Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
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 Riverbend Of South Natick during CMS and state inspections, most recent first.
A resident with scabies was not placed on Contact Precautions when returning from a dermatology visit that confirmed the diagnosis, and no precaution signage was posted at the room initially. Staff were observed entering the room without PPE, including a nurse delivering breakfast, laundry staff placing clothes in the closet, and a CNA touching items and the resident without donning the required PPE. The DON stated the resident should have been on Contact Precautions upon return and that staff were expected to use PPE before room entry and remove it before exiting.
Failure to post required nurse staffing data. Surveyors did not observe the staffing sheet in the front lobby on three observed days, and it did not include the facility name, current date, resident census, or the total number and actual hours worked by RNs, LPNs, and CNAs. The ADON, DON, and Administrator said it was usually posted there, and the DON later stated the nurse responsible for posting it could not locate the protective sleeve used to display the sheet.
A resident with dementia and other health issues experienced significant weight loss, but the facility failed to notify the Physician or NP in a timely manner. Despite the Registered Dietician identifying the weight loss, the NP was only informed after a recommendation to add Ensure supplements. The Physician's notes did not address the weight loss, indicating a lapse in communication and intervention.
A resident with Alzheimer's and breast cancer was found with their bed positioned against the wall, potentially acting as a restraint. The facility did not conduct an assessment or have a care plan for this setup, as confirmed by staff interviews. The bed's position was due to limited room space, but no documentation supported this decision.
A facility failed to refer a resident for a PASRR Level II evaluation despite documented diagnoses of Depression and Unspecified Psychosis. The resident's hospital records indicated a history of Mood Disorder-Depression and prescriptions for antipsychotic medications. The PASRR Level I screen inaccurately showed no mental illness, leading to a missed Level II evaluation. The Social Worker admitted the screen was incorrect, acknowledging the need for further evaluation.
The facility failed to update care plans for three residents, leading to deficiencies in their care. A resident's incontinence care plan was not revised to reflect the current catheter size. Another resident's fall care plan lacked new interventions after a fall incident. Additionally, a resident and their representative were not invited to care plan meetings, as confirmed by the social worker responsible for the process.
A resident with dementia, dysphagia, anemia, and celiac disease experienced significant weight loss, but the facility failed to notify the RD and NP in a timely manner. The RD's recommendation for lab work was not implemented, and there was a delay in addressing the resident's nutritional needs. Interviews revealed communication lapses and non-adherence to the weight assessment process.
The facility did not provide the required RN coverage for at least eight consecutive hours on two Saturdays, with no RN or DON available to oversee resident care, placing residents at risk.
A nurse in an LTC facility committed multiple medication errors, resulting in a 16% error rate. Errors included incorrect dosing of Vitamin D3 and Vitamin B12, failure to ensure complete administration of MiraLAX, and improper blood pressure measurement before administering Metoprolol. The nurse also neglected to encourage a resident to rinse their mouth after using an inhaler, contrary to facility policy.
A resident with hypertension, heart failure, and coronary artery disease was administered Metoprolol without the required blood pressure and heart rate checks. Despite facility policy requiring vital sign verification before medication administration, a nurse failed to perform these checks, leading to a significant medication error.
A nurse failed to perform hand hygiene during medication administration for two residents, one with a history of stroke, anxiety, depression, and diabetes, and another with hypertension, heart failure, coronary artery disease, and depression. The nurse did not wash or sanitize hands before and after administering medications, including eye drops, and used a single tissue for both eyes of a resident.
The facility failed to offer Pneumococcal Vaccinations to three residents over 65, despite their eligibility for updated doses. The medical records for these residents did not indicate that they were offered, received, or declined the vaccinations upon admission. The Director of Nursing acknowledged the oversight.
A facility failed to accurately code MDS assessments for a resident receiving Hospice services. The resident, with Alzheimer's and breast cancer, was on Hospice since September, but assessments in December and March did not reflect this. The MDS Coordinator, responsible for coding, acknowledged the error.
Failure to Implement Contact Precautions for Resident with Scabies
Penalty
Summary
The facility failed to ensure infection prevention and control measures were followed for a resident diagnosed with scabies. The resident was admitted with diagnoses including hemiplegia, hemiparesis following cerebral infarction, chronic kidney disease, and scabies, and the care plan identified actual skin impairment due to a scabies rash. The resident was cognitively intact with a BIMS score of 15 out of 15 and had been seen by dermatology for a rash to the back, arms, and chest with ongoing itching and rash. The dermatologist diagnosed scabies with positive microscopic findings and recommended treatment including ivermectin. The resident reported attending the dermatology appointment and receiving the diagnosis, but the clinical record showed the resident was not placed on Contact Precautions until the following day. Surveyor observation found no transmission-based precaution signage on the resident’s bedroom door or outside the room when the resident returned from the appointment. Staff were observed entering the resident’s room without donning PPE as required by the Contact Precautions sign and CDC guidance. A nurse entered to deliver breakfast without gloves or a gown, a laundry staff member entered to put clean clothes in the closet without PPE, and a CNA entered without PPE and touched items in the room and the resident’s shoulder. The DON stated the resident should have been placed on Contact Precautions upon return from the dermatology appointment and that staff were expected to don and remove PPE appropriately before and after room entry.
Failure to Post Required Nurse Staffing Data
Penalty
Summary
The facility failed to post the required nurse staffing data daily in a prominent place that was readily accessible to residents, staff, and visitors on three observed days. Surveyors did not find posted nurse staffing information that included the facility name, current date, resident census, and the total number and actual hours worked by RNs, LPNs, and CNAs on 8/5/25, 8/6/25, and 8/7/25. During interviews on 8/7/25, the ADON, DON, and Administrator each stated the staffing data was typically posted in the front entrance lobby, but it was not posted at the time of observation. Later that day, the DON stated the nurse responsible for posting the staffing data had not posted it on those days because she was unable to locate the protective sleeve used to display the sheet.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify the Physician or Nurse Practitioner of a significant change in condition for a resident who experienced a notable weight loss. The resident, who was admitted with diagnoses including dementia, dysphagia, anemia, and celiac disease, showed a weight decrease from 156.4 lbs to 140 lbs between March and April 2024, which was a 10.49% change. Despite the Registered Dietician identifying this significant weight loss, the facility staff did not inform the Physician or NP in a timely manner, preventing potential alterations in treatment. The facility's policy on weight assessment and intervention outlines specific thresholds for significant weight loss, which were exceeded in this case. However, the medical record review revealed that the NP was not made aware of the weight loss until the Dietician recommended adding Ensure supplements on April 24, 2024. The Physician's progress notes also failed to address the resident's weight loss or nutritional status during this period, indicating a lapse in communication and intervention regarding the resident's nutritional risk.
Failure to Assess Bed Position as Potential Restraint
Penalty
Summary
The facility failed to ensure that a resident was free from potential physical restraints, as observed by surveyors. The deficiency involved a resident with Alzheimer's Disease and Intraductal Carcinoma of the breast, who was found with the right side of their bed positioned flush against the wall. This arrangement potentially restricted the resident's ability to exit the bed freely, which could be considered a form of restraint. The facility's policy on restraints emphasizes that restraints should only be used for medical symptoms and not for convenience or discipline, and any restraint must be assessed and documented. The surveyor's observations revealed that there was no physician's order, assessment, or care plan regarding the bed's positioning against the wall. Interviews with the Unit Manager and a Certified Nurses Aide confirmed that no assessment had been conducted to determine if the bed's position acted as a restraint. The CNA mentioned that the bed was placed against the wall due to limited space in the room, and the resident preferred to be in bed with the head elevated. However, the lack of documentation and assessment for this setup was a clear oversight by the facility.
Failure to Refer Resident for PASRR Level II Evaluation
Penalty
Summary
The facility failed to refer a resident for a Preadmission Screening and Resident Review (PASRR) Level II evaluation, which is required for individuals with a positive Level I screen for mental illness, intellectual disability, or related conditions. The resident in question was admitted with diagnoses of Depression and Unspecified Psychosis, and the hospital documentation indicated a history of Mood Disorder-Depression, prescriptions for Sertraline, and recommendations for antipsychotic medications Seroquel and Haldol. Despite this, the PASRR Level I Screening Form inaccurately indicated that the resident did not have a documented diagnosis of a mental illness or mental disorder, resulting in a negative Level I screen. The facility's policy requires the Director of Social Services to initiate the pre-admission screen process upon receiving a referral. However, the Social Worker responsible for reviewing the hospital documentation and completing the PASRR Level I screen acknowledged that the screen was not accurate and that a Level II evaluation was necessary. This oversight occurred despite the resident's documented history of mental illness and the need for specialized services, as indicated by the hospital's referral form and the facility's initial nurse practitioner visit note.
Care Plan Deficiencies for Three Residents
Penalty
Summary
The facility failed to revise the care plans for three residents, leading to deficiencies in their care. For one resident, the incontinence care plan was not updated to reflect the current size of the suprapubic catheter, despite changes in the physician's orders. This oversight was confirmed during observations and interviews with the unit manager and the director of nursing, who acknowledged that the care plan should have been revised to include the correct catheter size. Another resident experienced a fall, but the facility did not update the fall care plan to include new interventions to prevent future falls. The resident had a history of falls and severe cognitive impairment, yet the incident report for the fall was not reviewed by the interdisciplinary team, and no new interventions were added to the care plan. This lack of action was confirmed during interviews with the director of nursing, who stated that the incident had not been reviewed as required. Additionally, the facility failed to ensure that a resident and/or their representative were invited to participate in care plan conference meetings. The resident, who had severe cognitive impairment, was unsure if they had attended any care plan meetings. The care plan conference summary notes did not document the resident's or their representative's attendance or invitation to the meetings. The social worker responsible for the care plan conference process confirmed that there was no documentation indicating that the resident or their representative had been invited or had declined to attend the meetings.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to address the nutritional needs of a resident who experienced significant weight loss. The resident, who was admitted with diagnoses including dementia, dysphagia, anemia, and celiac disease, experienced a weight loss of greater than 10% over six months. The facility did not notify the Registered Dietitian (RD) or the Physician/Nurse Practitioner (NP) in a timely manner when the weight loss was identified. Additionally, the facility did not implement the RD's recommendation to obtain lab work to assess the resident's nutritional status. The facility's policy required that any weight change of 5% or more be retaken the next day for confirmation, and if verified, the RD should be notified immediately. However, the RD was not informed of the resident's weight loss on 4/9/24 and only discovered it during a routine review of the weight report. The RD recommended obtaining lab work and initiating a nutritional supplement, but there was no documentation that these recommendations were followed. The NP was not notified of the weight loss until 4/24/24, resulting in a delay in addressing the resident's nutritional needs. Interviews with facility staff revealed a lack of communication and adherence to the weight assessment process. The RD relied on nursing staff to communicate dietary recommendations to the NP or MD, but this did not occur. The NP stated that she was not informed of the weight loss until the recommendation for a nutritional supplement was made. The Unit Manager and Director of Nursing acknowledged that the process for weight assessment was not followed, and there was no evidence of multidisciplinary meetings to address the resident's weight loss.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for at least eight consecutive hours a day, seven days a week, as required. Specifically, there was no evidence of RN coverage on two specific Saturdays, 5/4/24 and 5/11/24, and no nurse staff waivers were in place for these dates. Additionally, there was no Director of Nursing (DON) available to serve as a charge nurse during these times. This lack of RN coverage placed all residents at risk of not having their clinical needs met, either directly by an RN or indirectly by the Licensed Practical Nurses (LPNs) or Certified Nurses' Aides (CNAs) under the RN's supervision. Interviews with the facility's Scheduler, DON, and Administrator confirmed the absence of RN coverage on the specified dates.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by Nurse #1 committing four errors out of 25 opportunities, resulting in a 16% error rate. For Resident #9, Nurse #1 administered an incorrect dose of Cholecalciferol, providing only one tablet instead of the prescribed two. Additionally, Nurse #1 did not ensure that Resident #9 consumed the entire dose of MiraLAX, as the powder settled at the bottom of the cup and was left on the table. For Resident #4, Nurse #1 did not accurately check the resident's blood pressure and heart rate before administering Metoprolol, as required by the physician's orders. The nurse attempted to measure blood pressure without a stethoscope and documented an incorrect reading. Furthermore, Nurse #1 administered an incorrect dose of Vitamin B12, giving 100 mcg instead of the ordered 500 mcg. The nurse also failed to encourage the resident to rinse their mouth after using an inhaler, which is necessary to prevent fungal infections. The facility's policy on medication administration, which includes verifying vital signs and ensuring the correct dosage and method of administration, was not followed. Interviews with the Director of Nursing and Unit Manager confirmed these errors and acknowledged the discrepancies in medication administration for both residents. These actions and inactions led to the identified deficiencies in medication management.
Failure to Assess Vital Signs Before Medication Administration
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically for one resident who was not properly assessed before medication administration. The resident, who had a medical history of hypertension, heart failure, and coronary artery disease, was prescribed Metoprolol, a medication used to control blood pressure. According to the physician's orders, the medication was to be withheld if the resident's systolic blood pressure was less than 100 or if the heart rate was less than 50. However, during a medication pass, Nurse #1 administered Metoprolol without obtaining the required blood pressure and heart rate measurements. The facility's policy on administering medications, revised in 2012, mandates that vital signs must be checked if necessary before administering medications. Despite this policy, the surveyor observed that Nurse #1 did not measure the resident's blood pressure or heart rate before giving the Metoprolol. This oversight was confirmed during interviews with the Unit Manager and the Director of Nursing, who acknowledged that the nurse should have obtained the necessary measurements prior to administering the medication.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to adhere to infection control standards during the medication administration process, as observed by surveyors. Nurse #1 did not perform appropriate hand hygiene before and after administering medications to two residents. Specifically, during the administration of medications to Resident #9, Nurse #1 neglected to wash or sanitize her hands before and after the process. Similarly, while administering eye drops to Resident #4, Nurse #1 failed to perform hand hygiene both before and after the procedure. Additionally, Nurse #1 used a single tissue to wipe both of Resident #4's eyes after instilling the eye drops, which was then discarded. Resident #9 had been admitted with diagnoses including cerebrovascular accident, anxiety, depression, and diabetes. Resident #4 had been admitted with conditions such as hypertension, heart failure, coronary artery disease, and depression. The failure to follow proper hand hygiene protocols was acknowledged by Nurse #1, who attributed the oversight to being very busy. The Director of Nursing confirmed that Nurse #1 should have adhered to hand hygiene protocols during the medication administration process.
Failure to Offer Pneumococcal Vaccinations to Eligible Residents
Penalty
Summary
The facility failed to offer the Pneumococcal Vaccination to three residents, putting them at risk for developing facility-acquired pneumonia. Resident #5, admitted in September 2023, was over 65 and had their last Pneumococcal Vaccination (PCV13) in July 2018. The facility's records did not indicate that Resident #5 was offered, received, or declined the appropriate Pneumococcal Vaccination upon admission, despite being eligible for an updated dose. Resident #10, admitted in January 2023, was also over 65 and had their last Pneumococcal Vaccination (PCV13) in June 2015. The medical record for Resident #10 similarly failed to show that they were offered, received, or declined a Pneumococcal Vaccination upon admission, even though they were eligible for an updated dose. Resident #18, admitted in July 2023, was over 65 and had their last Pneumococcal Vaccination (PPSV23) in December 2008. The facility's records did not indicate that Resident #18 was offered, received, or declined a Pneumococcal Vaccination upon admission, despite being eligible for an updated dose. The Director of Nursing acknowledged that the facility should have offered the vaccinations to these residents as required.
Inaccurate MDS Coding for Hospice Services
Penalty
Summary
The facility failed to accurately code Minimum Data Set (MDS) assessments for a resident, leading to a deficiency. The resident, who was admitted to the facility with Alzheimer's Disease and Intraductal Carcinoma of the breast, was receiving Hospice services as of September 8, 2023. Despite this, the MDS assessments dated December 26, 2023, and March 8, 2024, did not reflect the resident's Hospice status. This discrepancy was identified during an interview with the MDS Coordinator, who acknowledged the incorrect coding of the assessments. The coordinator, responsible for coding MDS information for all residents, had been working at the facility since the end of December 2023.
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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 S Natick
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mary Ann Morse Nursing & Rehabilitation | 1.5 mi | ★★★★★ | 1 | 0 |
| Adviniacare Newton Wellesley | 2.4 mi | ★★★★★ | 11 | 0 |
| Beaumont Rehab & Skilled Nursing Ctr - Natick | 3.1 mi | ★★★★★ | 1 | 0 |
| Skilled Nursing Facility At North Hill (the) | 3.3 mi | ★★★★★ | 0 | 0 |
| Elizabeth Seton | 3.5 mi | ★★★★★ | 0 | 0 |
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