Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Adviniacare Newton Wellesley during CMS and state inspections, most recent first.
The facility failed to follow its water management plan for Legionella prevention and did not implement enhanced barrier precautions for a resident with a wound. Additionally, a nurse did not adhere to proper hand hygiene and dressing change protocols, placing supplies on an unclean surface and using the same gloves for multiple tasks. The Assistant Director of Nursing confirmed these lapses in infection control practices.
The facility failed to maintain resident dignity and privacy for two residents and six non-sampled residents. A CNA used a personal cell phone during care, violating the facility's policy and compromising residents' private space. Additionally, a resident was left exposed during care when the privacy curtain was not closed, contrary to the facility's policy. Interviews confirmed that cell phone use during care was not allowed, and privacy should have been maintained.
A resident with dementia and hypertension received Lisinopril despite physician-ordered parameters to hold the medication if systolic blood pressure was below 120. The facility's policy required checking vital signs before administering medications, but the resident's Medication Administration Record showed multiple instances of non-compliance. Interviews with nursing staff confirmed the medication should have been held, indicating a failure to follow the care plan and professional standards.
A facility failed to assess the use of pillows under a fitted sheet as a potential restraint for a resident with Alzheimer's and a history of falls. The resident's medical record lacked a restraint assessment, physician's order, or care plan documentation for this intervention. Staff confirmed the pillows were used to prevent the resident from moving or getting out of bed due to fall risks. The DON acknowledged the need for a restraint assessment.
A resident with severe cognitive impairment and requiring maximum assistance with personal hygiene was not provided with necessary facial hair removal, despite expressing a desire for assistance. Observations confirmed significant chin hair growth, and staff interviews indicated that this care should have been provided.
A facility failed to create a trauma-informed care plan for a resident with PTSD, who was unable to participate in a mental status exam due to severe cognitive impairment. The Social Worker expected an individual care plan for the resident, highlighting a lapse in providing trauma-informed care.
A facility failed to document a resident's wound during weekly skin checks, despite a physician's order and the resident's severe cognitive impairment. The nurse did not document the open area, assuming it was already recorded, which was confirmed as a deficiency by the DON.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to adhere to its water management plan for Legionella prevention. The Maintenance Director, who has been with the facility since December 2023, stated that the facility does not test the water for Legionella, believing it to be the town's responsibility. However, the town's report only monitors minerals and other contaminants, not Legionella, indicating a lapse in the facility's compliance with its own water management program, which requires annual Legionella culture tests. The facility also failed to implement enhanced barrier precautions (EBP) for a resident with a wound. The facility's policy requires EBP for residents with wounds or indwelling medical devices, regardless of MDRO colonization status. Despite this, there was no signage or evidence of EBP for the resident, and Nurse #1, who routinely completed the resident's wound treatment, did not use EBP, believing it was unnecessary. The Assistant Director of Nursing confirmed that EBP should have been utilized during wound care. Additionally, Nurse #1 did not follow the facility's policy for non-sterile dressing changes. The nurse placed dressing supplies on an unclean nightstand, failed to perform hand hygiene before applying gloves, and used the same gloves to handle both clean and dirty items, including picking up oxygen tubing from the floor and applying it to the resident. The nurse also did not change gloves or perform hand hygiene after removing the old dressing and before applying the new one. The Assistant Director of Nursing acknowledged that the nurse should have changed gloves and performed hand hygiene during the dressing change process.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to provide a dignified experience for several residents, including Resident #57 and Resident #11, as well as six non-sampled residents. For Resident #57 and six non-sampled residents, the deficiency occurred when a Certified Nursing Assistant (CNA) used a personal cell phone on speaker while providing care, which compromised the residents' private space and dignity. This action was against the facility's policy, which prohibits the use of personal cell phones during care, except in emergencies. The CNA was observed talking on the phone in a foreign language while in Resident #57's room and continued to do so while moving to an adjacent room, despite the presence of other residents. Interviews with the CNA, a nurse, the Ombudsman, and the Director of Nursing confirmed that cell phone use during care was not permitted. For Resident #11, the deficiency involved a failure to maintain privacy during care. The surveyor observed that the privacy curtain was not closed while Resident #11 was receiving care, leaving the resident exposed to their roommate. This was contrary to the facility's policy, which mandates the protection of resident privacy during personal care. The incident was further compounded when a nurse entered the room to perform a dressing change on Resident #11 without closing the privacy curtain, continuing to expose the resident. The Director of Nursing acknowledged that the curtain should have been closed during care to maintain the resident's dignity.
Failure to Adhere to Medication Parameters for a Resident
Penalty
Summary
The facility failed to ensure that nursing services were provided in accordance with the comprehensive care plan and professional standards of quality for a resident with dementia and hypertension. The resident had a physician's order for Lisinopril, a medication to manage hypertension, with specific parameters to hold the medication if the systolic blood pressure was less than 120 or the heart rate was less than 60. Despite these parameters, the medication was administered on multiple occasions when the resident's systolic blood pressure was below the specified threshold. The facility's policy on medication administration required verification of vital signs related to parameters before administering medications. However, the Medication Administration Record (MAR) showed that the resident received Lisinopril on numerous dates when the blood pressure readings were below the physician-ordered parameters. Interviews with nursing staff confirmed that the medication should have been held under these circumstances, indicating a failure to adhere to the care plan and professional standards.
Failure to Assess Pillows as Potential Restraint
Penalty
Summary
The facility failed to identify and assess the use of pillows placed underneath a fitted sheet as a potential restraint for a resident with Alzheimer's dementia and a history of repeated falls. The facility's policy on restraint use requires a comprehensive assessment to determine the safety and protective needs of a resident before applying any restraint. However, the medical record for the resident did not indicate that a restraint assessment had been completed for the use of pillows, nor was there a physician's order or care plan documentation for this intervention. Observations by the surveyor revealed that the resident was in bed with pillows placed underneath the fitted sheet at the hip/thigh level, and the foot of the bed was elevated. The resident was seen rolling in bed and attempting to kick their legs over the side, where the pillows were placed. Interviews with staff, including a CNA and a nurse, confirmed that the pillows were used to prevent the resident from moving or attempting to get out of bed due to the risk of falls. The Director of Nursing acknowledged that a restraint assessment should have been conducted to evaluate the use of pillows as a potential restraint.
Failure to Assist Resident with Personal Hygiene
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for a resident who was unable to perform these tasks independently. Specifically, the facility did not assist Resident #57, who had severe cognitive impairment and required maximum assistance with personal hygiene, in removing unwanted chin hair. Despite the resident's inability to perform this task independently and their expressed desire for assistance, the facility did not ensure that facial hair removal was completed during care. Observations by the surveyor over several days confirmed that Resident #57 had significant chin hair growth, which was not addressed by the care staff. Interviews with the Certified Nurse Assistant (CNA) and the Director of Nursing (DON) revealed that facial hair removal should have been part of the resident's care routine, and there was no indication that the resident refused care. The failure to provide this aspect of personal hygiene care was contrary to the facility's policy and the resident's care plan, which specified maximum assistance for personal hygiene.
Failure to Develop Trauma-Informed Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to develop a trauma-informed care plan for a resident diagnosed with post-traumatic stress disorder (PTSD). The resident was admitted in February 2023 and was unable to participate in the Brief Interview for Mental Status exam due to severe cognitive impairment. A review of the resident's care plans revealed that there was no trauma-informed plan developed for this individual. During an interview, the Social Worker, who was covering the building at the time, stated that she would have expected an individual care plan to be developed for a resident with a PTSD diagnosis. This indicates a lapse in the facility's responsibility to provide trauma-informed care for residents with specific mental health needs.
Failure to Document Resident's Wound in Medical Record
Penalty
Summary
The facility failed to maintain complete and accurate documentation in the medical record for a resident with a wound. The resident, who was admitted with diagnoses including dementia, hypertension, depression, and anxiety, had a severe cognitive impairment and was noted to have an open area on the mid-spine. Despite a physician's order for weekly skin checks and documentation, the facility did not document the resident's wound on a weekly skin check as required. The deficiency was identified when a surveyor observed a nurse performing a dressing change on the resident's spine. The nurse admitted to completing the skin check but did not document the open area, believing it was already documented. The Director of Nursing confirmed that skin checks should be accurately documented in the medical record, highlighting the facility's failure to adhere to its policy on risk and skin assessments.
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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 Wellesley
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Elizabeth Seton | 1.8 mi | — | 0 | 0 |
| Riverbend Of South Natick | 2.4 mi | — | 0 | 0 |
| Mary Ann Morse Nursing & Rehabilitation | 2.5 mi | — | 0 | 0 |
| Skilled Nursing Facility At North Hill (the) | 2.6 mi | — | 0 | 0 |
| Care One At Newton | 3 mi | — | 5 | 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.