Agawam South Rehab And Nursing
65 Cooper Street, Agawam, MA 01001 · For profit - Limited Liability company · 122 certified beds · (413) 786-8000 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
- about 23% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 11.6% | 16.4% | 15.4% | better |
| Long-stay residents who lose too much weight | 9.9% | 5.1% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.3% | 0.8% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.4% | 1.8% | 2.0% | better |
| Long-stay residents with depressive symptoms | 3.5% | 15.5% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 0.0% | 3.4% | 3.3% | check this* — see note marked star below the table |
| Long-stay residents whose ability to walk worsened | 16.9% | 15.4% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 13.1% | 19.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 94.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.1% | 4.2% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 33.6% | 21.2% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 10.0% | 21.4% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.7% | 1.4% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 84.6% | 77.7% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 20.7% | 25.7% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 7.4% | 11.9% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.51 | 1.88 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.00 | 1.50 | 1.80 | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
51.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 177 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 74.6% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 63 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.31 therapist hours per resident per day in 2026Q1 — more than 50% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 10% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 51.1%CMS range 43.7–56.5 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 12.0%CMS range 9.0–14.6 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 74.6% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 60.3% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 65.1% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 98.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 96.9% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 3.9% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 5.2%CMS range 2.8–10.3 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.93 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 122 beds and averages 95.8 residents a day — about 79% occupied, or roughly 26 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.64 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.74 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.15 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.14 hrs/resident/day on weekends vs 3.85 on weekdays — 18% thinner on weekends. RN hours go from 0.84 to 0.49 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 44% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
28 citations, most serious first. The 10 most serious are shown; the remaining 18 are one tap away and print in full.
- Potential for harm · Fcited before2026-03-10 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and records reviewed, the facility failed to maintain infection control practices relative to laundry services for three units (A Wing, C Wing and D Wing) out of three total units, placing all facility residents at risk for exposure to unsanitary linens, contamination and the spread of infections. Specifically, the facility failed to maintain infection control practices relative to laundry services when: -Resident #93 and Resident #32 indicated during a resident council meeting that their clothing washed by facility laundry smelled of mildew.-Feces were observed in the washer machine with a load of linens being washed. -the chemical programming box was not set to the correct program to ensure proper sanitization of resident's linens. -Washer machine #2 which was not functioning as required and not properly spinning or draining the linens was being used for one year. -Clean mop heads were being placed wet into a bin and not hung to dry as required. -A washed lift sling that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-10 · tag F0636 — isolatedAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to complete comprehensive assessments timely, according to the required Resident Assessment Instrument (RAI) process, for two Residents (#36 and #95) out of a total sample of 19 residents.Specifically, the facility failed to complete comprehensive assessments for Resident #36 and Resident #95 within the required 14 days of the Assessment Reference Date (ARD) date. Findings include:1. Resident #36 was admitted to the facility in November 2023 with diagnoses including chronic obstructive pulmonary disease (COPD), major depressive disorder, dementia and chronic respiratory failure with hypoxia. Review of the Annual Minimum Data Set (MDS) Assessment with an ARD of 10/23/25, indicated the assessment was completed by the facility staff on 11/11/25, five days late. 2.Resident #95 was admitted to the facility in August 2019 with diagnoses including protein malnutrition, anxiety disorder, mild cognitive impairment and a history of falling. Review of the Annual MDS Assessment with an ARD of 1/27/26, indicated the assessment was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-10 · tag F0638 — isolatedAssure that each resident’s assessment is updated at least once every 3 months.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to complete quarterly Minimum Data Set (MDS) assessments timely, according to the required Resident Assessment Instrument (RAI) process, for four Residents (#6, #36, #70 and #95) out of a total sample of 19 residents.Specifically, the facility failed to ensure the following quarterly MDS assessments were completed no later than 14 days after the Assessment Reference Date (ARD): for Resident #6 on two occasions, (ARD 9/22/25 and ARD 12/4/25)for Resident #36, on one occasion, (ARD 1/22/26)for Resident #70, on two occasions, (ARD 10/28/25) and ARD 1/27/26) andfor Resident #95, on one occasion (ARD 10/28/25).Findings include:1.Resident #6 was admitted to the facility in June 2025 with diagnoses including chronic respiratory failure, stage 3 kidney disease, and atherosclerosis heart disease.Review of the Quarterly MDS Assessment with an ARD of 9/22/25, indicated the assessment was completed by the facility staff on 10/22/25, 16 days late.Review of the Quarterly MDS Assessment with an ARD of 12/4/25, indicated it was completed by…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-10 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to accurately code Minimum Data Set (MDS) Assessments for two Residents (#21 and #6), out of a total sample of 19 Residents. Specifically, the facility failed to: 1) For Resident #21, accurately code functional limitation in Range of Motion (ROM- the extent to which a body part can be moved around) when the Resident had an impairment in ROM to one upper extremity. 2) For Resident #6, accurately code the use of an anticoagulant medication (medicine that increases the time it takes for blood to clot). Findings include: 1. Resident #21 was admitted to the facility in December 2023 with diagnoses including osteoarthritis and osteoporosis. Review of the Resident's Occupational Therapy Discharge Summary with dates of service 10/29/24 - 2/9/26, indicated that Resident #21 had a goal to tolerate the most appropriate left hand WHFO (Wrist Hand Finger Orthosis - used to support injured or weak joints affected by stiffness or contractures) to support…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-10 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure that Physician's orders were implemented in accordance with professional standards of practice for two Residents (#17 and #28), out of a total sample of 19 residents.Specifically, 1.For Resident #17, the facility failed to ensure the Wound Provider recommendations from January 2026 were implemented timely for the Resident's right heel and right superior ankle wounds, that new treatment recommendations were implemented in February 2026 for both right heel and right superior ankle wounds, and Physician orders were obtained for the Resident's right heel wound in March 2026, putting him/her at risk of decline in status of the wound and delayed wound healing.2.For Resident #28, the facility failed to ensure: -Physician orders were in place for a bowel regimen, when the Physician recommended initiating a bowel protocol, -Physician orders were in place prior to administering a suppository, and -Documentation was completed relative to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-10 · tag F0804 — failed to serve food at safe, palatable temperature — isolatedEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews and record reviewed, the facility failed to ensure resident meals were palatable and at appetizing temperatures on two (Units A and C), out of two units observed. Specifically, the facility failed to ensure that food served to the residents on Unit A and Unit C was attractive, palatable and hot foods were maintained at/above 135 degrees Fahrenheit (F) when served. Findings include: Review of the facility policy titled Food Preparation, revised February 2025, included the following:-The Dining Services Director/Cook(s) will be responsible for food preparation techniques which minimize the amount of time that food items are exposed to temperatures greater than 41 degrees F and/or less than 135 degrees F, or per state regulation. Review of the Food and Nutritional Services Meal Assessment Form, reviewed 10/6/13, included the following serving minimum temperatures at point of service:-Entree 135 degrees F-Starch 135 degrees F-Hot beverage 135 degrees F During the initial pool process on 3/3/26 from 7:30 A.M. through 2:30 P.M., facility residents relayed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-23 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on records reviewed and interviews for one of three sampled residents (Resident #1) who had an actual area of skin breakdown and was assessed upon admission by the Registered Dietitian (RD) to be at risk for nutritional decline, the Facility failed to ensure that Resident #1 was adequately monitored by the RD, and nutritional interventions were put in place in a timely manner in an effort to prevent significant weight loss and promote wound healing. Findings include: The Facility Policy titled Weight Assessment and Interventions, last revised 11/19/24 included but was not limited to: -It is the policy of this facility to prevent significant unplanned or unavoidable weight loss for our residents. -The threshold for significant unplanned and undesired weight loss/gain will be based on the following criteria: -One month - 5 percent (%) weight loss is significant, greater than 5% is severe -Any weight change of five pounds or more within 30 days will be retaken the next day for confirmation. If the weight is verified, nursing will notify the Provider and the Dietary…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-23 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on records reviewed and interviews for one of three sampled Residents (Resident #1), who required wound treatments, had significant weight loss, and required assistance with his/her Activities of Daily Living (ADLs), the facility failed to ensure they maintained a complete and accurate medical record when, 1) Weekly Wound Logs and a Weekly Nursing Skin Review User Defined Assessments (UDA) were not consistently completed by nursing staff, 2) nursing documentation in the Treatment Administration Record (TAR) related to wound care was incomplete with blank spaces, and 3) Certified Nurse Aide (CNA) ADL Flow Sheets for August, September, and October 2023 were incomplete with blank spaces. Findings include: Review of the Facility's policy titled, Skin Prevention, Assessment and Treatment, last revised 10/24/24, indicated but was not limited to: Purpose: To promote a systematic approach and monitoring process for the care of residents with existing wounds and for those at risk for skin breakdown. - Findings from the weekly skin assessments should be documented by the licensed nurse.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-11-26 · tag F0760 — failed to prevent significant medication errors — patternEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, and interview, the facility failed to ensure that one Resident (#10) out of a total sample of 22 residents, was free from significant medication errors. Specifically, the facility staff failed to adhere to the Physician's orders to hold (not administer) the dose of Midodrine (medication used to treat orthostatic [standing up] hypotension [low blood pressure]) when the blood pressure measured above 130 millimeters of mercury (mmHg) for a Systolic [the pressure in the arteries when the heart contracts] Blood Pressure (SBP). Findings include: Review of the facility policy titled Administering Medication, revised October 2024, indicated: -that medications shall be administered according to the physicians written/verbal orders upon verification of: >the right medication >the right dose >the right route >the right time >positive verification of the resident's identity when no contraindications are identified >the medication is labeled accordingly to accepted standards Resident #10 was admitted to the facility in December 2023, with the diagnoses including End Stage…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-11-26 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to adhere to infection control standards to prevent the potential transmission of communicable diseases and infections for three Residents (#346, #47 and #6) out of a total sample of 20 residents, and on three units (A Wing, C Wing, and D Wing) out of a total of three units. Specifically, the facility failed to: 1) ensure that wound care supplies used inside a Resident's room were not removed from the room and stored in the clean utility room on C Wing. 2) ensure infection control standards were maintained during wound care for Resident #346. 3) ensure that staff wore the necessary Personal Protective Equipment (PPE: items such as a gown, gloves, mask, eye protection, etc. to prevent transmission of communicable disease) to maintain contact isolation precautions (used to prevent transmission of a disease spread by touching a contaminated surface or person) for Resident #346 4) ensure that staff performed hand hygiene, wore the necessary PPE…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 18 citations
- Potential for harm · D2024-11-26 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, and interview, the facility failed to maintain a clean, comfortable, and homelike environment for one Resident (#79) out of a total sample of 20 residents. Specifically, for Resident #79, the facility failed to maintain the resident's wheelchair in a clean and sanitary manner. Findings include: Resident #79 was admitted to the facility in December 2023. On 11/20/24 at 8:27 A.M., the surveyor observed Resident #79's seated in a wheelchair in his/her room. The surveyor observed the wheelchair to have dirt/debris and/or food particles spackled on the chair cushion, frame, brakes, and wheels. On 11/21/24 at 1:18 P.M., the surveyor observed Resident #79 exiting the dining room after having lunch. The surveyor observed the Resident's wheelchair to have dirt/debris and/or food particles on the chair cushion, frame, brakes, and wheels. On 11/25/24 at 9:57 A.M., the surveyor observed Resident #79 sitting in his/her wheelchair in his/her room. The surveyor observed that the Resident's wheelchair remained with dirt/debris and/or food particles on the chair cushion, frame,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-26 · tag F0646 — isolatedNotify the appropriate authorities when residents with MD or ID services has a significant change in condition.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to notify the state mental health authority for a resident review (person-centered assessment taking into account all relevant information) after a significant change in mental condition occurred for one Resident (#12) out of a total sample of 20 residents. Specifically, the facility failed to request a Preadmission Screening and Resident Review Level II screen (PASRR-and evaluation done to determine if a resident has an intellectual or developmental disability [ID/DD] and/or serious mental illness [SMI] and is in need of additional specialized support services at the facility) after Resident #12 received a diagnosis of Bipolar Disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) and experienced limitations in major life activities due to mental illness. Findings include: Review of the facility policy titled Coordination with PASRR Program, dated 2/2/24, indicated the following: -Any resident who…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-26 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, and record review, the facility failed to ensure a baseline care plan was created within 48 hours of admission to the facility for two Residents (#47 and #36) out of a total sample of 20 residents. Specifically, the facility failed to: 1. for Resident #47, ensure a baseline care plan was created within 48 hours of admission relative to Resident #47 being actively treated for Methicillin-Resistant Staphylococcus Aureus (MRSA - an infection caused by a type of staph bacteria that has become resistant to many antibiotics, that is contagious and easy to spread by both direct and indirect contact requiring special precautions to be in place to prevent further spread) in a wound. 2. For Resident #36, ensure a baseline care plan was created within 48 hours of admission to ensure the Resident received the care and services necessary to care for him/her until a comprehensive care plan could be created. Findings include: Review of the facility policy titled Interim Care Plan, revised 11/6/24, indicated the following: -The purpose of the interim care plan is to guide care…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-11-26 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to provide care in accordance with professional standards of practice for one Resident (#346), for one applicable resident reviewed, out of a total sample of 20 residents. Specifically, for Resident #346, the facility failed to ensure the external catheter length and arm circumference were measured as ordered by the Physician when the Resident had a Peripherally Inserted Central Catheter (PICC: a thin, soft tube that is inserted into a vein in the arm, for long-term antibiotics, nutrition, medications, and blood draws. The PICC is a type of CVAD [Central Vascular Access Device] catheter) line) for intravenous administration of antibiotics increasing the potential risk of infiltration (when fluid or medication given by an intravenous [IV] device exits the vein and enters the soft tissues), migration (change in the length of catheter extruding from the insertion site, is a medical emergency and must be addressed immediately), and/or deep vein thrombosis (DVT: a blood clot in a deep vein). Findings include: Review…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-26 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure Activities of Daily Living (ADLs) were provided for one Resident (#45), out of a total sample of 20 residents. Specifically, the facility failed to provide assistance for Resident #45 to ensure daily oral hygiene was completed when the resident was unable to carry out ADLs independently. Findings include: Review of the facility policy titled Activities of Daily Living, initiated on January 23, 2024, indicated the following: -Residents will [sic] provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). -Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. -appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-26 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to provide respiratory care and services consistent with professional standards of practice for one Resident (#12), out of one applicable resident, out of a total sample of 20 residents. Specifically, the facility failed to ensure: -a Physician's order was in place for the use of Continuous Positive Airway Pressure (CPAP- a type of non-invasive device that involves the administration of air usually through the nose and/or mouth by an external device at a predetermined level of pressure to keep the airways open) -respiratory equipment was stored in such a manner to prevent contamination and risk of infection. Findings include: Review of the facility policy titled CPAP and BiPAP (Bi-level Positive Airway Pressure - a noninvasive device capable of generating two adjustable pressure levels: inspiratory [IPAP - higher level] and expiratory [EPAP - lower level] that assists with ventilation) Usage/Maintenance, dated 1/10/24, indicated the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-26 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure that Medication Regimen Review (MRR) was addressed timely by the Physician and facility for one Resident (#28), of five applicable residents reviewed for unnecessary medications, out of a total sample of 20 residents. Specifically, the facility failed to address the MRR recommendations made by the Consultant Pharmacist pertaining to Resident #28's use of a cholesterol medication and laboratory testing to monitor the Resident's cholesterol levels. Findings include: Resident #28 was admitted to the facility in December 2020, with diagnoses including Hypertension (HTN: high blood pressure. When the blood pressure measures consistently above 130/80 millimeters of mercury [mm Hg]) and hemiparesis/hemiplegia (paralysis on one side of the body) due to Cerebrovascular Accident (CVA: medical term for a stroke - when blood flow to a part of the brain is stopped either by a blockage or the rupture of a blood vessel). Review of the Resident #28's clinical record indicated the Consultant Pharmacist conducted an MRR and made a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-26 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to maintain a medication pass error rate of less than five percent (%) for one Resident (#28), out of four applicable residents, out of 35 opportunities. Specifically, the medication error rate was observed to be 5.71% when Resident #28 was administered two scheduled medications later than the allowed timeframe. Findings include: Review of the facility policy titled Administering Medication, dated October 2024, indicated the following: -To ensure safe and effective administration of medication in accordance with Physician orders and state/federal regulations. -Medication should be administered within one hour of the prescribed times. Resident #28 was admitted to the facility in December 2020, with diagnoses including Cerebral Infarction (a condition that occurs when blood flow to the brain is blocked, causing brain tissue to die), Vascular Dementia (a general term describing problems with reasoning, planning, judgement, memory and other though processes caused by brain damage from impaired blood flow to the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-26 · tag F0773 — isolatedProvide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, and record review, the facility failed to obtain lab work as ordered by the Physician for two Residents (#28 and #52), of five applicable residents, out of a total sample of 20 residents. Specifically, the facility failed to: 1. For Resident #28, obtain lab work to monitor his/her valproic acid level (measures the amount of valproic acid [medication used for the treatment of seizures or to manage behaviors] in the blood). 2. For Resident #52, obtain routine lab work to monitor his/her blood glucose levels, thyroid hormone levels, and lipid [fat]/cholesterol levels. Findings include: Review of the facility policy titled Diagnostic Services, revised October 2024, indicated the following: -access to radiologist and clinical laboratory diagnostic services will be available seven days a week, to ensure that diagnostic tests relevant to the residents' health status was provided and reported as required by the physician. -all diagnostic service/test requires an order by the licensed prescriber assigned to the resident. 1. Resident #28 was admitted to the facility with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-26 · tag F0803 — failed to meet residents' dietary needs — isolatedEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to follow the dietary plan as recommended by the Registered Dietitian (RD) to meet the nutritional needs and preferences of one Resident (#50), out of a total sample of 20 residents. Specifically, for Resident #50, the facility failed to ensure that food as recommended by the RD and as indicated on the meal tickets were provided to the Resident at meal times. Findings include: Resident #50 was admitted to the facility in April 2023, with diagnoses including Chronic Obstructive Pulmonary Disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe) and Gastro-Esophageal Reflux Disease (GERD - a digestive disease in which stomach acid or bile irritates the food pipe lining). Review of the Minimum Data Set (MDS) Assessment, dated 8/20/24, indicated Resident #50: -was cognitively intact as evidenced by Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15. -required set-up/clean-up for eating. -was dependent (helper does all of the effort. Resident does none of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-10-10 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews and policy review, the facility failed to store, prepare, distribute and serve food used for resident consumption in accordance with professional standards for food service safety within the main kitchen, and on three of three unit nourishment kitchens observed. Specifically, the facility failed to: -ensure that all food stored in the main kitchen area, walk-in refridgerator and unit nourishment kitchens were labeled and dated and expired food discarded to prevent cross-contamination and food-borne illnesses. -maintain the main kitchen and the unit nourishment kitchens in a clean and sanitary manner to prevent contamination and food-borne infections. Findings include: Review of the Food and Nutrition Services Use By Dating Guidelines posted in the nourishment kitchens within the facility indicated: -Manufacturer's expiration date, when available, is the use by date for unopened items. -Manufacturer's instructions for use by date of opened items overrides these guidelines. -Guidelines assume food is properly stored, covered, and handled. -Ready to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-10 · tag F0559 — isolatedHonor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide written notice of the reason for a room change for one Resident (#49) out of a sample of 18 residents. Specifically, the facility failed to provide Resident #49 and/or his/her Representative a written explanation of the room change prior to moving the the Resident. Findings include: Review of the facility policy titled Room Transfers, revised 8/7/23, indicated the following: -In the Commonwealth of Massachusetts, give the Massachusetts Notification Letter. Resident #49 was admitted to the facility in May 2019. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident was cognitively intact as evidenced by a score of 15 out of 15 on the Brief Interview for Mental Status (BIMS) Assessment. During an interview prior to the start of the survey on 10/3/23 at 11:52 A.M., the Ombudsman expressed concern regarding the facility asking residents to change rooms without providing written notice. Review of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-10-10 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to obtain the necessary Physician's orders prior to the administration of a vaccination for two Residents (#24 and #49) for an applicable sample of five residents, out of a total sample of 18 residents. Specifically, the facility failed to ensure a Physician's order was in place prior to the administration of a COVID-19 vaccination. Findings include: Review of the facility policy titled COVID-19 Vaccination, revised 6/30/23, indicated the following: -Centers will provide the opportunity to receive COVID-19 vaccinations following the Centers for Disease and Control and Prevention (CDC) recommendations . -A licensed nurse or authorized health care provider will provide COVID-19 vaccinations . -With attending physician order/authorization for patients. Review of the CDC website www.cdc.gov/vaccines/hcp/adults/for-practice/standards/referral.html, titled Standards for Practice: Vaccine Administration & Referral, last reviewed May 2, 2016, indicated the following: -Use standing orders (written protocols approved by a physician or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-10 · tag F0691 — failed to provide colostomy / ostomy care — isolatedProvide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide colostomy (a surgical opening [stoma] from the large intestine through the abdominal wall that allows stool to pass from the intestine to outside the body into a bag [appliance] which is attached to the abdomen) care for one Resident (#28) out of a total sample of 18 residents. Specifically, the facility staff failed to obtain Physician orders relative to the care and maintenance of Resident 28's colostomy and provide colostomy care according to professional standards. Findings include: Review of the facility procedure titled Colostomy and Ileostomy Care, last revised 6/1/2021, indicated the following: -Document: Date and time pouching system changed or emptied, -noting the character of the drainage including color, amount, type and consistency, -Type and size of appliance used, -Appearance of peristomal (around the stoma) skin. Review of the National Institutes of Health (NIH) National Library of Medicine Colostomy Care…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-10 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and policy review, the facility failed to ensure that one Resident (#32) out of a total sample of 18 residents, received dialysis (a process by which dissolved substances are removed from a patient's body by diffusion from one fluid compartment to another across a semipermeable membrane) care and services consistent with professional standards of practice. Specifically, the facility staff failed to ensure that emergency dialysis catheter equipment was easily accessible at the Resident's bedside, to provide timely intervention in the event the dialysis catheter became dislodged and bleeding resulted. Findings include: Review of the facility policy titled Dialysis: Hemodialysis - External Catheter: Evaluation and Maintenance, revised on 11/1/19, indicated the following: -Maintain two smooth edged clamps with the patient at all times. -Smooth edged clamps must be placed at the bedside at the time of admission. Resident #32 was admitted to the facility in September 2023 with the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-10 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews and records reviewed for one Resident (#47) of five applicable residents, out of a total sample of 18 residents, the facility failed to ensure the Resident's drug regimen was free from unnecessary medications. Specifically, the facility staff failed to ensure adequate monitoring for harmful side-effects was in place for a prescribed blood-thinning medication, putting the Resident at risk for bleeding. Findings include: Resident #47 was admitted to the facility in August 2023 with a diagnosis of Atrial Fibrillation (Afib - a quivering or irregular heartbeat which can lead to blood clots and stroke). Review of the October 2023 Physician's orders indicated the following: -Eliquis (a blood thinning medication) 5 milligram (mg) tablet, give 5 mg by mouth two times a day for Afib, initiated 8/31/23. Review of the manufacturer's recommendations (https://www.eliquis.bmscustomerconnect.com/) indicated: -Eliquis can cause serious, potentially fatal bleeding. -Promptly evaluate signs and symptoms of blood loss. Contact Physician or get medical help immediately…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-10 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and records reviewed for one Resident (#47) of five applicable residents out of a total of 18 sampled residents, the facility failed to ensure the Resident's drug regimen was free from unnecessary medications. Specifically, they failed to ensure adequate monitoring was in place for psychotropic medications (medication used to stabilize or improve mood, mental status, or behavior), putting the Resident at risk for adverse side effects. Findings include: Resident #47 was admitted to the facility in August 2023 with diagnoses including Tardive Dyskinesia (a condition affecting the nervous system often caused by long-term use of some psychiatric drugs), Schizoaffective Disorder (a combination of symptoms of both Schizophrenia and mood disorders such as Depression or Bipolar Disorder) and Anxiety. Review of the facility's policy titled Psychotropic Medication Use, revised 10/24/22, indicated but was not limited to: -All medications used to treat behaviors should be monitored for:…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-10 · tag F0790 — failed to provide dental care — isolatedProvide routine and 24-hour emergency dental care for each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and records reviewed for one Resident (#65) out of a total sample of 18 residents, the facility failed to ensure the Resident received dental care as required. Specifically, the facility staff failed to accommodate dental services for Resident #65, resulting in the Resident reporting mouth pain and increased difficulty eating his/her meals. Findings include: Review of the facility's policy titled, Dental Services, revised 9/1/22 indicated but was not limited to: -Centers will provide or obtain from an outside resource routine and emergency dental services to meet the needs of each patient. -Routine dental services mean an annual inspection of the oral cavity for signs of disease, diagnosis of dental disease, dental radiographs (x-rays) as needed, dental cleaning, fillings, minor partial or full denture adjustments, smoothing of broken teeth and limited prosthodontic procedures (taking impressions for and fitting dentures). Resident #65 was admitted to the facility in February…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to STERN CONSULTANTS — 22 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 2.5 | +1.5 vs chain |
| Health inspection | 3 of 5 | 2.4 | +0.6 vs chain |
| Staffing | 3 of 5 | 2.2 | +0.8 vs chain |
| Quality measures | 5 of 5 | 3.8 | +1.2 vs chain |
The other 21 homes this chain runs (chain average 2.5★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| FRIEDMAN, SHANA | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 12% | since 10/16/2023 |
| BEATTY, BRITTANY | Individual | DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/16/2023 |
| FRIEDMAN, BENJAMIN | Individual | DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/16/2023 |
| COM FAMILY TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 10% | since 10/16/2023 |
| MILLMAN, CHAIM | Individual | INDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; TRUSTEE OF THE SNF; ADP OF THE SNF | — | since 10/16/2023 |
| NEWHOUSE, ERIC | Individual | INDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; TRUSTEE OF THE SNF; ADP OF THE SNF | — | since 10/16/2023 |
| ERBLICH, AVRAHAM | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/16/2023 |
| SHEPS, BORUCH | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/16/2023 |
| ETN FAMILY HOLDINGS LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/13/2025 |
| STERN THERAPY CONSULTANTS LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/13/2025 |
| TLCO HOLDINGS LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/16/2023 |
| ASHKAR, RAMI | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/16/2023 |
| PLEW, ANDREA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/16/2023 |
| SUBIRA, MARTA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/22/2024 |
| AGAWAM SOUTH PROPCO LLC | Organization | ADP OF THE SNF | — | since 10/16/2023 |
| E NEWHOUSE FAMILY TRUST | Organization | ADP OF THE SNF | — | since 10/16/2023 |
| T NEWHOUSE FAMILY TRUST | Organization | ADP OF THE SNF | — | since 10/16/2023 |
| TLM FAMILY TRUST | Organization | ADP OF THE SNF | — | since 10/16/2023 |
| STERN, BEZALEL | Individual | ADP OF THE SNF | — | since 10/16/2023 |
CMS files one row per role, so the 43 rows in the source record cover these 19 parties — each is shown once here with every role it holds. Nothing is omitted.
8 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $2.2M paid to related parties — landlords or management companies under common ownership — equal to about 23% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in MA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Massachusetts Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 225176. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-10, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
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