Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before 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 Rehabilitation & Nursing Center At Everett (the) during CMS and state inspections, most recent first.
The facility's infection prevention and control program was found deficient due to inadequate tracking, monitoring, and analysis of infections. The Infection Preventionist did not track clinical signs or trends, relying on antibiotic prescriptions as infection indicators. The Director of Nurses expected adherence to infection control guidelines, but these were not followed.
The facility failed to implement an effective Antibiotic Stewardship Program, as the Infection Preventionist (IP) did not track clinical signs, symptoms, or infection trends, and did not obtain lab reports on antibiotic use. The Director of Nurses (DON) expected proper documentation and implementation of the program, including tracking and evaluating antibiotic use and infections, but the IP's actions did not meet these expectations.
A facility failed to obtain informed consents for psychotropic medications for a resident with severe cognitive impairment. The resident, with diagnoses including foot drop and peripheral vascular disease, was prescribed Mirtazapine and Fluoxetine for depression. Despite receiving these medications daily, the Unit Manager and DON confirmed the absence of required consents, which should have been obtained on admission and annually.
The facility failed to notify the Physician or NP of recommendations made by a Wound Physician and a Psychiatric NP for two residents. One resident with severe cognitive impairment and unhealed pressure ulcers did not receive updated wound care treatments, while another resident with bipolar disorder did not have their medication dosage adjusted as recommended. These lapses occurred due to a lack of communication from the nursing staff to the attending providers.
The facility failed to accurately code MDS assessments for two residents. One resident's eating abilities were incorrectly documented as 'not applicable,' despite requiring supervision due to aspiration risks. Another resident was discharged to the hospital without a completed discharge MDS assessment, which was acknowledged as an oversight by the MDS nurse.
A nurse failed to follow professional standards by leaving a cup of MiraLAX with a resident without ensuring its consumption, contrary to facility policy. The nurse acknowledged the mistake, and the DON confirmed that medications should not be left unattended.
A resident with severe cognitive impairment and esophageal issues was not adequately supervised during meals, despite care plan requirements for supervision and cueing. Observations showed staff leaving the resident alone during meals, contrary to the care plan. Interviews with staff confirmed the discrepancy between required and provided care.
A resident with severe cognitive impairment was found with a bruise on the right forearm, which was not documented or reported by staff. Despite the facility's policy requiring prompt reporting of skin changes, the bruise was only noted during a survey, and previous assessments inaccurately indicated intact skin.
A resident at high risk for pressure ulcers did not have a care plan developed, and a physician's order for Prevalon boots was not implemented. Despite assessments indicating high risk, the facility failed to create a person-centered care plan. Observations showed the resident was not wearing the prescribed boots, and staff interviews confirmed the lack of documentation and awareness of the order.
A resident receiving oxygen therapy in an LTC facility was found to have an oxygen concentrator without an air filter during two separate observations. The facility's policy requires weekly maintenance of the filter, which was not adhered to, as confirmed by staff interviews. The resident, admitted with respiratory conditions, was cognitively intact and had physician orders for weekly filter changes.
A nurse in an LTC facility made two medication errors, resulting in a five percent error rate. A resident received incorrect dosages of Vitamin D3 and calcium due to the nurse substituting medications without a physician's order. The DON confirmed that such substitutions should not occur without proper authorization.
The facility failed to secure medication storage areas properly, with an unlocked and unsupervised medication cart and medication room observed on separate units. Staff interviews confirmed that these areas should be locked unless attended by a nurse.
A resident with dementia and other health issues was not provided dental services upon admission, despite losing dentures prior to arrival and requesting new ones. The facility's policy required dental services to be offered and referrals made within three days if dentures were lost, but the resident was not seen by a dentist, and no consent or declination form was on file. Interviews with staff confirmed the oversight.
Inadequate Infection Control Program
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the lack of systematic tracking, monitoring, and analysis of infections. The facility's policy outlined a comprehensive surveillance protocol, including data collection from various sources such as clinical records and microbiology reports, and the calculation of infection rates. However, the facility's infection control program did not adhere to these guidelines. The QAPI Antibiotics form for May indicated a diagnosis of C. diff, but lacked details on infection control measures. Additionally, the infection control program's line listings did not show evidence of monitoring or analyzing infections. During an interview, the Infection Preventionist (IP) admitted to not tracking clinical signs, symptoms, or trends of infections, relying instead on the prescription of antibiotics as an indicator of infections. The IP did not obtain lab reports on antibiotic use or calculate monthly infection control rates, and was unable to provide documentation of infection control surveillance. The Director of Nurses (DON) expressed expectations for the facility to follow infection control guidelines, track and evaluate infections, and document surveillance of communicable diseases, but these practices were not being followed.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective Antibiotic Stewardship Program as required by the Centers for Disease Control and Prevention (CDC) guidelines. The facility's policy, revised in January 2024, outlined the responsibilities of the Infection Preventionist (IP) in tracking antibiotic use, monitoring adherence to prescribing standards, and reviewing antibiotic resistance patterns. However, the facility's Antibiotic Use Monthly Tracking Forms lacked the necessary detailed information to monitor appropriate antibiotic use. During an interview, the IP admitted to not tracking clinical signs, symptoms, or infection trends, and not obtaining lab reports on antibiotic use, relying instead on the number of antibiotics prescribed as an indicator of infections. The Director of Nurses (DON) expressed expectations for the facility to document and implement the antibiotic stewardship program, including tracking, evaluating, and reporting antibiotic use and infections. The DON expected cultures and labs to be reviewed, and evaluations to be discussed regarding the continuation or cessation of antibiotics. However, the IP's failure to track and evaluate infections and antibiotic use, as well as the lack of detailed tracking forms, contributed to the deficiency in the facility's antibiotic stewardship efforts.
Failure to Obtain Informed Consents for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consents for psychotropic medications for a resident with severe cognitive impairment. The resident, admitted in July 2024, had diagnoses including foot drop, chronic non-pressure wounds, and peripheral vascular disease. The resident's Minimum Data Set indicated a severe cognitive impairment with a score of 3 out of 15 on the Brief Interview for Mental Status. The resident was prescribed Mirtazapine and Fluoxetine for depression, as per physician orders dated 7/19/24 and 7/23/24, respectively. The August 2024 Medication Administration Record confirmed the resident received these medications daily. However, during an interview, the Unit Manager acknowledged the absence of psychotropic consents for these medications, which was confirmed by the Director of Nurses, who stated that consents should be obtained on admission and annually.
Failure to Communicate Physician Recommendations
Penalty
Summary
The facility failed to notify the Physician or Nurse Practitioner of recommendations made by a Wound Physician for two residents. Resident #141, who was admitted with diagnoses including foot drop, chronic non-pressure wounds, and peripheral vascular disease, had severe cognitive impairment and unhealed pressure ulcers. The Wound Physician recommended specific dressing treatments for the resident's wounds on two occasions, but these recommendations were not communicated to the Physician or Nurse Practitioner. As a result, the resident continued to receive the previous treatment plan, which did not align with the Wound Physician's updated recommendations. Similarly, for Resident #53, who was readmitted with diagnoses including bipolar disorder, dysphagia, and sleep apnea, the facility failed to communicate new medication recommendations made by a Psychiatric Nurse Practitioner. Despite the resident expressing feelings of increased depression, the recommendation to increase the dosage of Lamictal was not relayed to the attending Nurse Practitioner. Consequently, the resident continued to receive the previous dosage, as the nursing staff did not update the Nurse Practitioner about the new recommendations.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in their care documentation. For one resident, the MDS did not accurately reflect their functional abilities for self-care, specifically eating. Despite being observed eating with supervision due to aspiration risks, the MDS inaccurately documented their eating abilities as 'not applicable.' Interviews with staff revealed a lack of awareness regarding the incorrect documentation, indicating a failure in accurately assessing and recording the resident's needs. Another resident was discharged to the hospital and did not return to the facility, yet the facility failed to complete a discharge MDS assessment. The resident's medical record only contained a quarterly MDS assessment, and the discharge assessment was overlooked. The MDS nurse acknowledged the oversight during an interview, admitting that the discharge assessment was forgotten. This oversight highlights a lapse in the facility's process for ensuring complete and accurate documentation of resident discharges.
Failure to Ensure Medications Are Not Left Unattended
Penalty
Summary
The facility failed to adhere to professional standards of practice by not ensuring that nursing staff did not leave medications unattended with a resident. During a medication pass, a nurse prepared and administered medication, including MiraLAX mixed in water, to a resident. However, the nurse left the cup of MiraLAX with the resident and did not wait to confirm that the resident consumed the entire amount. This action was contrary to the facility's policy, which mandates that medications should not be left unattended and that nurses must observe residents to ensure medication consumption. Interviews with the nurse involved and the Director of Nursing confirmed the deviation from the facility's policy. The nurse acknowledged that she should have waited until the resident took all the medications, and the Director of Nursing reiterated that nurses are required to stay with residents until all medications are taken and should not leave medications with residents.
Failure to Supervise Resident During Meals
Penalty
Summary
The facility failed to provide adequate supervision during meals for a resident with severe cognitive impairment and a history of esophageal issues. The resident, who was admitted with diagnoses including dementia, bipolar disorder, and Barrett's esophagus, was observed on multiple occasions eating without the required supervision. The facility's policy and the resident's care plan clearly indicated the need for supervision and cueing during meals due to cognitive impairment and the risk of aspiration. Observations by the surveyor revealed that staff consistently left the resident alone during meal times, despite the care plan's directive for close supervision. On several occasions, staff set up the meal tray and exited the room, leaving the resident to eat without any oversight. This lack of supervision was contrary to the care plan, which specified that the resident required supervision to monitor for aspiration and to provide verbal cueing. Interviews with facility staff, including a CNA, a nurse, and the Director of Rehabilitation, confirmed the discrepancy between the care plan requirements and the actual care provided. The CNA believed the resident only needed setup assistance, while the nurse and the Director of Rehabilitation acknowledged the need for supervision. The Director of Rehabilitation agreed with the surveyor's observations that the resident was not receiving the necessary supervision during meals, which was a clear deficiency in the care provided by the facility.
Failure to Identify and Document Skin Injury
Penalty
Summary
The facility failed to implement standards of quality care for a resident, resulting in the failure to identify a skin injury on the resident's right forearm. The resident, who has severe cognitive impairment due to dementia, was observed with a round discoloration with yellowed edges on the right forearm, consistent with a bruise. Despite the presence of this bruise, the facility's progress notes from 7/30/24 to 8/26/24 did not document any skin discoloration, and a weekly skin assessment inaccurately indicated the resident's skin as intact. Interviews with facility staff revealed that the Certified Nursing Assistant (CNA) responsible for the resident's care did not report the skin change, and the nurse confirmed that the bruise appeared to be a few days old. The Assistant Director of Nursing (ADON) acknowledged that the bruise was not reported until it was brought to her attention by the nurse. The facility's policy requires that any skin changes or injuries be promptly reported and documented, which was not adhered to in this case.
Failure to Implement Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to develop a care plan for a resident at high risk for developing pressure ulcers and did not implement a physician's order for heel protection. The resident, who was admitted with conditions including chronic obstructive pulmonary disease, type 2 diabetes, and a partial traumatic amputation, was assessed multiple times as being at high risk for pressure ulcers. Despite this, the facility did not create a person-centered care plan with individualized goals and interventions to address this risk. Interviews with staff confirmed that a care plan should have been developed for the resident's risk of pressure ulcers. Additionally, the facility did not follow a physician's order for the resident to wear Prevalon boots while in bed. Observations and interviews revealed that the resident was not wearing the boots, and they were not present in the room. Staff interviews indicated a lack of awareness and documentation regarding the use of the boots, which were intended as a preventative measure for the resident's heel condition. The Assistant Director of Nursing acknowledged the oversight, noting that the boots were meant to be documented on the Treatment Administration Record.
Oxygen Concentrator Filter Missing for Resident
Penalty
Summary
The facility failed to provide respiratory care services in accordance with professional standards of practice for a resident who required oxygen therapy. The deficiency was identified when the oxygen concentrator used by the resident did not have an air filter in place during observations on two separate occasions. The facility's policy on oxygen therapy, dated January 3, 2024, mandates that filters should be washed weekly and dried thoroughly before being reinstalled. However, the absence of the air filter was noted during observations on August 26 and August 27, 2024. The resident involved was admitted to the facility in July 2024 with diagnoses including sepsis, pneumonia, acute respiratory failure with hypoxia, and chronic obstructive pulmonary disease. The resident was cognitively intact, as indicated by a perfect score on the Brief Interview for Mental Status. The physician's orders required the oxygen tubing and filter to be changed weekly, yet the air filter was missing during the surveyor's observations. Interviews with the Unit Manager and the Director of Nurses confirmed that the air filter should have been in place to prevent infection risks.
Medication Error Rate Exceeds Acceptable Limit
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by observations and interviews conducted during a survey. One nurse was observed making two medication errors out of 40 opportunities, resulting in a five percent error rate. These errors affected one resident, who received incorrect dosages of Vitamin D3 and calcium. Specifically, the resident was administered 5000 units of Vitamin D3 and calcium with 400 units of vitamin D, instead of the prescribed 1000 units of cholecalciferol and 600 milligrams of calcium carbonate. During an interview, the nurse admitted to substituting medications with what was available on hand, leading to the resident receiving an excess of 4400 units of vitamin D. The Director of Nursing confirmed that nurses should not substitute medications without a physician's order and that the correct procedure would be to contact the physician for an appropriate substitute if the prescribed medication is unavailable.
Medication Storage Security Lapses
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored securely in accordance with accepted professional standards of practice. Specifically, the medication cart on one of the units was observed to be unlocked and unsupervised at two different times on the same day. During interviews, both the Unit Manager and the Director of Nurses confirmed that the medication cart should be locked if a nurse is not present at it. Additionally, the medication room on another unit was found to be unlocked and unsupervised on two consecutive days. No staff were present in the medication room or at the nurses' station during these times. Interviews with a nurse and the Unit Manager confirmed that the medication room should always be locked unless a nurse is present in the room. The Director of Nurses also stated that she expects the medication rooms to be locked unless a nurse is present.
Failure to Provide Dental Services for Resident
Penalty
Summary
The facility failed to provide dental services for a resident who was admitted with multiple diagnoses, including dementia, dysphagia, and diabetes mellitus. The resident, who had intact cognition, reported losing dentures prior to admission and had been requesting new dentures since then. Despite the facility's policy requiring dental services to be offered upon admission and referrals to be made within three days if dentures are lost, there was no record of the resident being offered dental services or having a signed consent or declination form on file. The resident had not been seen by a dentist since admission, and the clinical record lacked documentation of any oral evaluation. Interviews with the Unit Manager and the Director of Nurses confirmed that the resident should have been offered dental services upon admission and should have been seen by a dentist to replace the lost dentures. The Unit Manager acknowledged that the resident had not received an oral evaluation and was not added to the list for dental evaluation, despite physician orders and nutritional recommendations indicating the need for such services. The Director of Nurses also confirmed that the resident should have been seen by a dentist for a follow-up to obtain new dentures.
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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 Everett
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lighthouse Rehabilitation And Healthcare Center | 0.9 mi | — | 0 | 0 |
| The Massachusetts Veterans Home At Chelsea | 0.9 mi | — | 3 | 0 |
| Katzman Family Center For Living | 1.1 mi | — | 5 | 0 |
| Dexter House Healthcare | 1.6 mi | — | 16 | 0 |
| Leonard Florence Center For Living | 1.8 mi | — | 2 | 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.