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Benjamin Healthcare Center

120 Fisher Avenue, Boston, MA 02120 · Non profit - Other · 205 certified beds · (860) 738-0231 Medicare & Medicaid certified

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Abuse-prevention, restraint, or reporting citations — no harm found (F0607, F0610) — most recent May 2024Behavioral-health or dementia-care citation — no harm found (F0758)1 immediate-jeopardy citation$96,705 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a high payroll-based staffing rating (4/5)
  • lower-than-typical staff turnover (12% vs 45% nationally) — better care continuity
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (32) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $96,705 in federal fines (most recent 2025-07-10)
  • its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
  • its independent health-inspection rating is low (1/5)

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.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 1 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 4 of 5

Worth a closer look. This home's staffing and quality-measure ratings run 3 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, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★★★ 5/5 CMS
Urgent care / clinic
150 S Huntington Ave · (617) 278-4569 · Call to confirm hours
Pharmacy
Walgreens0.4 mi
1630 Tremont St · (617) 232-5457 · Call to confirm hours
Grocery
34 Fisher Ave · (510) 516-1956 · Call to confirm hours
Park
James W. Hennigan K-8 School, 200 Heath St · (617) 635-8264 · Typically dawn to dusk
Place of worship
789 Parker St · (617) 286-2566

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 4 of 5
Long-stay residentspeople who live here 4 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 fell from 4 to 2 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.

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased18.3%16.4%15.4%worse
Long-stay residents who lose too much weight7.3%5.1%5.4%worse
Long-stay residents with a catheter left in their bladder0.9%0.8%0.9%typical
Long-stay residents with a urinary tract infection1.6%1.8%2.0%better
Long-stay residents with depressive symptoms5.1%15.5%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury3.6%3.4%3.3%typical
Long-stay residents whose ability to walk worsened13.7%15.4%16.1%better
Long-stay residents on antianxiety or hypnotic medication2.7%19.5%18.9%better
Long-stay residents given the seasonal flu vaccine97.5%94.8%95.3%typical
Long-stay residents with pressure ulcers4.0%4.2%4.7%better
Long-stay residents with worsening bladder/bowel control13.9%21.2%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table21.0%21.4%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.0%1.4%1.4%better
Short-stay residents given the seasonal flu vaccine33.3%77.7%79.4%worse
Long-stay hospitalizations per 1,000 resident days1.501.881.67better
Long-stay outpatient ER visits per 1,000 resident days0.491.501.80better

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.

0.19U.S. median 0.31
Therapy hours / resident / day
0.06hours / resident / day
Physical therapy
0.10hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.19 therapist hours per resident per day in 2026Q1 — more than 19% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 40% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identifiednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF staynot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFsnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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

0.80
RN hours/ resident / day
0.55
LPN hours/ resident / day
2.28
Aide hours/ resident / day
3.63
Total nurse hours/ resident / day
0.71
RN hoursweekends
11.5%
Total nursing turnover
7.1%
RN turnover

How full it usually is: this home is certified for 205 beds and averages 80.1 residents a day — about 39% occupied, or roughly 125 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 3.63 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.80 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.28 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 3.41 hrs/resident/day on weekends vs 3.72 on weekdays — 8% thinner on weekends. RN hours go from 0.83 to 0.71 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 12% is below 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

20
deficiencies at the latest standard inspection (2025-04-30)
4
at the previous standard inspection (2024-05-23)

Deficiencies are more than at the previous inspection — worsening. 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.

ABCDEFGHIJKL

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.

32 citations, most serious first. The 12 most serious are shown; the remaining 20 are one tap away and print in full.

  • Immediate jeopardy · Kcited before2025-07-10 · tag F0921 — failed to keep a safe, functional, sanitary building — pattern
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, records reviewed, and interviews, for one of three resident units (2-West Unit), which had a resident census of 27, nine of whom were identified to be at risk for elopement, the Facility failed to ensure they maintained a safe and functional environment for residents, staff, and visitors, when the alarm on the stairwell fire door malfunctioned, the alarm was removed, and then a staff member zip tied the fire door closed, preventing the door from opening in case of an emergency for seven days from 06/18/2025 through 06/24/2025. The Facility also failed to ensure that multiple fire doors throughout the facility had functioning alarms, that a fire door self-closed once opened, and that staff monitored malfunctioning alarmed doors for resident safety. Findings include: The Facility's Protocol, titled, Fire Safety Plan, undated, indicated the Facility would establish a clear and effective response plan for fire emergencies that ensured the safety of all residents, staff, and visitors, and staff would ensure all egress paths were unobstructed. The Facility's Policy,…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Actual harm · G2022-11-17 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    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 1) failed to prevent an accident resulting in a burn for 1 Resident (#29) and 2) failed to follow a fall care plan resulting in injury for 1 Resident (#2) out of a total sample of 19 residents. Findings include: 1. For Resident #29 the facility failed to provide supervision and setup assistance with a meal in accordance with the plan of care, resulting in a burn. Resident #29 was admitted to the facility in July 2018 with diagnoses including ataxia and muscle weakness. Review of Resident #29's Minimum Data Set Assessment (MDS) dated [DATE] indicated the Resident was cognitively intact and scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), had no behaviors, did not reject care and requires supervision with setup help for meals. During an interview on 11/15/22 at 1:48 P.M., Resident #29 said he/she was burned by hot tea a few months ago. Resident #29 said he/she has some weakness on his/her left side and when his/her breakfast tray was brought in…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-09-10 · tag F0921 — failed to keep a safe, functional, sanitary building — widespread
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, records reviewed and interviews, for three of three shower rooms utilized by the residents, the Facility failed to ensure it provided a safe, functional, and sanitary environment, when door locks to the shower rooms did not function properly, shower rooms were not clean, smelled musty, were observed with visible areas of mold, and the overhead ventilation system was nonfunctional.Findings include:The Facility Policy, Infection Prevention and Control Program, dated revised August 2016, indicated the infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program.The Policy indicated important facets of infection prevention includes the following, identifying possible infections or potential complications of existing infections, instituting measures to avoid complications or dissemination, educating staff and ensuring that they adhere to proper techniques and procedures and enhancing screening for possible significant pathogens.During…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-04-30 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure 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 observation, record reviews and interviews, the facility failed to ensure food is stored, prepared and distributed in accordance with professional standards in food safety and sanitation to prevent the spread of pathogens, which could result in foodborne illness for the residents. Specifically: 1. The facility failed to ensure frozen foods were maintained frozen. 2. The facility failed to ensure available food was not expired, and that food was dated and securely stored. 3. The facility failed to ensure the dietary staff practiced proper hand hygiene and handled food in a way to minimize possible cross-contamination. 4. The facility failed to ensure the dish machine met proper sanitation requirements when staff used expired test strips and the wrong test strips. 5. The facility failed to ensure staff tested the sanitation buckets used to clean and sanitize the kitchen and surfaces. Findings include: Review of the facility's policy titled (4) Freezers, Policy: It is the policy of the facility that the freezer be maintained in a clean and sanitary condition. 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-04-30 · tag F0553 — failed to let residents help plan their care — pattern
    Allow resident to participate in the development and implementation of his or her person-centered plan of care.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Resident #28 was admitted to the facility in August 2022 and has diagnoses that include but are not limited to Alzheimer's Disease, and urinary tract infection. Review of the Minimum Data Set (MDS) dated [DATE], indicated Resident #28 scored a 0 out 15 on the Brief Interview for Mental Status indicating he/she as having severe cognitive impairment. The MDS also indicated Resident #28 was dependent on staff for most aspects of daily care. On 4/28/25 at 8:38 A.M., Resident #28 was observed near the nursing desk in a recliner chair, Resident #28 was observed to be frail and did not respond to the surveyor's greeting. Review of Resident #28's medical record indicated that Resident #28 had a legal guardian. Review of Resident #28's paper medical record under both the care plan tab and social service tab failed to indicate documentation related to interdisciplinary care plan meetings. Review of Resident #28's electronic medical record indicated a Social Worker note, dated 5/25/24, which indiated the following: -IDT…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-04-30 · tag F0692 — failed to prevent malnutrition and dehydration — pattern
    Provide enough food/fluids to maintain a resident's health.
    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, record reviews and interviews, the facility failed to adequately maintain the nutrition and hydration status of three Residents (#71, #45 and #13) out of a total sample of 24 residents 1. For Resident #71, the facility failed to ensure significant weight loss was assessed and continually monitored. 2. For Resident #45, the facility failed to implement physician's orders for weekly weights, dietary recommendations for fortified foods and the dietitian failed to evaluate significant weight loss following hospitalization. 3. For Resident #15 the facility failed to ensure quarterly nutrition assessments were completed on a resident with a feeding tube. 4. For Resident #13, the facility failed to obtain weights as ordered. Findings include: Review of the facility policy titled, Resident Nutrition Services, dated 2001, indicated the following: -The multidisciplinary staff, including nursing staff, the attending physician and the dietitian will assess each resident's nutritional needs, food…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-04-30 · tag F0803 — failed to meet residents' dietary needs — pattern
    Ensure 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, record review and interview, the facility failed to ensure meals were provided in accordance with standards of nutritional standards to ensure the nutritional needs of residents were met. Specifically, the facility failed to ensure the menu, including the therapeutic breakdown for specialized diets, was provided to the staff serving the daily meals. Findings include: Review of the 268 CMR: BOARD OF REGISTRATION OF DIETITIANS/NUTRITIONISTS 268 CMR 5.00: PROFESSIONAL STANDARDS AND ETHICAL CODES, included but was not limited to the following: (4) Foodservice Systems: In the areas of menu planning, foodservice purchasing, production, distribution and service, safety and sanitation, facility layout, and management, examples of appropriate activities include, but are not limited to, the following: (a) Planning, developing, controlling and evaluating food service systems; (b) Establishing and maintaining standards of food production, service, sanitation, safety, and security; (c) Developing menu patterns and evaluating such for nutritional adequacy; (d) Planning…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-04-30 · tag F0842 — failed to keep accurate, complete medical records — pattern
    Safeguard 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Resident #65 was admitted to the facility in January 2025 with diagnoses that include type 2 diabetes mellitus, dementia and failure to thrive. Review of the Minimum Data Set (MDS) dated [DATE], indicated Resident #65 was unable to complete the Brief Interview for Mental Status (BIMS) and the staff assessed his/her to have severe cognitive impairment. The MDS also indicated Resident #65 is dependent on staff for daily care activities including bathing, dressing and eating. Further review of the MDS indicated Resident #65 as being 66 inches in height and weighing 114 pounds and has the nutritional approach of a feeding tube with the percentage of intake by artificial route as 51% or more. During an interview on 4/29/25 at 9:39 A.M., Certified Nursing Assistant (CNA) #3 said Resident #65 used to receive meal trays but he/she no longer eats or takes anything by mouth. During an interview on 4/29/25 at 4:24 P.M., Nurse #7 said when Resident #65 was admitted he/she had an order for puree food and enteral feeding.…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-30 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of 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, record review and interviews, the facility failed to provide a call light for one Resident (#11) out of a total sample of 24 residents. Findings include: Resident #11 was admitted to the facility in April 2020 with diagnoses including prostate cancer. Review of Resident #11's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 6 out of a possible 15, which indicated he/she had severe cognitive impairment. The MDS also indicated Resident #11 is dependent on staff for functional daily tasks. During an interview on 4/28/25 at 8:39 A.M., Resident #11 was observed lying in bed without a call light in place. Further observation indicated the Resident did not have a call light at all as the string was missing from the wall. Resident #11 said the call light string often breaks and he/she has not had a call light for some time. Resident #11 said he/she would like to have a call light as this is how he/she can call for help…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-30 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    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 Advance Directives (written documents that instruct health care providers of the decisions for specific medical treatment if a person was unable to speak or lacked the capacity to make decisions for themselves) were accurately documented for one Resident (#45) out of a total sample of 24 residents. Specifically, for Resident #45, the facility failed to ensure that Advanced Directives indicated on the MOLST form (Massachusetts Medical Order for Life-Sustaining Treatment form) were consistently documented in the medical record. Findings include: Review of Resident #45's most recent Minimum Data Set (MDS) Assessment, dated 2/1/25, indicated that the Resident could not participate in the Brief Interview for Mental Status Exam and was assessed by staff as having severe cognitive impairment. Further review of the MDS indicated the Resident's code status was a DNR (Do not resuscitate), DNI (Do not Intubate). Review of the medical record indicated a MOLST form signed and dated 9/21/22 that indicated Do Not Resuscitate…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-30 · tag F0641 — isolated
    Ensure 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, record review and interview, the facility failed accurately complete the Minimum Data Set Assessments (MDS) for three Residents (#45, #82 and #72) out of a total of 24 sampled residents. Specifically, 1. For Resident #45 the facility failed to accurately code the presence of a Stage 4 pressure ulcer. 2. For Resident #72 the facility failed to accurately assess his/her behaviors patterns on the comprehensive MDS. 3. For Resident #82 the facility failed to ensure an accurate discharge MDS assessment was completed. Findings include: Review of the Long-Term Care Facility Resident Assessment Instrument User's Manual (RAI Manual) 3.0, Version 1.19.1, dated October 2024 indicated the following: -Clinical standards do not support reverse staging or back staging as a way to document healing, as it does not accurately characterize what is occurring physiologically as the ulcer heals. For example, over time, even though a Stage 4 pressure ulcer has been healing and contracting such that it is less…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-30 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    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, record review and interviews, the facility failed to develop and implement a comprehensive person-centered care plan for two Residents (#31 and #16) out of a total sample of 24 Residents. Specifically, 1. For Resident #1 the facility failed to develop an Activities of Daily Living (ADLs) care plan. 2. For Resident #16, the facility failed to implement a care plan for risk of pressure injury. Findings include: Review of facility policy titled, Care Plans, Comprehensive Person-Centered, not dated, indicated the following: -A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. -1. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 1. Resident #31 was admitted to the facility in September 2024 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
Show the remaining 20 citations
  • Potential for harm · Dcited before2025-04-30 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure that physician's orders were followed for two Residents (#45 and #184) out of a total sample of 24 residents. Specifically, 1. For Resident #45 the facility failed to complete weekly skin checks as indicated in the physician's orders. 2. For Resident #184, the facility failed to implement physician's orders to apply compression stockings. Findings include: 1. Resident #45 was admitted to the facility in October 2023 with diagnoses that include hemiplegia and hemiparesis and anoxic brain injury. Review of Resident #45's most recent Minimum Data Set (MDS) Assessment, dated 2/1/25, indicated that the Resident could not participate in the Brief Interview for Mental Status Exam and was assessed by staff as having severe cognitive impairment. Review of Resident #45's physician's orders indicated the following: -Weekly skin assessment on Mondays, dated 5/6/24. Review of Resident #45's most recent Norton Assessment (an assessment to determine risk 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-30 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide 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 observations, record review and interviews, the facility failed to provide assistance with meals for two Residents (#16 and #5) out of a total sample of 24 residents. Findings include: Review of the facility policy titled, Preparing a Resident for a Meal, dated 2001, indicated the following: -Review the Resident's care plan and provide any special needs of the resident. Review of the facility policy titled, Assisting the Resident with In-Room Meals, dated 2001, indicated the following: -Review the Resident's care plan and provide any special needs of the resident. -Assist the resident as necessary. However, encourage the resident to feed himself or herself as much as possible. Review of the facility policy titled, Resident Nutrition Services, dated 2001, indicated the following: -Nursing personnel or feeding assistants will provide assistance with eating and ensure that assistive devices are available to residents as needed. 1. Resident # 16 was admitted to the facility in September 2007 with diagnoses…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-30 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide 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, record reviews and interviews, the facility failed to ensure standards of quality of care for two Residents (#22 and #35) out of a total sample of 24 residents. Specifically, 1. For Resident #22 the facility failed to identify a change in his/her skin condition and failed to ensure the weekly skin checks documented the skin change. 2. For Resident #35, the facility failed to a. accurately complete skin checks and b. complete skin checks weekly. Findings include: Review of the facility's policy, titled 'Skin Integrity Management Policy and Procedure', dated revised 12/1/2005 indicated the following: The implementation of an individual resident's skin integrity management occurs within the care delivery process. Staff continually observe and monitor residents for changes and implement revisions to the plan of care as needed. 3. Identify resident's skin integrity status and need for prevention intervention or treatment modalities through review of all appropriate assessment information.…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-30 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    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, record review and interviews, the facility failed to 1. follow the wound recommendations for one Resident (#184) and 2. implement wound treatment for a pressure ulcer for Resident (#60) out of a total sample of 24 residents. Findings include: Review of the facility policy 'Skin Integrity Management', undated, indicated: The implementation of an individual resident's skin integrity management occurs within the care delivery process. Staff continually observe and monitor residents for changes and implement revisions to the plan of care as needed. -10A. The Director of Nursing will review all wounds on a weekly basis with the Medical Director. -11. Document care daily in Nurse's Notes/ Treatment Administration Record (TAR) and weekly on Skin Integrity Report. -13. Evaluate resident and Center progress through routie, ongoing review and revision. -Review information at weekly wound meeting. 1. Resident #184 was admitted to the facility in April 2025 with diagnoses including bilateral heel…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-30 · tag F0687 — failed to care for feet properly — isolated
    Provide appropriate foot care.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review and interviews, the facility failed to ensure that one Resident (#31) out of a total sample of 24 residents, received proper treatment and care in accordance with professional standards, to maintain good foot health and prevent complications form the resident's medical conditions. Findings include: Resident #31 was admitted to the facility in September 2024 with diagnoses that include diabetes, adult failure to thrive, pain and acute embolism and thrombosis of the deep veins in the left lower extremity and left foot pain. Review of Resident #31's most recent Minimum Data Set (MDS) Assessment, dated 3/22/25, indicated a Brief Interview for Mental Status (BIMS) score of 14 out of a possible 15, indicating that the Resident is cognitively intact. -On 4/28/25 at 8:29 A.M., the surveyor observed Resident #31 awake in bed. Resident #31 was lying on his/her back with their heels directly on the mattress and blankets resting directly on his/her feet. Resident #31 said that he/she is waiting to see a podiatrist because of pain in his/her feet and problems…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-30 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    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 that services were provided in accordance with professional standards for one Resident (#65) with a gastrostomy tube (g-tube: a tube that is placed directly into the stomach through an abdominal incision for administration of nutrition) out of 2 applicable residents, out of a total sample of 24 residents. Specifically, Resident #65 was not seen by the Registered Dietician, when Resident #65 was no longer provided meal trays and became NPO (nothing by mouth) and had weight loss. Resident #65 was admitted to the facility in January 2025 with diagnoses that include type 2 diabetes mellitus, dementia and failure to thrive. Review of the Minimum Data Set (MDS) Assessment, dated 1/30/25, indicated Resident #65 was unable to complete the Brief Interview for Mental Status (BIMS) and staff has assessed him/her to have severe cognitive impairment. The MDS also indicated the Resident is dependent on staff for daily care activities including…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-30 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and interviews, the facility failed to ensure professional standards of practice for two Residents (#59 and #79) requiring respiratory care and treatment, out of a total sample of 24 residents. Specifically, For Residents #59 and #79, the facility failed to clean the oxygen concentrator filter and failed to provide the oxygen as ordered. Findings include: 1. Resident #59 was admitted to the facility in July 2023 with diagnoses including rheumatoid arthritis and dependence on oxygen. Review of the most recent Minimum Data Set (MDS) assessment, dated 1/8/25, indicated that Resident #59 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 2 out of 15. The MDS also indicated that Resident used oxygen. On 4/28/25 at 8:01 A.M., 4/29/25 at 8:02 A.M., and 4/30/25 at 8:23 A.M., the surveyor observed oxygen concentrator filter covered with a layer of gray dust. During all observations, the Resident's oxygen was set at 4 Liters. Review of Resident #59's physician orders indicated the following order inititated…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-30 · tag F0699 — isolated
    Provide care or services that was trauma informed and/or culturally competent.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, policy review and interviews, the facility failed to ensure a comprehensive care plan was developed for Trauma Informed Care for one Resident (#78) who had a history of trauma out of a total sample of 24 residents. Specifically, for Resident #78, the facility failed to develop a comprehensive trauma care plan, with individualized triggers. Findings Include: Resident #78 was admitted to the facility in April January 2025 with diagnoses that included Post-Traumatic Stress Disorder (PTSD), major depressive disorder, conversion disorder, and anxiety. Review of the most recent Minimum Data Set (MDS) assessment, dated 3/17/25, indicated that Resident #78 had a Brief Interview for Mental Status (BIMS) exam score of 14 out of 15 indicating he/she is cognitively intact. The MDS further indicated Resident #78 has an active diagnosis of PTSD. Review of Resident #78's medical record failed to indicate a plan of care was developed for PTSD with identified triggers or that a trauma assessment was completed. During an interview on 4/30/25 at 8:07 A.M., Nurse #1 said 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-30 · tag F0700 — isolated
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    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 that side rails were implemented in accordance to the Resident assessment for one Resident (#45) out of a total sample of 24 Residents. Findings Include: Review of facility policy titled Informed Consent for Use of Bed Rail(s), undated, indicated the following: -The [facility] will use bed rail(s) only after evaluation and care planning has indicated it is appropriate to treat the resident's medical symptoms and will assist the resident to attain or maintain his/her highest practicable physical and psychosocial well-being, and other considered alternatives are inadequate- The center will endeavor to use the least restrictive device. Resident #45 was admitted to the facility in October 2023 with diagnoses that include hemiplegia and hemiparesis, and anoxic brain injury. Review of Resident #45's most recent Minimum Data Set (MDS) Assessment, dated 2/1/25, indicated that the Resident could not participate in the Brief Interview 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-30 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement 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 records reviewed and interview, the facility 1) failed to ensure one Resident (#71) was free from unnecessary medications by not reassessing a PRN (as needed) psychotropic medication and 2) failed to ensure an Abnormal Involuntary Movement Scale (AIMS) assessment (a test used monitor for adverse consequences of antipsychotic medication) was completed for one Resident (#47) who was receiving antipsychotic medications out of a total sample of 24 Residents. Findings include: The surveyors asked for polilcies for the as needed psychotropic medication and AIMS assessments and they were not provided to them. 1. Resident #71 was admitted to the facility in November 2024 with diagnoses including depression and Alzheimer's Disease. Review of Resident #71's most recent Minimum Data Set (MDS) dated [DATE] indicated the Resident had a Brief Interview for Mental Status (BIMS) of 6 out of a possible15, which indicated he/she had severe cognitive impairment. The MDS also indicated Resident #71 requires supervision 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-30 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and interview the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections . Specifically, 1. The facility failed to maintain Enhanced Barrier Precautions (EBP) while performing wound care on a resident. 2. For Resident #60, the facility failed to implement EBP for a resident with an open wound. 3. The facility failed to provide documentation of measures to prevent the growth of Legionella (can grow in building water systems, particularly in warm, stagnant water and can cause a severe form of pneumonia -Legionnaires' disease) and other opportunistic waterborne pathogens in building water systems. Findings include: Review of the Centers for Disease Control (CDC) website indicated the following, dated June 28, 2024: -Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-05-23 · tag F0801 — widespread
    Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interviews the facility failed to designate a person who met the minimum qualifications to serve as the Director of Food and Nutrition Services (FSD). Findings Include: During an interview on 5/22/24 at 1:41 P.M., Dietary staff #1 said he was employed as a cook at the facility. Dietary staff #1 said that the FSD had resigned around September of 2023 and that the facility had not hired a replacement. [NAME] #1 said he was delegated responsibilities such as ordering food, scheduling staff, and conducting staff in-services in the absence of a Food Service Director. [NAME] #1 said he had completed a food safety course but did not have a certification for food service management, an associates or higher degree in food service management or hospitality, or two or more years of experience in the position of a Director of Food and Nutrition services in a nursing facility setting. During an interview on 5/22/24 at 12:32 P.M., the Registered Dietitian (RD) said she was in the facility two days a week and worked a total of 20 hours a week. The RD said she would expect the staff…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-05-23 · tag F0607 — failed to have anti-abuse policies — pattern
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview the facility failed to conduct CORI (Criminal Offender Record Information) checks for 5 of 5 employee files reviewed, prior to when their employment commenced in the facility. Findings include: The facility policy titled Abuse Program Policy and Procedure, dated 5/10, indicated the following: a. Screening of potential employees will include requesting information from previous and/or current employees and verifying information with appropriate licensing boards and certification registries. b. Criminal background check will be completed. Potential employees with negative findings of background checks will not be hired. Review of the employee files of the 5 most recent hires to the facility indicated the following: -2 of 5 employees never had a CORI completed and had worked at the facility. -3 of 5 employees had CORI checks completed after they began working at the facility. During an interview on 5/23/24 at 11:51 A.M., the Director of Nursing said that CORI checks absolutely must be completed prior to any employee working at the facility.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-23 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    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 record review and interviews the facility failed to ensure a resident-centered personalized care plan was developed and/or implemented for three Residents (#59, #14, and #60) out of a total sample of 19 residents. Specifically, 1. For Resident #59, the facility failed to ensure a resident-centered personalized care plan was developed for a pacemaker. 2. For Resident #14, the facility failed to apply booties per his/her physician's order. 3. For Resident #60, the facility failed to implement the use of built up handled utensils for all meals. Findings include: Review of the facility policy titled Pacemaker, dated 12/15, indicated For each resident with a pacemaker, document the following in the medical record and on a pacemaker identification card upon admission: a. The name, address and telephone number of the cardiologist; b. Type of pacemaker; c. Type of leads; d. Manufacturer and model; e. Serial number; f. Date of implant; and g. Paced rate. 1. Resident #59 was admitted to the facility in June 2021…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-23 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    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 ensure that acceptable parameters of nutritional status were maintained for one Resident (#30) out a total sample of 19 Residents. Specifically, the facility failed to address a clinically significant weight loss in a timely manner. Findings include: Review of the undated facility policy, titled Nutritional Management Policy indicated, but was not limited to, the following: -If the resident's weight differs by three (3) pounds (one kilogram = 2.2 pounds) more or less, the resident is to be reweighed on the same day. Any weight loss or gain of 3 pounds or greater requires the resident to be placed on weight focus review and dietitian should be notified. -Upon admission, quarterly, significant change of status, and annually the Registered Dietitian will evaluate each residents nutritional needs. -Residents who experience an unplanned significant weight loss or gain of more than 5% in one month and/or 10% in six months will be referred 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-12-15 · tag F0727 — failed to provide required RN coverage — widespread
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on records reviewed and interviews, the facility which maintained an average daily occupancy of greater than 60 residents (averaging 78 resident per day), failed to ensure the Director of Nurses (DON) did not serve as a charge nurse on a unit. Findings include: Review of the Facility's Job Description for The Director of Nurses (DON), dated and signed by the Director of Nurses on 11/22/20, indicated the Director of Nurses manages the services provided by the nursing personnel, oversees and manages nursing personnel, and has knowledge of regulations pertaining to long term care administration. Review of the Census Daily Detail Reports, dated 11/01/23 through 12/14/23, indicated that the Facility consistently maintains a daily census of greater than 60 residents. Review of the Facility's Midnight Census Report, dated 12/15/23, indicated the Facility census was greater than 60 residents. During interview on 12/15/23 at 8:32 A.M., and throughout the day of the survey, the Director of Nurses (DON) said she has worked as a charge nurse on the nursing unit at times. The DON said 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-11-17 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    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 policy reviews and interviews, the facility failed to investigate a potential incident of verbal abuse for 1 Resident (#61) out of a total sample of 19 residents. Findings include: Review of the facility policy titled, Abuse Prevention Program: Investigations, undated, indicated the following: *The facility investigates all potential and actual abuse, and protects the residents during the investigation process from possible and actual harm. *Should an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source be reported, the Administrator, or his/her designee, will appoint a member of management to investigate the alleged incident. The Clinical Director is responsible for investigation if in the building. *The individual conducting the investigation will, as a minimum: a. Review the completed documentation forms b. Review the patient's medical record to determine events leading up to the incident c. Interview the person(s) reporting the incident d. Interview 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-11-17 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and policy review, the facility failed to obtain a physician's order for a dressing for 1 Resident (#65) out of a total sample of 19 residents. Findings include: Review of facility policy titled 'Dressings, Dry/ Clean', undated, indicated: *Purpose: The purpose of this procedure is to provide guidelines for the application of dry, clean dressings. *Preparation: Verify that there is a physician's order for this procedure. Resident #65 was admitted to the facility in September 2018 with diagnoses including weakness, dysphagia (trouble swallowing) and hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body). Review of Resident #65's Minimum Data Set Assessment (MDS) dated [DATE] indicated the Resident was unable to complete the Brief Interview for Mental Status Exam (BIMS) and staff assessment for mental status indicated short and long term memory problems. The MDS further indicated the Resident had no behaviors, did not reject…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-11-17 · tag F0725 — failed to have enough nursing staff — isolated
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    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 ensure there was sufficient staffing in place to provide an escort for 1 Resident (#61) to attend his/her medical appointments out of a total sample of 19 residents. Subsequently, Resident #61's medical appointments had to be rescheduled twice as there was no staff available to go with him/her. Findings include: Resident #61 was admitted to the facility in March 2018 with diagnoses including glaucoma and pulmonary fibrosis. Review of his/her most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated he/she is cognitively intact, legally blind, and requires assistance with ambulation, dressing and toileting. During an interview with Resident #61 on 11/16/22 at 8:45 A.M., he/she said that there is not enough staff available at the facility. Resident #61 said he/she has missed a few appointments because the facility cannot pull a CNA (Certified Nurses Aide) off the unit to accompany him/her to his/her appointments. Review of Unit 2 East's…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-11-17 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain accurate medical records for 2 Residents (#1 and #65) out of a total sample of 19 residents. Findings include: 1. For Resident # 65 the facility failed to accurately document the route of administration for a medication. Review of facility policy titled 'Administering Medications', undated, indicated the following: -Medications must be administered in accordance with the orders, including any required time frame. -As required or indicated for a medication, the individual administering the medication will record in the resident's medical record: the date and time the medication was administered; the dosage; the route of administration; the injection site (if applicable); any complaints or symptoms for which the drug was administered; any results achieved and when those results were achieved; and the signature and title of the person administering the drug. Resident #65 was admitted to the facility in September 2018 with diagnoses…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction

“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.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • 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.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$96,705 in federal fines across 1 penalty.

  • $96,705 — penalty dated 2025-07-10

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Who owns this facility

Owner / managerTypeRoleSince
FEASTER, JOSEPHIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROLsince 04/03/2024
MARK, DELICIAIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 05/28/2024
HANSPARD, KENYAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/21/2025

CMS files one row per role, so the 6 rows in the source record cover these 3 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

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.

$9.3M
Net patient revenuemost recent cost report
-21.3%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 58%Medicare 2%Other / private 40%

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

$381per resident / day
operating cost
$11,589per month
≈ monthly operating cost
$314per day
avg. revenue, all payers

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

Paying with Medicaid

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.

Typical monthly cost in Massachusetts
$14,448/mo
Nursing home (semi-private)
$15,817/mo
Nursing home (private)
$9,600/mo
Assisted living

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 225654. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-30, 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 →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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