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 Chestnut Woods Rehabilitation And Healthcare Ctr during CMS and state inspections, most recent first.
A resident with dementia and weakness was observed eating alone without required supervision, contrary to their care plan. Despite needing assistance with meals, staff believed the resident was independent, leading to inadequate adherence to the care plan. Documentation showed supervision was provided for only 41 out of 121 meals.
The facility failed to follow physician orders and document care for several residents. One resident with a diabetic ulcer did not receive weekly skin checks, while another cognitively impaired resident also missed these checks. An air mattress was improperly set for a resident, and a resident on enteral nutrition did not have weekly weights recorded. Interviews confirmed the expectations for care, but documentation was lacking.
A resident with skin tears on both forearms did not receive timely treatment due to the facility's failure to initiate treatment orders upon readmission. Despite the resident's need for daily dressings, orders were not implemented until a week later, leading to a deficiency identified by surveyors.
A facility failed to implement physician orders and care plans for a resident's catheter use. The resident, admitted with various diagnoses, was observed with a catheter bag despite the Minimum Data Set Assessment indicating no indwelling catheter. Interviews with staff confirmed the catheter's presence without corresponding orders or care plans, revealing a lapse in communication and documentation.
A facility failed to maintain a resident's PICC line dressing according to policy, which required changes every seven days. The dressing was observed to be dated beyond the required change interval, and staff interviews confirmed the oversight. This failure was inconsistent with both the facility's policy and physician orders.
A facility failed to create a comprehensive trauma-informed care plan for a resident with PTSD, despite having a policy requiring individualized care plans to address past trauma and minimize triggers. The resident's care plan lacked specific triggers and interventions, as confirmed by interviews with facility staff, indicating non-compliance with the facility's standards.
A resident with dementia and psychotic disorder received incorrect dosages of Trazadone due to a medication error at the facility. The facility's policy requires verification of medication details and contacting the prescriber if dosages are inappropriate. However, a nurse identified that the medication card contained the wrong dosage, and the medication was administered incorrectly over two days. The physician was not notified of the error, and the pharmacy later acknowledged the mistake.
The facility did not date several opened medications, including inhalers and nasal sprays, as required by their policy. During an inspection, it was found that these medications were undated, contrary to the facility's guidelines which require dating upon opening. Interviews with staff confirmed the expectation for medications to be dated with an open and expiration date.
The facility failed to accurately document medication administration for two residents and blood pressure readings for another. Medications for a resident with chronic conditions and another with dementia were not documented as administered. Additionally, blood pressure readings for a resident with end-stage renal disease were incorrectly recorded as taken from the left arm, contrary to physician orders. The DON acknowledged these documentation errors.
The facility failed to implement Enhanced Barrier Precautions for a resident with a catheter, as required by their infection control policy. Staff were observed performing care without necessary PPE, and shared medical equipment was not sanitized between uses in precaution rooms. Interviews confirmed these oversights, highlighting a lapse in infection prevention protocols.
The facility failed to accurately complete MDS assessments for three residents, leading to discrepancies in discharge destination, intravenous line type, and oxygen therapy documentation. Interviews and observations confirmed these inaccuracies, highlighting a need for improved accuracy in resident assessments.
Failure to Implement Meal Assistance Care Plan
Penalty
Summary
The facility failed to implement the care plan for a resident who required assistance with meals. The resident, who was admitted with diagnoses including dementia and weakness, was observed eating alone in their room without the necessary supervision or assistance as outlined in their care plan. The care plan specified that the resident required set-up assistance and supervision with eating due to their cognitive impairment and self-care performance deficit. However, observations on multiple occasions revealed that the resident was left unsupervised, struggling to manage their meal independently. Interviews with staff, including a Certified Nursing Aide (CNA), indicated a misunderstanding or disregard for the care plan requirements. The CNA believed the resident was independent with eating once the meal was set up, contrary to the documented need for supervision. Documentation showed that the resident received the required supervision or assistance for only 41 out of 121 meals, highlighting a significant gap in adherence to the care plan. The Director of Nursing acknowledged that care plans should be followed, indicating a lapse in ensuring staff compliance with established care protocols.
Failure to Follow Physician Orders and Document Care
Penalty
Summary
The facility failed to meet professional standards of quality care for four residents, as identified during a survey. For one resident with a chronic diabetic ulcer, the facility did not perform weekly skin checks as ordered by the physician. Despite the presence of a care plan indicating the need for weekly skin checks, documentation showed that these checks were not completed for over two weeks. Interviews with nursing staff and the Director of Nursing confirmed that skin checks should be documented weekly, and there was no record of the resident refusing these checks. Another resident, who was severely cognitively impaired and dependent on staff for activities of daily living, also did not receive the required weekly skin checks. The clinical record indicated that a skin assessment had not been completed for over a month. Interviews with nursing staff and the Director of Nursing reiterated the expectation that weekly skin checks should be completed and documented, with any refusals noted in the progress notes. Additionally, a resident with an air mattress was found to have the mattress set incorrectly according to their weight, despite physician orders to adjust the setting based on weight. Observations over multiple days showed the mattress was consistently set at a weight much higher than the resident's actual weight. Lastly, a resident receiving enteral nutrition did not have weekly weights recorded as ordered, with several weeks left blank in the medication administration record. Interviews with the dietitian and nursing staff highlighted the importance of accurate weight monitoring for nutritional management, yet the facility failed to document or notify the physician of missed weights.
Delayed Treatment Orders for Resident's Skin Tears
Penalty
Summary
The facility failed to provide necessary treatment and care for a resident with skin tears, as treatment orders were not initiated in a timely manner. The resident, who was readmitted to the facility with diagnoses including chronic obstructive pulmonary disease, dysphagia, and venous insufficiency, had intact cognition and required assistance with bathing and dressing. Upon readmission, the resident had skin tears on both forearms that required dressings, as noted in the hospital discharge paperwork. However, the facility did not have any active treatment orders in place for these wounds until seven days after they were first identified. Observations and interviews revealed that the resident had dressings on both arms, but there were no physician's orders or care plans indicating the need for wound treatment until a week later. The Unit Manager confirmed that the resident was admitted with wounds needing daily dressings, but orders were not implemented until a week later. The Director of Nursing stated that it is expected for treatment orders to be implemented when residents are admitted with wounds from the hospital. This delay in initiating treatment orders led to the deficiency identified by the surveyors.
Failure to Implement Catheter Care Plans and Orders
Penalty
Summary
The facility failed to implement physician orders and care plans related to the use of a catheter for a resident. The resident was admitted with diagnoses including chronic obstructive pulmonary disease, dysphagia, and venous insufficiency. The Minimum Data Set Assessment indicated that the resident required assistance with toileting and did not have an indwelling catheter. However, observations by surveyors on two separate occasions revealed the presence of a catheter bag hanging off the side of the resident's bed. Interviews with facility staff, including a nurse, unit manager, CNA, and the Director of Nursing, confirmed that the resident had a catheter since being admitted to the unit. Despite this, there were no physician orders or care plans in place for the catheter's use or care. The Nurse Practitioner was unaware of the lack of orders related to the catheter, highlighting a breakdown in communication and documentation within the facility.
Failure to Maintain PICC Line Dressing as Per Policy
Penalty
Summary
The facility failed to provide care and maintenance of a peripheral inserted central catheter (PICC) for a resident, consistent with professional standards of practice. The deficiency was identified for a resident who was dependent on parenteral nutrition and had a PICC line in place. The facility's policy required dressing changes for central vascular access devices every seven days or immediately if the dressing was compromised. However, the surveyor observed that the dressing on the resident's PICC line was dated 8/25, indicating it had not been changed as required by the policy and physician orders. Interviews with facility staff, including a nurse, a unit manager, and the Director of Nursing, confirmed that dressing changes should occur weekly. Despite this, the dressing on the resident's PICC line had not been changed since 8/25, which was inconsistent with the physician's orders and the facility's policy. This oversight in care and maintenance of the PICC line was a failure to adhere to established protocols, leading to the identified deficiency.
Failure to Develop Trauma-Informed Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to develop a comprehensive trauma-informed care plan for a resident with a history of trauma, specifically Post-Traumatic Stress Disorder (PTSD). The resident, who was admitted in March 2019, has diagnoses including PTSD, major depressive disorder, and anxiety. Despite being cognitively intact and requiring assistance for daily activities, the care plan for this resident did not include identified triggers and individualized interventions related to their PTSD diagnosis. The facility's policy on Trauma Informed and Culturally Competent Care requires the development of individualized care plans that address past trauma and minimize triggers, which was not adhered to in this case. Interviews with facility staff, including a Unit Manager, Social Worker, and the Director of Nursing, confirmed that a care plan should have been developed with specific triggers for residents diagnosed with PTSD. The care plan reviewed was last revised in March 2020 and included general interventions for managing anger and stress but lacked specific details on triggers and individualized strategies for trauma-informed care. This oversight indicates a failure to comply with the facility's policy and professional standards of practice for trauma-informed care.
Medication Error Involving Trazadone Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically involving the administration of Trazadone, an antidepressant. The facility's policy on administering medications requires that the person preparing or administering the medication contact the prescriber if a dosage is believed to be inappropriate or excessive. Additionally, the policy mandates that the individual administering the medication checks the label three times to verify the correct resident, medication, dosage, time, and method of administration. However, during a medication observation pass, a nurse identified that the medication card containing Trazadone 50 mg half tablets was not the correct dosage per the physician's orders, which specified a quarter tablet (12.5 mg) to be given twice a day for anxiety. The resident involved had diagnoses including dementia and psychotic disorder, with impaired short-term and long-term memory. The medication blister pack showed two missing pills out of 30 tablets, indicating that the medication had been administered incorrectly over the last two days. The medical record did not show that the physician had been notified of the wrong medication dispensed to the facility. The Director of Nursing confirmed that the pharmacy had acknowledged the wrong dosage was dispensed, and emphasized that nurses should use their judgment during medication passes to prevent administering incorrect dosages.
Failure to Date Opened Medications
Penalty
Summary
The facility failed to ensure that medications with short expiration dates were properly dated when opened, as required by their policy. During an inspection of the [NAME] unit, several medications were found opened and undated, including two Incruse Ellipta inhalers, two Advair inhalers, one albuterol sulfate inhaler, one Symbicort inhaler, and one fluticasone nasal spray. The facility's policy, revised in February 2023, mandates that multi-dose vials be dated when opened and discarded within 28 days unless otherwise specified by the manufacturer. Interviews with Nurse #5 and the Director of Nursing confirmed that the inhalers should have been dated with both an open date and an expiration date.
Documentation Errors in Medication Administration and Blood Pressure Monitoring
Penalty
Summary
The facility failed to ensure accurate documentation of medication administration for two residents. Resident #33, who was readmitted with chronic obstructive pulmonary disease, dysphagia, and venous insufficiency, had multiple medications not documented as administered during a specific shift. These medications included Aripiprazole, Aspirin, Fenofibrate, Fexofenadine, Furosemide, Duloxetine, Fluticasone-Salmeterol, Levetiracetam, Gabapentin, Humalog Kwikpen, and Metformin. Similarly, Resident #35, who has dementia, cerebral infarction, and diabetes, also had several medications not documented as administered, including Amlodipine Besylate, Aspirin, Clopidogrel Bisulfate, Escitalopram Oxalate, Ezetimibe, Pantoprazole Sodium, Polyethylene Glycol, Venlafaxine, Carvedilol, Ferrous Sulfate, Sennosides, Humalog Injection Solution, and Novolog Flexpen. The Director of Nursing acknowledged that blank spaces on the Medication Administration Record (MAR) could indicate a failure to document medication administration. The facility also failed to accurately document blood pressure readings for Resident #37, who was admitted with end-stage renal disease. The resident's physician's orders specified that no blood pressure readings should be taken from the left arm due to a dialysis access shunt. However, records indicated that blood pressure readings were documented as taken from the left arm on multiple occasions. Interviews with the resident and nursing staff revealed that the left arm was not actually used for these readings, suggesting documentation errors. The Director of Nursing confirmed that the expectation was for accurate documentation of the arm used for blood pressure readings. These deficiencies highlight issues in the facility's documentation practices, particularly concerning medication administration and blood pressure monitoring. The inaccuracies in the MAR and blood pressure records could potentially impact the residents' care and treatment. The Director of Nursing acknowledged the documentation errors and the need for accurate record-keeping to ensure proper resident care.
Failure to Implement Enhanced Barrier Precautions and Sanitize Equipment
Penalty
Summary
The facility failed to implement and follow Enhanced Barrier Precautions (EBPs) for a resident with a catheter, as required by their infection prevention and control policy. Despite the presence of a catheter, which necessitates EBPs, there was no signage or personal protective equipment (PPE) available outside the resident's room. Staff, including nurses and certified nursing aides, were observed performing care activities such as dressing changes and repositioning the resident without donning the necessary gowns. Interviews with staff, including the Director of Nursing, confirmed that the resident should have been on EBPs due to the presence of a catheter, but this was not implemented. Additionally, the facility did not properly sanitize shared medical equipment between resident uses, particularly in rooms with enhanced barrier precautions. During a medication pass, a nurse was observed using a blood pressure cuff and tower in a precaution room and returning them to the medication cart and hallway without disinfecting them. The nurse acknowledged the oversight, and the Director of Nursing confirmed that shared equipment should be sanitized after each use, especially in precaution rooms.
Inaccurate MDS Documentation for Residents
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) assessments for three residents, leading to discrepancies in their documented care needs. For one resident, the MDS inaccurately recorded the discharge destination as a short-term general hospital, while the resident was actually discharged to their son's home. This discrepancy was confirmed through interviews with the social worker and the Director of Nursing (DON), who acknowledged the error in the MDS documentation. Another resident's MDS inaccurately documented the type of intravenous line as a midline, whereas the resident had a dual lumen PICC line, as observed by the surveyor and confirmed by the DON. Additionally, a third resident's MDS failed to reflect the use of oxygen therapy, despite observations and medical records indicating the resident consistently used oxygen. Interviews with the Unit Manager and the MDS nurse confirmed the oversight in the MDS documentation.
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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 Saugus
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Saugus Center | 0.5 mi | — | 0 | 0 |
| Phillips Manor Nursing Home | 1.6 mi | — | 0 | 0 |
| Life Care Center Of The North Shore | 3.2 mi | — | 0 | 0 |
| Lighthouse Rehabilitation And Healthcare Center | 3.2 mi | — | 0 | 0 |
| Abbott Skilled Nursing & Rehabilitation Center | 3.4 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.