Inspection Reports for
Whitney Place Assisted Living and Memory Care
3 Vision Dr, Natick, MA 01760, United States, MA, 01760
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
3.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
48% better than Massachusetts average
Massachusetts average: 7.3 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Deficiencies: 1
Date: Sep 16, 2025
Visit Reason
The inspection was conducted to investigate the facility's compliance with resident rights, specifically regarding the treatment of cognitively impaired residents and unauthorized haircuts given without consent.
Findings
The facility failed to ensure that three cognitively impaired residents were treated with respect and dignity, as they received haircuts without consent and the facility was unable to determine who performed the haircuts. The facility conducted an investigation, implemented staff education on resident rights, and initiated audits to monitor compliance.
Deficiencies (1)
F 0557: The facility failed to honor the residents' right to be treated with respect and dignity and to retain and use personal possessions. Three cognitively impaired residents received haircuts without consent, and the facility could not determine who performed the haircuts.
Report Facts
Brief Interview for Mental Status (BIMS) score: 5
Brief Interview for Mental Status (BIMS) score: 4
Brief Interview for Mental Status (BIMS) score: 1
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #1 | Certified Nurse Aide | Reported noticing Resident #1's uneven haircut and notified the nurse |
| Director of Social Services | Director of Social Services | Observed Resident #1's regular hairstyle on 7/12/25 |
| Moving Coordinator | Manager on Duty | Conducted environmental audit on 7/13/25 and found no scissors or hair |
| Director of Nurses | Director of Nurses | Participated in investigation and initiated staff education on resident rights |
| Administrator | Administrator | Reported thorough investigation and inability to determine who performed haircuts |
Inspection Report
Deficiencies: 2
Date: Jan 7, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including accurate completion of Minimum Data Set (MDS) assessments and posting of nurse staffing information.
Findings
The facility failed to accurately complete two MDS assessments for one resident by incorrectly coding a diagnosis of Psychotic Disorder. Additionally, the facility failed to post the required nurse staffing information daily, specifically omitting total and actual hours worked by nursing staff categories.
Deficiencies (2)
F0641: The facility failed to ensure two consecutive MDS Assessments for Resident #39 were accurately coded relative to a diagnosis of Psychotic Disorder, which was not supported by clinical records.
F0732: The facility failed to post the total number and actual hours worked by licensed and unlicensed nursing staff per shift as required in daily nurse staffing information.
Report Facts
Sample size of residents reviewed: 12
Dates of MDS Assessments with errors: 8/30/2024 and 11/26/2024
Date of survey completion: 01/07/2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Nurse | Interviewed regarding coding errors on Resident #39's MDS Assessments | |
| Facility Scheduler | Interviewed regarding nurse staffing postings and awareness of requirements | |
| Director of Nursing (DON) | Interviewed regarding awareness of nurse staffing posting requirements |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 4, 2024
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to maintain complete and accurate medical records for hospice residents, specifically the integration and accessibility of hospice care plans in the medical records.
Complaint Details
The investigation was complaint-driven, focusing on the failure to maintain integrated hospice care plans in medical records. The deficiency was substantiated with findings of missing hospice documentation and staff interviews confirming lack of access and unclear protocols.
Findings
The facility failed to ensure that hospice care plans were integrated into and accessible within the medical records for hospice residents, preventing effective collaboration with hospice services. Interviews revealed confusion and lack of clarity among staff regarding responsibility for receiving, uploading, and accessing hospice documentation.
Deficiencies (1)
F 0842: The facility failed to safeguard resident-identifiable information and maintain complete medical records for hospice residents, including the integration of hospice care plans into the facility's medical records.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Hospice Services | Stated that hospice patient information is stored electronically but not accessible to the facility. | |
| Unit Manager | Reported inability to locate integrated hospice care plans in medical records. | |
| Former Assistant Director of Nurses (ADON) | Unaware of facility protocol for hospice documentation integration. | |
| Social Worker (SW) | Unaware that printing and uploading hospice documents was her responsibility. | |
| Director of Nurses (DON) | Expected all hospice documentation to be scanned into resident medical records. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jan 17, 2024
Visit Reason
The inspection was conducted following a complaint investigation regarding the care provided to Resident #1, who was assessed as totally dependent on two staff members for mobility and care, after an incident resulting in injury.
Complaint Details
The investigation was triggered by a complaint concerning the care of Resident #1, who was fragile and required two-person assistance. The complaint was substantiated as the facility failed to follow the care plan, resulting in a fracture.
Findings
The facility failed to ensure nursing staff consistently followed Resident #1's care plan requiring two-person assistance, resulting in the resident sustaining a left humeral fracture. Multiple interviews and document reviews confirmed that Nurse Aide #1 provided care without assistance, contrary to care plan requirements.
Deficiencies (2)
F 0656: The facility failed to develop and implement a complete care plan that meets all the resident's needs with measurable timetables and actions. Nursing staff did not consistently follow the plan for Resident #1, who required two-person assistance, leading to injury.
F 0689: The facility failed to ensure the nursing home area was free from accident hazards and provided adequate supervision to prevent accidents. Resident #1 was provided care without required assistance, resulting in a major injury.
Report Facts
Bruise size: 14
Bruise size: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Aide #1 | Nurse Aide | Named in failure to provide two-person assistance to Resident #1 during care |
| Director of Nurses | Director of Nurses | Interviewed regarding care plan expectations and Nurse Aide #1's actions |
| Nurse #1 | Nurse | Reported to Nurse Aide #1 the requirement for two-person assistance for Resident #1 |
| CNA #8 | Certified Nursing Assistant | Discovered bruise on Resident #1 and alerted nursing staff |
| CNA #5 | Certified Nursing Assistant | Trained Nurse Aide #1 and confirmed awareness of Resident #1's care needs |
Inspection Report
Routine
Deficiencies: 2
Date: Nov 16, 2023
Visit Reason
The inspection was conducted to assess compliance with nursing staff requirements, including RN coverage and posting of nurse staffing data.
Findings
The facility failed to provide evidence of at least eight consecutive hours of RN coverage on specified dates and did not post nursing staff data daily in a prominent place accessible to residents and visitors.
Deficiencies (2)
F 0727: The facility failed to provide evidence that at least eight consecutive hours of RN coverage was provided on 10/15/23, 10/21/23, and 10/22/23 when no nurse staff waivers were in place.
F 0732: The facility failed to post nursing staff data daily at the start of each shift, including facility name, current date, total number and hours for RNs, LPNs, CNAs, and resident census in a prominent place accessible to residents and visitors.
Report Facts
Dates lacking required RN coverage: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #1 | Registered Nurse | Interviewed regarding RN coverage and weekend staffing |
| Nurse #2 | Licensed Practical Nurse | Interviewed regarding RN coverage and weekend staffing |
| Nurse #3 | Licensed Practical Nurse | Interviewed regarding RN coverage and weekend staffing |
| Director of Nursing | Interviewed about RN coverage and nurse staffing data posting | |
| Administrator | Interviewed about nurse staffing data posting |
Inspection Report
Routine
Deficiencies: 3
Date: Feb 16, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, infection prevention and control, and vaccination policies at Beaumont Rehab & Skilled Nursing Center - Natick.
Findings
The facility failed to accurately code Minimum Data Set assessments regarding immunizations for two residents, did not fully implement infection prevention and control measures during a COVID-19 outbreak for two residents, and failed to ensure proper administration and offering of influenza vaccinations for two residents.
Deficiencies (3)
F0641: The facility failed to ensure staff accurately coded Minimum Data Set assessments regarding influenza immunizations for two residents out of eight sampled.
F0880: The facility failed to implement infection prevention and control measures, including proper use of PPE and COVID-19 surveillance every shift, for two residents during an active COVID-19 outbreak.
F0883: The facility failed to ensure staff administered the influenza vaccine after obtaining consent for one resident and failed to offer the influenza vaccine to another resident out of five sampled.
Inspection Report
Routine
Deficiencies: 4
Date: May 6, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to wound care, food safety, infection control, and immunization policies at Beaumont Rehab & Skilled Nursing Center - Natick.
Findings
The facility failed to provide wound care as ordered for one resident, maintain safe food storage and clean equipment, ensure proper infection control practices related to contact precautions, and provide education and consent for influenza and pneumococcal vaccinations for two residents.
Deficiencies (4)
F 0684: The facility failed to provide wound care as ordered for one resident with unstageable wounds, including failure to implement skin prep orders and unclear discontinuation of treatments.
F 0812: The facility failed to maintain safe food storage and clean equipment, including undated opened food items, scoops stored in flour, unrefrigerated condiments, and dirty fryolator and mixer.
F 0880: The facility failed to ensure proper infection control practices by allowing food items to be removed from a contact precaution room, risking spread of infection.
F 0883: The facility failed to provide education and obtain consent for influenza and pneumococcal vaccinations for two residents prior to administration.
Report Facts
Residents sampled: 13
Residents affected: 1
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Unit Manager | Interviewed regarding wound care orders and infection control practices | |
| Nurse #2 | Interviewed regarding wound care orders and treatment discontinuation | |
| Food Service Director | Interviewed regarding food storage and sanitation deficiencies | |
| Director of Nurses | Interviewed regarding infection control practices related to contact precautions |
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