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 Garden Place Healthcare during CMS and state inspections, most recent first.
The facility failed to maintain a safe environment by leaving hazardous items accessible to cognitively impaired residents, not providing a wander guard for a high-risk resident, and leaving alcohol unsecured in a resident's room. Hazardous items like bleach wipes, razors, and medications were not properly secured, and a resident at high risk for elopement was not given a wander guard. Additionally, alcohol brought in by family was left unsecured in a resident's room, despite the presence of a roommate with a history of substance use disorder.
The facility failed to follow food safety and sanitation standards, leading to potential foodborne illness risks. Observations revealed improperly dated and stored food items, unclean ice machines with growths, and unsanitary conditions in a kitchenette. Staff interviews confirmed the lack of adherence to policies for dating and discarding food, and the absence of a cleaning schedule for ice machines.
A facility failed to maintain an active court-approved treatment plan for a resident receiving antipsychotic medication. The resident, diagnosed with psychosis and other mental health conditions, was administered Zyprexa without a current treatment plan due to delays in renewing the plan. Facility staff, including a social worker and administrator, acknowledged issues with documentation and communication with the facility lawyer, resulting in the absence of a scheduled court hearing for the renewal.
A facility failed to develop a comprehensive care plan for a resident undergoing chemotherapy for lung and rectal cancer. Despite being cognitively intact, the resident's care plan lacked details on cancer treatment. Interviews with staff, including nurses and the DON, confirmed the care plan was not updated to reflect the resident's current treatment, contrary to facility policy.
The facility failed to meet professional standards of care for two residents, leading to deficiencies in medication administration and documentation. A resident with cancer did not receive Dexamethasone as prescribed, with missed doses and incomplete documentation. Another resident with heart conditions received Propranolol despite blood pressure readings below the prescribed threshold. These issues highlight a lack of adherence to medication administration and documentation protocols.
A resident with a toothache and aphthous ulcer did not receive prescribed pain relief medications consistently, despite frequent complaints of pain. The MAR showed that Tylenol, Orajel, Ibuprofen, and Lidocaine Viscous were not administered over several days. Nursing staff failed to document or locate these medications, resulting in inadequate pain management.
A facility failed to provide appropriate dialysis care for a resident with an AV fistula in the left arm, crucial for long-term dialysis. The resident's care plan lacked specific instructions for the fistula's location and care, and there were no physician's orders for its monitoring. The facility's staff did not check the AV fistula site or dressing, and blood pressure was incorrectly taken from the arm with the fistula. Interviews confirmed the absence of necessary orders for monitoring and care, indicating a lapse in following professional standards.
A facility failed to assess a resident's trauma history and identify triggers, despite the resident's PTSD diagnosis. The resident, admitted with dementia, PTSD, and poly substance use disorder, was not properly evaluated for trauma history, and a trauma care plan was not initiated. Social workers did not review hospital discharge paperwork or inquire about trauma history from the family, leading to a deficiency in trauma-informed care.
A facility failed to act on a Consultant Pharmacist's recommendation to conduct lab monitoring for a resident on Levothyroxine. The recommendation was not documented in the resident's medical record, and the prescriber did not review or act upon it. Interviews revealed that the DON was responsible for distributing recommendations, but there was no evidence of review, and the prescriber response section was blank.
A resident with dementia and a known toothache was admitted to the facility, but timely dental services were not provided. Despite frequent complaints of tooth pain and a care plan indicating a need for a dental referral, the facility failed to arrange a timely appointment. The resident was given pain management medications, but the dental referral remained pending. The DON acknowledged the lack of a scheduled visit from the in-house consultant dentist and did not refer the resident to a community dentist until prompted by a surveyor.
A resident developed redness and irritation on their facial area after being shaved by a staff member. The facility failed to document the nurse's assessment, physician notification, and treatment order for the razor burn. Despite administering bacitracin as ordered, the nurse did not complete an incident report or document the progress toward healing, violating the facility's policies on charting and incident reporting.
Failure to Maintain a Safe Environment and Secure Hazardous Items
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for residents on the secure unit, particularly for two residents. Hazardous items such as bleach wipes, razors, and medications were accessible to cognitively impaired residents. The surveyor observed an unsecured cabinet with bleach wipes and an unlocked medication cart. Additionally, the soiled utility room was accessible without a code, and razors were protruding from a full sharps container. Staff interviews revealed a lack of awareness and adherence to safety protocols regarding the secure storage of hazardous items. Resident #105, who was assessed at high risk for elopement due to severe cognitive impairment, was not provided with the necessary intervention of a wander guard. Despite being identified as at risk for elopement in the care plan and nursing admission assessment, the resident was not included in the Wander guard book, and no wander guard was initiated. The resident exhibited wandering behavior and expressed a desire to leave the facility, yet the interdisciplinary team was not notified, and the required safety measures were not implemented. Resident #79, who was cognitively intact, had alcohol brought in by family members that was not securely stored. The alcohol was left in the resident's room, despite the presence of a roommate with a history of substance use disorder. Staff interviews indicated that alcohol should be treated like medication, requiring a physician's order and secure storage. However, the process was not followed, and the alcohol remained unsecured, posing a potential risk to the resident and others.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to its policy and professional standards for food safety and sanitation, which could potentially lead to the spread of foodborne illnesses among residents. The surveyor observed multiple instances where food items were not properly dated and stored in the main kitchen and kitchenettes. Specifically, opened containers of thickened apple juice, dairy drinks, and other beverages were found without proper date markings, despite manufacturer instructions indicating they should be discarded after seven days of opening. Interviews with staff, including a nurse and the Food Service Director (FSD), confirmed that the expectation was for all thickened liquids to be dated when opened and discarded after seven days. The facility also failed to maintain four ice machines in a clean and sanitary condition. Observations revealed orange-brown and black growths inside the ice machines, with condensation and water dripping from these growths onto the ice. The ice machines were reportedly cleaned by a vendor every three months, but there was no schedule for the facility to clean them between vendor visits. The FSD and the Director of Maintenance acknowledged the presence of growths and the lack of a cleaning schedule, which was confirmed during interviews with the Administrator. Additionally, one of the unit kitchenettes was not maintained in a clean and sanitary condition. The surveyor noted an open floor drain with black and brown growth, a greenish-white slimy substance, and dead drain flies on the floor. The area was described as having an extremely warm air temperature and a damp smell. The Administrator and the Director of Maintenance recognized the need for cleaning and replacing the tile and area surrounding the drain to remove the growth, acknowledging that the floor should be clean and free of any growth.
Expired Treatment Plan for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a court-approved treatment plan for the administration of antipsychotic medications was active and current for a resident with a guardian. The resident, who was diagnosed with psychosis, major depressive disorder, and anxiety, was receiving Zyprexa, an antipsychotic medication, on a routine basis. The treatment plan, which authorized the administration of this medication, had expired, and there was no evidence of a renewed plan being in place. Interviews with facility staff, including a nurse, unit manager, and social worker, revealed that the renewal process was delayed due to issues with documentation and communication with the facility lawyer. The social worker indicated that the required paperwork for the renewal of the treatment plan had been sent to the facility lawyer multiple times, but it was deemed invalid and needed to be resubmitted. Despite efforts to restart and resubmit the necessary documentation, a court hearing had not been scheduled by the end of the survey. The facility administrator acknowledged the issues with the renewal process and confirmed that the treatment plans should be renewed annually for residents with guardians receiving antipsychotic medications. However, as of the survey's conclusion, there was no additional evidence that the required paperwork had been completed and submitted to the courts.
Failure to Implement Comprehensive Care Plan for Cancer Treatment
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan for a resident with lung and rectal cancer, who was undergoing chemotherapy. Despite the resident being cognitively intact, as indicated by a perfect score on the Brief Interview for Mental Status, the care plan did not address the resident's cancer treatment. This oversight was identified during a review of the resident's medical records, which showed no comprehensive care plan for the cancer and chemotherapy treatment. Interviews with facility staff, including nurses and the Director of Nurses, revealed a lack of adherence to the facility's policy on comprehensive person-centered care plans. Staff acknowledged that care plans should be updated to reflect significant changes in treatment plans or medication orders. However, it was confirmed that the resident's care plan did not include the necessary details for managing cancer treatment, despite the potential side effects and the importance of reflecting the resident's current treatment status.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to meet professional standards of care for two residents, leading to deficiencies in medication administration and documentation. For Resident #33, who was admitted with lung and rectal cancer, the facility did not accurately transcribe, administer, and document the administration of Dexamethasone, a corticosteroid prescribed to manage inflammation related to chemotherapy. Despite clear orders to administer the medication twice daily on specific days surrounding chemotherapy sessions, the medication was not given as prescribed, and documentation was incomplete. Interviews with nursing staff revealed that doses were missed, and the medication was not properly recorded in the Medication Administration Record (MAR). For Resident #18, who had a history of transient ischemic attack, cerebral infarction, and chronic atrial fibrillation, the facility failed to adhere to physician orders regarding the administration of Propranolol, a medication used to manage heart conditions. The orders specified that the medication should not be given if the resident's systolic blood pressure was below 100. However, the MAR indicated that Propranolol was administered on multiple occasions when the resident's blood pressure was below the specified threshold. Interviews with nursing staff confirmed that the medication was given contrary to the physician's orders, and there was no documentation of any alternative instructions from the physician. These deficiencies highlight a lack of adherence to professional standards and facility policies regarding medication administration and documentation. The facility's failure to ensure accurate transcription and administration of medication orders, as well as proper documentation in the MAR, resulted in missed doses and inappropriate administration of medications, potentially compromising resident care.
Inadequate Pain Management for Resident with Tooth Pain
Penalty
Summary
The facility failed to provide appropriate pain management for a resident with tooth pain, as observed by surveyors. Resident #105, who was admitted with a diagnosis of toothache and aphthous ulcer, frequently complained of tooth pain. Despite having orders for pain relief medications such as Tylenol, Orajel, Ibuprofen, and Lidocaine Viscous, these were not consistently administered. The Medication Administration Record (MAR) showed that these medications were not given from October 31 to November 4, 2024, even though the resident continued to report pain. On November 3, 2024, the resident complained of tooth pain to a nurse, who acknowledged the complaint but failed to document the administration of Tylenol, which she claimed to have given. The nurse also admitted to not administering other prescribed medications like Lidocaine Viscous and Orajel, citing an inability to locate them. This lack of documentation and administration of prescribed pain relief measures contributed to the resident's ongoing discomfort. Interviews with nursing staff revealed a lack of awareness and availability of the prescribed medications. Nurse #4, who worked once a week, was aware of the Orajel order but could not find it, and was unaware of the Lidocaine Viscous. The Unit Manager confirmed that the Lidocaine was available but not administered, and the Orajel was missing from the medication cart. This indicates a breakdown in communication and medication management within the facility, leading to inadequate pain management for the resident.
Failure to Monitor and Care for Dialysis Access Site
Penalty
Summary
The facility failed to provide appropriate dialysis care and services for a resident with an arteriovenous (AV) fistula, which is crucial for long-term dialysis. The resident, who was admitted with end-stage renal disease and required dialysis three times a week, had an AV fistula in the left arm. The facility's policy required regular monitoring of the AV fistula site to prevent infection and ensure patency, including palpating for a thrill and auscultating for a bruit. However, the facility did not have physician's orders for the care of the AV fistula, and the resident's care plan did not specify the correct location of the fistula or the necessary care procedures. The facility's progress notes revealed that the resident's blood pressure was repeatedly taken from the left arm, where the AV fistula was located, contrary to the facility's policy. Additionally, the resident reported that the facility's nurses did not check the AV fistula site or the dressing, which was applied by the dialysis center staff. Interviews with the unit manager and the director of nursing confirmed that there should have been orders in place for monitoring and caring for the AV fistula site, which were not present, indicating a lapse in following professional standards of practice for dialysis care.
Failure to Assess Trauma History for Resident with PTSD
Penalty
Summary
The facility failed to assess a history of trauma and identify triggers to avoid potential re-traumatization for a resident with a known diagnosis of PTSD. The resident, who was admitted with diagnoses including dementia, PTSD, and poly substance use disorder, was not properly evaluated for trauma history as part of the comprehensive assessment. The facility's policy on Trauma Informed Care, which requires identifying past trauma or adverse experiences, was not followed. The Social Service Evaluation did not reflect the PTSD diagnosis, and a trauma care plan was not initiated. Interviews with the social workers revealed gaps in the assessment process. Social Worker #1 acknowledged that the PTSD diagnosis was not included in the evaluation and that the resident should have been assessed for trauma history and triggers. Social Worker #2, who completed the evaluation, admitted to not reviewing the hospital discharge paperwork, which contained the PTSD diagnosis, as she considered it clinical information outside her purview. Additionally, she did not inquire about trauma history from the resident's family, despite the resident's request to leave the facility.
Failure to Act on Pharmacist's Recommendations for Lab Monitoring
Penalty
Summary
The facility failed to act upon the recommendations made by the Consultant Pharmacist during the monthly Medication Regimen Reviews (MRR) for a resident with a thyroid disorder. The resident was admitted in August 2022 and was receiving Levothyroxine, a hormone used to treat thyroid disorder. In January 2024, the Consultant Pharmacist recommended that a lab test be conducted to monitor the efficacy of Levothyroxine. However, the surveyor found that the recommendation was not documented in the resident's medical record, and the prescriber had not reviewed or acted upon it. Interviews with facility staff revealed that the Director of Nurses (DON) was responsible for distributing the pharmacist's recommendations to prescribers, but there was no evidence that the recommendations for this resident were reviewed. The prescriber response section on the recommendation form was left blank, indicating that the recommendation was not addressed. The Administrator acknowledged that the facility should have followed its policy to ensure pharmacy recommendations were reviewed and documented.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to provide timely dental services for a resident who was admitted with a diagnosis of dementia and a known toothache. Upon admission, the resident's hospital discharge summary noted complaints of right lower tooth pain, dental caries, and an aphthous ulcer. The care plan included a referral to a dentist as needed. Despite frequent complaints of tooth pain documented in nursing progress notes, the facility did not arrange a timely dental appointment. The resident was given Tylenol, Orajel, and other pain management medications, but the dental referral remained pending. The Director of Nurses (DON) acknowledged that the in-house consultant dentist had no scheduled visit since the resident's admission, and the facility had not referred the resident to a community dentist until prompted by the surveyor's inquiry. The DON confirmed that a referral was sent to the in-house consultant dentist on a specific date, but there was no indication of when the dentist would visit. Consequently, the resident continued to experience pain without receiving the necessary dental evaluation and treatment in a timely manner.
Failure to Document Resident's Razor Burn and Treatment
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who developed redness and irritation on their facial area after being shaved by a staff member. The facility's policy requires documentation of all services provided, changes in condition, and incidents involving residents. However, there was no nursing documentation in the medical record related to the resident's razor burn, nor was there evidence that nursing staff assessed the razor burn or monitored its progress toward healing. The incident occurred when a CNA reported to a nurse that the resident had redness and irritation on their beard from shaving. The nurse assessed the resident's facial area, noted the redness, and notified the physician, who ordered the application of bacitracin to the affected area. Despite administering the treatment, the nurse failed to document the assessment, physician notification, or the new treatment order in the resident's medical record. Additionally, the nurse did not complete an incident report as required by the facility's policy. The Director of Nurses confirmed the lack of documentation in the resident's medical record, stating that nursing staff should have documented their assessments and any new treatment orders obtained from the physician. The absence of documentation indicates a failure to adhere to the facility's policies on charting and incident reporting, resulting in incomplete medical records for the resident.
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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 Attleboro
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Life Care Center Of Attleboro | 1.8 mi | — | 3 | 0 |
| Madonna Manor Nursing Home | 3.8 mi | — | 6 | 0 |
| Grandview Center | 7 mi | — | 1 | 0 |
| Harris Health Care Center North | 7.1 mi | — | 24 | 0 |
| Pawtucket Falls Healthcare Center | 7.3 mi | — | 1 | 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.