the resident's fluid intake. The Medication Administration Record (MAR) showed discrepancies in the 24-hour fluid intake totals, with several days of intake below 1000 ml, some days with no documentation, and instances where the intake exceeded the prescribed limit. Additionally, the facility did not provide food items to the resident prior to dialysis as indicated in the care plan and according to the resident's preferences. The resident reported not receiving any food or snacks from the facility staff before leaving for dialysis, resulting in hunger and discomfort. The resident's family had to provide crackers for the resident to eat. Interviews with staff revealed a lack of communication and understanding regarding the resident's fluid restriction and dietary needs, with some staff unaware of the fluid restriction and others unsure of the resident's food preferences. The facility's policies on fluid restrictions and dialysis care were not effectively implemented, leading to inadequate monitoring and provision of care for the resident. The failure to document and communicate the resident's fluid intake and dietary needs put the resident at risk for complications related to fluid imbalance and inadequate nutrition, particularly given the resident's history of diabetes and hypoglycemic episodes.
Failure to Conduct Timely AIMS Assessment for Resident on Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a resident was free from the risks of side effects resulting from the unnecessary use of psychotropic medications. Specifically, the facility did not complete the Abnormal Involuntary Movement Scale (AIMS) assessment in a timely manner for a resident receiving antipsychotic medication, as required by their policy. The AIMS assessment is crucial for monitoring adverse consequences and side effects, such as Tardive Dyskinesia, in residents taking antipsychotic medications. The resident in question was admitted with diagnoses including Alzheimer's disease, Major Depressive Disorder, Anxiety, Restlessness, Agitation, and Insomnia. Despite receiving Seroquel, an antipsychotic medication, on a routine basis, the resident's clinical record did not show an AIMS assessment within the last six months. Interviews with the Unit Manager and the Director of Nursing confirmed that the last AIMS assessment was completed several months prior, and it was acknowledged that these assessments should be conducted every six months for residents on antipsychotic medications.
Infection Control Lapses During Wound Care and G-tube Administration
Penalty
Summary
The facility failed to adhere to infection control standards during a wound care procedure for a resident with a Stage Four Pressure ulcer. The nurse involved did not perform appropriate hand hygiene on multiple occasions, increasing the risk of wound contamination and infection. Specifically, the nurse did not wash hands or use hand sanitizer after removing soiled gloves and before donning new gloves, despite handling potentially contaminated items such as a urinary drainage bag that had been on the floor. Additionally, the facility did not adhere to Enhanced Barrier Precautions (EBP) during medication and fluid administration through a gastrostomy tube for the same resident. The nurse administering the medication did not wear a gown as required by the EBP guidelines, despite handling the resident's feeding tube, which is considered a high-contact activity. The nurse acknowledged the oversight but failed to follow the established protocol. The resident involved had multiple medical conditions, including a Stage Four Pressure ulcer, neuromuscular dysfunction of the bladder, dysphagia, and a gastrostomy tube. The resident was severely cognitively impaired and dependent on staff for activities of daily living. The failure to follow infection control protocols during wound care and medication administration posed a risk of infection to the resident.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Framingham
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sudbury Pines Extended Care | 1.8 mi | ★★★★★ | 0 | 0 |
| St Patrick's Manor | 2.1 mi | ★★★★★ | 0 | 0 |
| Vantage At Sudbury Llc | 2.2 mi | ★★★★★ | 12 | 0 |
| Casa De Ramana Rehabilitation Center | 3.3 mi | ★★★★★ | 0 | 0 |
| Royal Wayland Rehabilitation And Nursing Center | 3.5 mi | ★★★★★ | 0 | 0 |
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