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 Thomas Upham House during CMS and state inspections, most recent first.
A resident with depression and severe cognitive impairment had repeated PRN trazodone orders that did not include an indication for use or a limited duration. The MAR showed the medication was given once, but the record did not show MD or NP reassessment or a documented clinical rationale supporting continued renewal of the PRN order, and the DON and MDS Nurse confirmed the missing documentation.
A resident with COPD and CHF was observed using O2 via nasal cannula connected to a humidifier cup and concentrator set to 4.5 liters, but the chart contained no physician order for O2, the equipment, or equipment care. The MAR/TAR also lacked documentation of O2 administration, delivery device, or flow rate, and the DON confirmed no orders were present in the record.
Improperly labeled beverages and an unclean microwave were observed in a First-Floor nourishment kitchenette. Surveyors repeatedly found the microwave with food residue and splatter on the top and sides, along with opened cartons of Med Pass 2.0+ fortified nutritional shake and thickened cranberry cocktail that were undated despite manufacturer instructions to discard within 4 days of opening. The FSD stated dietary staff were responsible for labeling, dating, and cleaning the kitchenette equipment.
The facility failed to maintain an effective infection prevention and control program, with deficiencies in surveillance and testing procedures. Staff did not accurately document or analyze infection data, delaying COVID-19 testing for symptomatic residents. Additionally, improper use of PPE and incorrect mask-wearing compromised infection control efforts.
The facility failed to provide a dignified dining experience for residents, as observed by surveyors. Residents were given clothing protectors without consent, meals were served off trays, and there was a lack of staff assistance during meals. Delays in meal service and the use of demeaning language further detracted from a dignified experience. The DON acknowledged these deficiencies, noting that meals should be served simultaneously and off trays.
The facility failed to adhere to professional standards in medication administration for two residents. One resident received wound care without a proper physician's order, and another had blood sugars checked and self-administered an inhaler without necessary orders. These actions highlight a lack of adherence to professional standards and facility policies.
The facility failed to secure treatment carts on the Second Floor Unit, leaving them unlocked and unattended, sometimes with a resident nearby. Interviews with staff confirmed that treatment carts should always be locked when not supervised by a nurse, and keys should not be left in the cart.
A facility failed to timely notify the NP about the unavailability of a prescribed treatment for a resident with a stage 4 pressure ulcer. The resident, with severe cognitive impairment, required Santyl for wound care, which was on back order. Nurse #2 delayed notifying the NP, and there was no documentation of this communication, leading to a deficiency.
A resident with a stage 4 pressure ulcer did not receive the necessary medication, Santyl, due to it being out of stock at the primary pharmacy. Despite facility policies allowing for backup pharmacy use, the medication was not procured, delaying treatment. The Director of Nursing and staff were unaware of the medication's unavailability and the option to use a backup pharmacy.
A facility failed to monitor adverse consequences of anticoagulant medications for a resident with conditions like polycythemia vera and deep vein thrombosis. Despite receiving Eliquis, the resident's records lacked documentation of monitoring for side effects, contrary to facility policy. Interviews with staff confirmed the absence of a current order for monitoring and documentation, highlighting a deviation from required procedures.
PRN trazodone orders lacked indication, duration, and documented reassessment
Penalty
Summary
The facility failed to ensure that one resident’s drug regimen was free from unnecessary psychotropic medication use when PRN trazodone orders were written without an indication for use and without a limited duration. The resident was admitted in January 2025 with depression and had severe cognitive impairment, with an MDS assessment showing a BIMS score of 2 out of 15 and use of an antidepressant medication. The medical record showed multiple PRN trazodone orders, including repeated renewals with re-evaluation dates, but the orders themselves did not identify why the medication was to be used and did not include a duration for the PRN order. The MAR showed PRN trazodone was administered once during the review period. The record also did not show that the MD or NP evaluated the resident and documented a clinical rationale for continued PRN trazodone use based on the resident’s condition and therapeutic goals before the order was renewed or extended. During interview, the DON and MDS Nurse confirmed the PRN order lacked a limited duration and indication for use and that there was no MD or NP documentation supporting continued use each time it was renewed.
Oxygen Used Without Physician Order
Penalty
Summary
Professional standards of practice were not followed for one resident when oxygen therapy was used without a physician's order. Resident #41, admitted in November 2025 with diagnoses including COPD and CHF, was observed seated in a recliner with a nasal cannula in place, tubing connected to a humidifier cup half filled with water, and an oxygen concentrator set to 4.5 liters. The resident stated that 4.5 liters of oxygen had been used continuously since admission. The medical record contained an order to measure SpO2 every shift and keep O2 levels above 90%, but it did not contain an order for oxygen, oxygen equipment, or care of the oxygen equipment. The November 2025 MAR/TAR also did not document oxygen administration, the delivery device, or the oxygen flow rate. A nurse stated she learned the resident was on oxygen from the nursing communication book and could not find a physician's order anywhere in the record. The DON reviewed the record and confirmed there were no orders for oxygen, the humidifier cup, nasal cannula, tubing, or maintenance of the equipment, and stated oxygen is a medication that must have a complete physician's order for its use.
Improperly Labeled Beverages and Unclean Microwave in Nourishment Kitchenette
Penalty
Summary
The facility failed to follow professional standards of practice for food safety and sanitation in one of two nourishment kitchenettes. On 11/19/25 at 8:05 A.M., 11:20 A.M., 12:47 P.M., and again on 11/20/25 at 8:04 A.M., the surveyor observed the First-Floor nourishment kitchenette with the inside of the microwave containing food residue and splatter on the top and sides. During each observation, two opened and undated cartons of vanilla Hormel Med Pass 2.0+ Fortified Nutritional Shake were found on the refrigerator door, and one opened and undated carton of nectar consistency thickened cranberry cocktail was also found in the refrigerator. The manufacturer guidelines on the cartons indicated they should be discarded within four days of opening. During an interview on 11/20/25 at 9:26 A.M., the Food Service Director stated dietary staff were responsible for ensuring items in the nourishment kitchenettes were properly labeled and dated and that equipment was cleaned. The FSD and surveyor reviewed the observations, and the FSD stated the opened beverages should have been dated and should not have been in the refrigerator without an open date. The FSD also stated the microwave should have been clean and free of food residue and splatter.
Inadequate Infection Control and COVID-19 Testing Procedures
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies in their surveillance and testing procedures. The infection preventionist (IP) and nursing staff did not accurately document and analyze surveillance data, leading to incomplete and inaccurate records of infections. This lack of proper documentation and analysis prevented the facility from identifying trends or potential outbreaks, as the surveillance sheets were not reviewed for accuracy or completion. Additionally, the facility did not track signs and symptoms of illnesses that did not meet the criteria for antibiotic treatment, which could have helped in early intervention and prevention of infections. The facility also failed to perform COVID-19 testing in accordance with established guidelines. For instance, a resident who exhibited symptoms of COVID-19 was not tested immediately, contrary to the facility's policy and CDC guidelines. This delay in testing potentially increased the risk of transmission within the facility. Furthermore, staff did not adhere to the manufacturer's instructions for the COVID-19 antigen self-test kits, resulting in tests being read too early or too late, which could lead to inaccurate results. Additionally, staff did not consistently use appropriate personal protective equipment (PPE) when conducting tests, increasing the risk of exposure to the virus. Moreover, the facility did not enforce proper source control measures during a COVID-19 outbreak. Staff were observed not wearing masks correctly, with some having their masks below their noses or chins while in resident care areas. This non-compliance with mask-wearing protocols compromised the facility's efforts to control the spread of COVID-19. The facility's failure to implement and enforce these infection control measures highlights significant gaps in their infection prevention and control program, which could have serious implications for resident and staff safety.
Lack of Dignified Dining Experience for Residents
Penalty
Summary
The facility failed to ensure a dignified dining experience for residents in two dining rooms, as observed by the surveyor. Residents were seen wearing clothing protectors without being asked for their preference, and meals were served directly off trays, which is contrary to the facility's policy for a homelike dining experience. Additionally, staff did not wash residents' hands before meal delivery, and there was a lack of staff presence to assist residents during meals, leading to delays in meal service and assistance. In the second-floor dining room, residents were observed receiving meals at different times, with some having to wait up to 17 minutes for assistance after their meal was placed. This delay in service was compounded by the absence of staff to assist or socialize with residents, as noted by Nurse #3, who was instructed only to monitor the dining room. The practice of serving meals at different times and not removing trays after meals further detracted from a dignified dining experience. On the first-floor unit, similar issues were observed, with staff placing clothing protectors on residents without asking and using demeaning language such as 'bib.' The Director of Nurses and Nurse #5 acknowledged these deficiencies, agreeing that meals should be served simultaneously and off trays for a more dignified and homelike experience. The report highlights the facility's failure to adhere to its mission statement and resident rights policies, resulting in a lack of dignity and respect for residents during meal times.
Failure to Adhere to Professional Standards in Medication Administration
Penalty
Summary
The facility failed to provide care and services consistent with professional standards of practice for two residents. For Resident #9, the facility did not ensure that wound care was consistent with professional standards. The resident, who had a stage 4 pressure ulcer, was receiving treatment without a proper physician's order. The wound consultant recommended a change in treatment to include Santyl, but this was administered without an order from the physician or nurse practitioner. Additionally, the Santyl was used from a discontinued treatment for another wound, and when it was depleted, the nurse did not document the unavailability or notify the physician promptly. For Resident #2, the facility failed to obtain physician's orders for fingerstick blood sugars (FSBS) necessary for implementing the sliding scale insulin order. The resident, who had diabetes mellitus, had their glucose levels checked on multiple occasions without a physician's order. Furthermore, the resident was self-administering an albuterol inhaler without a current physician's order, as the previous order had been discontinued. The nurse confirmed the absence of orders for both the FSBS and the self-administration of the inhaler. These deficiencies highlight a lack of adherence to professional standards and facility policies regarding medication administration and documentation. The nursing staff administered treatments and medications without proper orders, failed to document verbal orders, and did not ensure that necessary prescriptions were in place for the residents' care. This resulted in unauthorized treatments and a lack of proper medical oversight for the residents involved.
Failure to Secure Treatment Carts
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in accordance with currently accepted professional principles. Specifically, the treatment carts on the Second Floor Unit were not consistently locked when not under the direct supervision of a licensed nurse. On multiple occasions, the treatment cart was observed to be either locked with the keys left in the lock or completely unlocked and unattended, with a resident sitting nearby. During interviews, Nurse #6 acknowledged that the treatment cart should not have been left unlocked and unattended, especially with a resident sitting next to it. Nurse #9 confirmed that treatment carts should never be left unattended and unlocked, regardless of the presence of a resident. The Director of Nursing reiterated that the expectation is for treatment carts to be locked at all times when unattended, and keys should not be left in the cart but should remain with the nurse.
Failure to Timely Notify NP of Unavailable Treatment for Pressure Ulcer
Penalty
Summary
The facility failed to notify the Physician/Nurse Practitioner (NP) in a timely manner about the unavailability of a prescribed treatment for a resident with a stage 4 pressure ulcer. The resident, who was admitted with a diagnosis of a pressure ulcer on the right buttock, had severe cognitive impairment and was dependent on staff for all activities of daily living. A progress note from the facility's consultant wound NP recommended a treatment involving Santyl, which was unavailable from the pharmacy. Nurse #2 was aware of the unavailability but delayed notifying NP #1 for five days after the recommendation was made. Interviews revealed that neither the NP nor the Director of Nursing (DON) was initially aware of the Santyl being on back order. The consultant wound care NP also confirmed not being informed until much later. Although Nurse #2 eventually notified NP #1, there was no documentation in the medical record to support this communication. The lack of timely notification and documentation led to a deficiency in the facility's obligation to ensure proper care and treatment for the resident.
Failure to Obtain Necessary Medication for Resident's Pressure Ulcer
Penalty
Summary
The facility failed to ensure pharmaceutical services met the needs of a resident with a stage 4 pressure ulcer. The resident, who was admitted with a diagnosis of a pressure ulcer, had their condition worsen from a stage 3 to a stage 4 ulcer, as noted by the facility's consultant wound Nurse Practitioner (NP). The NP recommended a treatment change to include Santyl, a prescription medication for removing dead tissue from wounds. However, the facility did not obtain the Santyl from the pharmacy, as it was out of stock and on back order. Despite the facility's policy to act promptly in such situations by notifying the pharmacy and obtaining medication from a backup pharmacy, the Santyl was not procured. The facility's consultant pharmacy representative confirmed that the Santyl was out of stock but could be obtained from a backup pharmacy. The Director of Nursing and other staff were unaware of the medication's unavailability and the option to use a backup pharmacy, leading to a delay in the resident's treatment.
Failure to Monitor Anticoagulant Side Effects
Penalty
Summary
The facility failed to monitor adverse consequences of anticoagulant medications for one resident, who was admitted with conditions including polycythemia vera, gastrointestinal hemorrhage, and deep vein thrombosis. The resident was cognitively intact and received Eliquis as prescribed. However, upon review, it was found that the resident's medical record, including the Medication Administration Record (MAR) and Treatment Administration Record (TAR), did not indicate monitoring for adverse consequences of the anticoagulant medication since admission. The resident was admitted with bruising, and the Interim Care Plan noted a risk for bleeding due to Eliquis, yet monitoring for signs and symptoms of bleeding was not documented. Interviews with the Director of Nursing and several nurses revealed that the facility's process required documentation of side effects of anticoagulant medications in the TAR. Despite this requirement, the resident did not have a current order to monitor for adverse consequences of Eliquis, and the monitoring was not documented. Nurses acknowledged the lack of documentation and the absence of a current order for monitoring adverse consequences, which was a deviation from the facility's policy on anticoagulation therapy management.
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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 Medfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Premier Healthcare At Harrington House | 4.2 mi | ★★★★★ | 0 | 0 |
| Charlwell House Health And Rehabilitation | 4.7 mi | ★★★★★ | 0 | 0 |
| Victoria Haven Nursing Facility | 5.1 mi | ★★★★★ | 27 | 0 |
| Medway Country Manor Skilled Nursing & Rehabilitat | 5.5 mi | — | 9 | 0 |
| Norwood Healthcare | 5.6 mi | ★★★★★ | 21 | 2 |
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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.