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 Dexter House Healthcare during CMS and state inspections, most recent first.
A nurse administered Epinephrine instead of Glucagon to a resident with diabetes who was experiencing hypoglycemia and unable to take oral glucose. The error occurred after the nurse was unable to access the medication room and obtained emergency medications from another unit, mistakenly selecting the EpiPen despite reviewing Glucagon instructions. The resident did not have an order for Epinephrine, and the error was discovered the following day.
A nurse failed to clean and disinfect shared equipment, including a glucometer and a portable vital sign device, between resident uses. The glucometer was used in multiple rooms without cleaning, and the vital sign device lacked disinfectant wipes. The nurse acknowledged the oversight, and the Assistant Director of Nurses confirmed the requirement for cleaning shared equipment.
The facility failed to identify and minimize bed entrapment risks, particularly for a resident with dementia, where a significant gap was found between the headboard and mattress. The facility did not conduct routine inspections for 72 beds without side rails, leaving potential entrapment risks unaddressed. Staff interviews revealed a lack of policies for bed safety and entrapment prevention.
Two residents in the facility did not receive a dignified dining experience as staff members were observed standing over them while providing feeding assistance, contrary to the facility's policy. One resident with a traumatic brain injury and another with dementia were both in bed, and staff did not adjust the bed to be at eye level, as confirmed by the ADON.
The facility failed to implement a care plan for a resident by not keeping the call light within reach, as observed on multiple occasions. Additionally, the facility did not develop a care plan for another resident with a history of suicide attempts, despite documentation of this history. Interviews with staff revealed a lack of awareness and expected care planning for these issues.
A resident with diabetes did not receive insulin as ordered by the physician due to multiple instances of non-administration by the nursing staff. The resident's blood sugar levels, documented in September, indicated the need for insulin according to a sliding scale, but the required doses were not given. The facility's policy mandates that medications be administered as prescribed, which was not followed in this case.
The facility failed to provide necessary meal assistance to two residents with cognitive and physical impairments, despite care plans indicating the need for supervision and total assistance. Observations showed residents left alone with untouched meals, and staff interviews revealed inconsistencies in understanding residents' needs.
A facility failed to securely store medications, as a resident's prescribed lotion was repeatedly found on their roommate's bedside table. Despite the facility's policy requiring medications to be locked away, the lotion was left unattended. Nursing staff confirmed the resident did not self-administer medications, and the Assistant DON acknowledged the lapse in policy adherence.
A resident with moderate cognitive impairment and a cancer diagnosis reported ill-fitting dentures, but the facility failed to schedule or document follow-up dental care. Staff interviews revealed communication lapses, with a CNA not informing the nurse of the resident's complaints, and the nurse being unaware of any follow-up appointments. The ADON expected documentation of appointment refusals and implementation of dentist recommendations, highlighting a failure in ensuring necessary dental care.
Medication Error: Epinephrine Administered Instead of Glucagon
Penalty
Summary
A significant medication error occurred when a nurse administered Epinephrine instead of Glucagon to a resident who was experiencing hypoglycemia. The resident, who had a history of diabetes, hypertension, and a recent femur fracture, was found to have a low blood glucose level of 59 mg/dl and was unable to take oral glucose. The nurse, after being unable to access the medication room on her unit, obtained emergency medications from another unit. She was handed both Glucagon and an EpiPen by another nurse, and despite reading the instructions for Glucagon, mistakenly administered the EpiPen. The nurse did not realize the error until the following day when informed by the facility administrator. The facility's medication administration policy required staff to verify the right resident, medication, dosage, time, and route before administration. The resident did not have a physician's order for Epinephrine, only for Glucagon to be given intramuscularly for blood sugar less than 70 mg/dl if unresponsive or unable to swallow. The error was identified through review of records and staff interviews, and the Director of Nursing confirmed that the nurse failed to ensure the correct medication was administered.
Infection Control Breach in Equipment Cleaning
Penalty
Summary
The facility failed to adhere to infection control standards during the cleaning of shared resident equipment, specifically the glucometer and portable vital sign device. During a medication observation on the Dolphin Lane unit, a surveyor noted that a nurse did not clean or disinfect the glucometer between uses as it was carried in and out of multiple residents' rooms. The glucometer, a handheld device used to measure blood glucose levels, was not cleaned between each resident use or before being returned to the medication cart. Additionally, the same nurse did not clean the portable vital sign device between uses. This device, which measures pulse, blood pressure, temperature, and oxygen saturation, was observed being wheeled in and out of residents' rooms without being disinfected. The portable device also lacked the necessary cleaners or disinfectant wipes on its bracket shelf. During interviews, the nurse admitted to not disinfecting the equipment, and the Assistant Director of Nurses confirmed that shared equipment should be cleaned before use with another resident.
Failure to Identify and Minimize Bed Entrapment Risks
Penalty
Summary
The facility failed to identify and minimize areas of possible entrapment in resident beds, specifically for one resident and across multiple beds. For one resident, who was admitted with dementia and adult failure to thrive, a significant gap was observed between the headboard and mattress, which was wide enough to allow a human head to become entrapped. This gap was identified in Zone 7, as defined by the FDA's guidance on bed entrapment zones. The Maintenance Director confirmed that the bed had never been measured for entrapment risk, and the facility's Entrapment Log did not indicate any measurements had been taken for this resident's bed. The facility also failed to conduct routine inspections of all bed frames and mattresses to identify possible areas of entrapment for 72 resident beds. The Maintenance Director admitted that inspections were only conducted on beds with side rails, leaving beds without side rails uninspected for potential entrapment risks, particularly in Zone 7. The facility lacked a process to inspect, monitor, or identify possible entrapment for beds without side rails, and the Entrapment Log did not show any measurements for these beds since 2019. Interviews with various staff members, including the Maintenance Director, Nurse, Assistant Director of Nursing, Administrator, and Director of Clinical Operations, revealed a lack of policies related to bed inspections, bed safety, or entrapment. Staff acknowledged that there should never be a gap wide enough to fit a human head between the head or footboard and the mattress end, but they were unable to provide information on how the facility ensured bed gaps were identified and minimized for all beds. The facility's failure to monitor and address these gaps was evident, as no policies or procedures were in place to prevent such deficiencies.
Failure to Provide Dignified Dining Experience
Penalty
Summary
The facility failed to provide a dignified dining experience for two residents, as observed by surveyors. Resident #1, who was admitted with a traumatic brain injury and has impaired upper extremity range of motion, was observed on two separate occasions receiving feeding assistance from a staff member who was standing over the resident. The resident was in bed, and the staff member did not adjust the bed to ensure they were at eye level with the resident, which is contrary to the facility's policy on resident rights. Similarly, Resident #34, who has a diagnosis of dementia and moderate cognitive impairment, was also observed receiving feeding assistance in a manner that did not respect their dignity. The staff member was standing over the resident while providing assistance, without raising the bed to be at eye level. The Assistant Director of Nursing confirmed that staff should be at eye level with residents during feeding assistance, indicating a failure to adhere to the facility's policy on treating residents with dignity and respect.
Failure to Implement and Develop Care Plans for Residents
Penalty
Summary
The facility failed to implement the care plan for a resident who was admitted with diagnoses of weakness and unsteadiness on feet. The care plan, dated December 2021, included an intervention to keep the call light within reach. However, observations on multiple occasions revealed that the call light was draped over the overbed light and out of the resident's reach. Interviews with the Assistant Director of Nursing and the Administrator confirmed that call lights should be within reach at all times, indicating a failure to adhere to the care plan. Additionally, the facility did not develop a care plan for another resident with a history of suicide attempts, despite this being documented in a behavioral health group note. The resident, admitted with diagnoses including cancer, manic depression, and schizophrenia, had a documented history of jumping out of a window in a nursing home. Interviews with a nurse, the social worker, and the Assistant Director of Nursing revealed that they were unaware of the resident's history and expected a care plan to be developed to address this issue, highlighting a lapse in communication and care planning.
Failure to Administer Insulin as Ordered
Penalty
Summary
The facility failed to ensure that medications were administered as ordered for a resident with diabetes, leading to a deficiency in medication administration. The resident, who was admitted in April 2024, had severe cognitive impairment and required assistance with daily activities. The physician's orders specified a sliding scale for insulin administration based on the resident's blood sugar levels. However, the Medication Administration Record for September 2024 showed multiple instances where the resident's blood sugar levels warranted insulin administration, but no insulin was documented as given. Specifically, on several occasions, the resident's blood sugar levels were recorded, but the corresponding insulin doses were not administered as per the sliding scale order. For example, on 9/3/24, the resident had a blood sugar level of 200, but no insulin was documented. Similar omissions occurred on 9/8/24, 9/13/24, and 9/22/24, where the resident's blood sugar levels indicated the need for insulin, yet no insulin was administered. Additionally, on 9/9/24 and 9/29/24, there were no blood sugar levels or insulin administration documented. During an interview, the Assistant Director of Nursing and the Administrator acknowledged that medications should be administered according to the physician's orders.
Failure to Assist Residents with Meals
Penalty
Summary
The facility failed to provide necessary assistance with meals for two residents, leading to deficiencies in care. Resident #21, who was admitted with conditions such as cerebral infarction, malnutrition, and dysphagia, required supervision or assistance with eating. Observations revealed that Resident #21 was left alone with meal trays, often with eyes closed and food untouched, without staff supervision or assistance. Despite the care plan indicating the need for supervision, staff interviews confirmed that Resident #21 was not consistently monitored during meals. Similarly, Resident #59, diagnosed with dementia and malnutrition, was observed without the required assistance during meals. The care plan specified total assistance with eating, yet Resident #59 was left alone with meal trays, and staff were not present to provide necessary help. Family members reported having to assist with meals due to the lack of staff support. Staff interviews showed a misunderstanding of Resident #59's needs, with some CNAs incorrectly stating that the resident did not require assistance. The Assistant Director of Nursing and the Administrator acknowledged that care plans should be followed, and staff should be present to cue residents during meals. However, the observations and interviews indicated a failure to adhere to these care plans, resulting in inadequate assistance for residents who were unable to eat independently.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in a safe and secure manner, specifically for a resident who had moderately intact cognition. The resident was prescribed Ammonium Lactate 12% lotion to be applied to their feet every evening. However, the lotion was repeatedly observed by a surveyor on the bedside table of the resident's roommate, indicating it was left unattended and not stored securely as required by the facility's policy. The facility's policy mandates that medications, including those for external use, should be stored separately and securely, and not left in residents' rooms. Despite this, the lotion was observed on multiple occasions over two days on the roommate's bedside table. Interviews with nursing staff confirmed that the resident did not self-administer medications, and the nursing staff were responsible for administering the lotion. The Assistant Director of Nursing acknowledged that all medications should be locked in the medication or treatment carts, highlighting a lapse in adherence to the facility's medication storage policy.
Failure to Provide Routine and Emergency Dental Care
Penalty
Summary
The facility failed to provide routine and 24-hour emergency dental care for a resident who had voiced concerns about ill-fitting dentures. The resident, who was admitted with a diagnosis including cancer and had moderate cognitive impairment, reported that their dentures did not fit well and expressed a desire to have them adjusted. Despite the resident's complaints, the facility did not schedule or document any follow-up dental appointments after the initial visit where the dentures were provided, and recommendations for follow-up appointments were made. Interviews with staff revealed a breakdown in communication and follow-through regarding the resident's dental care needs. A CNA acknowledged being aware of the resident's complaints but did not inform the nurse, assuming the nurse was already aware. The nurse, however, was not informed of the resident's issues with the dentures and was unaware of any scheduled follow-up appointments. The Assistant Director of Nursing expected that any refusal of dental appointments would be documented and that the dentist's recommendations would be implemented, indicating a failure in the facility's processes to ensure the resident received necessary dental care.
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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 Malden
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Regalcare At Glen Ridge | 1.4 mi | — | 35 | 0 |
| Rehabilitation & Nursing Center At Everett (the) | 1.6 mi | — | 0 | 0 |
| The Massachusetts Veterans Home At Chelsea | 2.1 mi | — | 3 | 0 |
| Leonard Florence Center For Living | 2.2 mi | — | 2 | 0 |
| Katzman Family Center For Living | 2.3 mi | — | 5 | 0 |
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