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John Scott House Nursing & Rehabilitation Center

233 Middle Street, Braintree, MA 02184 · For profit - Limited Liability company · 138 certified beds · (781) 843-1860 Medicare & Medicaid certified

Call the home — (781) 843-1860 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0610) — cited Dec 2022Behavioral-health or dementia-care citation — no harm found (F0758)2 actual-harm citations
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
  • lower-than-typical staff turnover (31% vs 45% nationally) — better care continuity
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 2 actual-harm citations
  • a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags

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.

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

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
400 Washington St · (781) 849-7330 · Call to confirm hours
Pharmacy
178 Washington St · (781) 843-0731 · Call to confirm hours
Grocery
390 Washington St · (781) 817-5096 · Call to confirm hours
Park
Typically dawn to dusk

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 3 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 improved from 3 to 5 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 rating5★
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 increased13.1%16.4%15.4%better
Long-stay residents who lose too much weight6.1%5.1%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%0.8%0.9%better
Long-stay residents with a urinary tract infection1.7%1.8%2.0%better
Long-stay residents with depressive symptoms0.7%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 injury0.6%3.4%3.3%better
Long-stay residents whose ability to walk worsened9.5%15.4%16.1%better
Long-stay residents on antianxiety or hypnotic medication12.7%19.5%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%94.8%95.3%typical
Long-stay residents with pressure ulcers2.1%4.2%4.7%better
Long-stay residents with worsening bladder/bowel control22.3%21.2%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table17.5%21.4%17.1%typical
Short-stay residents who newly got an antipsychotic medication0.8%1.4%1.4%better
Short-stay residents given the seasonal flu vaccine90.2%77.7%79.4%better
Short-stay residents rehospitalized after admission30.7%25.7%22.6%worse
Short-stay residents with an outpatient ER visit7.6%11.9%12.0%better
Long-stay hospitalizations per 1,000 resident days1.391.881.67better
Long-stay outpatient ER visits per 1,000 resident days0.531.501.80better

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.

61.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 273 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

61.7%U.S. median 51.5%
Got home and stayed home
10.7%U.S. median 10.7%
Went back to hospital
21.7%U.S. median 56.6%
Met the expected recovery
0.32U.S. median 0.31
Therapy hours / resident / day
0.12hours / resident / day
Physical therapy
0.15hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 21.7% 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 161 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 0.32 therapist hours per resident per day in 2026Q1 — more than 53% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 23% 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 SNF61.7%CMS range 56.2–67.251.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.7%CMS range 7.7–13.310.7%Oct 2022–Sep 2024no 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 discharge21.7%56.6%Oct 2024–Sep 2025CMS 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 discharge18.6%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge24.8%50.0%Oct 2024–Sep 2025CMS 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 identified98.5%98.7%Oct 2024–Sep 2025CMS 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 setting98.9%100.0%Oct 2024–Sep 2025CMS 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 discharge98.5%98.7%Oct 2024–Sep 2025CMS 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 stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened1.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization8.0%CMS range 5.4–13.27.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.841.02Oct 2022–Sep 2024CMS 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

0.75
RN hours/ resident / day
0.85
LPN hours/ resident / day
2.05
Aide hours/ resident / day
3.65
Total nurse hours/ resident / day
0.50
RN hoursweekends
31.4%
Total nursing turnover
42.9%
RN turnover

How full it usually is: this home is certified for 138 beds and averages 112.5 residents a day — about 82% 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 3.65 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.75 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.05 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 3.26 hrs/resident/day on weekends vs 3.81 on weekdays — 14% thinner on weekends. RN hours go from 0.85 to 0.50 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 31% 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

6
deficiencies at the latest standard inspection (2025-04-02)
3
at the previous standard inspection (2024-04-30)

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.

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

  • Actual harm · G2022-12-30 · 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

    Based on observation, record review, policy review, and interviews, the facility failed to promote and manage the delivery of safe nursing care in accordance with accepted Standards of Nursing Practice by failing to implement wound care recommendations to promote wound healing for one Resident (#64), in a total sample of 22 residents, which resulted in deterioration of an arterial wound to the Resident's left ankle. Findings include: Review of the facility's policy titled Wound and Skin Care Protocols/Definitions, last revised September 2022, included but was not limited to: -The interdisciplinary plan of care will address problems, goals, and interventions directed toward the prevention and/or treatment of impaired skin integrity/pressure injury/ulcer; -Monitor and document interventions and outcomes; -Reclining and dependent residents should have position changes, alternating or low air loss mattress addressed in their care plan; -Use pillows or foam wedges to keep bony prominences such as knees and ankles from direct contact with each other; Resident #64 was admitted 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
  • Actual harm · G2022-12-30 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record review, the facility failed to ensure pain management consistent with professional standards and the resident's goals and preferences was provided to one Resident (#66), out of a total sample of 22 residents. Specifically, for Resident #66, the facility failed to administer medications timely and manage pain effectively during a dressing change. Findings include: Review of the facility's policy titled Pain Management Guidelines, last updated September 2022, included but was not limited to: -Attempts to control pain will be employed and adjusted until the resident reaches an acceptable comfort level. When several medications or varying doses of medication are used to control pain, criteria must be established to identify varying levels of pain. Resident #66 was admitted to the facility in November 2022 with diagnoses including a history of falls and a pelvic fracture. Review of the most recent Minimum Data Set (MDS) assessment, dated 11/24/22, indicated the Resident was cognitively intact as evidenced by a Brief Interview for Mental…

    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 · Dcited before2026-01-15 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the 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 records reviewed and interviews for one of three sampled residents (Resident #1), who had an invoked Health Care Proxy (HCP), the Facility failed to ensure that staff promptly notified his/her Health Care Agent (HCA) and his/her Physician when he/she experienced a significant change in status related to a fall.Findings include:Review of Facility Policy titled Change in Resident Condition, dated as last revised 09/2025, indicated the Facility will promptly notify the resident, his or her Physician, and the resident representative of changes in the resident's medical/mental condition and/or status.The Policy indicated that the nurse would notify the resident's physician when there has been an accident or incident. During a telephone interview on 01/13/26 at 3:39 P.M., Family Member #1 said on 10/28/25, she went to visit Resident #1 and when she walked into his/her room she immediately noticed a bruise near his/her right eye and asked the nurse where the bruise had come from. Family Member #1 said that 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.

    Resident Rights Deficiencies · Past Non-Compliance
  • Potential for harm · Dcited before2026-01-15 · 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 records reviewed and interviews for one of three sampled residents (Resident #1), who experienced an unwitnessed fall, the Facility failed to ensure he/she was provided care and treatment that met professional standards for quality of care, when he/she was not adequately assessed and monitored by nursing after being found on the floor after an unwitnessed fall.Findings include:Review of the Facility Policy titled Falls Program Policy, dated as last reviewed 09/2025, indicated that the documentation of a fall should include;-Notification to Physician and family;-Complete Fall Incident Report;-Fall investigation Report and obtain witness statements;-Monitor Vital Signs; and-Neurological Checks for any unwitnessed falls. Resident #1 was admitted to the Facility in 10/2025 diagnoses include status post fall sustaining a subdural hematoma (brain bleed) requiring a right craniotomy (surgical procedure removing part of the skull to get to the brain), Parkinson's disease, and anticoagulation use. Review of…

    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 · Past Non-Compliance
  • Potential for harm · E2025-04-02 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to ensure the residents' environment was clean, comfortable, and homelike. Specifically, the facility failed: 1. To ensure two ([NAME] 1 and East 2) out of four units were homelike, comfortable, and in overall good repair; 2. To ensure the Whirlpool tub room and room [ROOM NUMBER] East were free of water damage; and 3. To maintain and clean the window air conditioner in room [ROOM NUMBER] East. Findings include: Review of the facility's policy titled Environment of Care, dated 9/24, indicated but was not limited to the following: -Responsibilities of the maintenance department will include but not to be limited to painting, mechanical repairs (electrical, plumbing), and grounds keeping. -The facility has a program of preventative maintenance and safety, which are to be implemented by the maintenance department. Review of the facility's policy titled Environment of Care- EOC manual, dated 9/24, indicated but was not limited to the following: -The facility…

    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 · D2025-04-02 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and records reviewed, for one Resident (#55) of 23 sampled residents, the facility failed to treat each resident with respect and dignity and care for each resident in a manner that promotes maintenance or enhancement of his/her quality of life while recognizing his/her individuality. Specifically, for Resident #55, the facility failed to identify and maintain the Resident's wishes to grow a handlebar mustache. Findings include: Review of the facility's policy titled Resident Right and Organizational Ethics and Resident Rights and Overview, dated 10/17, indicated but was not limited to: -individual rights will be retained by all residents/patients of the facility -this facility will protect and promote the rights of each patient/resident as described below -residents have the right to the quality of life that supports independent expression, choice, and decision-making, consistent with all applicable laws and regulations -residents have a right to perform or refuse to perform tasks in or for the facility -residents have a right to refuse care 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-02 · 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 observation, interview, and record review, the facility failed to implement the person-centered plan of care for one Resident (#74), out of 23 sampled residents. Specifically, the facility failed to implement the care plan interventions for safe swallowing strategies for a resident with oropharyngeal dysphagia (a condition that affects the movement of food and liquid from the mouth to the esophagus during swallowing). Findings include: Resident #74 was admitted to the facility in February 2025 with diagnoses of dementia and dysphagia. Review of the Minimum Data Set (MDS) assessment, dated 3/4/25, indicated Resident #74 scored 9 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident had a moderate cognitive impairment. The MDS further indicated Resident #74 had a swallowing disorder as presented by complaints of pain or difficulty while swallowing, had a mechanically altered diet and received supervision for eating (helper provides verbal cues or touching assistance as 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-02 · tag F0712 — isolated
    Ensure that the resident and his/her doctor meet face-to-face at all required visits.
    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 one Resident (#62), in a sample of 23 residents, had been seen by a physician/Nurse Practitioner (NP) every 60 days. Findings include: Review of the facility's policy titled Essential Guidelines for Licensed Independent Practitioners, dated as reviewed September 2024, indicated but was not limited to the following: -In keeping with Company, State, Federal, and JCAHO (Joint Commission on Accreditation of Healthcare Organizations) regulations for long term care facilities, the following requirements apply to physicians and/or licensed independent practitioners treating patient/residents within facilities; -Patient/Residents require reassessment and an updated medical care plan at a minimum of every 30 days for the first 90 days, every 60 days thereafter, and as needed in between as indicated by clinical condition; -Progress notes and signed and dated physician orders are required at each physician visit. Resident #62 was admitted to the facility in May 2020. Review of Physician's Progress Notes indicated Resident #62…

    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 before2025-04-02 · tag F0812 — failed to store, cook, and serve food safely — isolated
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to ensure the main kitchen floor and ceiling were maintained in a sanitary and safe condition. Findings include: Review of the 2022 Food Code by the Food and Drug Administration (FDA), revised 1/2023, indicated but was not limited to the following: 1-2 Definitions 1-201 Applicability and Terms Defined 1-201.10 Statement of Application and Listing of Terms. Easily Cleanable. (1) Easily cleanable means a characteristic of a surface that: (a) Allows effective removal of soil by normal cleaning methods; (b) Is dependent on the material, design, construction, and installation of the surface; and (c) Varies with the likelihood of the surface's role in introducing pathogenic or toxigenic agents or other contaminants into food based on the surface's approved placement,…

    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 · D2025-04-02 · tag F0924 — isolated
    Put firmly secured handrails on each side of hallways.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to ensure a secure handrail was in place on one Unit (East 2) out of four total Units. Findings include: On 3/31/25 at 2:30 P.M., the surveyor observed and tested the handrails on the East 2 unit. The surveyor was able to move three separate pieces of handrails with minimal effort in three different areas on the unit where the handrails had come loose from the wall. The surveyor observed residents walking in the hallway on the East 2 unit. During an interview on 3/31/25 at 3:35 P.M., the Director of Nurses said all handrails should be affixed securely to the wall. She said the handrails were used by residents and should not be loose or unsecure. During an interview on 3/31/25 at 3:50 P.M., the Administrator said the handrails not being securely fashioned to the walls were a concern and having them repaired was a priority for safety. He said there was not a specific process for identifying broken handrails but he depends on staff to inform the maintenance department when they are loose. He said the handrails in all locations…

    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 · Dcited before2024-07-18 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    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 has an activated Health Care Proxy (HCP), the Facility failed to ensure that staff promptly notified Resident #1's Health Care Agent (HCA) when he/she experienced a change in status with a decline in condition, which resulted in the need for new physician's orders related to a change in his/her treatment plan. Findings include: Review of the Facility Policy titles, Change on Resident Condition, dated as last revised 06/2024, indicated that the Facility shall promptly notify the resident, his/her Attending Physician, and the resident's representative of changes in the resident's medical/mental condition and/or status. The Policy further indicated that unless otherwise instructed by the resident, the nurse will notify the resident's representative when there is a significant change in the resident's physical, mental, or psychosocial status. Resident #1 was admitted to the Facility in February 2023, diagnoses include Alzheimer's type dementia, acquired hypothyroidism with history of thyroid…

    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 · E2024-04-30 · tag F0883 — failed to offer flu and pneumonia vaccines — pattern
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    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, policy review, and interview, the facility failed to provide education, assess eligibility, and offer Pneumococcal Vaccinations per the Centers for Disease Control and Prevention (CDC) recommendations and facility policy for three Residents (#9, #67, and #52), out of a total sample of five residents. Specifically, the facility failed to ensure that staff offered, assessed, and provided education on the recommended 20-Valent Pneumococcal Conjugate Vaccine (PCV20) (an active immunizing agent used to prevent infection caused by certain types of pneumococcal bacteria). Findings include: Review of the facility's policy titled Infection Control, Pneumococcal Vaccine, dated as reviewed 9/2023, indicated but was not limited to the following: - residents admitted to or residing in the facility will be offered the Pneumococcal conjugate vaccine (PCV 13, PCV 15 or PCV 20) based on availability of the vaccine and the individual's previous vaccination history. This vaccine is only administered once…

    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
Show the remaining 12 citations
  • Potential for harm · D2024-04-30 · 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, interviews, and policy review, the facility failed to develop a person-centered plan of care which included trauma informed approaches and identified triggers to avoid potential re-traumatization for two Residents (#10, #100), out of a total sample of 23 residents. Specifically, the facility failed: 1. For Resident #10, to identify triggers related to his/her known history of post-traumatic stress disorder (PTSD- a mental health condition that is triggered by an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being) to avoid potential re-traumatization; and 2. For Resident #100, to complete a trauma assessment resulting in the facility failing to provide trauma informed care. Findings include: Review of the facility's policy titled Trauma Informed Care and Post-Traumatic Stress Disorder (PTSD), revised 9/2023, indicated but was not limited…

    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 · Dcited before2024-04-30 · 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 observation, interview, policy review, and record review, the facility failed to follow Enhanced Barrier Precautions guidelines while performing wound care for one Resident (#51), out of one observed wound care treatment. Findings include: Review of the facility's policy titled Enhanced Barrier Precautions, dated as new 4/29/24, indicated but was not limited to the following: -Enhanced Barrier Precautions (EBP) refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities -EBP are used in conjunction with standard precautions and expand the use of Personal Protective Equipment (PPE) to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of Multi-drug Resistant Organisms (MDRO) to staff hands and clothing -EBP are indicated for residents with any of the following: -Infection or colonization with a Center for Disease Control (CDC) targeted MDRO when Contract Precautions do not otherwise…

    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 · E2022-12-30 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — pattern
    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

    Based on observations, interviews, and record reviews, the facility failed to ensure pressure relieving devices were utilized following professional standards for 3 Residents (#59, #20, and #66), in a sample of 7 residents with pressure ulcers. Specifically, the facility failed to ensure 1. For Resident #59, an ROHO cushion (an inflatable seat cushion) was checked for proper inflation to promote pressure ulcer healing; 2. For Resident #20, the proper use of a gel seating cushion by placing a folded sheet between the Resident and the cushion; and 3. For Resident #66, the pressure relieving air mattress was consistently set to optimize wound healing. Findings include: 1. Resident #59 was admitted to the facility in June 2021 with an unstageable pressure area to the left buttock. Review of the Physical Therapy Progress Notes indicated on 6/25/21 Resident #59 was provided with a 3-inch high ROHO cushion related to the pressure area on the buttock. Review of the wound consultant Physician's Wound Evaluation and Management Summary, dated 12/23/22, indicated Resident #59 had a stage 4…

    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 · E2022-12-30 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    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

    Based on observations, interviews, and record review, the facility failed to maintain an environment free of accident hazards for one Resident (#44), out of a sample of 22 residents. Specifically, the facility failed to ensure that effective care plan interventions were developed and implemented to prevent nine falls in a six month period. Findings include: Review of the facility's policies titled Falls Program Policy and Incident Reporting, both last revised September 2022, included but was not limited to: -Purpose: To prevent the actual occurrence of falls and reduce the risk of any injury from a fall; -Residents experiencing a fall will receive appropriate care with investigation of cause; -Care plan will reflect new intervention initiated if fall should occur; -When an incident involving a resident occurs, a nurse will document the incident in a nursing note and complete an incident report. Be sure the form is complete. These reports shall contain information that is pertinent, factual, accurate, objective, and concise; and -Incidents involving residents that fall will have 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-12-30 · tag F0812 — failed to store, cook, and serve food safely — pattern
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and policy review, the facility failed to store food in accordance with professional standards for food service safety and maintain a sanitary kitchen environment. Findings include: Review of facility's kitchen policy titled Food Storage and Preparation, dated August 2017, and reviewed with no changes in September 2022, indicated but was not limited to the following: -All food items will be wrapped properly and tightly, or stored in clean, covered containers clearly marked, including the preparation date and discard date. -All temperature control for safety foods (TCS), ready to eat (RTE) or leftover foods will be labeled and dated with the date the food was prepared and a discard date. -All ready to eat salads or leftovers will be discarded within five calendar days from the preparation day, including day one. -Dry Storage: Once the package has been opened, the product should be stored in a clean sanitized tightly covered container, clearly labeled with common name of the 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-12-30 · tag F0880 — failed to prevent and control infections — pattern
    Provide 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, record review, and policy review, the facility failed to establish and maintain an infection prevention and control program to help prevent the development and potential transmission of communicable diseases and infections in the facility. Specifically, the facility failed to: 1. Ensure that healthcare personnel performed hand hygiene per the facility policy during a clean dressing change for Resident #66; 2. Ensure that healthcare personnel performed hand hygiene, and donned (put on) and doffed (took off) the appropriate personal protective equipment (PPE) prior to entering resident rooms as indicated by posted signs outside of resident rooms; and 3. Follow infection control procedures while administering a COVID-19 Binax test. Findings include: 1. Resident #66 was admitted to the facility in November 2022 with diagnoses which included fracture of lumbosacral spine and pelvis. Review of the facility's policy titled Dry/Clean Dressings, revised September 2013, indicated but 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-12-30 · tag F0552 — isolated
    Ensure that residents are fully informed and understand their health status, care and treatments.
    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 one Resident's (#155) right to be informed of, and participate in, his/her treatment plan was honored when his/her Health Care Agent, which was not invoked, made treatment decisions, out of a total sample of 22 residents. Findings include: Review of the facility's handbook titled Resident Rights, dated as revised October 2022 indicated resident rights included but was not limited to: -right to be informed of, and participate in, his/her treatment. Resident #155 was admitted to the facility in December 2022 with diagnoses that included coronary disease, history of diabetes, and bipolar disorder. During an interview on 12/27/22 at 9:10 A.M., Resident #155 said he/she had been admitted for short term care. Resident #155 said there was poor communication between him/her and the staff, including the physician. Resident #155 said medication changes had occurred and the facility staff or physician had not informed him/her of the changes,…

    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 · D2022-12-30 · 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

    Based on observations, interviews, and record review, the facility failed to ensure an alleged perpetrator (Nurse #1) did not have access to an alleged victim (Resident #20) following an allegation of sexual abuse. The total sample was 22 residents. Findings include: Resident #20 was admitted to the facility in June 2019. Review of the Minimum Data Set (MDS) assessment, dated 10/13/22, indicated Resident #20 scored a 15 out of 15 on the Brief Interview for Mental Status, indicating the Resident was cognitively intact. During an interview on 12/27/22 at 3:45 P.M., Resident #20 said he/she had been raped on 12/24/22 or 12/25/22 by four or five men. The surveyor immediately notified Unit Manager #2. The surveyor observed Unit Manager #2 interview Resident #20. Resident #20 said he/she had been dragged out of their room by four or five men and rectally raped over a barrel. He/she said one of the men was a family member and one of the men was Nurse #1. The Resident said he/she was not sure if Nurse #1 physically participated but had watched the rape occur. The Resident said he/she had…

    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 before2022-12-30 · 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

    Based on observation, interview, policy review, and record review, the facility failed to ensure Resident #67 was provided care in accordance with professional standards of practice from a total sample of 22 residents. Specifically, the facility failed to ensure: a. orders were in place for fingerstick blood tests, and b. bilateral seizure pads were in place and the Resident's foot was elevated on pillows while in bed according to physician's orders. Findings include: Review of the facility's policy titled Nursing Care of the Resident with Diabetes Mellitus, last revised December 2015, included but was not limited to: Glucose Monitoring -The management of individuals with diabetes mellitus should follow relevant protocols and guidelines; -The Physician will order the frequency of glucose monitoring; -Residents whose blood sugar is poorly controlled or those taking insulin may require more frequent monitoring; -Finger sticks (capillary blood samples (CBG)) measure current blood glucose levels. Resident #67 was admitted to the facility in December 2020 with diagnoses 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-12-30 · tag F0694 — isolated
    Provide for the safe, appropriate administration of IV fluids for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, policy review, interview, and record review, the facility failed to ensure staff provided care for a Peripherally Inserted Central Catheter (PICC - a long catheter inserted through a peripheral vein then into the central vascular system to administer intravenous (IV) treatments over a long period of time) for one Resident (#157), out of a total sample of 22 residents. Specifically, the facility failed to ensure PICC line flushes, assessment, tubing changes, and dressing changes were completed and documented before and after the catheter became occluded (blockage of the access line) which caused a delay in administering the Resident's antibiotics to treat a serious infection. Findings include: Review of the facility's policies for PICC/Central Venous Access Device (CVAD) for flushing, for Catheter needleless connector changes, for Catheter dressing change and for clearing Catheter Occlusions (dated as reviewed January 2022) included but was not limited to: -Flushing is performed to ensure and maintain patency -A physician's order is required to flush a PICC…

    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 · D2022-12-30 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the facility failed to ensure residents were provided respiratory care in accordance with professional standards of practice for two Residents (#22 and #28) receiving Oxygen therapy, out of a sample of 22 residents. Findings include: [NAME] NURSING PROCEDURES, 8th edition Oxygen: all Oxygen delivery systems should be checked at least once each day -verify the practitioner's order for the Oxygen therapy, because Oxygen is considered a medication or therapy and should be prescribed -monitor the patient's Oxygen saturation level by pulse oximetry to assess response to Oxygen therapy - assess the patient frequently for signs and symptoms of hypoxia, such as restlessness, decreased level consciousness, increased heart rate, arrhythmias, perspiration, dyspnea, use of accessory muscles, yawning or flared nostrils, cyanosis, and cool, clammy skin, obtain vital signs, as needed. DOCUMENTATION: record the date and time of Oxygen administration, the type of…

    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 · D2022-12-30 · 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

    Based on record review, policy review, and staff interviews, the facility failed to ensure drug regimens were free from unnecessary medications for 2 Residents (#155 and #25), from a sample of 5 residents with potential unnecessary medications. Specifically, the facility failed to ensure 1. For Resident #155, an antipsychotic medication ordered as needed (PRN) was limited to 14 days and was reviewed by the physician with a documented rationale for continued use. 2. For Resident #25, a psychotropic medication ordered as needed (PRN) was limited to 14 days and was reviewed by the physician with a documented rationale for continued use. Findings include: Review of the facility's policy titled Antipsychotic Medication Use, dated September 2022, indicated antipsychotic medication will be used based on a comprehensive assessment. Residents who have not used psychotropic drugs are not given those drugs unless such drug therapy is necessary to treat a specific condition, as diagnosed and documented in the clinical record and informed written consent must be obtained and documented prior 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.

    Pharmacy Service 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

No federal fines in the current CMS record.

Part of a chain

This home belongs to BANECARE MANAGEMENT — 7 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 →

RatingThis homeChain avg
Overall 5 of 54.0+1.0 vs chain
Health inspection 4 of 53.9+0.1 vs chain
Staffing 4 of 53.6+0.4 vs chain
Quality measures 5 of 53.9+1.1 vs chain
The other 6 homes this chain runs (chain average 4.0★, 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 / managerTypeRoleShareSince
MORRIS HEALTH MANAGEMENT LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 01/28/2022
FARIA, MARIEIndividualW-2 MANAGING EMPLOYEEsince 01/28/2022
BANE CARE MANAGEMENT LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 07/01/2016

2 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.

$15.4M
Net patient revenuemost recent cost report
-1.6%
Operating marginrevenue minus expenses
$847K
Related-party expense5% of expenses
Who pays — share of resident-days
Medicaid 59%Medicare 11%Other / private 29%

This home reported $847K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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

$378per resident / day
operating cost
$11,481per month
≈ monthly operating cost
$372per 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 225054. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-02, 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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