Average — CMS composite of the measures below.
The next survey window likely opens around February 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 Stone Rehabilitation And Senior Living during CMS and state inspections, most recent first.
Infection control failed when a nurse used the same vital signs tower on multiple residents without disinfecting it between uses, and disinfecting wipes were not readily available on the tower. Staff also opened milk carton spouts with ungloved fingers, repeatedly touching the spouts in an unsanitary manner. The DON, IP, and other nurses stated the tower should be disinfected between residents and the milk spout should not be touched when opening it.
Incomplete Care Planning and Failure to Implement Ordered Interventions: A resident with multiple diagnoses and moderate cognitive impairment did not have a comprehensive person-centered care plan developed within the required timeframe after the admission MDS, and the active plan only listed a few focuses. Another resident with Parkinson's disease, dementia, and stroke had care plan interventions for TED stockings and Geri-sleeves, but staff observed the resident multiple times without either intervention in place, and the chart did not document refusals or include the interventions on the Kardex.
Failure to provide required meal supervision: A resident with dysphagia, cognitive impairment, and a history of aspiration-related pneumonitis was assessed as needing supervision/touching assistance for eating, but was observed eating alone and later left with the tray not set up for breakfast. The care plan did not clearly identify the level of feeding assistance, CNA documentation did not show meal assistance on multiple days, and staff interviews showed meal needs were mainly communicated by verbal report rather than consistently using the care card/Kardex.
PICC Site Not Visible Under Transparent Dressing: A resident with a PICC line, intact cognition, and orthopedic aftercare needs had the insertion site covered by gauze beneath a transparent dressing, preventing visualization of the site during survey observations. Facility policy and MD orders required routine site assessment every shift, and staff interviews confirmed the site could not be properly observed with gauze under the dressing, despite TAR documentation showing assessments were signed off as completed.
Failure to Follow Oxygen Order: A resident with dementia, depression, and acute respiratory failure with hypoxia was observed multiple times receiving O2 via NC at 3 L/min, while the physician's order directed 2 L/min continuous and 2 L/min PRN for O2 sats below 90% on room air. The care plan referenced oxygen use, and nursing notes also documented the resident on 3 L/min. Staff interviews confirmed that oxygen should be given per the MD order.
A facility failed to accurately complete an MDS assessment for a resident, incorrectly indicating hospice care services. The resident, with severe cognitive impairment and multiple diagnoses, was not on hospice care, as confirmed by the absence of a physician's order and care plan. Staff interviews revealed a coding error in the assessment.
The facility failed to create comprehensive care plans for two residents with pacemakers, lacking essential details such as paced rate, serial number, and cardiologist information. One resident's nurse was unaware of the pacemaker, and there was no transmission box in the room. Another resident's care plan was missing pacemaker specifics, and monitoring was done through vital signs due to the absence of a transmission box. The facility was in the process of obtaining the necessary information.
A resident with congestive heart failure experienced significant weight changes, but the facility failed to notify the physician as required by the resident's care plan. Despite multiple weight fluctuations, there was no documentation of communication with the medical team, violating the facility's policy and physician's orders.
A resident with severe cognitive impairment and legal blindness was observed with unclean fingernails over multiple shifts, despite being dependent on staff for daily care. The facility's policy requires daily nail cleaning, but staff cited time constraints as a reason for not completing this task. The Unit Manager did not notice the issue until it was pointed out by a surveyor.
A resident with a stage 3 pressure ulcer on the left heel did not receive the necessary care to offload the heels as ordered by the physician. Despite being at mild risk for pressure sores, the resident was observed with heels directly on the mattress, and staff confirmed the lack of appropriate interventions to float the heels.
A resident with dysphagia was not provided meals in accordance with their prescribed soft and bite-sized diet (IDDSI level 6). Observations showed the resident received whole bananas, inadequately cut sandwiches, and dry toast, contrary to dietary orders. Staff interviews confirmed non-compliance with dietary guidelines, compromising the resident's safety.
A resident with an indwelling urinary catheter had their drainage bag repeatedly observed on the floor, contrary to the facility's infection control policy. Despite being cognitively intact and dependent on staff for daily activities, the resident's catheter bag was not properly managed, as confirmed by a nurse who acknowledged the oversight.
Infection Control Lapses With Vital Sign Equipment and Milk Cartons
Penalty
Summary
The facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment and help prevent the development and transmission of communicable diseases and infections on two units. On 3/11/26 at 6:48 A.M., a nurse took vital signs on one resident, then exited the room with the vital signs tower and entered another resident's room without disinfecting the tower or equipment. The nurse repeated this sequence with a third resident at 6:51 A.M., a fourth resident at 6:53 A.M., and a fifth resident at 6:56 A.M., each time using the same vital signs tower without disinfecting it between residents. At 6:56 A.M., the surveyor also observed that the vital signs tower did not have disinfecting wipes readily available in its attached basket. The facility also failed to ensure personal milk cartons were opened in a sanitary manner. On 3/10/26 at 8:21 A.M., Certified Nurse's Aide #2 used an ungloved finger two times to open milk carton spouts, sticking a bare finger into the spout. At 8:27 A.M., Certified Nurse's Aide #3 did the same thing two times, and at 8:30 A.M., Certified Nurse's Aide #4 used an ungloved finger to open a milk carton spout in the same manner. During interviews, Nurse #1, Nurse #3, the Infection Preventionist, and the DON stated that the vital signs tower should be disinfected between each resident, and the DON and Certified Nurse's Aide #5 stated that the milk carton spout should not be touched when opening it for infection control reasons.
Incomplete Care Planning and Failure to Implement Ordered Interventions
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for Resident #34 within the required timeframe after the admission MDS assessment was completed. Resident #34 was admitted in January 2026 with diagnoses including metabolic encephalopathy, sleep apnea, dysphagia, urinary tract infection, and pneumonitis due to inhalation of food and vomit. The admission MDS, completed on 2/9/26, showed a BIMS score of 8, indicating moderate cognitive impairment, and triggered care areas including functional abilities, cognitive loss/dementia, urinary incontinence and indwelling catheter, dehydration/fluid management, communication, nutritional status, and pressure ulcer injury. Review of the care plan on 3/10/26 showed only four focuses: actual skin breakdown, advanced directives, nutrition, and potential for discharge planning. The record did not show a comprehensive person-centered care plan had been developed, and the MDS nurse stated that the active care plan on 3/10/26 was not comprehensive. During interview, staff stated that care plans were developed in the electronic medical record, but the MDS nurse said that outside of the four listed focuses, all other focuses were added on 3/11/26. The DON stated that comprehensive care plans should be developed within a week of admission. The facility also failed to implement ordered interventions for Resident #66. Resident #66, admitted in February 2022 with Parkinson's disease, dementia, and stroke, had a 12 out of 15 BIMS score on the 12/26/25 MDS and was totally dependent on staff for all ADLs. The care plan included interventions to apply TED stockings in the morning and remove them at bedtime as tolerated, and to apply Geri-sleeves to both upper extremities every shift. However, the resident was observed multiple times on 3/10/26 and 3/11/26 lying in bed without TED stockings or Geri-sleeves. CNA ADL documentation and progress notes did not show refusals of care, and the Kardex did not indicate the need for Geri-sleeves or TED stockings. Staff interviews indicated that refusals should be documented, but documentation of refusals was not present.
Failure to Provide Required Meal Supervision
Penalty
Summary
The facility failed to ensure assistance with ADLs was provided for one resident, specifically supervision/touching assistance with meals as outlined in the plan of care. The resident was admitted in January 2026 with diagnoses including metabolic encephalopathy, sleep apnea, dysphagia, and pneumonitis due to inhalation of food and vomit. The MDS dated 1/30/26 indicated a BIMS score of 8, showing moderate cognitive impairment, and also indicated that supervision or touching assistance was required for eating. The assessment further indicated that rejection of care was not a behavior exhibited by the resident. Survey observations showed the resident eating breakfast alone in a wheelchair in the room on 3/10/26, and on 3/11/26 the resident was observed lying flat in bed with the breakfast tray left on the bedside table and not set up for eating. During a continuous observation, a staff member elevated the head of the bed to about 45 degrees and then left the room. The care plan did not identify the level of assistance needed for eating, although a rehab communication form in the CNA resident care plan book indicated minimal assist for feeding and up in wheelchair for all meals. A speech therapy discharge summary stated to continue 1:1 supervision for meals for safety. CNA task documentation did not show meal assistance on 3/8/26, 3/9/26, or 3/10/26, and staff interviews indicated meal assistance was communicated verbally rather than through consistent use of the care card/Kardex system.
PICC Site Not Visible Under Transparent Dressing
Penalty
Summary
The facility failed to provide care and maintenance of a PICC line consistent with professional standards of practice for Resident #6, who was admitted in February 2026 with diagnoses including encounter for orthopedic aftercare, broken internal left hip prosthesis, and history of falling. The resident’s MDS dated 2/9/26 indicated a BIMS score of 15 out of 15 and the presence of a PICC line. Facility policy required the nurse to inspect the PICC site every shift and to change PICC dressings at least weekly with a transparent dressing. On 3/10/26 and again on 3/11/26, the surveyor observed the PICC dressing dated 3/9/26, and the insertion site was not visible because gauze was placed under the transparent dressing. Physician orders directed site observation every shift when not in use and every 2 hours during continuous therapy, and the March 2026 TAR showed the every-2-hour assessments were signed off as completed through 6:00 A.M. on 3/11/26. During interviews, Nurse #2 stated gauze should not be under the transparent dressing because it prevents observation of the insertion site, the Unit Manager said the site should still be observable, and the DON stated nurses should assess the insertion site every shift and could not do so if gauze was under the dressing.
Failure to Follow Oxygen Order
Penalty
Summary
Resident #73, who was admitted with diagnoses including dementia, depression, and acute respiratory failure with hypoxia, had a Minimum Data Set indicating a BIMS score of 14 out of 15 and the use of continuous oxygen therapy. The resident was observed multiple times receiving oxygen via nasal cannula at 3 liters per minute, including while awake in bed, sitting in a wheelchair, and sleeping in bed. However, the physician's orders dated 3/7/26 directed oxygen at 2 liters via nasal cannula continuously and 2 liters via nasal cannula as needed for oxygen saturations less than 90% on room air. The facility's care plan for impaired gas exchange included an intervention to administer oxygen as needed per MD/NP order, and nursing progress notes documented the resident on 3 liters of oxygen with oxygen saturation of 91% and later noted the resident received 3 liters via nasal cannula. During interviews, Nurse #2, the Unit Manager, and the DON each stated that oxygen should be administered per the physician's order and that if more oxygen was needed, the physician should be notified and new orders obtained. The report indicates the facility failed to ensure that respiratory care and services were provided consistent with the physician's orders for Resident #73.
Inaccurate MDS Assessment for Hospice Care
Penalty
Summary
The facility failed to complete an accurate Minimum Data Set (MDS) assessment for a resident, resulting in a deficiency. The MDS assessment inaccurately indicated that the resident was receiving hospice care services, despite there being no physician's order or comprehensive person-centered care plan for hospice care in the resident's medical record. The resident, who was admitted in August 2017, has diagnoses including chronic obstructive pulmonary disease, dementia, and adult failure to thrive, and is severely cognitively impaired, dependent on staff for daily care. Observations noted the resident as small in stature and frail. Interviews with the unit manager and MDS nurse revealed that while there was a discussion about enrolling the resident in hospice care, the health proxy agent did not agree, and the MDS nurse acknowledged the coding error in the assessment.
Deficiency in Pacemaker Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive, individualized care plans for two residents with pacemakers, leading to deficiencies in monitoring and care. Resident #10, admitted with conditions including Parkinson's disease and a cardiac pacemaker, had no care plan detailing the pacemaker's paced rate, serial number, or cardiologist information. Interviews revealed that the resident's regular nurse was unaware of the pacemaker, and there was no transmission box in the resident's room. The Unit Manager and MDS Nurse confirmed the absence of necessary information in the care plan, which should have included the cardiologist's details and the frequency of pacemaker checks. Similarly, Resident #221, admitted with severe cognitive impairments and a cardiac pacemaker, lacked a care plan specifying the pacemaker's type and serial number. The Unit Manager and MDS Nurse reiterated the need for a care plan with comprehensive pacemaker details. Nurse #1, aware of the pacemaker, monitored it by taking vital signs due to the absence of a transmission box. The Corporate Nurse acknowledged that the facility was in the process of obtaining the necessary pacemaker information for this new admission.
Failure to Notify Physician of Significant Weight Changes
Penalty
Summary
The facility failed to meet professional standards of quality for a resident with multiple diagnoses, including congestive heart failure, adult failure to thrive, dysphagia, and muscle weakness. The deficiency was identified when the facility did not implement the physician's orders to notify the physician or nurse practitioner of significant weight changes. The resident's physician's orders required notification for weight changes of +/-2 pounds in one day or +/-5 pounds in one week. However, the facility did not document any notifications to the medical team despite several instances of significant weight fluctuations. The resident experienced multiple weight changes that met the criteria for physician notification, including a 3.8-pound gain, a 4.4-pound loss, a 3.4-pound gain, a 2.3-pound loss, and a 5.4-pound loss, among others. Interviews with the unit manager, a nurse, and the Director of Nurses confirmed that the facility's policy required documentation of such notifications, which was not done. This lack of documentation and communication with the medical team constituted a failure to adhere to the established policy and physician's orders, leading to the identified deficiency.
Failure to Provide Adequate Fingernail Care for a Dependent Resident
Penalty
Summary
The facility failed to provide adequate fingernail care for a resident who is dependent on staff for activities of daily living. The resident, who has severe cognitive impairment and is legally blind, was observed multiple times over two days with dark grey matter under the fingernails, indicating a lack of cleanliness. The facility's policy requires daily cleaning and regular trimming of nails to prevent infections, but this was not adhered to for the resident in question. Interviews with staff revealed that the Certified Nursing Assistant (CNA) responsible for the resident's care acknowledged the need for nail cleaning but cited time constraints as a reason for not completing the task. The Unit Manager, who assisted the resident with meals, did not notice the unclean nails until it was pointed out by the surveyor. The resident's care plan indicated a dependency on staff for all ADLs, yet the staff failed to maintain the resident's personal hygiene as required by the facility's guidelines.
Failure to Implement Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent the development and promote healing of pressure ulcers for a resident with a stage 3 pressure ulcer on the left heel. The resident was admitted with diagnoses including a stage 3 pressure ulcer, adult failure to thrive, and spondylosis. Despite physician orders to offload the heels while in bed, the resident was observed multiple times with heels directly on the mattress, indicating non-compliance with the prescribed care plan. Interviews with the resident and staff revealed that the resident was aware of the wound on the heel and had not been offered any support to offload the heels. Both a nurse and a certified nurse aide confirmed that the resident's heels were not elevated as ordered, and no pillows were available to float the heels. The Braden Scale assessment indicated a mild risk for pressure sores, yet the necessary interventions to mitigate this risk were not implemented, leading to the deficiency.
Failure to Provide Appropriate Diet for Resident with Dysphagia
Penalty
Summary
The facility failed to provide food in a form that met the individual needs of a resident with dysphagia, as ordered by the physician and recommended by the Speech Language Pathologist (SLP). The resident, who has multiple diagnoses including Multiple Sclerosis and dementia, was prescribed a soft and bite-sized diet (IDDSI level 6) due to chewing and swallowing difficulties. Despite this, the resident was repeatedly served meals that did not adhere to these dietary requirements, such as whole bananas, sandwiches not cut into bite-sized pieces, and dry toast. Observations by the surveyor revealed that the resident's meals consistently included items that were not prepared according to the prescribed diet. For instance, the resident was served a whole, unpeeled banana instead of banana bread, and sandwiches that were only cut in half rather than into bite-sized pieces. Additionally, the resident received dry toast and slices of orange with the skin on, which were not suitable for their dietary needs. These observations were made without staff present to assist the resident during meal times, which further compromised the resident's safety and dietary compliance. Interviews with facility staff, including the Registered Dietitian (RD), Food Service Director (FSD), and Unit Manager, confirmed that the resident's diet was not being followed as per the IDDSI guidelines. The RD acknowledged that the resident's meals did not comply with the IDDSI level 6 diet, and the FSD stated that bread or sandwiches should be cut into smaller pieces. The Director of Rehab also confirmed that the meals provided did not meet the required dietary standards, as the resident received inappropriate bread products and inadequately prepared fruit. The facility's Speech Language Pathologist was unavailable for comment.
Failure to Maintain Infection Control for Urinary Catheter
Penalty
Summary
The facility failed to implement infection prevention procedures for a resident with an indwelling urinary catheter. The facility's policy on catheter care, which aims to prevent catheter-associated urinary tract infections, specifies that catheter tubing and drainage bags should be kept off the floor. However, observations revealed that the urinary catheter drainage bag of a resident was repeatedly found resting on the carpeted floor. This occurred despite the resident being cognitively intact and dependent on staff for activities of daily living, including toileting and bathing. Multiple observations on different occasions showed the drainage bag on the floor, indicating a lack of adherence to infection control protocols. A staff member was seen entering and exiting the resident's room without addressing the improperly placed drainage bag. During an interview, a nurse acknowledged that the catheter bag should not be on the floor and should be hung on the side of the bed, confirming the facility's failure to follow its own infection control procedures.
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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 Newton Upper Falls
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Care One At Newton | 1.9 mi | ★★★★★ | 8 | 0 |
| Skilled Nursing Facility At North Hill (the) | 2.1 mi | ★★★★★ | 0 | 0 |
| Elizabeth Seton | 2.2 mi | ★★★★★ | 0 | 0 |
| Lasell House | 2.4 mi | ★★★★★ | 1 | 0 |
| West Newton Healthcare | 2.6 mi | ★★★★★ | 16 | 0 |
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