Above 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 Commons Skilled Nursing & Rehabilitation during CMS and state inspections, most recent first.
A resident with multiple fractures and non-Hodgkin lymphoma, who was cognitively intact and dependent on staff, was standing in the bathroom holding a grab bar when the resident reported being unable to continue standing due to knee weakness. A CNA lowered the resident to the floor, then independently lifted the resident, placed the resident in a wheelchair, and transferred the resident back to bed before notifying nursing staff, despite facility policy requiring a nursing assessment for injury before moving a resident found on the floor. Nursing staff later learned of the event only after the resident was back in bed and initially were informed only of a skin tear sustained during a transfer, not that the resident had been lowered to the floor, resulting in the resident not being assessed by a nurse prior to being moved.
The facility failed to maintain complete CNA flow sheet documentation for three residents, including individuals with Type 2 DM, HTN, UTI, dementia, anxiety, and a right lower leg infection following a fall. Policy required all services and changes in condition to be documented, yet multiple entire days and shifts in two consecutive months were left blank for each resident. A CNA reported they are expected to document care in the electronic flow sheets after providing care and noted there is no electronic alert for missing entries, while the DON stated CNAs are expected to complete flow sheets at the end of each shift and acknowledged multiple days of missing documentation.
Failure to Report Injury of Unknown Origin: A resident with dementia and a prior leg fracture was found with a swollen, bruised hand of unknown origin, and the resident said it hurt and did not know how it happened. A nurse had noticed the injury earlier that morning and gave Tylenol, but the DON later said she had not started an investigation and had not reported the injury to the state agency, believing she had 24 hours because the cause could not be determined.
Failure to Immediately Investigate Injury of Unknown Origin: A resident with dementia and a prior leg fracture was observed with a swollen, bruised hand of unknown origin, and the resident said it hurt and did not know how it happened. The injury was not documented in progress notes, the nurse said it was not present the prior day, and the DON had not started an investigation when she learned of the bruise; the MD could not determine the cause.
Failure to complete baseline AIMS assessment for a resident on antipsychotic medication. A resident admitted with depression and anxiety had a BIMS score indicating cognitive intactness and was receiving aripiprazole for major depressive disorder. The record did not show an AIMS assessment was completed, and the DON stated no AIMS was ever done for the resident and that there was no specific facility policy for AIMS completion.
A resident with dysphagia who was documented as NPO and receiving nutrition via feeding tube had a physician order for Propranolol transcribed as oral administration, and staff administered the medication by mouth as ordered. Nurse, Dietitian, and DON interviews confirmed the resident should have been receiving meds via G-tube and that the order was transcribed incorrectly.
Arbitration Agreement Missing Required Voluntary-Signature Statement: A resident with metabolic encephalopathy, HF, and cancer was moderately cognitively impaired, and the activated HCP signed an arbitration agreement that did not state that neither the resident nor the representative was required to sign it as a condition of admission or continued care. The Administrator said she was not aware of the requirement.
Arbitration Agreement Lacked Convenient Venue Selection: A resident with metabolic encephalopathy, HF, and cancer was moderately cognitively impaired, and the HC proxy was activated before signing an arbitration agreement. The agreement signed by the proxy did not state that the resident or representative could select a convenient venue, and the Administrator said she was not aware of that requirement.
Infection control practices were not followed during EBP care and medication preparation. An RN entered a resident’s room without a gown, handled a feeding tube, removed gloves, then returned to the tube without hand hygiene or new gloves. During med pass, the RN handled capsules and tablets with bare hands for multiple residents, including opening capsules and picking up a dropped capsule from the cart.
Failure to Obtain Nursing Assessment After Resident Lowered to Floor
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a dependent resident received care and treatment consistent with professional standards and the facility’s fall assessment policy after being lowered to the floor in the bathroom. The resident, admitted with diagnoses including non-Hodgkin lymphoma, a left femur fracture, and a pelvic fracture, was cognitively intact and dependent on staff for care. On the date of the incident, the resident reported standing in the bathroom holding a grab bar while a CNA provided care, then telling the CNA that the resident’s knee was giving out and that they could not continue standing. The resident stated the CNA told them to hold on, but because the resident could not stand any longer, the CNA had to lower the resident to the floor, after which the resident cried due to right knee pain. According to the incident report and staff interviews, CNA #1 confirmed lowering the resident to the floor, then independently lifting the resident, placing them in a wheelchair, and transferring them back to bed before notifying any nurse. The facility’s policy on assessing falls requires that when a resident has fallen or is found on the floor, staff must evaluate for possible injuries to the head, neck, spine, and extremities before moving the resident. Multiple nurses and the nursing supervisor reported that CNA #1 did not inform them of the resident being lowered to the floor until after the resident had been moved back to bed, and some were only told about a skin tear sustained during a transfer, not that the resident had been on the floor. The DON and nursing supervisor both stated that being lowered to the floor is considered a fall and that a nurse should have assessed the resident for potential injury before the resident was moved, which did not occur in this case.
Failure to Maintain Complete CNA Flow Sheet Documentation for Multiple Residents
Penalty
Summary
The facility failed to maintain complete and accurate medical records when CNA flow sheets documenting the provision of care were left blank for multiple days and shifts for three residents. Facility policy on Charting and Documentation, revised 07/2017, required that all services provided to residents, progress toward care plan goals, and any changes in residents' conditions be documented in the medical record. For a resident admitted in November 2025 with diagnoses including Type 2 Diabetes Mellitus, Hypertension, and Urinary Tract Infection, review of CNA flow sheets for December 2025 showed multiple dates where all three shifts (day, evening, and night) were left blank, including 12/02, 12/04 through 12/08, 12/11, 12/13, and 12/14. A second resident admitted in December 2025 with diagnoses including status post fall and a right lower leg infection had CNA flow sheets for January 2026 with no documentation on several dates across all shifts, specifically 01/02 through 01/04, 01/07, 01/08, 01/12, and 01/13. A third resident admitted in December 2023 with dementia and anxiety had extensive gaps in CNA flow sheet documentation for December 2025 and January 2026, with multiple consecutive days and shifts left blank, including large portions of early, mid, and late December and early to mid-January. During interview, a CNA stated they are supposed to document care on the electronic flow sheet once completed and noted there is no electronic alert if documentation is not done. In a separate interview, the DON stated CNAs were supposed to complete their flow sheets at the end of every shift and acknowledged there were several missing days of CNA documentation for the three residents.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin immediately, and no later than 2 hours after the injury was discovered, to the state agency for one resident out of a sample of 17. The facility policy titled Abuse, Neglect and Exploitation Prohibition and Prevention Program, dated August 2023, stated that an injury of unknown origin is an injury not observed by anyone and cannot be explained by the resident, and that such injuries are reported and investigated as potential abuse. The policy further stated that injuries of unknown origin must be reported to the state agency within 2 hours. Resident #51 was admitted in November 2025 with diagnoses including dementia and a fracture of the left leg. The medical record did not indicate a completed MDS assessment. On 11/25/2025 at 8:15 A.M., the surveyor observed the resident's left hand to be swollen and bruised over an area of approximately three inches in diameter. The resident stated the area hurt, did not know how it happened, and said it was not there the day before. A nurse stated she noticed the area earlier that morning and gave Tylenol for pain, and said the hand was not bruised or swollen on Sunday. Later that day, the DON stated she learned of the bruise at 12:30 P.M., had not started an investigation into how the injury occurred, and had not reported it to the state agency. The DON stated she did not think the injury was abuse and believed she had 24 hours to report it because the etiology could not be determined. The physician also stated she was unable to determine how the injury occurred and said the resident could have banged the area against something, but the etiology remained unknown.
Failure to Immediately Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to immediately investigate an injury of unknown origin for one resident. The facility policy titled Abuse, Neglect and Exploitation Prohibition and Prevention Program, dated August 2023, stated that an injury of unknown origin is an injury not observed by anyone and cannot be explained by the resident, and that this type of injury is reported and investigated as potential abuse. The policy further stated that the facility must start an investigation into the etiology of the injury immediately. Resident #51 was admitted in November 2025 with diagnoses including dementia and a fracture of the left leg. The medical record did not indicate a completed MDS assessment. On 11/25/2025 at 8:15 A.M., the surveyor observed the resident’s left hand to be swollen and bruised over an area of about three inches in diameter. During interview at that time, the resident said the area hurt, did not know how it happened, and said it was not there the day before. Review of progress notes did not mention the injury. A nurse said she noticed the area earlier that morning and stated it was not bruised or swollen when she worked on Sunday. Later that day, the DON said she did not find out about the bruise until 12:30 P.M. and had not started an investigation into how the injury occurred. The physician said she could not determine how the injury occurred and that the resident may have banged the area against something, but the etiology could not be determined.
Failure to Complete Baseline AIMS Assessment for Resident on Antipsychotic
Penalty
Summary
The facility failed to ensure services provided met professional standards of quality for one resident, who was admitted in November 2025 with diagnoses including depression and anxiety disorder and had a BIMS score of 13 out of 15, indicating cognitive intactness. The resident’s MDS indicated use of antipsychotic medications, and physician orders showed aripiprazole 10 mg daily for major depressive disorder, with the medication administered daily beginning on 11/14/25. Review of the medical record did not show that a baseline AIMS assessment was completed upon admission or at the initiation of the antipsychotic medication. During interview, the DON stated that no AIMS assessment was ever completed for the resident and that the expectation was for AIMS assessments to be completed on admission when a resident is taking an antipsychotic or when an antipsychotic is initiated; she also stated there was no specific facility policy for completion of AIMS assessments.
Inaccurate transcription of physician order for NPO resident
Penalty
Summary
The facility failed to maintain medical records in accordance with nursing professional standards by inaccurately transcribing a physician's order for one resident out of a sample of 17. The facility policy on charting and documentation required all services and changes in condition to be documented in the medical record and for documentation to be objective and accurate. Resident #8 was admitted in January 2025 with dysphagia, was rarely or never understood on the most recent MDS, and was documented as being on a feeding tube and NPO in the nutritional risk assessment and speech therapy evaluation. Review of Resident #8's physician's orders showed Propranolol 10 mg orally three times daily was ordered starting 11/13/25 and discontinued 11/25/25, and staff administered the medication by that oral route during that period. During interviews, Nurse #2 stated the resident's medications should be given via G-tube and that the resident is strictly NPO. The Dietitian stated the resident had been NPO since admission and should not be receiving medication by mouth. The DON and surveyor reviewed the orders and the DON stated the resident is NPO, should not be getting medication by mouth, and that the physician's orders were transcribed incorrectly.
Arbitration Agreement Missing Required Voluntary-Signature Statement
Penalty
Summary
The facility failed to ensure that the arbitration agreement explicitly stated that neither the resident nor the resident’s representative was required to sign the binding arbitration agreement as a condition of admission or as a requirement to continue receiving care at the facility. Resident #24 was admitted in October 2025 with diagnoses including metabolic encephalopathy, heart failure, and cancer. The Minimum Data Set assessment dated [DATE] showed the resident was moderately cognitively impaired, with a Brief Interview for Mental Status score of 12 out of 15. The facility’s Massachusetts Health care Proxy dated 10/1/25 identified a family member as the designated health care proxy, and the Activation of Health Care Proxy/Durable Power of Attorney for Health Care indicated the proxy was activated on 10/15/25. The Exhibit C Arbitration Agreement dated April 2025 and signed by the health care proxy on 10/23/25 did not include the required statement that signing was not a condition of admission or continued care. During interview, the Administrator stated she was not aware of the requirement for the arbitration agreement to include that statement.
Arbitration Agreement Lacked Convenient Venue Selection
Penalty
Summary
The facility failed to ensure its arbitration agreement provided for the selection of a venue that is convenient to both parties. Resident #24 was admitted in October 2025 with diagnoses including metabolic encephalopathy, heart failure, and cancer. The Minimum Data Set assessment dated [DATE] showed the resident was moderately cognitively impaired, with a Brief Interview for Mental Status score of 12 out of 15. The facility record titled Massachusetts Health care Proxy dated 10/1/25 identified a family member as the designated health care proxy, and the Activation of Health Care Proxy/Durable Power of Attorney for Health Care indicated the proxy was activated on 10/15/25. The Exhibit C Arbitration Agreement dated April 2025 and signed by the health care proxy on 10/23/25 did not indicate that the resident or representative would be given an opportunity to select a convenient venue. During interview on 11/26/25 at 8:05 A.M., the Administrator stated she was not aware of the requirement that the arbitration agreement must state the resident or representative would be provided an opportunity to select a convenient venue.
Infection Control Failures During EBP Care and Medication Pass
Penalty
Summary
The facility failed to use appropriate infection control practices for a resident with Enhanced Barrier Precautions. Resident #8 was admitted in January 2025 with dysphagia and was on a feeding tube. During observation, Nurse #2 entered the resident’s room without a gown, put on gloves, and straightened a kink in the G-tube. The nurse then removed the gloves, balled them in a fist, returned to the feeding tube without performing hand hygiene or putting on a new pair of gloves, and later discarded the gloves and performed hand hygiene outside the room. The facility policy for Enhanced Barrier Precautions stated that gowns and gloves are to be used during high-contact care activities, including device care such as feeding tube care, and staff interviews confirmed expectations for gown use and hand hygiene between glove removal and re-gloving. The facility also failed to maintain infection control practices during medication preparation. During medication pass observations, Nurse #2 opened two Drizalma capsules with bare hands for one resident, popped two Bumex tablets from a medication card into bare hands for another resident, and dropped a fish oil capsule onto the medication cart before picking it up with bare hands and placing it into a medication cup for a third resident. When interviewed, Nurse #2 stated he should not have touched medications with bare hands before administering them, and the DON stated nurses should not touch medications with bare hands when preparing them for administration.
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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 Lincoln
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Care One At Concord | 2.7 mi | ★★★★★ | 3 | 0 |
| Rivercrest Long Term Care | 3 mi | ★★★★★ | 0 | 0 |
| Campion Health & Wellness, Inc | 4.6 mi | ★★★★★ | 0 | 0 |
| Carleton-willard Village Retirement & Nursing Ctr | 4.9 mi | ★★★★★ | 0 | 0 |
| Brookhaven At Lexington | 5 mi | ★★★★★ | 7 | 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.