Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 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 Champion Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
The facility failed to create comprehensive care plans for three residents, neglecting to address specific needs such as smoking supervision, epilepsy management, and monitoring for suicidal ideation. One resident required supervision while smoking, another had frequent seizures without a care plan for triggers, and a third had a history of suicidal ideation without a mental health care plan. Staff were unaware of these needs, and the DON acknowledged the oversights.
The facility failed to provide trauma-informed care to three residents, each with PTSD or a history of trauma. A resident admitted with PTSD did not receive a trauma assessment, and staff were unaware of their trauma history. Another resident, newly diagnosed with PTSD, lacked a completed Trauma Questionnaire and specific care plan triggers. A third resident with a history of abuse did not have a trauma assessment or care plan addressing their PTSD. Staff interviews revealed a lack of awareness and completion of necessary assessments.
The facility failed to ensure proper hand hygiene during meal service, as observed by surveyors on two units. Nurses and CNAs did not consistently perform hand hygiene when delivering food trays to residents, despite the facility's policy requiring it to prevent infection spread. The Food Service Manager confirmed the oversight during an interview.
A resident with epilepsy experienced frequent seizures, but the LTC facility failed to schedule recommended Neurology and Epilepsy Center appointments. Despite initial refusal, the resident later agreed to an inpatient evaluation, yet the facility did not follow through. Interviews revealed staff were unaware of the appointment status, and the facility did not contact the Epilepsy Center to confirm insurance acceptance.
A resident with dementia and on hospice care developed a stage 3 pressure ulcer on the sacrum, and the facility failed to implement the ordered treatments. Communication lapses and incorrect wound care practices, including the use of wrong supplies and poor hand hygiene, contributed to the deficiency. The DON acknowledged that treatment orders were not updated timely, leading to missed treatments.
A resident with muscular dystrophy and cognitive intactness was not provided with adequate supervision and safety measures while smoking, as required by their care plan. The facility failed to conduct quarterly smoking evaluations and did not ensure the use of an adaptive ashtray, leading to unsafe smoking practices. Staff supervision was inadequate, with the resident being observed smoking unsafely and other residents assisting them, contrary to facility policy.
A resident with moderate cognitive impairment and epilepsy returned from a hospital stay with a Foley catheter due to urinary retention. The facility failed to assess the catheter for removal or schedule a recommended urology follow-up and voiding trial. The resident experienced catheter issues, and staff were unaware of the missed appointment, indicating a lapse in care coordination.
A resident with anoxic brain damage, dysphagia, and dementia experienced a 9.68% weight loss over six months due to the facility's failure to monitor their nutritional status. Despite a care plan goal to maintain a specific weight, weekly weights were not consistently obtained as ordered. The RD had not completed a quarterly assessment since March, and the resident was not on the list for weekly weights. The physician's notes did not acknowledge the weight loss, contributing to the oversight.
A resident was administered Azithromycin for an excessive duration of one year without adequate indication. Despite being discharged from the hospital with a 5-day antibiotic course for pneumonia, the resident continued to receive Azithromycin three times a week for COPD without documented justification. Facility staff could not provide documentation from the pulmonologist or PCP supporting the prolonged use.
A resident with severe cognitive impairment and dysphagia was observed consuming crackers, contrary to their physician-ordered pureed diet. Staff interviews revealed no documentation or physician's order allowing this deviation, highlighting a failure to adhere to the therapeutic diet, posing a risk for choking and aspiration.
A nurse failed to follow infection control protocols during wound care for a resident with severe cognitive impairment and an unhealed pressure ulcer. The nurse did not perform hand hygiene between glove changes and applied ointments directly from tubes onto the wound, contrary to facility policy. Interviews confirmed these lapses in infection prevention practices.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a person-centered comprehensive care plan for three residents, leading to deficiencies in addressing their specific needs. For one resident, the facility did not create a care plan for smoking needs, despite a smoking assessment indicating the resident required supervision while smoking. The resident was observed smoking without any special instructions noted in their care plan, and the unit manager and DON acknowledged the oversight. Another resident with epilepsy did not have a care plan addressing their condition, even though they had been hospitalized multiple times due to seizures. The resident's medical record included physician orders for seizure monitoring and medication, but no care plan was developed to manage triggers and interventions. The nurse and DON confirmed the absence of a care plan, which was supposed to include known triggers like door alarms. A third resident with a history of suicidal ideation and recent psychiatric hospitalization did not have a care plan addressing their mental health needs. The CNA and unit manager were unaware of the resident's suicidal history, and the social worker admitted to not reviewing the hospital discharge summary. The DON confirmed that a care plan should have been developed to monitor for signs of worsening depression and suicidal ideation.
Failure to Provide Trauma-Informed Care
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care to three residents, as identified in a survey. Resident #36, admitted with diagnoses including dementia and PTSD, did not receive a trauma-informed care assessment upon admission. The medical record lacked information on PTSD symptoms and triggers, and staff, including a CNA and a social worker, were unaware of the resident's trauma history. The Director of Nurses acknowledged that a trauma assessment should have been completed but was not. Resident #51, who was admitted with muscular dystrophy, depression, and anxiety, received a new PTSD diagnosis after a traumatic event in July 2024. Despite this, the facility did not complete a Trauma Questionnaire, and the care plan lacked specific triggers to prevent re-traumatization. Interviews with staff revealed a lack of awareness and completion of necessary assessments, with the DON admitting that the care plan was generic and not tailored to the resident's needs. Resident #89, with a history of suicidal ideation and major depressive disorder, also did not receive a trauma assessment. The care plan did not address the resident's history of trauma, despite documentation indicating a history of sexual and physical abuse. The social worker admitted to missing information in the resident's PASARR and hospital discharge summary, resulting in a lack of a comprehensive care plan to address the resident's PTSD and associated triggers.
Failure in Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to adhere to professional standards of practice for food safety and sanitation, specifically in the area of hand hygiene during meal service. Observations by the surveyor on two separate occasions revealed that nurses and CNAs did not consistently perform hand hygiene when delivering food trays to residents. On the first occasion, some hand hygiene was observed, but it was not consistent. On the second occasion, no hand hygiene was observed at all. This lack of adherence to hand hygiene protocols occurred during meal service on two of the three units observed. The facility's policy on hand washing and hygiene, revised in August 2019, clearly states that hand hygiene is the primary means to prevent the spread of infections. It requires personnel to perform hand hygiene before and after direct contact with residents, contact with objects in the immediate vicinity of the resident, and before and after assisting a resident with meals. Despite this policy, the CNAs and nurses failed to consistently follow these procedures, as confirmed by the Food Service Manager during an interview. The FSM acknowledged the lack of hand hygiene during meal service, which is a critical step in preventing the spread of infections among high-risk residents.
Failure to Schedule Specialist Appointments for Resident with Epilepsy
Penalty
Summary
The facility failed to ensure that a resident with epilepsy had their recommended specialist appointments scheduled. The resident, who had moderate cognitive impairment, was experiencing frequent seizures and had been hospitalized recently. Despite recommendations for follow-up appointments with a Neurology office and an Epilepsy Center, the facility did not schedule these appointments. The resident initially refused an inpatient evaluation at the Epilepsy Center but later agreed, yet the facility did not follow through with scheduling. The facility's records, including the Appointment Communication Form and nursing progress notes, showed a lack of documentation and follow-up regarding the scheduling of these critical appointments. The resident continued to experience frequent seizures, and there was no evidence that the facility staff had reached out to the Epilepsy Center or Neurology office to arrange the necessary evaluations. The facility's Appointment book and nursing notes failed to indicate any progress in scheduling these appointments, despite the resident's ongoing health issues. Interviews with facility staff revealed a lack of awareness and follow-up on the resident's care plan. Nurse #4 and the Director of Nurses admitted to not knowing the status of the appointments and acknowledged that the process had been mishandled. The facility did not know that the Epilepsy Center would not accept the resident's insurance because they had not contacted the office. The Director of Nurses confirmed that the resident's condition had worsened, with more frequent seizures, and that the necessary appointments had not been made in a timely manner.
Deficiency in Pressure Ulcer Care and Treatment
Penalty
Summary
The facility failed to provide appropriate care and treatment for a resident with a pressure ulcer, leading to a deficiency in wound management. The resident, who was admitted with dementia and on hospice care, developed a deep tissue injury on the sacrum, which progressed to a stage 3 pressure ulcer. Despite specific treatment recommendations from both hospice and a wound consultant physician, the facility did not implement the treatments as ordered. The Treatment Administration Record (TAR) showed inconsistencies in treatment application, including missed dressing changes and incorrect implementation of wound care protocols. The deficiency was further compounded by communication lapses between the facility staff and the primary physician, as well as between the facility and hospice services. The primary physician could not recall approving changes to the treatment plan, and the hospice staff did not perform dressing changes on specified dates. Additionally, the Director of Nurses (DON) acknowledged that the treatment orders were not updated in a timely manner, resulting in a missed treatment. The wound consultant physician emphasized that the dressing should not have been left unchanged for an extended period, especially on a necrotic wound. During an observation, a nurse failed to follow proper wound care procedures, using incorrect supplies and not adhering to hand hygiene protocols. The nurse used the wrong strength of Dakins solution, incorrect calcium alginate, and ointments belonging to another resident. Furthermore, the nurse applied ointments directly from the tubes onto the wound, contrary to infection control practices. The DON and Infection Preventionist confirmed that the nurse did not follow the treatment order and failed to perform hand hygiene with each glove change, as required.
Failure to Ensure Safe Smoking Practices for Resident
Penalty
Summary
The facility failed to ensure a safe environment for Resident #51, who was cognitively intact and had a history of muscular dystrophy, ambulatory dysfunction, and generalized weakness. The resident was known to smoke and required supervision and specific safety interventions, such as using an adaptive ashtray and wearing a smoking apron. However, the facility did not complete the required quarterly smoking evaluations, with the last evaluation being conducted in March 2023. This evaluation indicated that Resident #51 was unable to safely light, use an ashtray, or extinguish a cigarette, necessitating staff supervision and the use of a smoking apron. Observations revealed that Resident #51 was not using the adaptive ashtray as outlined in the care plan. On multiple occasions, the resident was seen smoking with a cigarette hanging from their mouth, without the use of the adaptive ashtray, and with ashes falling onto the smoking apron. Staff supervision was inadequate, as the supervising nurse was inside the building, and other residents were observed assisting Resident #51 by picking up dropped cigarettes. This lack of direct supervision and failure to use the adaptive ashtray posed a safety risk to the resident. Interviews with staff, including the Director of Nurses and the Staff Development Coordinator, confirmed that Resident #51 did not use the adaptive ashtray and preferred to smoke with the cigarette hanging from their mouth. The Director of Nurses acknowledged that the care plan was not being followed and that Resident #51's practice of keeping cigarettes in their room was against policy. The staff also recognized that Resident #51 required one-on-one supervision while smoking, which was not being provided, leading to the deficiency in ensuring a safe environment for the resident.
Failure in Foley Catheter Management and Follow-Up Care
Penalty
Summary
The facility failed to provide appropriate care and management for a resident with an indwelling Foley catheter, which was not assessed for removal after the resident returned from a hospital stay. The resident, who had moderate cognitive impairment and a history of epilepsy, was hospitalized for seizures and returned with a Foley catheter due to acute urinary retention and urethral trauma. Despite discharge recommendations for a urology follow-up and a voiding trial, the facility did not document any attempts or discussions regarding these recommendations. The facility's records did not show a scheduled urology appointment, and the resident missed an appointment due to it not being logged or transportation arranged. Nursing staff were unaware of the appointment status, and the Director of Nurses acknowledged the oversight, indicating a need for process improvement. The resident experienced issues with the catheter, including leakage and discomfort, but there was no evidence of staff contacting the physician to discuss the voiding trial or follow-up care.
Failure to Monitor Nutritional Status and Weight Loss
Penalty
Summary
The facility failed to adequately monitor the nutritional status of a resident who experienced an unplanned gradual weight loss of 9.68% over six months. The resident, who was admitted with diagnoses including anoxic brain damage, dysphagia, and dementia, was identified as nutritionally at risk. Despite a care plan goal to maintain a weight of 185 pounds plus or minus 5 pounds, the resident's weight decreased from 169.4 pounds to 153 pounds over the specified period. The facility's Weight Management policy required residents to be weighed at least monthly, with more frequent weights as necessary, but the resident's weekly weights were not consistently obtained as ordered by the physician on 3/5/24. Interviews and record reviews revealed that the resident was not included on the list of those needing weekly weights, and the Registered Dietitian (RD) had not completed a quarterly assessment since March 2024. The RD, who began covering the facility in June 2024, was unaware of the resident's insidious weight loss until the week of the survey. The RD acknowledged the lack of a quarterly assessment and the failure to ensure weekly weights were obtained, which contributed to the oversight in monitoring the resident's nutritional status. The physician's progress notes also failed to recognize the significant weight loss, despite the resident's good meal intake.
Unnecessary Prolonged Use of Antibiotics
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs, specifically Azithromycin, which was administered without an adequate indication for use for an excessive duration of one year. The resident, who was admitted with chronic respiratory failure, COPD, and pneumonia, was discharged from the hospital with a 5-day course of antibiotics for pneumonia. However, the discharge summary did not recommend long-term prophylactic antibiotic treatment. Despite this, the resident continued to receive Azithromycin three times a week for COPD without a documented indication for its prolonged use. The medical records lacked documentation from the pulmonologist or primary care physician justifying the need for long-term antibiotic use. Interviews with facility staff, including a nurse and the Director of Nurses, revealed that there was no clear documentation or rationale for the continued use of Azithromycin. The Director of Nurses attempted to contact the pulmonologist for clarification but was unable to provide additional documentation by the conclusion of the survey.
Failure to Adhere to Therapeutic Diet for Resident
Penalty
Summary
The facility failed to ensure that a physician-ordered therapeutic diet was followed for a resident with significant medical conditions, including dysphagia, pneumonitis, and hemiplegia. The resident was assessed to be severely cognitively impaired and required a pureed diet with thin liquids for safe swallowing. Despite these orders, the surveyor observed the resident consuming crackers, which were not part of the prescribed diet. The resident's care plan indicated the need for tube feedings and pureed diet for pleasure foods, with supervision required during oral intake. Interviews with facility staff, including the Unit Manager, Director of Nursing, and Rehabilitation Director, revealed a lack of awareness and documentation regarding any exceptions to the resident's therapeutic diet. The Unit Manager acknowledged that staff would have had to assist the resident with the crackers, and the Rehabilitation Director confirmed that there was no documentation supporting the resident's ability to safely consume crackers unsupervised. The failure to adhere to the therapeutic diet was recognized as a risk for choking and aspiration, with no physician's order allowing for deviations from the prescribed diet.
Inadequate Infection Control During Wound Care
Penalty
Summary
The facility failed to implement proper infection prevention and control measures for a resident, leading to potential cross-contamination. The deficiency was observed during a wound care procedure performed by a nurse on a resident with severe cognitive impairment and an unhealed pressure ulcer. The nurse did not follow the facility's hand hygiene policy, which requires hand hygiene before and after glove changes and after contact with potentially contaminated surfaces. During the wound care procedure, the nurse removed soiled dressings and changed gloves multiple times without performing hand hygiene. The nurse also handled incorrect ointment tubes, touched the treatment cart, and continued the procedure without changing gloves or performing hand hygiene. Additionally, the nurse applied ointments directly from the tubes onto the resident's wound, which is against infection control practices. Interviews with the nurse and the Director of Nursing (DON) and Infection Preventionist/Staff Development (IP/SDC) confirmed the failure to adhere to hand hygiene protocols. The nurse admitted to not performing hand hygiene with every glove change and acknowledged the improper application of ointments. The DON and IP/SDC emphasized that hand hygiene should be performed with every glove change and that ointments should be applied to a clean surface before being used on wounds.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Brockton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St Joseph Manor Health Care Inc | 0.8 mi | — | 4 | 0 |
| Colony Center For Health And Rehabilitation | 2.2 mi | — | 1 | 0 |
| The Guardian Center | 2.6 mi | — | 2 | 0 |
| Brockton Post Acute Care | 2.7 mi | — | 0 | 0 |
| Alliance Health At West Acres | 3.3 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 August 2026) and official state health department websites.