Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
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 Melrose Healthcare during CMS and state inspections, most recent first.
The facility failed to provide residents with private access to telephones, requiring them to use the phone at the nurses' station where conversations could be overheard. Previously available portable phones for private calls were no longer accessible, and staff were unaware of the option to use a private office for calls.
The facility failed to develop comprehensive care plans for two residents, one with legal blindness and severe cognitive impairment, lacking plans for vision, communication, and fall risk, and another with a pacemaker, missing a care plan for its management. Despite policy requirements and triggered assessments, these care plans were not implemented, as confirmed by staff.
The facility failed to secure and properly label medications, with medication carts left unlocked and unattended, and several inhalers and an insulin pen found opened and undated. Nursing staff acknowledged the need for secure storage, and the DON confirmed the requirement for proper labeling and storage.
The facility failed to adhere to food safety standards, with improperly stored and undated food items found in the kitchen, and mold and standing water observed in a basement refrigerator. Dented cans were improperly stored, indicating a lapse in following procedures for handling damaged goods.
The facility failed to obtain informed consent for psychotropic medications for two residents with severe cognitive impairments. One resident was prescribed Mirtazapine without a signed consent form, and another received Ativan without documented consent. Both the DON and a nurse confirmed that consent should have been obtained prior to administration.
The facility failed to maintain valid guardianships and health care proxies for two residents. One resident's guardianship for anti-psychotic medication was not reviewed as required, while another resident's health care proxy was unreachable, and no new representative was established. Both residents had moderate cognitive impairment, and the facility did not pursue necessary guardianship actions.
A resident with a history of stroke and paralysis was found confined to bed in a dark room without a means to get out, indicating involuntary seclusion. Despite expressing a desire to get out of bed, the resident was not provided with a chair or assistance, and staff were unaware of the resident's mobility needs. The care plan lacked documentation of the resident's preferences, and physical therapy was insufficient, highlighting a failure in communication and coordination among staff.
A resident with a history of stroke and moderate cognitive impairment was found with a pillow under the fitted sheet of their bed, restricting movement and acting as a restraint. The pillow was placed to prevent the resident from getting out of bed due to high fall risk, but no restraint assessment was documented. The DON confirmed this was against facility policy.
A resident with peripheral vascular disease and obesity did not receive daily wound dressing changes as ordered by the physician for five days. Despite records indicating compliance, observations and interviews revealed the dressing was unchanged, and there was no documentation of refusal. The DON confirmed the need for adherence to the physician's order and proper documentation.
Two residents in an LTC facility were not provided with necessary meal assistance, leading to deficiencies in care. One resident with moderate cognitive impairment was left unsupervised during meals, contrary to their care plan. Another resident with dysphagia and a history of stroke was observed eating in an unsafe position without supervision, despite requiring assistance. Staff interviews confirmed the need for supervision, which was not provided.
The facility failed to provide an adequate activity program for three residents, leading to a deficiency in meeting their needs. A resident with moderate cognitive impairment was observed spending entire shifts in bed without any activity materials or entertainment. Another resident with Alzheimer's expressed boredom and a desire for activities but was not observed participating in any. A third resident with severe cognitive impairment was also not engaged in activities, despite preferences for music and religious activities. The Activities Director cited being understaffed as a reason for the lack of engagement.
A resident with severe cognitive impairment and a history of Wernicke's encephalopathy and other conditions expressed a desire for vision services. Despite recommendations for cataract surgery and a referral to ophthalmology, the facility failed to make an appointment or contact the resident's health care agent for approval, as revealed in staff interviews and record reviews.
A resident with COPD did not receive oxygen as per physician's orders in a facility. Despite having a continuous oxygen order, the resident was observed multiple times without oxygen, and no portable concentrator was present. The facility's records showed no recent oxygen saturation assessments, and staff interviews confirmed the oversight.
A resident with end-stage renal disease did not have a care plan for monitoring their AV fistula, and the facility lacked an emergency kit at the bedside as required. Staff were unaware of the resident's dialysis access method, and observations confirmed the absence of the emergency kit, despite physician's orders and care plan requirements.
A facility failed to implement a pharmacist's recommendation for a resident's PRN Ativan order, which should have been limited to 14 days. Despite the physician agreeing to the recommendation, the nursing staff did not update the orders, leading to a deficiency. The resident had severe cognitive impairment and multiple diagnoses, including end-stage renal disease.
A facility failed to limit a PRN Ativan order to 14 days for a resident with severe cognitive impairment and multiple diagnoses, including anxiety. The physician's order lacked a stop date, and the medication was administered without the required limitation. The DON acknowledged the expectation for a 14-day stop date and re-evaluation.
The facility failed to maintain accurate medical records for three residents, leading to discrepancies in care documentation. A resident with paralysis was incorrectly documented as being transferred out of bed, while another resident's wound dressing changes were falsely recorded as completed. Additionally, a third resident's skin assessments contained inaccuracies, including a non-existent stage IV pressure ulcer. These issues were confirmed by staff and the DON.
Lack of Privacy in Resident Phone Calls
Penalty
Summary
The facility failed to ensure that residents on all three units had access to a telephone for private conversations. During a Resident Group Interview, residents reported that they could only use the phone at the nurses' station, where their conversations could be overheard by others. Previously, the facility had a portable phone that allowed residents to make calls in private, but it was no longer available. This issue was observed by surveyors when a resident was seen making a call at the nurses' station, with staff and other residents present who could overhear the conversation. Interviews with staff, including a CNA and the Activity Director, confirmed that residents were required to use the phone at the nurses' station due to the absence of the previously available cordless phone. The Director of Nursing mentioned that there was an office available for private calls but was unaware that staff were not assisting residents to use this space for private conversations. This lack of privacy in communication methods was consistent across all units, as reported by both residents and staff.
Deficiencies in Care Plan Development for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, leading to deficiencies in addressing their specific needs. Resident #47, who was admitted with diagnoses including legal blindness, anxiety, dementia, and depression, did not have care plans for vision, communication, or fall risk, despite these areas being triggered in the Care Area Assessment (CAA) of the Minimum Data Set (MDS). The resident was observed to have severe cognitive impairment and required assistance for all tasks, yet the care plans did not reflect these needs. The MDS nurse confirmed that care plans should have been developed for the triggered areas, but they were not. Resident #53, admitted with a pacemaker and other medical conditions, did not have a care plan addressing the pacemaker, despite the presence of a Medtronic device used for monitoring. The facility's policy requires documentation of specific details about the pacemaker and monitoring procedures, but these were absent from the resident's medical record. The Director of Nurses and a nurse acknowledged the lack of a care plan and orders for pacemaker checks, despite the resident's awareness of having a pacemaker and the device being observed in use.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that medications and biologicals were stored securely and labeled according to professional standards. On multiple occasions, medication carts on two of the four units were observed to be left unlocked and unattended. Specifically, on the second floor, medication carts were found unlocked and out of the line of vision of the nursing staff. Nurses acknowledged that medication carts should be locked when unattended, yet this practice was not consistently followed. The Director of Nursing confirmed that medication carts should always be locked when not in use. Additionally, the facility did not adhere to proper labeling and storage guidelines for medications. During a medication administration pass, an unlabeled and undated inhaler was found in a vital sign machine in the hallway, and it was unclear to whom it belonged. The inhaler was left on top of a medication cart, unattended and out of the nurse's line of vision. Furthermore, several inhalers and an insulin pen in the A Unit Medication Cart were found opened and undated, contrary to the facility's policy and manufacturer's guidelines. The Director of Nursing stated that inhalers should be labeled with the resident's name, the date opened, and stored in the manufacturer's box, which was not done in these instances.
Food Storage and Preparation Deficiencies
Penalty
Summary
The facility failed to store and prepare food in accordance with professional standards for food service safety. During an initial tour of the kitchen, several food items were found improperly stored, including an opened and undated container of cool whip, a container of coleslaw with a discard date that had passed, a container of tuna salad with an expired discard date, undated cold cuts, an undated prepared salad, and undated slices of pizza wrapped in tin foil. These observations indicate a lack of adherence to the facility's policy on food and supply storage, which requires discarding food that exceeds its use-by date or is incorrectly stored. Additionally, during an observation in the basement food storage area, a strong musty odor was detected, and mold was observed along with standing water in a chest refrigerator containing multiple cases of milk. Two dented cans were also found in the basement storage area. The Regional Food Service Director acknowledged that staff should notify management if the refrigerator needs maintenance and that dented cans should be set aside for return to the vendor. However, two significantly dented cans of chili con carne were found stored on the can rack in the kitchen, indicating a failure to follow the procedure for handling damaged goods.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent for the administration of psychotropic medications for two residents, leading to a deficiency in compliance with their own policy. Resident #47, who was admitted with severe cognitive impairment and dependent on staff for all care, was prescribed Mirtazapine for increased appetite. However, the medical record did not contain a signed consent form for this medication. The Director of Nursing confirmed that consent should have been obtained prior to administration. Similarly, Resident #76, who was also severely cognitively impaired and admitted with conditions including end-stage renal disease and anxiety, was prescribed Ativan. The resident's medical record lacked a signed consent form for the administration of Ativan, despite the medication being administered as ordered. Both the Director of Nursing and a nurse acknowledged that consent should have been obtained before administering psychotropic medications.
Failure to Maintain Valid Guardianships and Health Care Proxies
Penalty
Summary
The facility failed to ensure that advanced directives related to guardianships were valid and in place for two residents. For one resident, the facility did not review and renew an established guardianship for authorizing treatment with anti-psychotic medication as required by a court order. The resident, who was admitted with diagnoses including schizoaffective disorder and bipolar disorder, had moderate cognitive impairment. The guardianship was supposed to be reviewed by a specific date, but the clinical record did not show that this was done, and the social worker confirmed the oversight during an interview. For another resident, the facility did not establish a new health care agent or representative when the current health care proxy became unreachable. This resident, admitted with conditions such as Wernicke's encephalopathy and chronic obstructive pulmonary disease, also had moderate cognitive impairment. Attempts to contact the health care agent were unsuccessful, and a certified letter was sent without further follow-up. The Director of Nursing acknowledged the difficulty in reaching the health care agent and the lack of other family or friends involved, indicating that guardianship should have been pursued but was not prior to the surveyor's inquiry.
Failure to Prevent Involuntary Seclusion of a Resident
Penalty
Summary
The facility failed to ensure that a resident was free from involuntary seclusion, as evidenced by the case of Resident #31. The resident, who was admitted with a history of stroke and paralysis, was observed lying in bed in a dark room with a closed door on multiple occasions. A pillow was placed under the fitted sheet on the left side of the mattress, preventing the resident from moving his/her legs to that side of the bed. The resident expressed a desire to get out of bed but was unable to do so due to the lack of a chair in the room and the inability to move the pillow. The resident's care plan indicated a need for assistance with transfers and locomotion, but there was no documentation of the resident's preference to stay in bed or refusal to get out of bed. Physical therapy notes showed that the resident only received two therapy sessions, and there was no indication of attempts to assist the resident with sitting or transferring out of bed. Interviews with staff revealed a lack of awareness and action regarding the resident's mobility needs, with some staff believing it was safer for the resident to remain in bed due to fall risks. The Director of Nursing and other staff members acknowledged that residents should be asked daily if they wish to get out of bed and should be provided with a means to do so. However, there was a clear lack of communication and coordination between nursing and therapy staff, resulting in the resident being effectively confined to bed without proper assessment or provision of mobility aids.
Improper Use of Restraint with Pillow Under Fitted Sheet
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints, as evidenced by the use of a pillow placed under a fitted sheet on the resident's bed. This setup restricted the resident's ability to move his or her legs to one side of the bed, effectively acting as a restraint. The resident, who had a history of stroke with paralysis on the right side and required maximal assistance for bed mobility, was unable to remove the pillow due to moderate cognitive impairment and physical limitations. The resident expressed unawareness of the pillow's purpose and an inability to remove it. Observations revealed that the pillow was placed under the fitted sheet to prevent the resident from getting out of bed, as confirmed by a CNA who stated that the resident was a high fall risk. The facility's policy on restraints indicated that restraints should only be used for medical symptoms and not for staff convenience or fall prevention. However, the resident's medical record did not show any assessment for the use of restraints, and the Director of Nursing acknowledged that the pillow constituted a restraint, which was against the facility's policy.
Failure to Follow Physician's Order for Wound Dressing
Penalty
Summary
The facility failed to adhere to professional standards of quality care for a resident with peripheral vascular disease and obesity, who was admitted in December 2022. The resident had a physician's order for a daily wound dressing on an open lesion on the right foot, which was not followed for five consecutive days. Despite the treatment administration record indicating that the dressing was changed daily, observations and interviews revealed that the dressing had not been changed since 3/27/24, contradicting the documented records. Interviews with the nursing staff and the wound physician confirmed that the dressing was not changed as ordered, and there was no documentation of the resident refusing the dressing changes. The Director of Nursing acknowledged that the dressing should have been changed according to the physician's order and that any refusal or failure to change the dressing should have been documented properly. The lack of communication and documentation regarding the dressing changes led to the deficiency in care for the resident.
Failure to Provide Meal Assistance for Residents
Penalty
Summary
The facility failed to provide necessary assistance with meals for two residents, leading to deficiencies in care. Resident #379, who has moderate cognitive impairment and requires supervision during meals, was observed eating alone in their room on multiple occasions. Despite the care plan indicating the need for supervision and assistance as needed, the resident was left unsupervised, with food observed on their chest during one instance. Interviews with staff confirmed that the resident requires supervision while eating, which was not provided as per the care plan. Similarly, Resident #30, who is cognitively intact but has a history of stroke, dysphagia, and paraplegia, was observed eating in an unsafe position without supervision. The resident's care plan indicated a need for varying levels of assistance, including supervision due to swallowing difficulties. Despite this, the resident was left alone during meals, with staff acknowledging the need for supervision due to frequent coughing while eating. The Director of Nursing and CNAs confirmed that supervision was expected but not provided, leading to a failure in adhering to the care plan.
Failure to Provide Adequate Activity Program for Residents
Penalty
Summary
The facility failed to provide an adequate activity program for three residents, leading to a deficiency in meeting their physical, mental, and psychosocial needs. Resident #31, who was admitted with a stroke and moderate cognitive impairment, was observed spending entire shifts in bed without any activity materials or entertainment like television or music. Despite having preferences for music, reading, and spiritual activities, there was no activity care plan developed for this resident, and no documentation of participation in activities since admission. Resident #38, diagnosed with Alzheimer's Disease and depression, expressed boredom and a desire for activities such as card games and music. However, the resident was not observed participating in any activities during the survey period, and there was no radio in the room despite the resident's preference for music. The activity care plan for this resident was outdated, and there was no documentation of activity participation since March 2024. Resident #47, with severe cognitive impairment, was also not observed participating in activities during the survey period. The resident's activity assessment indicated a preference for music and religious activities, but there was no radio available, and the staff reportedly hid the resident's radio. The activity care plan included interventions for one-on-one contacts and structured programs, but the resident had only participated in activities twice since March 2024. The Activities Director cited being understaffed and pulled away for other duties as reasons for the lack of activity engagement.
Failure to Follow Up on Ophthalmology Referral for Resident
Penalty
Summary
The facility failed to follow up on a referral for ophthalmology services for a resident with severe cognitive impairment. The resident, admitted in February 2016, has diagnoses including Wernicke's encephalopathy, chronic obstructive pulmonary disease, and alcohol dependence. The resident expressed a desire to see an eye doctor and obtain glasses. Optometry notes from November 2023 and March 2024 indicated the resident was a glaucoma suspect and had cataracts, with a recommendation for cataract surgery and a referral to ophthalmology. However, the clinical record did not show that a referral was made or an appointment scheduled, nor was there evidence that the recommendation was reviewed with the resident's activated health care agent. Interviews with facility staff revealed that the eye appointment was not made, and the facility had been unable to contact the resident's health care agent for many months. A certified letter was sent to the health care agent in January 2024 regarding vaccination consent, but there was no documentation of attempts to reach the agent about vision services. The Director of Nursing acknowledged the need for approval from the health care proxy to proceed with the referral, highlighting a communication gap in addressing the resident's vision care needs.
Failure to Administer Oxygen as Ordered
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for a resident diagnosed with chronic obstructive pulmonary disease (COPD). The resident, who was cognitively intact, had a physician's order for continuous oxygen administration to maintain oxygen saturation levels above 90%. However, observations by the surveyor on multiple occasions revealed that the resident was not receiving oxygen, and there was no portable oxygen concentrator present in the room. The facility's records indicated that oxygen was supposedly administered, but there was no evidence of oxygen saturation assessments being conducted since the last recorded measurement on March 27, 2024. Interviews with nursing staff and the Director of Nursing confirmed the oversight. Nurse #7 admitted to not assessing the resident's oxygen saturation during her shift and acknowledged the continuous nature of the oxygen order. The Director of Nursing also confirmed that the oxygen order was continuous and expected that oxygen saturation should be assessed every shift. Despite these expectations, the facility's documentation and observations indicated a failure to adhere to the physician's orders and the facility's own policy on oxygen administration.
Failure to Provide Appropriate Dialysis Care and Emergency Preparedness
Penalty
Summary
The facility failed to provide appropriate dialysis care for a resident with end-stage renal disease who required hemodialysis. The resident, who was cognitively intact, had an AV fistula in the left arm for dialysis access, but the facility did not have a care plan in place for monitoring this site. The resident's active physician's orders did not include instructions to monitor the AV fistula, and the nursing progress notes from February to April did not document any monitoring of the site. Interviews with nursing staff revealed a lack of awareness regarding the resident's dialysis access method, with conflicting information about whether the resident received dialysis through a chest catheter or the AV fistula. Additionally, the facility failed to maintain an emergency kit at the resident's bedside, as required by the physician's orders and the dialysis care plan. Observations on multiple occasions confirmed the absence of the emergency kit, which was supposed to be available in case of bleeding from the dialysis access site. Interviews with nursing staff and the Director of Nursing confirmed that the emergency kit was missing, despite the expectation that it should be present in the resident's room.
Failure to Implement Pharmacist's Recommendations for PRN Medication
Penalty
Summary
The facility failed to act upon irregularities identified in the pharmacist's Medication Regimen Review (MRR) for a resident with end-stage renal disease, anxiety, and a left leg above-the-knee amputation. The resident was assessed as severely cognitively impaired and had a physician's order for Ativan, a psychotropic medication, to be administered as needed. The pharmacist recommended that the PRN order for Ativan should be limited to 14 days, and if extended, the prescribing practitioner must document the rationale and specify a stop date. The physician agreed with this recommendation, but the nursing staff did not follow through with updating the physician's orders to reflect the pharmacist's recommendations. The deficiency was further highlighted by a practitioner progress note indicating that the Ativan order should have a 14-day stop date, which was not implemented. During an interview, the Director of Nursing expressed that she expected the recommendations from the pharmacist's MRR to be followed. This oversight in updating the physician's orders after the pharmacist's recommendations and the practitioner's agreement led to the deficiency identified by the surveyors.
Failure to Limit PRN Psychotropic Medication to 14 Days
Penalty
Summary
The facility failed to ensure that PRN (as needed) ordered psychotropic drugs were limited to 14 days for a resident. Specifically, the facility did not include a 14-day stop date for a PRN Ativan order for a resident who was admitted with diagnoses including end-stage renal disease, anxiety, and a left leg above-the-knee amputation. The resident was assessed as being severely cognitively impaired and unable to participate in a mental status exam. The physician's order for Ativan, dated March 19, 2024, prescribed 0.5 milligrams every four hours as needed, but did not specify a stop date. The medication was administered on March 22, 2024, without the required stop date. During an interview, the Director of Nursing stated that she would expect a PRN order for Ativan to have a 14-day stop date and then be re-evaluated.
Inaccurate Medical Record Documentation for Residents
Penalty
Summary
The facility failed to maintain accurate medical records for three residents, leading to deficiencies in care documentation. For one resident with a history of stroke and paralysis, the facility inaccurately documented that the resident had been transferred out of bed, despite observations and staff interviews indicating the resident remained in bed for safety reasons. This discrepancy was confirmed by the Director of Nursing, who acknowledged that the CNAs should not have documented an activity that did not occur. Another resident, diagnosed with peripheral vascular disease and obesity, experienced a failure in wound care documentation. The resident's physician ordered daily dressing changes for a foot wound, but the dressing was not changed for five consecutive days, despite being documented as completed. This was confirmed by a nurse and the Director of Nursing, who both stated that the dressing changes should have been performed as ordered and accurately documented. The third resident, with end-stage renal disease and a left leg amputation, had inconsistencies in skin assessment documentation. The resident's records showed conflicting information about the presence and severity of pressure ulcers, with one report inaccurately indicating a stage IV pressure ulcer that was not present. The Director of Nursing confirmed the inaccuracies in the skin evaluations, highlighting a failure to document the resident's skin condition accurately.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 892 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Melrose
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Elmhurst Healthcare (the) | 0.6 mi | — | 0 | 0 |
| Life Care Center Of Stoneham | 0.9 mi | — | 15 | 0 |
| Greenwood Nursing & Rehabilitation Center | 1.5 mi | — | 0 | 0 |
| Regalcare At Glen Ridge | 1.9 mi | — | 35 | 0 |
| Dexter House Healthcare | 2.6 mi | — | 16 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Melrose Healthcare.
100% money-back within 48 hours.
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.