Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Guardian Center during CMS and state inspections, most recent first.
A resident with an activated HCP and severe cognitive impairment developed MASD to the buttocks, and the nurse obtained a new Triad cream order after notifying the NP. The HCA later reported she was not told when the skin breakdown first appeared or when the new treatment began, and the chart contained no documentation that the HCA was notified of the significant change in condition or the new order.
Nursing staff did not promptly notify a resident's Health Care Agent of a significant change in condition involving new deep tissue injuries to both heels, despite facility policy requiring such notification. Documentation incorrectly indicated that the HCA had been informed, but interviews confirmed only the provider was notified, and the HCA learned of the injuries through a family member.
A resident with multiple chronic conditions developed new deep tissue injuries to the heels. Nursing documentation indicated that both the provider and the resident's HCA were notified, but interviews revealed that only the provider was actually contacted. The nurse responsible for the documentation believed the Unit Manager had notified the HCA, but this was not confirmed. This resulted in incomplete and inaccurate medical records regarding the notification of significant changes in the resident's condition.
Failure to Notify HCA of New Buttocks MASD and Treatment Order
Penalty
Summary
The facility failed to ensure that nursing staff promptly notified a resident’s Health Care Agent when the resident experienced a significant change in status related to the development of Moisture-Associated Skin Damage (MASD) to the buttocks. The resident was admitted with diagnoses including Parkinson’s disease, dementia, and Type II diabetes mellitus, and had an activated Health Care Proxy. The resident’s annual MDS assessment showed a BIMS score of 2 out of 15, indicating severe cognitive impairment. Facility policy stated that the facility promptly notifies the resident, attending physician, and resident’s representative of changes in medical or mental condition and/or status. The resident’s interim skin assessment documented MASD to the buttocks and notification of the wound team, and a physician’s order was obtained for Triad Hydrophilic cream to be applied every shift. The resident’s HCA stated that when she visited and observed purple-red discolored open areas on the buttocks, she was not notified when the skin areas first developed and did not know when the Triad cream order began. A nurse stated she notified the NP and believed she had informed the HCA, but there was no documentation in the medical record that the HCA was notified of the new skin areas or the new treatment order. The DON also reviewed the record and confirmed there was no documentation that the HCA had been notified of the change in condition and new order.
Failure to Notify Health Care Agent of Significant Change in Resident Condition
Penalty
Summary
Nursing staff failed to promptly notify the Health Care Agent (HCA) of a resident who had an invoked Health Care Proxy (HCP) when the resident experienced a significant change in condition, specifically the development of deep tissue injuries (DTIs) to both heels. The facility's policy requires prompt notification of the resident, attending physician, and resident's representative in the event of changes in medical or mental condition. The resident, who had moderate cognitive impairment and diagnoses including vascular dementia and diabetes, was found to have unstageable pressure injuries on both heels. Documentation in the nurse's progress note and incident report indicated that both the provider and family (HCA) were notified of the new skin developments. However, interviews revealed that the nurse had only notified the provider and not the HCA, mistakenly believing the Unit Manager had done so. The Unit Manager, upon review, did not recall notifying the HCA and stated that the nurse should not have documented notification unless it was personally completed. The DON assumed proper notification had occurred based on the documentation, but later confirmed that facility expectations require prompt notification and accurate documentation only after confirmation. The HCA ultimately learned of the injuries through a family member, not from facility staff.
Failure to Accurately Document and Notify Health Care Agent of Pressure Injuries
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident with multiple diagnoses, including vascular dementia, diabetes mellitus, depression, and anxiety. On review, documentation in both the Nurse Progress Note and the Skin Incident Report indicated that the resident's Health Care Agent (HCA) and provider were notified of newly observed deep tissue injuries to the resident's heels. However, interviews with the nurse responsible for the documentation revealed that only the provider was notified, and the nurse had not contacted the HCA as documented. The nurse stated she believed the Unit Manager had made the notification, but the Unit Manager did not recall doing so. Further interviews with the Unit Manager and the Director of Nursing (DON) confirmed that the expectation was for nursing staff to promptly notify the HCA of any significant change and only document such notification once it had occurred. The DON assumed proper notification had been made based on the documentation, but it was determined that the HCA had not actually been notified as required. This discrepancy between documentation and actual practice resulted in incomplete and inaccurate medical records for the resident.
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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 Brockton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brockton Post Acute Care | 1.3 mi | ★★★★★ | 0 | 0 |
| Alliance Health At West Acres | 1.8 mi | ★★★★★ | 0 | 0 |
| The Center At Blue Hills | 2.3 mi | ★★★★★ | 4 | 0 |
| Champion Rehabilitation And Nursing Center | 2.6 mi | ★★★★★ | 0 | 0 |
| St Joseph Manor Health Care Inc | 2.7 mi | ★★★★★ | 4 | 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 August 2026) and official state health department websites.