Average — CMS composite of the measures below.
The next survey window likely opens 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 The Center At Blue Hills during CMS and state inspections, most recent first.
A severely cognitively impaired, legally blind resident with dementia and depression was involved in an incident where a CNA was reported to have slapped the resident in the face in an alcove near a utility room. Staff heard a commotion and a sound like a slap, then found the resident holding their face with both hands, with red marks and a small scratch on the right side of the face. One CNA reported directly witnessing the slap, while the CNA involved denied slapping but admitted to pushing the resident away by the shoulders when the resident allegedly blocked her path and reached for her glasses. The resident told multiple staff and police that someone had hit or slapped them in the face, and physical findings of facial redness and scratches were documented, demonstrating a failure to keep the resident free from physical abuse despite an existing abuse-prevention policy.
A facility failed to ensure Advance Directives were valid for a resident due to a missing clinician signature on the MOLST form. The resident's healthcare proxy signed the necessary sections, but the absence of a clinician's signature rendered the directives, including DNR, DNI, and DNH, invalid. The Director of Nurses confirmed the oversight during interviews.
The facility failed to secure a utility room containing hazardous materials in the Dementia Special Care Unit, leaving it accessible to wandering residents. Observations showed the door consistently left ajar and unlocked, with staff entering and exiting without securing it. Interviews revealed that several residents wander without direction, and staff acknowledged the use of stop signs to deter them, but these measures were inadequate to prevent access to the hazardous room.
The facility failed to maintain food safety and sanitation standards, risking foodborne illness spread. In the resident kitchenette, food items were improperly labeled, dated, and stored. The main kitchen ceiling was flaking, risking contamination of food and clean dishes. The FSM and Maintenance Director acknowledged these issues, with previous repair attempts proving ineffective.
A resident with severe cognitive impairment and pressure ulcers did not receive timely wound care as recommended by the wound physician. The facility failed to implement the physician's recommendations for Stage 3 pressure ulcers on the coccyx and right buttock, with delays of up to 12 days. Staff interviews revealed issues with the integration of wound care notes into the electronic medical record, contributing to the delay in treatment.
A resident with severe cognitive impairment was prescribed Trazodone for anxiety, agitation, and insomnia, with PRN orders initially set for 14 days. The facility failed to document a rationale for extending these orders to 90 days, as required by policy. Despite the resident not experiencing related symptoms or receiving the PRN medication, the extension was made without proper documentation, leading to a deficiency.
The facility failed to complete Comprehensive MDS assessments within the required time frame for five residents, with delays ranging from two to eight days. The MDS Coordinator was absent, and no support was available to assist with the assessments, leading to the deficiency.
The facility failed to complete Quarterly MDS assessments on time for three residents, with assessments being three days late. The delay was due to the absence of the MDS Coordinator, and no support was provided to ensure timely completion. The Administrator acknowledged the lack of support during the Coordinator's absence.
Failure to Protect Cognitively Impaired Resident From Physical Abuse by CNA
Penalty
Summary
The deficiency involves the facility’s failure to protect a severely cognitively impaired resident from physical abuse by a staff member. Facility policy on abuse, neglect, and exploitation, last revised in January 2025, defines abuse as the willful infliction of injury, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and specifies that physical abuse includes hitting and slapping. Despite this policy, on the morning of 01/14/26, a certified nurse aide (CNA #1) was reported to have slapped a resident in the face in an alcove area near the dirty utility room and the resident’s room. The resident, admitted in September 2025 with dementia with behavioral disturbances, major depression, and legal blindness, had a recent MDS showing a BIMS score of 3/15, indicating severe cognitive impairment. Multiple staff observations and interviews described the events surrounding the incident. A nurse (Nurse #1), while putting away the resident’s clothes, heard someone say, “why did you do that?” and went to the alcove, where she found the resident holding their face with both hands, with a red area on the right side of the face and a scratch near the right eyebrow. CNA #2 reported to Nurse #1 that she had just witnessed CNA #1 slap the resident in the face and stated she saw the slap and observed a red mark and a small cut on the right side of the resident’s face. A medical records employee reported hearing commotion near the dirty utility room and a sound like a slap around the same time. The staff development coordinator (SDC) and the DON each separately assessed the resident shortly after and both observed a small pink/red scratch and red marks on the right side of the resident’s face; the resident told them that someone had hit or slapped them in the face, though could not identify who. CNA #1 denied slapping the resident but admitted to pushing the resident. In interviews with the SDC, DON, and police, CNA #1 stated that the resident was in front of her near the soiled utility room, would not move, and was grabbing for her face or glasses, and that she pushed the resident away by the shoulders. The police report documented that the resident described having gotten into a “tussle,” pointed to the right eye, and stated they were hit in the eye, and the officer observed two small red marks on the right side of the resident’s head near the eye. The facility’s own HCFRS report recorded that CNA #1 had been witnessed slapping the resident, that the resident had red markings on the right side of the face, reported facial pain, and received pain medication. Based on these observations and statements, surveyors determined that the facility failed to ensure the resident was free from physical abuse, and that, under the reasonable person concept, a cognitively impaired resident would experience emotional upset after being slapped by a caregiver.
Invalid Advance Directives Due to Missing Clinician Signature
Penalty
Summary
The facility failed to ensure that Advance Directives were properly formulated and signed by a clinician, rendering them invalid for one resident. The Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST) form for this resident, dated 8/10/13, required signatures in Sections D and E to be valid. While the resident's healthcare proxy signed both sections on 9/18/21, the clinician's signature was missing in Section E, making the MOLST form invalid. The resident's care plan included directives such as Do Not Resuscitate (DNR), Do Not Intubate (DNI), Do Not Hospitalize (DNH), and no dialysis, with the healthcare proxy invoked. The care plan also indicated that these directives would be honored for the next 90 days and reviewed quarterly. During interviews, the Director of Nurses confirmed the absence of a clinician's signature on the MOLST form, acknowledging the oversight.
Failure to Secure Hazardous Utility Room in Dementia Unit
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards on one of its three units, specifically the Dementia Special Care Unit. The surveyor observed an unlocked utility room with hazardous items such as open bottles of no-rinse floor stripper, unsecured dentures, containers of used sharps, and a bottle of concentrated degreaser cleaner. This room was easily accessible to wandering residents, as the door was consistently found ajar and unlocked over multiple observations. Staff, including housekeepers and CNAs, were seen entering and exiting the room without securing the door, despite the presence of wandering residents in the hallway. Interviews with staff, including a CNA and a nurse, revealed that several residents on the unit wander without direction, often entering rooms they should not. The staff acknowledged the use of stop signs to deter residents from entering certain areas, but these measures were insufficient to prevent access to the hazardous utility room. The Director of Nurses confirmed that the expectation was for the utility room door to be closed and secured at all times to prevent resident access to hazardous materials.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards of food safety and sanitation, which could potentially lead to the spread of foodborne illnesses among high-risk residents. In the resident kitchenette, the facility did not maintain cleanliness and proper labeling and dating of food items. Observations included an unsealed box of Jamaican Hot Beef Patties in the freezer, and various food items in the refrigerator that were either not labeled, not dated, or past the three-day consumption period as per the facility's policy. The Food Service Manager acknowledged these issues, despite claiming that staff check the refrigerator multiple times a day. Additionally, the facility did not maintain the main kitchen ceiling in a safe and sanitary condition. The ceiling above the dishwasher and milk refrigeration chest was observed to be flaking, with a large brown water stain present. This condition posed a risk of contamination to food and clean dishes stored below. The Maintenance Director and Administrator were aware of the issue, with the Maintenance Director having attempted repairs previously. However, the ceiling continued to flake due to a leak from a bathroom above, which had not been effectively addressed.
Delayed Implementation of Wound Care Recommendations for Resident with Pressure Ulcers
Penalty
Summary
The facility failed to provide timely care and treatment for a resident with pressure ulcers, specifically neglecting to implement the wound physician's recommendations for two Stage 3 pressure ulcers on the coccyx and right buttock. The resident, who was admitted with severe cognitive impairment and an unstageable pressure ulcer, did not receive the recommended wound care treatments promptly. The facility's policy required systematic pressure injury management, including prompt assessment and treatment, but this was not adhered to in the case of this resident. The resident's medical records indicated a lack of timely implementation of the wound care physician's recommendations. Despite the wound physician's evaluations and recommendations for specific dressing treatments and supplements, these were not ordered or documented in the physician's orders in a timely manner. There were delays of up to 12 days in implementing the recommended treatments, and there was no documentation indicating that the attending physician reviewed or declined these recommendations. Interviews with facility staff, including the Director of Nurses (DON) and Assistant Director of Nurses (ADON), revealed issues with the integration and timely receipt of the wound care physician's notes and recommendations. The ADON admitted to delays in writing orders due to issues with uploading notes into the electronic medical record and a lack of direct communication with the wound physician. The DON and wound physician acknowledged system problems with note integration, which contributed to the delays in treatment implementation.
Failure to Document Rationale for Extending PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure that PRN orders for psychotropic medications were limited to 14 days unless a documented rationale was provided by the attending physician or prescribing practitioner. This deficiency was identified for a resident who was admitted with diagnoses including insomnia, psychotic disorder with delusions, mood disorder, falls, and dementia. The resident was prescribed Trazodone for various conditions, including anxiety, agitation, and insomnia, with PRN orders initially set for 14 days. However, the PRN orders were extended to 90 days without a documented rationale in the medical record, as required by the facility's policy. The deficiency was highlighted during a review of the resident's medical records and staff interviews. The records showed that the resident had not experienced anxiety, agitation, or insomnia since admission, and the PRN medications had not been administered. Despite this, the PRN orders were extended without proper documentation. Interviews with the ADON/SDC, DON, and Corporate Nurse revealed that they were unable to provide a documented rationale for the extension, although it was suggested that the extension was due to the resident's history of behaviors prior to admission. This lack of documentation and adherence to policy led to the identified deficiency.
Delayed Completion of MDS Assessments
Penalty
Summary
The facility failed to complete the Comprehensive Minimum Data Set (MDS) assessments within the required time frame for five residents. The MDS is a federally mandated process for clinical assessment of residents in Medicare or Medicaid-certified nursing homes. It is required that an Admission MDS assessment be completed within 14 calendar days after a resident's admission to the facility. However, the assessments for five residents were completed late, ranging from two to eight days past the deadline. The MDS Coordinator acknowledged the delay in completing the assessments, attributing it to her recent absence from work and the lack of support to assist with the assessments during her absence. The facility's Administrator also recognized the issue, noting that there should be someone available to support the MDS Coordinator to prevent such delays. This deficiency was identified during a review of 28 comprehensive assessments conducted from September 2024 through October 9, 2024.
Failure to Complete Timely MDS Assessments
Penalty
Summary
The facility failed to ensure the timely completion of Quarterly Minimum Data Set (MDS) assessments for three residents, as required by federal regulations. The MDS assessments for these residents were completed three days late, beyond the 92-day requirement from the most recent OBRA Assessment reference date. This deficiency was identified during a review of 28 comprehensive assessments conducted between September 2024 and October 9, 2024. The delay in completing the MDS assessments was attributed to the absence of the MDS Coordinator, who was responsible for these assessments. During her absence, there was no designated staff member to assist with the completion of the assessments, leading to the delay. The facility's Administrator acknowledged the issue, noting that there should have been support for the MDS Coordinator to prevent such delays.
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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 Stoughton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Copley At Stoughton Nursing Care Center | 1 mi | ★★★★★ | 11 | 0 |
| Alliance Health At West Acres | 1.8 mi | ★★★★★ | 6 | 0 |
| Brockton Post Acute Care | 2.1 mi | ★★★★★ | 0 | 0 |
| The Guardian Center | 2.3 mi | ★★★★★ | 2 | 0 |
| New England Sinai Hospital Transitional Care Unit | 2.7 mi | — | 0 | 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.