Above average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Skilled Nursing Facility At North Hill (the) during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment and visual hallucinations received PRN Seroquel orders that exceeded the required 14-day limitation. Medical records showed these orders were written for 30 and 60 days, and interviews with the physician, NP, and DON confirmed the orders did not comply with regulations for PRN antipsychotic use.
A resident with severe cognitive impairment and dementia was administered Zyprexa and Mirtazapine for agitation and depression, but the care plan did not identify specific target behaviors, individualized non-pharmacological interventions, or measurable treatment goals. Nursing staff and the DON confirmed the absence of resident-specific symptoms and interventions in the care plan.
A nurse prepared to administer metoprolol to a resident using two medication cards with incorrect pharmacy labels that instructed a dose of 75 mg twice daily, instead of the physician-ordered 37.5 mg. The error was not previously identified by nursing staff, despite routine administration, and was confirmed by the DON as a significant discrepancy between the pharmacy label and the prescriber's order.
A resident at risk for elopement was not provided with a WanderGuard bracelet despite assessments indicating the need. The resident, who was confused and had a history of wandering, left the facility undetected and suffered a fatal fall. Staff failed to document the rationale for not using the device, and no reassessment was conducted despite ongoing wandering behaviors.
A resident with a history of wandering and cognitive impairment was able to leave the facility undetected, resulting in a fall and fatal injuries. Despite being assessed as high risk for elopement, the resident was not equipped with a WanderGuard bracelet. The resident was left unattended, and the receptionist did not notice the resident leaving through the main entrance. The incident highlights a failure in supervision and communication among staff.
The facility failed to offer the PCV-20 vaccine to eligible residents, as required by CDC guidelines. Three residents with various medical conditions, including dementia and chronic diseases, were not informed about the vaccine or its benefits. The facility's infection preventionist identified the issue but had not made progress in addressing it. The immunization consent form and computerized application used by the facility did not support the necessary shared decision-making process.
A facility failed to create a care plan for a resident with dementia who exhibited wandering behavior and was at risk for elopement. Despite the use of a wanderguard device and notes indicating wandering on certain shifts, the care plan did not address these behaviors. Staff and family were unaware of the elopement risk, and the facility's care planning process was not followed, leading to the deficiency.
A facility failed to ensure staff wore required PPE when attending to a COVID-19 positive resident. Despite CDC guidelines and facility policy mandating a gown, N95 mask, gloves, and eye protection, a CNA entered the resident's room without PPE. Observations showed continued non-compliance with PPE protocols, including improper mask use and lack of eye protection, even after reminders. The infection preventionist and a nurse confirmed the breach, highlighting the need for staff education.
Failure to Limit PRN Antipsychotic Orders to 14 Days
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications by not adhering to the required 14-day limitation for as needed (PRN) antipsychotic medication orders. Specifically, the resident, who had a diagnosis including visual hallucinations and moderate cognitive impairment, received PRN orders for Seroquel that were written for durations exceeding 14 days on multiple occasions. Medical record review showed that these PRN Seroquel orders were written for 30, 60, and other periods longer than the allowed 14 days, contrary to regulatory requirements. Interviews with facility staff, including a physician, nurse practitioner, and the DON, confirmed that the PRN Seroquel orders should have been limited to 14 days but were not. The physician stated he was unaware that antipsychotic PRN orders could not exceed 14 days without exception, and both the nurse practitioner and DON acknowledged that the orders were not compliant with the 14-day limitation. This resulted in the resident receiving PRN antipsychotic medication orders for extended periods without the required limitation and evaluation.
Failure to Develop Individualized Care Plan for Psychotropic Medication Use
Penalty
Summary
The facility failed to develop an individualized, person-centered care plan to address the use of psychotropic medications for a resident with severe cognitive impairment and a diagnosis of unspecified dementia. The resident had been receiving Zyprexa for agitation and Mirtazapine for depression since admission. The care plan in place did not identify specific targeted signs, symptoms, or behaviors that warranted the use of these medications. Additionally, the care plan lacked individualized, measurable non-pharmacological interventions and did not include measurable goals of treatment or a target date for achieving those goals. Interviews with nursing staff and the DON confirmed that the care plan did not specify resident-specific symptoms or targeted behaviors related to the use of psychotropic medications. The care plan also did not include non-pharmacological approaches tailored to the resident's needs. Review of the resident's care card and medical record further supported that there were no individualized interventions or documentation of targeted behaviors for the use of these medications.
Incorrect Medication Labeling and Dosing Instructions Identified
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled accurately and in accordance with the physician's order for one resident. During a medication pass, a nurse prepared to administer metoprolol to a resident as ordered in the electronic Medication Administration Record (eMAR) for a dose of 37.5 mg twice daily. The nurse obtained two medication cards from the pharmacy, one containing 25 mg tablets and another containing 12.5 mg tablets, and combined them to reach the prescribed dose. However, the labels on both medication cards contained incorrect dosing instructions, stating to administer a total of 75 mg twice daily, which did not match the physician's order. The nurse acknowledged that the labeling on the medication cards was incorrect and had not previously noticed the discrepancy, despite routinely administering the medication. The Director of Nursing confirmed that the error in the pharmacy labeling could have resulted in the resident receiving twice the ordered dose if the instructions had been followed. The facility's policy required verification of medication labels and administration in accordance with prescriber orders, but this process failed to identify the incorrect pharmacy directions prior to the surveyor's observation.
Failure to Implement Elopement Prevention Measures
Penalty
Summary
The facility failed to provide appropriate care for a newly admitted resident who was at risk for elopement. Despite being assessed by two different nurses upon admission and triggering the need for a WanderGuard bracelet, the device was not placed on the resident. The resident, who was confused and had a history of wandering, was able to leave the facility undetected, resulting in a fall that caused significant injuries. The facility's policy required that residents at risk for elopement be assessed and provided with interventions such as a WanderGuard bracelet. However, both the admitting nurse and the nursing supervisor failed to document a rationale for not placing the device on the resident, despite the resident meeting multiple criteria for its use. The resident's medical history included conditions such as a recent stroke, altered mental status, and medications that increased confusion, all of which contributed to the resident's high risk for wandering and falls. Interviews with staff revealed a lack of communication and documentation regarding the resident's need for a WanderGuard. The resident continued to exhibit wandering behaviors, yet no reassessment was conducted to address the safety concerns. This oversight led to the resident's elopement and subsequent fall, resulting in a fatal intracranial hemorrhage.
Failure to Prevent Resident Elopement and Fall
Penalty
Summary
The facility failed to provide adequate supervision and assistance to a resident who was at high risk for falls and elopement. The resident, who had a history of wandering and exit-seeking behavior, was able to leave the facility undetected and subsequently suffered a fall that resulted in serious injuries. Despite being assessed as high risk for elopement, the resident was not equipped with a WanderGuard bracelet, and the rationale for this decision was not documented. On the day of the incident, the resident was observed wandering and attempting to exit the unit. Staff were aware of the resident's behaviors and the need for close supervision, yet the resident was left unattended in a television room. The receptionist, responsible for monitoring the main entrance, did not notice the resident leaving the facility. The resident exited through the main lobby doors, which were unlocked by the receptionist, and was later found outside by the Director of Nursing and the Administrator. The resident's medical history included a stroke, cognitive impairment, and other conditions that increased the risk of falls and confusion. Despite these known risks, the facility's policies and procedures for fall and elopement prevention were not adequately followed, leading to the resident's unsupervised exit and subsequent fall. The incident highlights a breakdown in communication and supervision among staff, contributing to the resident's ability to leave the facility and sustain fatal injuries.
Failure to Offer PCV-20 Vaccine to Eligible Residents
Penalty
Summary
The facility failed to implement policies and procedures to ensure that eligible residents were offered the pneumococcal vaccine (PCV-20) and educated on its benefits and potential side effects. This deficiency was identified through record reviews and interviews, revealing that three residents, out of a sample of five, were not offered the PCV-20 vaccine despite being eligible according to CDC recommendations. The facility's policy required offering the vaccine to all admitted residents, but this was not adhered to. Resident #52, admitted in June 2023, had a history of dementia, hypertension, and chronic kidney disease. The resident's immunization record showed previous pneumococcal vaccinations but lacked documentation of the PCV-20 vaccine. Despite having physician orders to administer immunizations with consent, there was no indication that the resident or their legal representative was informed about the PCV-20 vaccine. Similarly, Resident #59, admitted in May 2024 with dementia and other conditions, also had incomplete documentation regarding the PCV-20 vaccine. The immunization consent form did not reflect any offer or information about the vaccine. Resident #41, admitted in March 2022 with chronic obstructive pulmonary disease and other diagnoses, also did not have documentation of receiving the PCV-20 vaccine. The facility's infection preventionist acknowledged identifying the issue in April 2024 but had not made significant progress in addressing it. The immunization consent form used by the facility did not include the PCV-20 vaccine, and the computerized application used to track vaccinations did not support the shared decision-making process recommended by the CDC.
Failure to Develop Care Plan for Wandering and Elopement Risk
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for a resident who exhibited wandering behavior and was at risk for elopement. The resident, admitted with diagnoses including dementia, was observed with a wanderguard device, yet the medical record lacked documentation of wandering behavior or elopement risk. Despite nursing progress notes indicating wandering on evening or night shifts, the care plan did not reflect these behaviors or the need for a wanderguard device. Interviews with CNAs revealed a lack of awareness regarding the resident's elopement risk and the presence of a wanderguard. Family members and nursing staff were not informed of the resident's wandering behavior or elopement risk, and no care plan was developed to address these issues. The nursing supervisor and assistant director of nurses acknowledged the absence of a care plan, despite the expectation that one should have been created when the behavior and risk were identified. The director of nurses confirmed that the facility's care planning process was not followed, resulting in the deficiency.
Failure to Adhere to PPE Protocols for COVID-19 Positive Resident
Penalty
Summary
The facility failed to ensure that staff adhered to the required personal protective equipment (PPE) protocols while attending to a COVID-19 positive resident. According to the Centers for Disease Control (CDC) guidelines and the facility's own policy, staff entering the room of a COVID-19 positive resident should wear a gown, N95 mask, gloves, and eye protection. However, during the survey, it was observed that a certified nurse assistant (CNA) entered the room of a COVID-19 positive resident without wearing any PPE, despite the presence of a sign indicating the need for full PPE and a bin with PPE supplies outside the room. Further observations revealed that the CNA, even after being reminded of the PPE requirements, failed to properly secure the N95 mask and did not wear eye protection. The CNA acknowledged the oversight and admitted to not following the posted PPE guidelines. The infection preventionist and a nurse confirmed the breach in protocol, noting that the staff did not adhere to the guidelines as required, which necessitated further education for the staff.
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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 Needham
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Briarwood Rehabilitation & Healthcare Center | 1.3 mi | ★★★★★ | 0 | 0 |
| Elizabeth Seton | 1.4 mi | ★★★★★ | 0 | 0 |
| Stone Rehabilitation And Senior Living | 2.1 mi | ★★★★★ | 5 | 0 |
| Adviniacare Newton Wellesley | 2.6 mi | ★★★★★ | 11 | 0 |
| Care One At Newton | 2.7 mi | ★★★★★ | 8 | 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.