Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before 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 Southeast Rehabilitation & Skilled Care Center during CMS and state inspections, most recent first.
A resident with complex medical needs was readmitted without proper medication reconciliation, resulting in missed and incorrectly administered doses of Eliquis, Buspar, and Gabapentin. Facility staff did not complete or document the required reconciliation process, leading to significant medication errors that went unaddressed until the resident reported missing medication.
Surveyors found significant sanitation and food safety deficiencies in the facility's kitchen and resident kitchenettes. Persistent odors and water leaks were observed, along with unlabeled and undated food items in the main kitchen refrigerator. Staff failed to follow proper hand hygiene and glove use during food preparation. Resident kitchenettes contained unlabeled and undated food, despite regular checks by staff.
The facility failed to maintain secure and accurate medical records, with missing physician documentation and overflowing shredding bins. A resident's physician visits were not properly documented, and secure medical record bins were full, making records accessible to unauthorized individuals. The facility had not been serviced by the shredding company due to billing issues, leading to unsecured medical records.
The facility failed to maintain essential equipment, including microwaves with rust and damage in resident kitchenettes, a malfunctioning milk refrigerator, and an inadequately serviced grease trap causing a persistent odor. The FSM and Maintenance Director acknowledged these issues, which were not addressed in a timely manner.
The facility failed to maintain kitchen plumbing, resulting in pungent odors, water puddling, and a black substance leaching from walls. Drainpipes leaked water/sewage, and the hand washing sink's malfunction led to wastewater on the floor. The dish machine's pipes were also leaking, with a container overflowing onto the floor. Despite staff awareness, a plumber was not contacted until surveyors' intervention.
The facility failed to provide a dignified dining experience, as residents were not served meals simultaneously, leading to some watching others eat. Staff were observed standing while assisting residents, contrary to policy. Additionally, basic hygiene practices were neglected, and a lack of supervision was evident during meal times.
A facility failed to obtain proper consent from a resident, who was responsible for their own care, for treatment and psychotropic medication administration. Despite the resident being cognitively intact, consent was obtained from the family without an Invocation of the Health Care Proxy. Interviews confirmed the resident did not sign the necessary paperwork, and the facility staff acknowledged the oversight.
A resident was found self-administering Mupirocin ointment without a physician's order or proper assessment. Despite being cognitively intact, the resident was not evaluated for self-administration capability, nor educated on the correct application frequency. Nursing staff were unaware of how the resident obtained the ointment, and the facility failed to follow its own protocols for self-administration of medications.
Staff at the facility failed to adhere to infection control protocols by not consistently wearing gowns and gloves during high-contact care activities for a resident on Enhanced Barrier Precautions. Despite the presence of a CDC sign indicating the need for PPE, staff were observed providing care without the required protective equipment, risking the spread of multi-drug resistant organisms.
The facility failed to implement an effective antibiotic stewardship program, as antibiotics were prescribed without necessity and not reassessed within 48-72 hours for several residents. Despite policies requiring reassessment and monitoring, these protocols were not followed, leading to potential risks of adverse drug events and antibiotic resistance. Interviews revealed systemic failures in monitoring and documentation, with no audit sheets completed to track antibiotic usage.
The facility failed to implement its vaccination policies, resulting in three residents not receiving proper education, consent, or administration of influenza and pneumococcal vaccines. The medical records lacked documentation of follow-up, education, and consent, leaving the residents not up to date with their vaccinations. Interviews with the IP and DON confirmed the facility's non-compliance with its policies.
The facility failed to educate, assess eligibility, and offer COVID-19 vaccinations to two residents per CDC guidelines and facility policy. Despite previous vaccinations, the residents were not up to date, and documentation of education, consent, and follow-up was lacking. Interviews revealed that the facility did not adhere to its immunization program, and a booster clinic did not ensure all residents received the vaccine.
Failure to Reconcile Medications on Readmission Leads to Significant Errors
Penalty
Summary
A deficiency occurred when a resident was readmitted to the facility and their medications were not accurately reconciled, resulting in multiple significant medication errors. The facility's policies required medication reconciliation upon admission and readmission, to be completed by two nurses and verified by nursing management. However, upon the resident's readmission, there was no documentation that a Medication Reconciliation Form was completed, nor evidence that nursing staff clarified or obtained new physician orders for the resident's medications. As a result, discrepancies arose between the hospital discharge summary and the facility's physician orders, particularly regarding the administration and discontinuation of Eliquis, Buspar, and Gabapentin. The resident, who had a history of subarachnoid hemorrhage, bilateral femoral DVTs, and an IVC filter, experienced missed doses and incorrect administration of critical medications. Eliquis was not administered for 48 days due to lack of order clarification, Buspar was given at an incorrect frequency before being increased, and Gabapentin was omitted entirely for 83 days. Interviews with nursing staff and management revealed a lack of awareness regarding the missed reconciliation, and the required documentation could not be located. The failure to follow established medication reconciliation procedures directly led to these significant medication errors.
Sanitation and Food Safety Deficiencies in Kitchen and Kitchenettes
Penalty
Summary
The facility failed to maintain sanitary conditions in the main kitchen, as observed by surveyors. There was a persistent musty, pungent odor in the main hallway and kitchen, with water leaking from various areas, including the handwashing sink and the two-bay sink. A black substance was noted leaking from the wall, and a mop head was used to catch water, indicating ongoing plumbing issues. The kitchen floor was wet, and debris, including trash and food remnants, was found under the prep table and in the dry storage room. Food storage practices were inadequate, with several items in the main kitchen refrigerator not labeled or dated, including desserts, chicken fingers, and grated cheese. Some items were uncovered or improperly wrapped, and a container of cottage cheese was dated well beyond the facility's policy of discarding potentially hazardous foods within three days. The FSM acknowledged that all food should be labeled and dated, and discarded after three days. The facility also failed to adhere to proper hand hygiene and glove use during food preparation. A Cook/Dietary Aide was observed using the same pair of gloves for multiple tasks, including plating food and handling various kitchen surfaces, without changing them. This practice was repeated on another occasion by a different staff member. Additionally, resident kitchenettes were found with unlabeled and undated food items, such as a half-eaten pie and a grilled cheese sandwich, despite the FSM stating that staff check these areas twice daily.
Deficiencies in Medical Record Maintenance and Security
Penalty
Summary
The facility failed to maintain medical records securely and accurately, as evidenced by the lack of documentation for physician visits and improper handling of medical record disposal. Specifically, the facility did not have documentation of physician visits for a resident admitted in January 2021. The medical records showed that all visits since August 2023 were conducted by Nurse Practitioners, and there was a delay in obtaining the physician's progress notes. The Director of Nurses confirmed that the facility only had Nurse Practitioner notes and was in the process of obtaining the missing physician notes. The Medical Record Staff indicated that there was no system in place to ensure all physician progress notes were received, leading to gaps in the resident's medical records. Additionally, the facility failed to maintain secure medical record shredding bins on the resident units and by staff offices. Observations revealed that the secure medical record trash receptacles were full-to-capacity, with resident medical records easily accessible to unauthorized individuals. The Corporate Nurse acknowledged the lack of a policy for securely discarding resident medical records and noted that a cardboard box was being used for overflow, which was not an acceptable practice. The facility had not been serviced by the consultant shredding company since February 2024 due to billing issues, contributing to the overflow problem. Interviews with facility staff, including the Administrator and Front Desk Receptionist, revealed a lack of awareness and communication regarding the billing issues with the shredding company. The facility was a high-volume site scheduled for bi-weekly shredding services, but the service had been interrupted, leading to the accumulation of unsecured medical records. This situation posed a risk to the confidentiality and security of resident information, as the disposed records were accessible to residents, visitors, and staff.
Facility Fails to Maintain Safe Equipment and Sanitation Standards
Penalty
Summary
The facility failed to maintain essential equipment in safe working order, as observed by surveyors. Three out of four microwaves located in the resident kitchenettes on the 200, 300, and 400 units were found to have significant rust and damage. The microwave on the 300 Unit had a large rusted area and flaking rust on the inside ceiling. The microwave on the 200 Unit also had flaking rust on the ceiling. The microwave on the 400 Unit had a large rusted area on the rear wall, rusted holes in the ceiling, and a broken front door handle and leg. The Food Service Manager (FSM) acknowledged the need for replacement microwaves, which had not been ordered by the Maintenance Director. Additionally, the milk refrigerator unit in the dry storage room was not maintaining the required temperature, with internal thermometers reading 48 degrees Fahrenheit and a milk carton at 49 degrees Fahrenheit. The FSM confirmed the unit was not functioning properly. Furthermore, a persistent musty, pungent odor was detected in the main hallway near the kitchen, attributed to an inadequately serviced grease trap. The Maintenance Director admitted that the grease trap had not been fully pumped since August 2023 due to financial issues, despite a recommendation for additional servicing.
Plumbing Issues in Kitchen Lead to Sanitation Concerns
Penalty
Summary
The facility failed to maintain the plumbing in the main kitchen, leading to a buildup of pungent odors, water puddling on the kitchen floor, and a black substance leaching from the wall between the dish machine and the prep sink. The drainpipes within the wall were not maintained, resulting in leakage of water or sewage into the main kitchen, a buildup of a black substance oozing from the door jamb, and a foul odor permeating the main hallway. The issue was reported by dietary staff and observed by surveyors, but no corrective action was taken by the maintenance director or the previous food service manager. Additionally, the facility did not maintain the drain servicing the hand washing sink and the overflow valve to the ice machine, which resulted in water draining directly onto the kitchen floor. Despite the malfunction, the hand washing sink remained in service, contributing to the wastewater on the kitchen floor. The issue was known to the food service manager and the maintenance director, but a plumber was not contacted until the surveyors' visit. The water pipes for the dish machine were also not maintained, with a red plastic container placed under the dishwasher to catch leaking water. This container was observed to be overflowing onto the floor. The consultant plumber, contacted only after the surveyors' visit, confirmed that the pipes under the dishwasher and the prep sink were rotted and leaking, indicating a sanitation issue with grease from the pipes seeping onto the kitchen floor.
Lack of Dignified Dining Experience for Residents
Penalty
Summary
The facility failed to ensure a dignified dining experience for residents in one of its dining rooms, as observed by surveyors. During multiple dining observations, it was noted that residents seated at the same tables were not served meals simultaneously, resulting in some residents having to watch others eat or be fed by staff. This delay in meal service was observed on several occasions, with some residents waiting up to 26 minutes for their meals. Additionally, staff members were observed standing while assisting residents with eating, which is against the facility's policy for providing a pleasant dining experience. The surveyor also noted that staff did not wash residents' hands or wipe down tables prior to meal delivery, which is a basic hygiene practice expected in meal service. On one occasion, a resident reached out and took food from another resident's tray, indicating a lack of supervision and coordination during meal times. Furthermore, a staff member was observed feeding a resident in a recliner chair while standing, holding the meal plate in one hand, which does not align with the facility's standards for a dignified dining experience. Interviews with staff, including a Unit Manager and a Nurse, revealed an acknowledgment of the issues observed. The Unit Manager admitted that it was challenging to serve all residents at the same time but agreed that it would be ideal for residents seated together to receive meals simultaneously. The Nurse admitted to standing while assisting a resident due to personal discomfort, despite knowing the expectation to be seated. The Administrator confirmed that staff should be seated when assisting residents and that all residents should have a dignified and homelike dining experience.
Failure to Obtain Proper Consent for Treatment
Penalty
Summary
The facility failed to ensure that a resident, who was responsible for their own care, was fully informed and involved in decisions regarding their treatment, specifically concerning the administration of psychotropic medication. The resident, identified as cognitively intact with a BIMS score of 13 out of 15, did not sign the necessary consent forms for treatment and psychotropic medication upon admission. Instead, the facility obtained consent from the resident's family, despite the absence of an Invocation of the Health Care Proxy or a physician's order to invoke it. Interviews with the resident and facility staff revealed that the resident could not recall signing any admission paperwork, and the Director of Social Services confirmed the lack of documentation for an Invocation of the Health Care Proxy. The Administrator acknowledged that the expectation was for the resident to sign all consents unless a Health Care Proxy was activated, which was not the case. This oversight led to the resident not being properly informed or involved in their care decisions.
Failure to Ensure Proper Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that medications were not self-administered without a physician's order and an assessment for self-administration for a resident. The facility's policy on self-administration of medications requires an evaluation of the resident's cognitive, physical, and visual ability to self-administer medications safely, followed by obtaining a physician's order if the resident is deemed capable. However, this process was not followed for a resident who was found to be self-administering Mupirocin ointment without the necessary assessments or orders. The resident, who was admitted with diagnoses including schizophrenia and metabolic encephalopathy, was observed to have a BIMS score indicating cognitive intactness. Despite this, the resident was given antibiotic ointment for a thumb wound and was applying it independently without supervision or a physician's order. The resident expressed a preference for self-administration and was not aware of the correct frequency for applying the ointment, indicating a lack of proper education and assessment by the facility. Interviews with nursing staff revealed that the required procedures for self-administration were not followed. The nurse responsible for the resident's care was unaware of how the resident obtained the ointment and confirmed that no self-administration assessment or physician's order was in place. The Director of Nursing acknowledged that the facility failed to complete the necessary assessments and education for the resident, resulting in a deficiency in medication management protocols.
Inadequate PPE Use in Infection Control
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by staff not adhering to protocols for personal protective equipment (PPE) use. Specifically, staff did not consistently wear gowns and gloves when providing care to a resident on Enhanced Barrier Precautions, which is required to prevent the transmission of multi-drug resistant organisms. Observations revealed that staff members, including nurses and a certified nursing assistant, engaged in high-contact care activities such as touching bed linens, repositioning the resident, and changing the resident's gown without wearing the appropriate PPE. The resident involved had significant medical conditions, including urinary retention, an indwelling urinary catheter, and two Stage III pressure ulcers. Despite the presence of a CDC Enhanced Barrier Precaution sign at the entrance of the resident's room, staff were observed not following the required infection control measures. Interviews with staff, including Nurse #2, the Director of Nursing, and the Infection Control Nurse, confirmed that they were aware of the requirement to wear gowns and gloves during high-contact care activities but failed to consistently implement these precautions.
Failure in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program, as evidenced by the lack of necessary protocols and monitoring of antibiotic use. Specifically, the facility did not ensure that antibiotics prescribed were necessary for one resident, and failed to reassess antibiotics 48-72 hours after initiation for five residents. The facility's policy on antibiotic stewardship, revised in April 2023, mandates that antibiotics should only be prescribed for symptomatic infections meeting specific criteria, and that they should be reassessed within 48-72 hours to ensure continued appropriateness. However, these protocols were not followed, leading to potential risks of adverse drug events and antibiotic resistance. Resident #114 was prescribed Keflex for right hand cellulitis, despite not meeting the criteria for appropriate antimicrobial use according to the facility's Revised McGeer Criteria. The medical record lacked a clinical rationale for initiating the antibiotic, and there was no documentation of reassessment 48-72 hours after the antibiotic was started. Similarly, other residents, including those with urinary tract infections and dental abscesses, were prescribed antibiotics without documented reassessment within the required timeframe. This oversight indicates a systemic failure in monitoring and reassessing antibiotic use as per the facility's policy. Interviews with the Director of Nurses (DON) and the Infection Preventionist (IP) revealed that the facility did not complete audit sheets to monitor antibiotic usage, and reassessment documentation was not located for any of the sampled residents. The DON acknowledged the difficulty in ensuring providers adhere to the criteria for prescribing antibiotics. The IP confirmed that audits were not conducted to ensure orders were complete and reassessments were performed, highlighting a significant gap in the facility's antibiotic stewardship efforts.
Failure to Implement Vaccination Policies
Penalty
Summary
The facility failed to implement its policies and procedures regarding the education, consent, and administration of influenza and pneumococcal vaccinations for three residents. For Resident #45, the facility did not provide education on the benefits and potential side effects of the vaccines, nor did it document consent or refusal in the medical record. The resident's immunization record indicated historical vaccinations, but there was no follow-up to confirm the administration of the current influenza vaccine or to assess eligibility for the pneumococcal vaccine. Resident #106, who was admitted with a diagnosis of diabetes mellitus type 2, also did not receive the necessary education or documentation regarding the pneumococcal vaccine. The medical record lacked evidence of consent or refusal, and there was no follow-up to ensure the resident was up to date with the recommended pneumococcal vaccination schedule. The facility's failure to document and follow up on the resident's vaccination status was confirmed during interviews with the Infection Preventionist (IP) and Director of Nursing (DON). Similarly, Resident #8's medical record did not include documentation of education, consent, or administration of the influenza and pneumococcal vaccines. Although the resident had a legal guardian, there was no follow-up after leaving messages regarding the influenza vaccine. The resident's immunization record showed previous doses of PCV13, but there was no evidence of offering or administering the recommended PCV20 or PPSV15 dose. Interviews with the IP and DON revealed that the facility did not adhere to its vaccination policies, resulting in the residents not being up to date with their vaccinations.
Failure to Provide COVID-19 Vaccination and Education
Penalty
Summary
The facility failed to provide education, assess eligibility, and offer the COVID-19 vaccination to two residents, as per CDC recommendations and facility policy. The CDC guidance recommends updated COVID-19 vaccines for individuals 5 years and older to protect against serious illness. The facility's policy mandates offering immunization to residents, documenting education, consent, and vaccination status in the medical record. However, for Resident #8, there was no documentation of follow-up screening, eligibility assessment, or education related to the COVID-19 vaccine. The resident's legal guardian was contacted, but no further action was taken, and the resident was not up to date with the COVID-19 vaccination. Similarly, Resident #107's records lacked documentation of follow-up screening, eligibility assessment, and education regarding the COVID-19 vaccine. Although the resident had received previous COVID-19 boosters, there was no recent consent for the updated booster, and no documentation of discussion with the resident. The facility's immunization tracking log did not indicate that the resident had received the most up-to-date vaccination, and the resident was not up to date with the COVID-19 vaccination. Interviews with the Infection Preventionist (IP) and Director of Nursing (DON) revealed that the facility did not follow its immunization program process. The IP and DON acknowledged that education should be provided before vaccine administration and that residents should be screened each time a vaccine is given. Despite a COVID-19 booster clinic conducted by the partnered pharmacy, not all residents, including Residents #8 and #107, received the vaccine. The DON admitted to not following up with the pharmacy or requesting a supply of vaccines for in-house administration, resulting in a failure to protect residents in accordance with national standards of practice.
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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 North Easton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Copley At Stoughton Nursing Care Center | 3.6 mi | — | 11 | 0 |
| Alliance Health At West Acres | 3.8 mi | — | 6 | 0 |
| Blue Hills Health And Rehabilitation Center | 3.8 mi | — | 4 | 0 |
| Brockton Post Acute Care | 4.4 mi | — | 0 | 0 |
| Life Care Center Of West Bridgewater | 5.1 mi | — | 0 | 0 |
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