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 Affinity Healthcare during CMS and state inspections, most recent first.
A resident with acute on chronic respiratory failure, continuous O2 dependence, obstructive sleep apnea, asthma, and schizoaffective disorder had an order for pulse oximetry each shift with instructions to notify the physician if O2 saturation fell below 90%. Over multiple days, nursing staff recorded several dangerously low saturation readings while the resident was on 3 L O2 via nasal cannula, yet there was no documentation that the physician was notified as ordered. In interviews, the nurse, Unit Manager, and DON all stated they were unaware of the specific parameter to notify the physician when saturation dropped below 90%, and acknowledged that multiple sub-90% readings occurred without physician notification.
A resident with cognitive impairment and a history of expressing a desire to leave, who was identified as an elopement risk and resided on a secured unit, was able to exit the facility unsupervised after staff failed to respond appropriately to a door alarm. The staff mistook the alarm for a malfunction and did not investigate, allowing the resident to leave the premises and remain missing for several hours before being located.
Three residents from a secured unit in an LTC facility eloped due to inadequate supervision and response to exit door alarms. Despite being on safety checks, they exited through a locked and alarmed door undetected, leading to one resident being injured. The facility's policies on safety and elopement were not effectively implemented, as staff failed to respond to the alarm and did not ensure the residents were supervised.
The facility failed to conduct monthly drug regimen reviews for several months due to a change in ownership and lack of awareness of previous pharmacy arrangements. This affected multiple residents, as no reviews were documented from May to August 2024, impacting medication management.
The facility failed to maintain a clean and homelike environment in units M2 and B2, with issues such as unpainted drywall, holes in walls, and dirty common areas. Maintenance and housekeeping staff were unable to keep up with necessary tasks due to understaffing and a focus on crisis management. The facility had been without a Director of Maintenance for several months, contributing to the backlog of maintenance work.
A facility failed to maintain Advance Directives for a resident with myocardial infarction, heart disease, and Parkinson's disease. Despite being noted as DNR/DNI, there was no MOLST form in the medical records. Staff interviews revealed the form was missing, and a new MOLST was completed but not signed by a physician. The absence of a valid MOLST could lead to unwanted resuscitation efforts.
A resident with a gastrostomy tube did not receive medications according to the physician's order. Nurse #3 crushed and mixed all medications together instead of administering each separately with 5 ml of water, as instructed. The medications included Lasix, Aspirin, Docusate sodium, Fluoxetine Hcl, Metoprolol, a multivitamin, and Vitamin D3. The DON confirmed the error.
The facility failed to follow professional standards for medication storage and administration. Medications were pre-poured and stored improperly in a medication cart for three residents, with one cup containing oxycodone not stored under double lock as required. The DON confirmed that medications should not be pre-poured and narcotics must be stored securely.
A resident's MDS assessments were inaccurately coded, showing anticoagulant use instead of the prescribed antiplatelet medication, Clopidogrel Bisulfate (Plavix). This error was consistent across 11 assessments, despite physician orders confirming no anticoagulant prescription. The MDS Nurse and DON acknowledged the mistake, indicating the need for corrections.
Failure to Notify Physician of Critically Low Oxygen Saturation Levels
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s physician of significant changes in oxygen saturation levels as required by physician orders and facility policy. The facility’s policy on change in a resident’s condition, last revised 02/2021, states that the nurse will promptly notify the attending or on-call physician when there has been a specific instruction to notify the physician of changes in the resident’s condition. Resident #1, admitted in April 2025 with diagnoses including acute on chronic respiratory failure, dependence on continuous oxygen, obstructive sleep apnea, asthma, and schizoaffective disorder, had a physician’s order in December 2025 to obtain oxygen saturation levels every shift and to notify the physician if saturation fell below 90%. Normal oxygen saturation is described as 95–100%, slightly low as 90–94%, low (hypoxemia) as below 90%, and dangerously low as below 88%. Review of the resident’s oxygen saturation log and MAR from 12/01/25 through 12/29/25 showed multiple dangerously low readings while on 3 L continuous O2 via nasal cannula: 85% on 12/08, 88% on 12/11, 88% on 12/12, 86% on 12/18, 86% on 12/19, 84% on 12/25, and 87% on 12/28. The medical record contained no documentation that nursing staff notified the physician of these low readings, despite the explicit order to do so when levels fell below 90%. In interviews, the assigned nurse stated he was unaware of the parameter to notify the physician and acknowledged he never notified the physician when saturations were below 90%. The Unit Manager and the DON both reported they were not aware that the order included a parameter to notify the physician if oxygen saturation fell below 90%, and the Unit Manager confirmed there were multiple readings below 90% without documentation that the physician had been informed.
Failure to Provide Adequate Supervision Resulting in Resident Elopement
Penalty
Summary
A resident with a history of traumatic brain injury, cognitive communication deficit, adjustment disorder, and difficulty in walking, who was under guardianship and identified as an elopement risk, was residing on a secured unit. The resident had a care plan in place indicating the need for supervision and interventions such as residing on a secure unit, structured activities, and safety supervision checks. Despite these measures, the resident made verbal statements expressing a desire to leave the facility. On the night of the incident, three staff members on the secured unit failed to recognize and appropriately respond to a sounding door alarm, which was triggered when the resident forcefully opened a locked and alarmed door leading to a fire escape. The staff mistook the alarm for a malfunction and did not investigate the source or check on the resident, despite the alarm continuing to sound for an extended period. The nurse on duty was unfamiliar with the unit's alarm system and was not aware of the resident's elopement risk or care plan. The resident was able to exit the unit, descend the fire escape, climb over a fence, and leave the facility grounds without staff knowledge. The resident's absence went unnoticed until the following shift, when staff were unable to locate the resident and notified facility leadership. The resident's whereabouts were unknown for approximately twelve hours until located by police in a bar several miles away. The failure to provide adequate supervision and to respond appropriately to the door alarm resulted in the resident's elopement and placed the resident at risk for serious harm.
Inadequate Supervision Leads to Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision and response to exit door alarms, resulting in an elopement incident involving three residents from a locked, secured unit. These residents, who required staff supervision both on and off the unit, managed to exit through a locked and alarmed door undetected by staff. They proceeded to the main entrance, exited the facility, and walked away without being questioned or stopped by staff. The incident was only discovered when an off-duty staff member noticed two of the residents down the street with police. Resident #1, who had a history of traumatic brain injury, schizoaffective disorder, and substance abuse, was at moderate risk for elopement and required continual supervision. Despite being on 5-minute safety checks, Resident #1 was able to leave the facility with the other residents. Resident #2, who was not initially assessed as at risk for elopement but had a care plan for such a risk, suffered injuries after falling from his wheelchair during the elopement. Resident #3, identified as high risk for elopement, was involved in the escape plan and assisted Resident #1 in leaving the unit. The facility's policies on safety awareness and elopement were not effectively implemented, as staff failed to respond to the alarm and did not ensure the residents were supervised. Surveillance footage showed that the alarm on the unit was functioning, but staff did not respond to it. Interviews with staff revealed a lack of awareness and communication regarding the residents' whereabouts and the functioning of the secured unit's alarm system.
Removal Plan
- The Neurological Program Director and Director of Nurses (DON) placed Resident #1, #2, and #3 on five-minute safety checks. Resident #1, #2, and #3 remain on 15-minute safety checks and physician's orders were obtained for Resident #1 and #2's wheelchairs to be equipped with a wander guard device (Resident #3 continues to refuse the use of a device).
- The Administrator and Director of Maintenance changed the facility entrance and secured unit codes, inspected all doors and all were in functioning order. The Facility also contracted for an inspection by an outside vendor who also confirmed there were no issues with door alarm function. The Administrator and Director of Maintenance continue to search for a potential additional alarm device that may enhance the system already in place.
- The Administrator and DON added an additional staff member stationed at the main entrance during the off-shift hours to ensure that no one is allowed to exit the Facility without staff knowledge. The staff member was placed on the daily schedule.
- The Director of Nurse and/or designee completed new Elopement Risk Assessments for Resident #1, #2, and #3, assured their photographs were placed in the Elopement Book at the main entrance, the B1 unit and each of the Resident's care plans were updated to reflect the recent elopement.
- The Facility held an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting to review the event, develop interventions and audit tools to minimize the risk of an event of this nature from happening again.
- The DON and Staff Development Coordinator (SDC) educated all staff, including the Life Enhancement Specialist (LES) regarding the revised policy for Levels of Observations, Safety Check Procedures, and the Facility's Alarm Procedures. Education included steps to take if an alarm is sounding, ensuring residents are supervised when seen off the unit, and notifying a supervisor when a resident is observed unsupervised at any time. Administrative staff will conduct random audits for five weeks or until found to be in compliance, with all staff on all units to ensure their understanding of each of the identified issues.
- The DON and SDC completed new Elopement Assessment for all residents in the facility and care plans were updated by nursing staff according to the results.
- Results of all audits and observations will be brought to and reviewed at QAPI meetings for the next three months or until compliance is achieved.
- The Administrator and/or Designee are responsible for overall compliance.
Failure to Conduct Monthly Drug Regimen Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist conducted a monthly drug regimen review for residents over several months. Specifically, the drug regimen reviews were not completed for the months of May, June, July, and August 2024 for five residents selected for unnecessary medication review and one resident reviewed for medication side effects. The facility's pharmaceutical services contract indicated that a third-party consultant pharmacist was to provide pharmacy consulting services, but there was no documentation of these reviews being conducted during the specified months. Interviews with facility staff, including the Director of Nurses (DON) and unit managers, revealed that the facility underwent a change in ownership in April 2024, and the new administration was unaware of the previous arrangements for pharmacy reviews. The DON and unit managers confirmed that no pharmacy reviews were completed from May to August 2024, and there was no evidence of a pharmacist visiting the facility during this period. This oversight affected the medication management of residents admitted as early as 2019 and as recently as 2023.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for residents, particularly in the common areas of units M2 and B2. Observations during the survey revealed multiple deficiencies, including unpainted and damaged drywall where hand sanitizer pumps had been removed, a hole in the dining room wall, and visibly dirty and marked walls. The activity room had scraped paint, dust and debris on the air conditioner, and dirt and trash under the baseboard heater. The pub/parlor area was left unfinished with painting tape and visible scuffs on the walls. Interviews with staff indicated a lack of recent maintenance and painting, with the maintenance department understaffed and focused on crisis management tasks. The housekeeping manager acknowledged that the housekeeping staff were responsible for cleaning tasks that were not being adequately performed, such as wiping down walls and cleaning under heaters. The corporate manager confirmed that the maintenance department was understaffed, with only two staff members available to address urgent issues, leaving routine maintenance tasks like painting unfinished. The facility had been without a Director of Maintenance since June, contributing to the backlog of maintenance work. The report highlights the facility's failure to uphold its policy of providing a safe, clean, and homelike environment for residents.
Failure to Maintain Advance Directives in Medical Records
Penalty
Summary
The facility failed to ensure that Advance Directives were properly formulated and maintained in the medical record for a resident, identified as Resident #106. This resident was admitted with diagnoses including myocardial infarction, heart disease, and Parkinson's disease, and was cognitively intact, making their own medical decisions. Despite being noted as Do Not Resuscitate/Do Not Intubate (DNR/DNI) in the physician's orders, there was no Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST) or DNR form scanned into the electronic or paper medical records. The facility's policy required that advanced directives be respected and documented in the medical record, yet a review of the records showed no evidence of a MOLST form or any documentation of discussions regarding advanced directives. Progress notes from social services and nursing staff failed to indicate any such discussions or the presence of a MOLST form. Interviews with staff, including the Unit Manager, Director of Social Services, and Director of Nurses, revealed that the MOLST form was missing, and there was uncertainty about its whereabouts. The deficiency was further highlighted when a new MOLST form was completed after the issue was identified, indicating the resident's wish for CPR but not intubation. However, this form was not yet signed by a physician, and there was no progress note confirming a discussion about the resident's wishes. The absence of a valid MOLST form in the medical record meant that emergency medical personnel might not have been informed of the resident's DNR/DNI status, potentially leading to unwanted resuscitation efforts.
Failure to Administer Medications Separately via Gastrostomy Tube
Penalty
Summary
The facility failed to ensure that medications for a resident with a gastrostomy tube were administered according to the physician's order and professional standards of practice. Specifically, Nurse #3 did not follow the physician's instructions to mix and administer each medication separately with 5 milliliters of water. Instead, Nurse #3 crushed all the resident's medications together, mixed them in a single cup with 5 milliliters of warm water, and administered them via the gastrostomy tube, followed by a flush with an additional 5 milliliters of water. The medications involved included Lasix, Aspirin, Docusate sodium, Fluoxetine Hcl, Metoprolol, a multivitamin with minerals, and Vitamin D3. During an interview, Nurse #3 acknowledged the failure to adhere to the physician's order. The Director of Nursing confirmed that the medications should have been prepared and administered separately as per the physician's instructions.
Medication Storage and Administration Deficiency
Penalty
Summary
The facility failed to adhere to accepted professional standards of practice regarding the storage and administration of medications. During an observation, it was noted that medications were pre-poured and stored in a medication cart for three residents, which is against the facility's policy. Specifically, three plastic pill cups containing multiple medications were found in the top drawer of a medication cart, with two cups unlabeled and the third labeled only with a resident's first name. This practice was contrary to the facility's guidelines, which state that medications should be administered at the time they are prepared and not pre-poured in advance. Additionally, the facility did not ensure that Schedule II-V controlled substances were stored in a separately locked, permanently affixed compartment. It was observed that a pill cup containing oxycodone, a Schedule II drug, was pre-poured and not stored in the narcotic box under double lock as required. Nurse #1 admitted to pre-pouring the medications for convenience and acknowledged that the oxycodone should have been stored properly. The Director of Nurses confirmed the expectation that medications should not be pre-poured and that narcotics must be stored under double lock.
Inaccurate MDS Coding for Resident's Medication
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) assessments for a resident, leading to incorrect documentation of medication use. Specifically, the resident was inaccurately coded as taking anticoagulant medications on 11 out of 11 MDS assessments reviewed, despite the resident only being prescribed an antiplatelet medication, Clopidogrel Bisulfate (Plavix). This discrepancy was identified through a review of the resident's physician orders, which confirmed the absence of any anticoagulant prescription. The resident, admitted in February 2023, had diagnoses including myocardial infarction, heart disease, and Parkinson's disease. The MDS assessments consistently misrepresented the resident's medication regimen, indicating anticoagulant use and failing to acknowledge the antiplatelet medication. Interviews with the MDS Nurse and the Director of Nurses confirmed the errors, acknowledging that the MDS assessments were incorrect and required modification to accurately reflect the resident's medication status.
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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 Braintree
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Alliance Health At Braintree | 0.9 mi | — | 0 | 0 |
| John Scott House Nursing & Rehabilitation Center | 1.5 mi | — | 2 | 0 |
| Royal Braintree Nursing And Rehabilitation Center | 2.4 mi | — | 18 | 0 |
| Regalcare At Quincy | 2.7 mi | — | 0 | 0 |
| Pope Nursing Home | 2.8 mi | — | 0 | 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.