The Center at Blue Hills

In the surveyor’s words

From the most serious findings on record at The Center at Blue Hills, in the surveyor’s own words.

• Actual harm, isolatedF600Jan 29, 2026

  Based on interviews and records reviewed, for one of the three sampled residents (Resident #1), who was severely cognitively impaired and dependent on staff for care, the Facility failed to ensure Resident #1 was free from physical abuse when, on 01/14/26 around 7:30 A.M., Certified Nurse Aide (CNA) #1 slapped Resident #1 in the face, which was witnessed by another staff member. Resident #1 was observed to have red marks on his/her face, told staff his/her face hurt and that he/she had been slapped. […]

• Actual harm, isolatedF686Feb 9, 2022

  Based on observation, interview, and record review, the facility failed to prevent the development and worsening of a left heel pressure ulcer for one Resident (#40), out of 18 sampled residents. Findings include: Resident #40 was admitted to the facility in September 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment, dated 12/9/21, indicated the Resident was totally dependent on staff for bed mobility and transfers. The MDS also indicated the Resident was at risk for the development of pressure ulcers. Review of the Nurse's Progress Note, dated 1/12/22, indicated the Resident had a new open area to the left heel. […]

• Actual harm, isolatedF689Feb 9, 2022

  Based on observation, record review, policy review, and interview, the facility failed to ensure adequate supervision and safety interventions were developed and consistently implemented to maintain each Residents' safety. Specifically, the facility failed to 1) For Resident #61, provide adequate supervision, monitor the effectiveness of fall interventions, and revise the plan of care as per the facility policy, in an attempt to prevent four falls, two of which resulted in major injury; and 2) Ensure a treatment cart was locked and not accessible to residents on one unit (East Unit) out of three units in the facility. […]

• No harm, potential for more than minimal, widespreadF838Feb 9, 2022

  Based on documentation review and interview, the facility failed to ensure staff accurately conducted and documented a facility wide assessment to determine what resources were necessary to care for its residents. The Assessment Tool had multiple areas of inaccurate information including equipment resources, services, and staff education. Findings include: During an interview on [DATE] at 4:30 P.M., the Administrator and the surveyor reviewed the Facility Assessment Tool, dated [DATE], which indicated information was missing or inaccurately documented as evidenced by the following: 1. The Assessment Tool section, acuity level of the resident population, specifically, Assistance with Activities of Daily Living, indicated the facility had no residents who were independent in ambulation. […]

• No harm, potential for more than minimal, widespreadF867Feb 9, 2022

  Based on review of facility documentation and interview, the facility failed to ensure the quality assurance and performance improvement (QAPI) plan identified quality deficiencies related to the facility's Infection Control and Prevention Program and practices during the COVID-19 pandemic. Findings include: Review of the facility's Quality Assurance/Quality Improvement (QAPI) plan, dated 2022, indicated the following, but was not limited to: - The purpose of QAPI is to take a proactive approach to continually improve the way we care for and engage with our residents, caregivers, and other partners so that we may realize our vision to exceed our customer's expectation for the highest level of quality care in a safe, clean, supportive environment. […]