Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around October 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 Maristhill Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
A resident sustained a second-degree burn on the forehead when a CNA used a personal curling iron to style the resident's hair, contrary to facility policy. The incident was not immediately reported, and the burn was discovered the next day. The CNA was unaware that using personal electric devices was against policy and outside her scope of practice.
The facility failed to follow wound care orders for three residents, leading to deficiencies in pressure ulcer management. One resident with a stage 4 ulcer was not using prescribed pressure relief boots, another with severe cognitive impairment had a boot misplaced, and a third had wound care orders not transcribed into the TAR, resulting in inconsistent treatment.
Improper food handling practices were observed in the facility, with staff failing to follow sanitation protocols. Servers and the FSD were seen using potentially contaminated gloves to handle food, violating the facility's policy on glove use and hand hygiene. Despite training, these lapses in procedure were noted during meal service observations.
A facility failed to report a resident's abuse allegations within the required two-hour timeframe. The resident reported mistreatment by a CNA, including excessive TV volume and denial of care. Despite being informed, the DON delayed reporting to the state agency for over 24 hours, citing a lack of immediate feedback from the social worker who investigated the claims.
A facility failed to accurately complete a Level 1 PASARR for a resident with schizotypal disorder, a serious mental illness, resulting in the omission of a required Level II evaluation. The facility's policy requires screening for mental disorders upon admission, but the PASARR incorrectly indicated no mental illness. Interviews revealed that the PASARR form is completed by an external nurse, with the social worker as a backup, and both the social worker and DON acknowledged the error.
A facility failed to create a comprehensive care plan for a resident with a pacemaker, omitting crucial details such as the paced rate, serial number, and cardiologist information. The resident reported heart fluttering and a lack of recent pacemaker checks, which the Unit Manager was unaware of. The DON confirmed that a care plan should have been in place upon admission.
A resident with dementia and edema was observed multiple times without prescribed Teds stockings, despite physician orders and documentation indicating they were applied. Interviews with staff confirmed the oversight, highlighting a deficiency in following professional standards of practice.
A resident with chronic congestive heart failure and bradycardia, who was dependent on staff for all ADLs, did not receive scheduled weekly showers, only bed baths, despite expressing a desire for showers. Staff assumed the resident did not want showers and stopped offering them, contrary to facility policy. Interviews with staff revealed a lack of adherence to the shower schedule and documentation of refusals.
A resident with moderate cognitive impairment had a bruise on their upper left arm that went unnoticed by staff, despite facility policies requiring regular skin assessments and daily inspections. The bruise was discovered by a surveyor, and staff interviews revealed that the CNA responsible for the resident's care was unaware of the injury, which should have been reported to the nurse. The DON confirmed that new skin conditions should be reported immediately.
A facility failed to ensure a resident consistently used hearing aids, despite being cognitively intact and having adequate hearing with them. Observations showed the resident without hearing aids, which were left in the charger. Interviews revealed inconsistencies in staff assistance and documentation regarding the use of hearing aids, contrary to facility policy.
A resident with heart failure and COPD did not receive oxygen therapy as per physician's orders, with observations showing incorrect flow rates and empty oxygen tanks. Despite care plans specifying 1L/min oxygen, the resident was often given 2L/min. Elevated CO2 levels were noted, and a nurse's attempt to wean the resident off oxygen was not in line with orders. The DON confirmed the need to follow physician's directives.
A facility failed to create a trauma-informed care plan for a resident with PTSD, despite the resident's intact cognitive status and diagnosis. The resident's medical record lacked documentation related to PTSD, and no individualized care plan was developed. Social workers admitted they do not inquire about PTSD history to avoid discomfort, and both social workers and the DON agreed that the resident would benefit from a care plan addressing PTSD triggers.
The facility failed to maintain accurate medical records for a resident with dementia and edema. The resident was observed without ted stockings, although the TAR indicated they were worn. Nurses signed off on the TAR, suggesting completion of the task, which was not done. Interviews with the Unit Manager and DON confirmed this documentation error.
A facility failed to assess and offer a pneumococcal vaccination to a resident as per CDC guidelines. The resident, admitted with conditions including pneumonia and COPD, had no documentation of being offered the vaccine. Interviews with staff revealed that the MDS Nurse and Infection Control Nurse did not follow procedures, and the DON acknowledged the lapse in assessing and documenting the resident's vaccination status.
Resident Burned by Unauthorized Use of Curling Iron
Penalty
Summary
The facility failed to ensure the safety of a resident during personal care, resulting in a second-degree burn. A Certified Nurse Aide (CNA) used an electric curling iron to curl the resident's hair, which led to the resident sustaining a burn on the upper left side of the forehead. The facility's policy on electric safety for residents, which aims to protect residents from injuries associated with electric devices, was not adhered to in this instance. The resident, who was admitted to the facility with conditions including polyosteoarthritis, hypertension, and atrial fibrillation, required staff assistance with personal hygiene. Despite being alert and oriented, the resident was unable to independently carry out activities of daily living. On the day of the incident, the CNA brought her personal curling iron to work and used it on the resident's hair, resulting in the burn. The CNA was unaware that bringing personal electric devices into the facility was against policy and not within her scope of practice. The incident was not immediately reported or noticed by the staff, as the burn was discovered the following day by a nurse who observed redness and peeling skin on the resident's forehead. The resident confirmed that the burn occurred when the curling iron touched the forehead. The facility's Director of Nursing later confirmed that the CNA's actions were outside the scope of practice and against facility policy, which only allows CNAs to wash, towel dry, and comb residents' hair.
Failure to Implement Wound Care Orders
Penalty
Summary
The facility failed to implement treatment orders recommended by the Wound Physician for three residents, leading to deficiencies in pressure ulcer care. Resident #74, who was admitted with a stage 4 pressure ulcer on the right heel, was observed multiple times with heels directly on the bed, despite orders for pressure relief boots. The resident, cognitively intact, confirmed not wearing the boots, and staff interviews revealed a lack of adherence to the physician's recommendations. Resident #40, with severe cognitive impairment and a stage 3 pressure ulcer, was also observed with heels directly on the mattress, contrary to the physician's order to offload the right heel using a foam boot. The boot was found behind the television, and staff were unaware of the requirement to use it, indicating a failure to follow the prescribed treatment plan. Resident #55, with moderate cognitive impairment and a stage 2 pressure ulcer, had a physician's order for specific wound care that was not transcribed into the Treatment Administration Record (TAR). This oversight resulted in inconsistent implementation of the wound care order, as confirmed by staff interviews, highlighting a lapse in documentation and treatment adherence.
Improper Food Handling Practices Observed
Penalty
Summary
The facility failed to ensure proper sanitation and food handling practices were followed by staff, leading to potential contamination of food and an increased risk of foodborne illness. Observations on the third-floor unit during breakfast and lunch meals revealed multiple instances of improper glove use by servers and the Food Service Director (FSD). Staff members were seen changing gloves without washing hands in between, touching various surfaces and utensils with potentially contaminated gloves, and handling food directly with bare hands. These actions were in direct violation of the facility's policy, which mandates that bare hands must not touch ready-to-eat food and that gloves must be discarded after each use, with handwashing required before and after glove use. During interviews, the FSD acknowledged the importance of hand hygiene and stated that training is consistently provided to kitchen staff. However, the observed practices demonstrated a lack of adherence to these protocols. The FSD also confirmed that once gloves come into contact with objects other than food, they are considered contaminated and should not be used to handle food. Despite this understanding, both the FSD and other staff members were observed handling food with potentially contaminated gloves, indicating a significant lapse in following established food safety procedures.
Failure to Timely Report Allegations of Abuse
Penalty
Summary
The facility failed to report allegations of abuse to the state agency within the required two-hour timeframe for one resident. On the morning of October 8, 2024, the Director of Nursing (DON) was informed of a resident's allegations of mistreatment by a certified nursing assistant (CNA). The resident reported that the CNA would raise the television volume excessively and close the window blinds without consent, actions perceived as controlling. Additionally, the resident mentioned being denied assistance with incontinence care, which reminded them of previous mistreatment at another facility. Despite being informed of these allegations, the DON did not report them to the state agency until over 24 hours later, following an inquiry by a surveyor. The facility's policy mandates that any knowledge of abuse allegations must be reported to the Department of Public Health within two hours. However, the DON delayed reporting, citing that the social worker was sent to follow up with the resident but did not immediately report back. The social worker admitted to interviewing the resident but was unsure how to document the findings, contributing to the delay. This inaction resulted in a failure to comply with the facility's policy and state regulations regarding timely reporting of abuse allegations.
Failure to Complete Accurate PASARR Screening for Resident with SMI
Penalty
Summary
The facility failed to accurately complete a Level 1 Preadmission Screening and Resident Review (PASARR) for a resident with a diagnosis of schizotypal disorder, which is classified as a serious mental illness (SMI). This oversight resulted in the necessary Level II PASARR evaluation not being conducted as required. The facility's policy mandates that all new admissions and readmissions be screened for mental disorders, intellectual disorders, or related disorders through the PASARR process. If the Level 1 screen indicates potential criteria for these conditions, a referral to the state PASARR representative for a Level II evaluation is required. However, for this resident, the Level 1 PASARR incorrectly indicated no documented diagnosis of a mental illness, despite the resident's active diagnosis of schizotypal disorder. Interviews with facility staff revealed that the PASARR form is typically completed by an external nurse, with the facility's social worker serving as a backup to ensure completion prior to admission. The social worker acknowledged that the PASARR should have been accurately completed given the resident's diagnosis of a serious mental illness. The Director of Nursing also confirmed that the Level 1 PASARR should have been documented correctly upon the resident's admission. This failure to accurately complete the PASARR process highlights a lapse in the facility's adherence to its own admission criteria and screening procedures.
Failure to Develop Comprehensive Pacemaker Care Plan
Penalty
Summary
The facility failed to develop a comprehensive, resident-centered care plan for a resident with a pacemaker, leading to a deficiency. The resident, who was admitted with diagnoses including heart failure and the presence of a cardiac pacemaker, did not have a care plan that included essential pacemaker information such as the paced rate, serial number, frequency of pacemaker checks, and cardiologist contact details. This omission was identified during a review of the resident's physician orders and care plans, which lacked these critical details. The deficiency was further highlighted during interviews with the resident and facility staff. The resident reported experiencing heart fluttering and noted that the pacemaker had not been checked recently. The Unit Manager was unaware of the resident's symptoms and acknowledged the absence of a care plan with the necessary pacemaker information. The Director of Nursing confirmed that a pacemaker care plan should have been established upon admission, including all relevant details to ensure proper monitoring and care.
Failure to Implement Physician's Orders for Compression Stockings
Penalty
Summary
The facility failed to provide services that met professional standards of practice for a resident who was admitted with diagnoses including dementia, instability of the left knee, and localized edema. The resident was moderately cognitively impaired and dependent on staff for activities of daily living. The physician's orders required the application of Teds (compression) stockings to both legs while the resident was out of bed once a day for edema management. However, on multiple occasions throughout the day, the surveyor observed the resident without the prescribed Teds stockings, indicating a failure to adhere to the physician's orders. The Treatment Administration Record (TAR) for the specified date was signed off, incorrectly indicating that the Teds stockings had been applied. Interviews with the Unit Manager and the Director of Nursing confirmed that the physician's orders should have been followed, and the resident should have been wearing the Teds stockings as prescribed. This discrepancy between the documented care and the observed care highlights a deficiency in the facility's adherence to professional standards of practice.
Failure to Provide Scheduled Showers for a Dependent Resident
Penalty
Summary
The facility failed to provide assistance with activities of daily living (ADLs) for a dependent resident, specifically failing to provide weekly showers. The resident, who was admitted with chronic congestive heart failure and bradycardia, was found to have intact cognition and was dependent on staff for all ADLs. Despite being scheduled for weekly showers, the resident only received bed baths over the past 31 days and expressed a desire for showers if deemed safe by staff. The facility's policy indicated that residents should receive frequent showers or baths, and the resident's care plan included providing sponge baths only when a full bath or shower could not be tolerated. Interviews revealed that staff had stopped offering showers to the resident, assuming they were not wanted, despite the resident's willingness to have them. A CNA admitted to not asking the resident about their preference for showers, and a nurse confirmed that residents should be offered showers weekly. The Director of Nursing stated that all residents should be offered showers weekly, and any refusals should be documented. The lack of documentation of refusals and failure to follow the shower schedule contributed to the deficiency.
Failure to Identify and Report Skin Injury
Penalty
Summary
The facility failed to implement standards of quality care for a resident with moderate cognitive impairment, who was admitted with diagnoses including unspecified dementia and anxiety disorder. The deficiency was identified when a surveyor observed a round, purple mark with yellow edging on the resident's upper left arm, which the resident was unaware of. The resident mentioned a fall about a week prior, but staff had not informed them about the bruise. The facility's policy required comprehensive skin assessments and daily skin inspections, yet the most recent skin check evaluation and physician's progress note did not document any abnormalities or bruising. Interviews with facility staff revealed that the Certified Nursing Assistant (CNA) responsible for the resident's care was unaware of the bruise and acknowledged that it should have been reported to the nurse. The nurse confirmed that such marks should be identified during activities of daily living (ADL) care. The Director of Nursing (DON) stated that CNAs are expected to report new skin conditions immediately for investigation. The failure to identify and report the bruise indicates a lapse in the facility's adherence to its skin assessment and reporting protocols.
Failure to Ensure Consistent Use of Hearing Aids for a Resident
Penalty
Summary
The facility failed to ensure that a resident received proper treatment to maintain hearing and utilize assistive devices for communication. Specifically, the facility did not consistently implement the use of hearing aids for a resident who was admitted with cognitive and cardiac conditions. The resident was cognitively intact and had adequate hearing with the use of hearing aids, as indicated in the Minimum Data Set assessment. However, during multiple observations, the resident was found not wearing the hearing aids, which were left in the charger on the television stand. Interviews with the resident and staff revealed inconsistencies in the assistance provided for wearing hearing aids. The resident mentioned that staff sometimes assisted with the hearing aids, while the Unit Manager and Director of Nursing indicated that CNAs or nurses should assist and document any refusal to wear the aids. The medical record did not show any documentation of the resident refusing to wear the hearing aids, indicating a lapse in following the facility's policy for assisting hearing-impaired residents.
Failure to Follow Physician's Orders for Oxygen Therapy
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident who required continuous oxygen therapy, as per the physician's order. The resident, diagnosed with acute systolic congestive heart failure and chronic obstructive pulmonary disease (COPD), was observed multiple times receiving oxygen at an incorrect flow rate of 2 liters per minute, contrary to the physician's order of 1 liter per minute. Additionally, the resident was found using an empty portable oxygen tank on two occasions, indicating a lack of proper monitoring and management of the resident's oxygen supply. The resident's care plans for congestive heart failure and COPD both specified oxygen therapy at 1 liter per minute, yet observations revealed discrepancies in the administration of oxygen. The resident's lab results also showed elevated carbon dioxide levels, which were flagged as high. During an interview, a nurse mentioned attempts to wean the resident off oxygen due to CO2 retention, but this was not aligned with the physician's orders. The Director of Nursing confirmed that the physician's orders should have been followed, highlighting a failure in adhering to prescribed respiratory care protocols.
Failure to Develop Trauma-Informed Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to develop a trauma-informed care plan for a resident diagnosed with Post-Traumatic Stress Disorder (PTSD). The resident, who was admitted in May 2024, had a diagnosis of PTSD and an unspecified mood disorder. Despite having an intact cognitive status as indicated by a perfect score on the Brief Interview for Mental Status, the resident's medical record lacked documentation related to the PTSD diagnosis. Furthermore, the active care plans did not include an individualized care plan addressing the PTSD diagnosis with specific interventions or approaches. Interviews with the facility's social workers revealed that although residents are assessed during admission, they do not inquire about a resident's PTSD history to avoid discomfort. The social workers acknowledged that the resident would benefit from a care plan with individualized interventions and approaches related to PTSD triggers. The Director of Nursing also confirmed that the resident should have an individualized PTSD care plan with specific interventions and approaches for managing PTSD triggers.
Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain an accurate medical record for a resident, identified as Resident #55, who was admitted with diagnoses including dementia and localized edema. The resident was moderately cognitively impaired and dependent on staff for activities of daily living. On two separate occasions, the surveyor observed the resident in bed without ted stockings, despite the Treatment Administration Record (TAR) indicating that the resident was wearing them. The TAR for the morning of the observation was signed off by nurses, suggesting the task was completed when it was not. Interviews with the Unit Manager and the Director of Nursing confirmed that nurses should not document tasks as completed if they were not performed.
Failure to Assess and Offer Pneumococcal Vaccination
Penalty
Summary
The facility failed to assess and offer pneumococcal vaccinations to a resident as per CDC recommendations. The policy in place required that residents be assessed for eligibility and offered the vaccine within 30 days of admission unless contraindicated or previously vaccinated. However, for one resident, who was admitted with diagnoses including pneumonia, COPD, heart failure, and dementia, there was no documentation in the medical records to indicate that the pneumococcal vaccine was offered or administered. The resident's Minimum Data Set assessment also lacked information on the vaccination status. Interviews with facility staff revealed lapses in following the established procedures. The MDS Nurse admitted to not having documentation to support that the resident was offered the vaccine, and the Infection Control Nurse confirmed that the resident was not assessed or offered the vaccine upon admission. The Director of Nursing acknowledged that the nursing staff should have assessed the resident's eligibility for the pneumococcal vaccine and documented it in the medical record.
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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 Waltham
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| West Newton Healthcare | 1.8 mi | — | 16 | 0 |
| Belmont Manor Nursing Home, In | 2 mi | — | 13 | 0 |
| Lasell House | 2.6 mi | — | 1 | 0 |
| Brookhaven At Lexington | 2.8 mi | — | 7 | 0 |
| Pine Knoll Nursing Center | 3.2 mi | — | 33 | 1 |
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