Below average — CMS composite of the measures below.
The next survey window likely opens around January 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 Westborough Healthcare during CMS and state inspections, most recent first.
Dish Machine Operated Below Required Temperature: The facility failed to maintain the low-temp dish machine at the minimum wash temp required by manufacturer guidance. While an FSD and surveyor observed the machine running, an aide continued loading and washing dishware and meal trays even though the wash temp was seen at 80 F and later 100 F. The FSD and Admin stated the temp was acceptable because chemical sanitizer was present, but the aide could not verbalize the machine temp and no evidence was provided that the machine reached 120 F.
Infection control practices were not followed for two residents on EBP and during meal tray service on one unit. CNAs provided ADL care to two residents without wearing gowns, failed to perform hand hygiene when entering and exiting rooms, and one CNA moved a hydraulic lift from an EBP room without disinfecting it. On the 2nd Floor, a CNA passed multiple meal trays to residents without performing hand hygiene between rooms, including after entering a room with contact precautions.
Call Light Not Within Reach: A resident with intact cognition and diagnoses including Bell's Palsy, anxiety, depression, and unspecified dementia was repeatedly observed lying in bed with the call bell hanging on the wall beyond reach, on the far side of a bedside chair. The resident stated not having a call bell and said he or she would go into the hallway to ask for help. An RN observed the call bell was not accessible and unhooked it from the wall; the DON stated call bells should always be accessible.
A resident with anxiety disorder, alcoholic liver disease, and CKD stage 4 was receiving psychotropic meds, including sertraline and trazodone, despite the record lacking signed informed consent from the resident or representative before administration. The resident was cognitively intact with a BIMS of 15, and the MAR showed both meds were given as ordered over several months. A nurse and the DON stated consent should be obtained before new psychotropic meds are administered, but no signed consent could be found.
Failure to provide preferred TV access for a resident's psychosocial needs. A cognitively intact resident with anxiety, depression, insomnia, PTSD, trach, and G-tube relied on in-room TV as the only source of entertainment and preferred cable news and movies. The resident reported repeated requests for help over several weeks because most channels were nonfunctional and only TURBO and Golf were available, causing increased anxiety and depressed mood. The ADM knew of the issue after the Ombudsman reported it but did not follow up with the resident.
Unlabeled Multi-Dose Vials in Medication Storage Room: Two multi-dose vials in a 2nd Floor med storage room were found opened with no open date or expiration date, including Tuberculin and Insulin Lispro. Nurse #1 said she did not know when they were opened and acknowledged they should have been labeled when opened, and the DON stated that all multi-dose vials should have an open date.
A resident with complex medical needs was found unresponsive, and nursing staff were unable to quickly determine the individual's code status due to missing documentation in the medical record and Physician's Orders. The facility's policy required code status to be displayed, but it was not present or easily accessible at the time of the event, leading to confusion among staff regarding the resident's resuscitation wishes.
The facility failed to provide necessary transfer documentation for several residents, including advanced directives and care instructions, during hospital transfers. This deficiency was identified through record reviews and staff interviews, revealing a lack of essential information being communicated to receiving health care institutions.
The facility failed to provide required Bed-Hold notices to residents or their representatives during hospital transfers. This issue affected five residents, as confirmed by staff interviews and clinical record reviews, indicating a systemic lapse in following the facility's policy on bed-hold notifications.
A facility failed to provide proper respiratory care for three residents, including not obtaining physician's orders for oxygen administration and failing to maintain oxygen concentrators and filters. One resident used oxygen without a physician's order, and the equipment was improperly labeled and stored. Two other residents had poorly maintained oxygen concentrators, with staff failing to clean them as required. The director of nursing confirmed the cleaning procedures were not followed, compromising care quality.
The facility failed to post daily nurse staffing information, omitting the total and actual hours worked by RNs, LPNs, LVNs, and CNAs. The Administrator and staff were unaware of the requirement to include this information and to maintain records for 18 months, leading to the deficiency.
The facility failed to implement safe food practices in the main kitchen, leading to potential contamination. Surveyors observed spoiled food, unlabeled and undated items, and unclean equipment. Dietary staff and the Food Service Director acknowledged these deficiencies, confirming that spoiled and unlabeled items should have been discarded and the delivery truck/cart cleaned.
A resident, who was cognitively intact but dependent on staff for ADLs, was observed naked and being washed by a CNA with the room door open and privacy curtain not drawn. This allowed two other residents in the room to see the resident being washed, and another resident walked in and out of the room. The CNA admitted to not closing the privacy curtain, and the DON confirmed that staff were expected to provide privacy during ADL care.
The Spruce Unit in the facility failed to maintain a clean and homelike environment, with surveyors noting persistent odors of stale urine and unclean body odors in the hallway. The Maintenance Director and Housekeeping Department Manager acknowledged the issue, attributing it to the number of incontinent residents and the heating system. Despite a daily cleaning schedule, the odors remained unresolved.
A facility failed to conduct a new PASARR assessment for a resident who returned from psychiatric hospitalization with a new diagnosis of Delusional Disorders and an antipsychotic medication order. The resident, initially admitted with Major Depressive Disorder, did not receive the required Level I PASARR assessment or a referral for a Level II evaluation, as confirmed by a social worker.
The facility failed to complete the PASRR process for two residents with mental disorders before admission. One resident's PASRR Level I screen was inaccurately completed, omitting a history of psychiatric hospitalization. Another resident was admitted without a Level I PASRR screen, despite having active mental disorder diagnoses.
A resident with multiple health issues, including Morbid Obesity and COPD, did not receive a physician-ordered sleep study to diagnose Obstructive Sleep Apnea. The facility lacked a policy for implementing physician's orders, and the nurse responsible did not schedule the study, leading to delayed interventions.
The facility failed to provide necessary grooming assistance to two residents, one with cognitive decline and another with a right above-knee amputation. Observations revealed untrimmed nails with a black substance for one resident and disheveled hair, untrimmed facial hair, and unchanged clothing for the other. Despite care plans indicating the need for assistance, the facility did not consistently provide the required personal hygiene care.
A resident with a history of COPD and dependence on supplemental oxygen was found to have cigarettes and a lighter unsecured in their room, contrary to the facility's smoking policy. The resident, who was assessed as an independent smoker, was not informed about the requirement to store smoking materials securely. The Unit Manager confirmed the policy but failed to enforce it, leading to a significant safety risk.
A resident with an indwelling urinary catheter did not receive appropriate care and services from the facility. Despite having a catheter due to conditions like benign prostatic hypertrophy and urine retention, the facility failed to obtain physician's orders or develop a care plan for its maintenance. The resident managed the catheter independently, and the Director of Clinical Relations confirmed the lack of a care plan or orders, highlighting a deficiency in adhering to professional standards.
A nurse in the facility failed to maintain proper competencies in medication administration and storage. During an observation, it was found that the nurse pre-poured medications for two residents and stored them unlabeled in the medication cart. The medications included Gabapentin, Topamax, Remeron, Trazodone, Lorazepam, Tramadol, and Valproic Sodium. The nurse admitted to pre-pouring these medications to administer them with meals, contrary to facility policy.
The facility failed to ensure safe pharmaceutical services by allowing medications to be pre-poured and stored without proper labeling. During an observation, a surveyor found unlabeled crushed and liquid medications in a medication cart. Nurse #1 admitted to pre-pouring medications for two residents to administer later, which was against facility policy. The Nursing Supervisor and DON confirmed that pre-pouring was not allowed.
A nurse in an LTC facility made multiple medication administration errors, resulting in a 15.15% error rate, impacting a resident with complex medical needs. The nurse failed to administer medications as ordered, including incorrect doses and forms, and did not follow the facility's policy for medication administration via a gastrostomy tube. The errors were confirmed by the DON.
A resident with Alzheimer's and depression had a legal guardianship updated to include a DNR directive, but the facility failed to update the MOLST form. When the resident was found unresponsive, staff initiated CPR based on the blank MOLST form, believing it indicated a full code status. The facility had not received the updated guardianship due to staffing changes, leading to the oversight.
Dish Machine Operated Below Required Temperature
Penalty
Summary
The facility failed to maintain proper sanitation and food handling practices in the main kitchen when the low temperature dish machine was operating below the minimum wash temperature required by the manufacturer's guidelines. Review of the facility's temperature log for the low temperature dish machine indicated the wash and rinse temperatures were expected to be 120 degrees F, and the log instructed staff not to wash dishes if levels were out of acceptable range and to notify a supervisor. During an observation, the surveyor and the Food Service Director (FSD) saw the dish machine running while Dietary Aide #1 pre-rinsed and loaded dirty dishware and meal trays into the racks for washing, even though the wash temperature fluctuated and did not rise above 120 degrees F. At the time of the observation, the dish machine wash temperature was seen at 80 degrees F, and Dietary Aide #1 was unable to verbalize the temperature reading on the machine. The FSD stated that washing and rinsing dishes at 80 degrees F was acceptable because the machine had chemical sanitizer in the water, demonstrated the sanitizer test strip reading, and said there was no concern with the temperature remaining at 80 degrees F. The Administrator later stated the machine was operating at an acceptable temperature because sanitizer levels were acceptable. During a later observation, the dish machine was again in operation while Dietary Aide #1 continued washing dishes, and the wash temperature was observed at 100 degrees F. At survey exit, no evidence was provided that the low temperature dishwashing machine met the minimum required temperature of 120 degrees F.
Infection Control and Hand Hygiene Failures
Penalty
Summary
The facility failed to follow infection control practices for two residents who were on Enhanced Barrier Precautions (EBP). Resident #9, admitted with unspecified dementia and ordered for EBP due to wounds, was observed with EBP signage posted at the door, but CNA #3 entered the room, pulled the curtain, and provided washing and dressing care without wearing a gown. CNA #3 then left the room without washing or sanitizing hands. CNA #3 later returned with CNA #4, and both CNAs transferred the resident with a hydraulic lift from the bed to a chair. CNA #5 then removed the hydraulic lift from the room and took it to another resident’s room without disinfecting it first. Resident #38, admitted with moderate protein-calorie malnutrition and gastrostomy status, also had EBP orders related to a G-tube and wounds. During observation, CNA #6 entered the room, pulled the curtain, and provided washing and dressing care without wearing a gown. CNA #6 then exited the room without washing or sanitizing hands. During interview, CNA #6 stated she forgot to wear a gown. The facility also failed to ensure hand hygiene was performed between handling meal trays on the 2nd Floor unit. CNA #7 was observed entering multiple resident rooms with meal trays, setting up trays, exiting rooms, and then going directly to the meal tray cart to pick up the next tray without performing hand hygiene. This occurred repeatedly while passing trays to several residents, including a resident in contact precautions. CNA #7 stated she should have been performing hand hygiene between every meal tray passed, and the ADON/IP stated staff should perform hand hygiene between every resident meal tray passed to decrease the risk for spread of infection.
Call Light Not Within Resident's Reach
Penalty
Summary
The facility failed to provide appropriate access to the call light for one resident out of a sample of 21. The resident was admitted in January 2023 with diagnoses including Bell's Palsy, insomnia, anxiety disorder, Major Depressive Disorder, and unspecified dementia. The resident's MDS assessment indicated the resident was cognitively intact with a BIMS score of 15 out of 15, had adequate hearing and vision, clear speech, and could understand and make self understood. The facility policy stated that when a resident is in bed, the call light should be within easy reach. During multiple observations, the resident was lying in bed while the call bell was hanging on the wall on the far side of a bedside chair and beyond the resident's reach. When asked, the resident stated not having a call bell and said he or she would get out of bed and go into the hallway to ask for help. On another observation, the resident again stated being unaware of any call bell and said he or she would go into the hallway to call for help. Later, the resident said he or she never had a call bell. A nurse observed that the call bell should always be accessible and unhooked it from the wall, and the DON stated that call bells should always be accessible to residents.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to inform one resident in advance of the risks and benefits of psychotropic treatment prior to implementation, and failed to obtain signed informed consent for two psychotropic medications before they were administered. Resident #5 was admitted with diagnoses including Anxiety Disorder, Alcoholic Liver Disease, and Chronic Kidney Disease Stage 4, and the MDS indicated the resident was cognitively intact with a BIMS score of 15 out of 15 and was taking anti-anxiety and antidepressant medications. The resident’s psychotropic medication care plan noted that the resident was taking psychotropic medications and included discussion with the MD and family regarding the ongoing need for medication, as well as review of behaviors, interventions, and alternate therapies attempted. Review of physician orders showed Sertraline HCL 200 mg daily for depression and Trazodone HCL 100 mg at bedtime for anxiety and insomnia, and the MAR showed both medications were administered as ordered over multiple months. The medical record did not contain evidence that the resident or the resident’s representative signed written informed consent for either medication before administration. During interviews, a nurse and the DON stated that written consent should be obtained prior to administering new psychotropic medications, but neither could find evidence that consent had been completed for the resident’s Sertraline and Trazodone.
Failure to Provide Preferred TV Access for Resident's Psychosocial Needs
Penalty
Summary
The facility failed to provide independent activities of choice to meet the mental and psychosocial needs of one resident. Resident #13, who was cognitively intact with a BIMS score of 15 and had diagnoses including tracheostomy, gastrostomy, anxiety, insomnia, depression, and PTSD, had an activity assessment showing a preference for self-directed activities, 1:1 room activity, and entertainment in the room such as TV, phone, radio, and reading materials. The resident’s activity care plan indicated a goal of satisfaction with preferred daily routine and noted that the resident preferred to spend leisure time in the room and did not regularly attend group activities. Resident #13 reported that television was the only source of entertainment and activity and that he/she preferred cable news programming and movies in the room. The resident stated that there were no movies, news, or other TV channels available, and that repeated reports to staff, including maintenance, over the prior twenty-five days had not resulted in assistance. The resident said the lack of response was causing a lot of anxiety and was destroying mental health. During observation, the resident demonstrated that only TURBO and Golf Channel were functional, while other channels showed static. The Administrator acknowledged awareness of the inability to obtain TV channels and stated the Ombudsman had reported the concern about two weeks earlier, but he did not follow up with the resident because the facility was in the process of acquiring satellite television. The Ombudsman confirmed she had informed the Administrator that the issue was interfering with the resident’s mental health, and the Administrator later stated he should have followed up and offered a resolution but did not.
Unlabeled Multi-Dose Vials in Medication Storage Room
Penalty
Summary
Drugs and biologicals were not stored in accordance with State and Federal laws in one of the facility’s medication storage rooms on the 2nd Floor. During observation with Nurse #1, two multi-dose vials were found opened with no open date or expiration date indicated: Tuberculin, Purified Protein Derivative Diluted/Aplisol 5TU for intradermal testing, and Insulin Lispro 10 mL multi-dose vial, 100 units per mL. The facility policy required drugs and biologicals to be stored in a safe, secure, and orderly manner and prohibited the use of discontinued, outdated, or deteriorated drugs or biologicals. The package insert for Tuberculin indicated the vial should be dated when opened and discarded after 30 days, and the package insert for Insulin Lispro indicated the vial should be discarded 28 days after opening. Nurse #1 stated she did not know when either vial had been opened and acknowledged that both should have been labeled when opened. The DON stated that all multi-dose medication vials should be labeled with an open date indicating when they were first opened.
Failure to Maintain Accurate Code Status Documentation
Penalty
Summary
The facility failed to maintain a complete and accurate medical record regarding a resident's Advanced Directives and code status. When a resident with multiple diagnoses, including cerebrovascular accident with hemiplegia, chronic atrial fibrillation, diabetes mellitus, and dysphagia, was found unresponsive and without a pulse, nursing staff were unable to readily locate or identify the resident's code status in the medical record. The resident's Physician's Orders did not document the code status, and there was no completed Medical Orders for Life-Sustaining Treatment (MOLST) form available at the time of the incident. The nurse involved reported being unable to find the code status in the medical record or Physician's Orders and assumed the resident was a Do Not Resuscitate (DNR) due to their illness. Interviews with facility staff confirmed that the resident had been admitted without a MOLST form and that, according to facility practice, residents are considered Full Code until a MOLST is completed. However, the code status was not identified in the Physician's Orders or prominently displayed in the medical record, as required by facility policy. The Director of Nursing acknowledged that the code status was not properly documented or displayed, and the issue was discovered during the facility's investigation into the incident.
Failure to Provide Required Transfer Documentation
Penalty
Summary
The facility failed to ensure that the required transfer documentation was completed and communicated to the receiving health care institution for five residents. This deficiency was identified through record reviews and interviews, revealing that important medical information was not provided during transfers to the hospital. The lack of documentation included missing advanced directives, specific instructions for ongoing care, and contact information for the responsible practitioners. Resident #64 was transferred to the hospital for evaluation of difficulty swallowing, but there was no evidence of discharge paperwork, including advanced directives or specific care instructions, being communicated to the hospital. Similarly, Resident #18, who was moderately cognitively impaired, was transferred to the emergency room after a fall, yet no necessary medical transfer information was provided. Resident #39, who had chronic respiratory failure and other conditions, was transferred without any discharge paperwork or care instructions being sent to the hospital. Resident #11, with a history of traumatic brain injury, was transferred to the hospital after a fall, but the facility failed to provide essential information such as practitioner contact details and advanced directives. Lastly, Resident #29, who experienced chest pain and difficulty breathing, was transferred without the necessary transfer paperwork being completed. Interviews with facility staff confirmed the absence of required documentation for these transfers, indicating a systemic issue in the facility's transfer process.
Failure to Provide Bed-Hold Notices During Hospital Transfers
Penalty
Summary
The facility failed to provide a Notice of Bed-Hold Policy to residents or their representatives at the time of transfer to a hospital or shortly thereafter. This deficiency was identified for five residents out of a sample of 19. The facility's policy, revised in November 2024, mandates that residents or their representatives be informed in writing about the bed-hold and return policy prior to transfers out of the facility. However, the clinical records of Residents #64, #18, #39, #11, and #29 showed no evidence of such notifications being provided when these residents were transferred to hospitals with an anticipated return. Interviews with facility staff, including social workers and a corporate nurse, confirmed the absence of documentation for the required Bed-Hold notices. For instance, Social Worker #2 and Corporate Nurse #1 were unable to provide evidence of the Bed-Hold information being given to the residents or their representatives. The Director of Clinical Operations also acknowledged that the necessary paperwork had not been completed for Resident #29's hospital transfer. These findings indicate a systemic issue in the facility's process for handling bed-hold notifications during resident transfers to hospitals.
Deficiencies in Respiratory Care and Equipment Maintenance
Penalty
Summary
The facility failed to provide respiratory care and services consistent with professional standards of practice for three residents. For one resident, the facility did not obtain physician's orders for oxygen administration or the maintenance of oxygen and respiratory equipment. This resident, who was admitted with diagnoses including emphysema and COPD, was observed using oxygen without a corresponding physician's order in the medical record. Additionally, the resident's oxygen tubing was not properly labeled or dated, and the portable oxygen concentrator was found on the floor, which is against the facility's policy. Two other residents had issues with the maintenance of their oxygen concentrators and filters. Both residents were receiving oxygen therapy, but their oxygen concentrators were observed to be coated in dust and debris, indicating a lack of proper cleaning and maintenance. Despite the facility's policy requiring weekly cleaning of the concentrators and filters, the staff responsible for this task failed to perform it adequately. One nurse admitted to signing off on the cleaning without thoroughly completing the task, and the unit manager acknowledged the oversight, noting the importance of cleaning for infection control. The director of nursing confirmed that the procedure for cleaning the oxygen concentrators and filters was not followed as specified by the physician's orders. The failure to maintain the equipment in a clean and functioning manner posed a risk of infection and compromised the quality of care provided to the residents. The facility's lack of adherence to its own policies and procedures for respiratory care and equipment maintenance led to these deficiencies.
Failure to Post and Maintain Nurse Staffing Information
Penalty
Summary
The facility failed to comply with the requirement to post daily nurse staffing information, which includes the total number and actual hours worked by Registered Nurses (RNs), Licensed Practical Nurses (LPNs) or Licensed Vocational Nurses (LVNs), and Certified Nurses Aides (CNAs) directly responsible for resident care per shift. During the survey, it was observed that the staffing information posted in the front lobby at the elevator on several days did not include the necessary details about the hours worked by the nursing staff. This omission was confirmed through interviews with the Director of Clinical Operations and the facility Scheduler, who both acknowledged the lack of a facility policy for posting staffing and the absence of the required information in the postings. Additionally, the facility did not maintain a copy of the staffing records for the required 18 months. The Administrator admitted to being unaware of the requirement to include the actual and total number of hours worked by nursing staff in the postings and to keep these records for 18 months. The Administrator also stated that the staff postings were discarded after a few days, with only recent postings available for review. This lack of awareness and failure to maintain records contributed to the deficiency identified during the survey.
Failure to Adhere to Safe Food Practices in Kitchen
Penalty
Summary
The facility failed to adhere to safe food practices in the main kitchen, leading to potential contamination of food and beverage items intended for resident consumption. During an initial walk-through, surveyors observed several deficiencies, including spoiled food items such as a large box of cucumbers and lemons covered in mold, and an unlabeled and undated metal container of brown sauce also covered in mold. Additionally, there were multiple instances of unlabeled and undated food items, including white cooked meat, individual containers of pudding, juice, and fruit, which were not properly labeled or dated as per the facility's policy. The facility's dry storage area also exhibited deficiencies, with opened and resealed food items such as cake mix, brownie mix, macaroni, penne, and breadcrumbs that were undated. Furthermore, a delivery truck/cart was found with clean cups covered in food debris and a splattered white substance with brown flecks. Interviews with Dietary Staff #1 and the Food Service Director confirmed that the spoiled and unlabeled items should have been discarded, and the delivery truck/cart should have been cleaned, but these actions were not taken.
Failure to Maintain Resident Privacy During Personal Care
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of a resident during personal care, resulting in a deficiency. The incident involved a resident who was cognitively intact but dependent on staff for activities of daily living, including bathing. During a surveyor's observation, the resident was found naked and being washed by a Certified Nurses Aide (CNA) with the room door open and the privacy curtain not drawn. This allowed two other residents in the room, who were awake, to see the resident being washed. Additionally, another resident walked in and out of the room while the door remained open. The CNA involved admitted to not being aware that the door was open and acknowledged failing to close the privacy curtain. The Director of Nursing confirmed that staff were expected to provide privacy during activities of daily living care. The facility's policy on Resident's Rights, which emphasizes a dignified existence and privacy, was not adhered to in this instance, leading to the breach of the resident's privacy.
Persistent Odors on Spruce Unit Due to Inadequate Cleaning
Penalty
Summary
The facility failed to maintain a clean and homelike environment on the Spruce Unit, as evidenced by persistent odors of stale urine and unclean body odors in the hallway. Surveyors observed these odors on multiple occasions, specifically outside the Day Room and resident rooms. The Maintenance Director acknowledged the presence of the odors, noting that staff might have become accustomed to them, making them more noticeable to those entering the unit from other floors. The Housekeeping Department Manager (HDM) confirmed the presence of the odors and attributed them to the increased number of incontinent residents on the Spruce Unit and the amplification of odors when the heating system is activated during colder months. Despite having a cleaning schedule with three housekeepers assigned daily for a complete room cleaning, the HDM admitted that the strong odors had not improved since the implementation of this schedule.
Failure to Conduct PASARR Assessment for Resident with New Diagnosis
Penalty
Summary
The facility failed to coordinate an assessment with the Preadmission Screening and Resident Review (PASARR) program for a resident who experienced a significant change in status. The resident, who was initially admitted with a diagnosis of Major Depressive Disorder and dependence on renal dialysis, underwent a psychiatric hospitalization due to altered mental status. Upon returning to the facility, the resident had a new diagnosis of Delusional Disorders and was prescribed an antipsychotic medication, Zyprexa. Despite these changes, the facility did not complete a new Level I PASARR assessment or refer the resident for a Level II PASARR evaluation, as required. The oversight was confirmed during an interview with a social worker, who acknowledged the absence of a new Level I screening and the lack of a referral for a Level II evaluation following the resident's return from the hospital with the new diagnosis and medication order.
Failure to Complete PASRR Screening for Residents with Mental Disorders
Penalty
Summary
The facility failed to ensure that the Preadmission Screening and Resident Review (PASRR) process was properly completed for two residents prior to their admission. For one resident, the PASRR Level I screen was inaccurately completed, failing to reflect a history of inpatient psychiatric hospitalization, despite the resident being admitted from an inpatient psychiatric hospital. This resident had multiple diagnoses, including alcohol abuse, depression, anxiety, psychotic disorder with delusions, manic episodes, and dementia. For another resident, the facility did not complete a Level I PASRR screen before admission, even though the resident had active diagnoses of mental disorders, including delusional disorder, unspecified psychosis, and dementia. The absence of a completed Level I PASRR screen was confirmed during an interview with a social worker, who acknowledged that it should have been completed prior to the resident's admission.
Failure to Implement Physician's Order for Sleep Study
Penalty
Summary
The facility failed to meet professional standards of practice by not implementing a physician's order for a sleep study to diagnose Obstructive Sleep Apnea for a resident. The resident, who was admitted with diagnoses including Morbid Obesity, Congestive Heart Failure, and Chronic Obstructive Pulmonary Disease, had an active physician's order for a sleep study written in March 2024. However, there was no evidence in the clinical record that the sleep study was scheduled or completed, resulting in delayed interventions and treatments for the resident. Interviews with the Director of Nursing (DON) and the Director of Clinical Operations revealed that there was no policy in place for implementing or following physician's orders. The DON acknowledged that the nurse responsible for transcribing the order should have ensured the sleep study was scheduled. The resident's care plan included goals to maintain respiratory health, but the failure to conduct the sleep study as ordered by the physician indicates a lapse in following through with necessary medical evaluations.
Deficiencies in Personal Hygiene Care for Two Residents
Penalty
Summary
The facility failed to provide necessary assistance with personal hygiene care for two residents, leading to deficiencies in their grooming and overall care. Resident #69, who was admitted with diagnoses including age-related cognitive decline and adult failure to thrive, required partial to moderate assistance with personal hygiene. Despite this, observations revealed that the resident's fingernails were untrimmed and had a black substance underneath, indicating a lack of grooming care. The facility's records showed no evidence of the resident refusing care, and staff interviews confirmed that nail care should have been provided on shower days, yet it was not. Resident #82, admitted with a right above-knee amputation and non-traumatic subdural hemorrhage, required extensive to total assistance with hygiene, bathing, and dressing. Observations showed that the resident's hair was disheveled, facial hair was untrimmed, and clothing was unchanged from the previous day, despite the resident's requests for assistance. Interviews with staff confirmed that the resident needed help with all ADLs and should have been provided daily assistance, including facial hair removal and clothing changes, which were not consistently done. The facility's policy for ADLs, which was last revised in November 2024, indicated that appropriate care and services should be provided for residents unable to carry out ADLs independently. However, the facility failed to adhere to this policy, as evidenced by the lack of grooming assistance provided to Residents #69 and #82, despite their assessed needs and care plans indicating the necessity for such assistance.
Failure to Secure Smoking Materials in Resident's Room
Penalty
Summary
The facility failed to maintain a safe environment for Resident #18 by not ensuring that potentially hazardous smoking materials were stored securely. Resident #18, who was moderately cognitively intact and dependent on supplemental oxygen, was found to have cigarettes and a lighter stored in their bedroom. This was in direct violation of the facility's smoking policy, which prohibits residents from keeping lighters and requires smoking materials to be stored in a designated secure area. During an interview and observation, Resident #18 disclosed that they had been independently smoking outside without staff supervision and had not been informed about the requirement to store smoking materials securely. The Unit Manager confirmed that the resident was assessed as an independent smoker and did not require supervision while smoking. However, the Unit Manager also stated that the resident's smoking materials should be stored in the medication cart for safety, which was not being followed. The surveyor observed that the resident's cigarettes and lighter were left unsecured in the room, alongside a portable oxygen concentrator, posing a significant safety risk. The Administrator later intervened to remove the smoking materials from the resident's room and reiterated the facility's policy on the secure storage of such items. This incident highlights a lapse in adherence to the facility's smoking policy and the need for better communication and enforcement of safety protocols.
Failure to Provide Catheter Care for a Resident
Penalty
Summary
The facility failed to provide appropriate care and services for a resident with an indwelling urinary catheter. The resident, who was admitted with diagnoses including benign prostatic hypertrophy, urine retention, and mild cognitive impairment, had a urinary catheter in place. However, the facility did not obtain physician's orders or develop a care plan for the catheter's maintenance and monitoring. The resident's care plan, last revised in November, lacked any goals or interventions related to the catheter care. During interviews, the resident reported managing the catheter drainage bag independently and did not recall staff providing any catheter care. The Director of Clinical Relations confirmed the absence of physician's orders and a care plan for the catheter, despite its identification in the resident's assessments. This oversight indicates a failure to adhere to professional standards of practice for catheter care.
Improper Medication Administration and Storage by Nurse
Penalty
Summary
The facility failed to ensure that a nurse maintained appropriate competencies and skills related to medication administration and storage. During an observation of the medication cart on the Hickory Nursing Unit, it was found that Nurse #1 had pre-poured medications for two residents and stored them in the bottom drawer of the medication cart without any labels, names, or dates. The medications included crushed Gabapentin, Topamax, Remeron, Trazodone, Lorazepam, Tramadol, and a liquid medication, Valproic Sodium. Nurse #1 admitted to pre-pouring these medications to administer them with the residents' meals at supper time, as it was the only way one resident would take their medication. The Nursing Supervisor confirmed that nurses were not supposed to pre-pour medications for later administration. The Director of Nursing (DON) also stated that nurses were expected not to pre-pour medications for multiple residents. Despite this expectation, Nurse #1, who was hired as a Per Diem nurse but worked regularly, had pre-poured and stored medications improperly. The DON reviewed Nurse #1's annual competency evaluation, which was completed earlier in the year, but the report does not mention any corrective actions taken following the incident.
Improper Medication Pre-pouring and Storage
Penalty
Summary
The facility failed to accurately and safely provide pharmaceutical services by allowing medications to be pre-poured and stored in medication carts without proper labeling. During an observation of the Hickory Nursing Unit medication cart, the surveyor found two cups of crushed medications and one pre-poured liquid medication, all lacking names, dates, or labels. This practice was contrary to the facility's policy, which requires medications to be stored in pharmacy containers with appropriate labels. Interviews with staff revealed that Nurse #1 had pre-poured nighttime medications for two residents, intending to administer them with their meals at supper time. The Nursing Supervisor confirmed that nurses were not supposed to pre-pour medications and administer them later. The Director of Nursing also stated that nurses were not expected to pre-pour medications for multiple residents, indicating a deviation from the established medication administration procedures.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by a 15.15% error rate during a medication pass procedure. Nurse #2, the only nurse observed, made five errors in 35 opportunities, impacting one resident out of five observed. The errors included administering incorrect doses and forms of medications, such as Ferrous Sulfate Elixir and Omeprazole, and failing to administer other medications like Glycolax Powder, Levetiracetam Solution, Artificial Tears Solution, and Ocean Spray Nasal Solution as ordered. Additionally, Nurse #2 did not individually crush and administer medications separately, as required by the facility's policy. Resident #2, who was affected by these errors, had a complex medical history, including cardiovascular disease, hemiplegia, traumatic brain injury, and required a gastrostomy tube for medication administration. The nurse's actions were inconsistent with the physician's orders and the facility's medication administration policies, as confirmed by the Director of Nursing during an interview. The nurse admitted to not following the physician's orders and acknowledged the medication errors made during the administration process.
Failure to Update DNR Status Leads to Unnecessary CPR
Penalty
Summary
The facility failed to ensure that new physician's orders were obtained for a resident with a legal guardianship that included a Do Not Resuscitate (DNR) directive. The resident, who had Alzheimer's Disease and depression, was admitted to the facility with a full code status. However, the guardianship was updated to include a DNR directive, which was not reflected in the resident's Medical Order for Life Sustaining Treatment (MOLST) form. As a result, when the resident was found unresponsive, staff initiated cardiopulmonary resuscitation (CPR) based on the blank MOLST form, which indicated a full code status. The incident occurred when a nurse, unfamiliar with the resident, was alerted by a Certified Nurse Aide that the resident was unresponsive. The nurse found a blank MOLST form in the resident's medical record and initiated CPR, believing that a blank form required resuscitation efforts. The Assistant Director of Nurses and the former Director of Nurses assisted with CPR until emergency medical services arrived, but the efforts were unsuccessful, and the resident was pronounced dead. Interviews with facility staff revealed that the updated guardianship, which included the DNR directive, had not been received by the facility due to multiple staffing changes, particularly in the Social Services Department. The Director of Clinical Operations confirmed that the facility never received the expanded guardianship documentation, which would have prompted a change in the resident's code status to DNR. This oversight led to the initiation of CPR against the resident's updated advanced directive.
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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 Westborough
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Beaumont Rehab & Skilled Nursing Ctr - Westboro | 0.6 mi | ★★★★★ | 10 | 0 |
| Whittier Westborough Transitional Care Unit | 2.3 mi | ★★★★★ | 0 | 0 |
| Beaumont Rehab & Skilled Nursing Ctr - Northboro | 3.4 mi | ★★★★★ | 0 | 0 |
| Alliance Health At Coleman | 3.7 mi | ★★★★★ | 10 | 0 |
| Shrewsbury Rehabilitation And Nursing At Southgate | 4.9 mi | ★★★★★ | 6 | 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.