Brighton Post Acute Care
170 Corey Road, Brighton, MA 02135 · For profit - Limited Liability company · 78 certified beds · (617) 731-0515 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a middle-of-the-pack inspection score (3/5)
- 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 1 actual-harm citation
- a high number of inspection citations overall (31) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $200,070 in federal fines (most recent 2023-11-03)
- its payroll-based staffing rating is low (2/5)
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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 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 held steady at 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 19.2% | 16.4% | 15.4% | worse |
| Long-stay residents who lose too much weight | 3.5% | 5.1% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.8% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.5% | 1.8% | 2.0% | better |
| Long-stay residents with depressive symptoms | 37.8% | 15.5% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 1.9% | 3.4% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 15.4% | 15.4% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 15.1% | 19.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 98.3% | 94.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.5% | 4.2% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 23.2% | 21.2% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 12.0% | 21.4% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.7% | 1.4% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 64.6% | 77.7% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 25.4% | 25.7% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 10.4% | 11.9% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.72 | 1.88 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 1.79 | 1.50 | 1.80 | typical |
‡ 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.
54.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 191 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 61.2% 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 49 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 0.24 therapist hours per resident per day in 2026Q1 — more than 32% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 33% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 54.5%CMS range 47.5–62.3 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.5%CMS range 7.9–14.6 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 61.2% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 46.9% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 59.2% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.4% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 5.9%CMS range 3.0–10.4 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.97 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 78 beds and averages 73.1 residents a day — about 94% occupied, or roughly 5 beds typically open. It runs fairly full. 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 3.74 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.97 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.96 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 3.00 hrs/resident/day on weekends vs 4.04 on weekdays — 26% thinner on weekends — a notable drop. RN hours go from 1.20 to 0.40 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 53% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are 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.
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.
31 citations, most serious first. The 11 most serious are shown; the remaining 20 are one tap away and print in full.
- Actual harm · H2023-11-03 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure 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 observation, record review, and interview, the facility failed to 1.follow the care plan intervention to prevent a fall with a fracture and laceration for one Resident #1.2. implement and develop appropriate interventions to prevent a fall with a fracture for one Resident (#35), 3. complete a fall investigation report after a fall for one Resident (#7), and 4. keep one Resident (#67) free from accidents/hazards after ingestion of lotion with subsequent hospitalization, . 5(a). For Resident #5, the facility failed to implement a scoop mattress intervention in a timely manner (b). have a bed alarm in good working condition out of a total sample of 30 residents. Findings include: Review of the facility policy titled Falls Program Policy, dated 09/2023, indicated the following: - Fall assessment should be completed upon admission, re-admission, quarterly, significant change in resident status and as needed. Identify residents fall risk after completing and reviewing the fall assessment. - Develop…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-11-14 · tag F0712 — patternEnsure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure physician visits were completed as required for three Residents (#32, #4 and #15) out of a total of 22 sampled residents. Findings include: 1. Resident #32 was admitted to the facility in December 2024 with diagnoses including heart failure, asthma and respiratory failure. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #32 was cognitively intact evidenced by a score of 13 out of a possible 15 on the Brief interview for Mental Status Exam (BIMS). Review of Resident #32's clinical record indicated he/she had been seen by the Physician on 12/28/24 and 9/2/25 and by the Nurse Practitioner (NP) on 1/3/25, 1/4/25, 1/7/25, 3/28/25, 4/15/25, 5/20/25, 6/8/25, 7/9/25, 7/27/25, 8/1/25 and 8/8/25. Resident #32 was not seen in February 2025 as required and the Physician did not alternate visits with the NP, as required. During an interview on 9/26/25 at 11:03 A.M., the Medical Director (Resident #32's attending physician)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-11-14 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard 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 record review and interview, the facility failed to maintain medical records in accordance with accepted professional standards and practices that are complete and readily accessible for facility staff for four Residents (#8, #44, #32 and #42) out of a total sample of 22 residents. Specifically:1. For Resident #44 and #8, the facility failed to ensure the Physician and other licensed professionals' progress notes were documented in the Electronic Health Record (EHR).2. For Resident #42, the facility failed to ensure nursing staff accurately documented the administration of lidocaine pain patches.3. For Resident #32, the facility failed to accurately document the cleaning of an oxygen concentrator filter. Findings include: 1. Resident #44 was admitted to the facility in March 2022 with diagnoses including end stage renal disease, acute kidney failure, dependence on renal dialysis, shortness of breath atherosclerotic heart disease, essential primary hypertension, chronic atrial fibrillation,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-11-14 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably 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 observation, record review and interview, the facility failed to ensure a call light was able to be utilized for one Resident (#15), out of a total of 22 sampled residents. Findings include: Review of the facility policy titled, Call Bell Procedure, dated as reviewed September 2024, indicated: Purpose: The purpose of this procedure is to respond to the resident's requests and needs. 5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. Resident #15 was admitted to the facility in January 2023 with diagnoses including stroke and cognitive communication disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #15 is cognitively intact as evidenced by a score of 15 out of a possible 15 on the Brief Interview for Mental Status exam and is dependent on staff for all activities of daily living. During an interview on 9/24/25 at 8:29 A.M., Resident #15 asked the surveyor to pick up his/her television remote control…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-11-14 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
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 attending care plan meetings was offered to one Resident (#44) out of a total of 22 sampled Residents. Specifically, the facility failed to ensure the Resident was notified of the care plan meetings or was offered to attend. Findings include: Resident #44 was admitted to the facility in March 2022 with diagnoses including end stage renal disease and major depressive disorder. A diagnosis of dependence on supplemental oxygen was added to his/her record on 9/12/24. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #44 is severely cognitively impaired as evidenced by a score of seven out of a possible 15 on the Brief Interview for Mental Status exam. During multiple interviews throughout the survey, Resident #44 was able to engage in discussions about his/her healthcare related to his/her use of oxygen, attendance at dialysis and pain levels. Review of Resident #44's clinical record indicated his/her health care proxy…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-11-14 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and records reviewed, the facility failed to meet professional standards of practice for two Residents (#44, and #35) out of a total of 22 sampled residents. Specifically:1. For Resident #44, the facility failed to implement physician orders for fluid restrictions.2. For Resident # 35, the facility failed to implement physician's orders for fluid restrictions.Findings include: Review of facility policy titled Encouraging and Restricting Fluids dated September 2024, indicated: - The purpose of this procedure is to provide the resident with the amount of fluids necessary to maintain optimum health. This may include encouraging or restricting fluids. - Verify there is a physician's order for this procedure. - Review the residents care plan and or your daily assignment sheet to assess for any special needs of the resident. - Follow specific instructions concerning fluid intake or restrictions. - Record the amount of fluids consumed on the intake side of the intake and output record…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-11-14 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility failed to provide supervision with meals for one Resident (#44) out of a total sample of 22 residents. Findings include:Review of the facility policy titled Activities of Daily Living (ADL) Supporting, dated as revised September 2024, indicated: - Residents will be provided with care, treatment and services to ensure that their activities of daily living (ADLs) do not diminish unless the circumstances of their clinical condition(s) demonstrate that diminishing ADLs are unavoidable. ADLs are provided in according with resident preference and needs. - Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: Dining (meals and snacks). - Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-11-14 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to ensure that respiratory care and services, consistent with professional standards of practice, were provided for three Residents (#44, #1, and #32) out of sample of 22 residents. Specifically:For Resident #44, the facility failed to obtain physician orders for oxygen use prior to administration.For Resident #1, the facility failed to obtain physician orders for oxygen use prior to administration.For Resident #32, the facility failed to clean the oxygen concentrator filter, resulting in a thick build-up of dust. Findings include:Review of facility policy titled Resident Care and Treatment- Use of Oxygen dated as reviewed September 2024, indicated the following but not limited to- Nursing personnel administer oxygen as prescribed by policy and ensure compliance with all Life Safety Codes.- Adjust the oxygen delivery device so that it is comfortable for the Resident and the proper flow of oxygen is being administered. Resident #44 was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-11-14 · tag F0697 — failed to manage pain — isolatedProvide 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed for one Resident (#42) of 22 sampled residents, to provide adequate pain relief. Specifically, did not remove the used patch and replace it with a new patch for two days, which resulted in the Resident experiencing mild pain, and the potential for the body to absorb excessive amounts of lidocaine. In addition, facility staff applied two patches when there was an order for only one patch, which also contributed to the potential for the body to absorb excessive amounts of lidocaine. Findings include:Review of the facility policy Pain Management Guidelines dated September 2024 indicated it did not reference the use of Lidocaine patches, specifically.Lidocaine is an externally applied topical anesthetic used for the temporary relief of minor pain.Review of the Federal Drug Administration guidance for the use of lidocaine 4% patches indicated:- - Do not use more than one patch on your body at a time or with other topical analgesics at the same…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-11-14 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
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 medications were stored as required for one Resident (#22), out of a total sample of 22 residents. Specifically, the facility failed to ensure that medications were not left at the bedside for Resident #22 while unsupervised by staff.Findings include: Review of the facility policy titled Medication Management-Medication Storage, dated and revised September 2024, indicated the following:-The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. -Drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received.Review of the facility policy titled Self-Administration of Medications, dated and revised September 2024, indicated the following:-It is the responsibility of the interdisciplinary team (IDT) to determine that it is safe for the resident to self-administer medications.-The decision that a resident has the ability to self-medicate is subject…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-10-31 · tag F0641 — patternEnsure 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 observations, record review and interview the facility failed to accurately complete a Minimum Data Set (MDS) assessment for four Residents (#61, #41, #59, and #32) out of a total sample of 17 residents. Specifically, 1. For Resident #61 the facility inaccurately coded no significant weight gain when there was one. 2. For Resident #41 and Resident #59, the facility inaccurately coded their ability to be understood. 3. For Resident #32, the facility inaccurately coded that the Resident was in a comatose state. Findings Include: 1. Resident #61 was admitted to the facility in November 2023 with diagnoses including stroke, heart disease, asthma and diabetes. Review of the medical record indicated the following weights: 2/27/2024 15:14 146.2 Lbs. (pounds) 3/5/2024 13:51 151.4 Lbs. 3/12/2024 12:11 147.0 Lbs. 3/19/2024 14:24 147.0 Lbs. 3/26/2024 16:26 149.0 Lbs. 4/2/2024 08:34 148.0 Lbs. 4/10/2024 13:10 146.3 Lbs. 4/17/2024 12:06 148.0 Lbs. 4/23/2024 15:06 148.7 Lbs. 4/30/2024 07:50 147.0 Lbs. 5/7/2024 14:18…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 20 citations
- Potential for harm · Ecited before2024-10-31 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, policy review and interview the facility failed to store medications in a safe manner, store medications in accordance with currently accepted professional principles and failed to follow manufacturer's instructions for storage. Specifically the facility failed to: 1. Store medication in secured (locked) locations, accessible only to designated staff in two medication carts on one of two units. 2. Store and label medications in accordance with currently accepted professional principles in one medication cart on one of two units. 3. Maintain temperatures in accordance with manufacturer specifications on one of two units Findings include: Review of the facility policy titled Medication Management-Medication Storage and dated reviewed 9/24 indicated that the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Further review indicated that medications requiring refrigeration must be stored and monitored in a refrigerator located in the drug room at the nurse's station or other secured location. 1. On 10/29/24 at 7: A.M., the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-31 · tag F0637 — isolatedAssess the resident when there is a significant change in condition
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interviews, the facility failed to identify and complete a Significant Change in Status (SCSA) Minimum Data Set assessment (MDS) for one Resident (#16), out of a total sample of 17 residents, when the Resident was discharged from hospice services. Findings include: Review of the MDS 3.0 Resident Assessment Instrument (RAI) Manual, dated October 2023, indicated: - A Significant Change in Status Assessment (SCSA) is required to be performed when a resident is receiving hospice services and then decides to discontinue those services (known as revoking of hospice care). The ARD (assessment reference date) must be within 14 days from the effective date of the hospice election revocation. Resident #16 was admitted to the facility in November 2021 with diagnoses that include dementia and history of Covid-19. Review of the most recent Minimum Data Set Assessment, (MDS) Assessment, dated 9/6/24 indicated that the Resident could not participate in a Brief Interview for Mental Status exam, but was assessed by staff to have severe cognitive impairment. The MDS further…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-11-03 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, policy review, and interview, the facility failed to 1.) ensure nursing staff disinfected reusable resident care equipment (a vital sign machine) between residents and 2.) ensure nursing staff disinfected a blood glucose monitor after use. 3.) maintain measures they have in place to prevent the growth of Legionella, specifically, failed to monitor and document weekly testing protocols. Findings include: Review of the facility policy titled, Cleaning Equipment, dated as reviewed September 2023, indicated: 4. DME (durable medical equipment) must be cleaned and disinfected before reuse by another resident. 1.) The facility failed to ensure nursing staff disinfected reusable resident care equipment (a vital sign machine) between residents. On 10/19/23 at 8:30 A.M., the surveyor observed Nurse #3 obtain a Resident's blood pressure using a reusable blood pressure cuff. The cuff directly touched the Resident's bare skin. Nurse #3 did not clean the blood pressure cuff after use. The surveyor continued to observe Nurse #3. On 10/19/23 at 8:34 A.M., the surveyor…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-11-03 · tag F0759 — failed to keep medication error rate low — patternEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, records reviewed, policy review, and interviews, the facility failed to ensure it was free from a medication error rate of greater than 5% when 2 out of 4 nurses observed made 4 errors out of 31 opportunities, resulting in a medication error rate of 12.9%. Those errors impacted 2 Residents (#11 and #63), out of 4 residents observed. Findings include: Review of the facility policy titled, Administering Medications, dated as Revised December 2012, indicated medications shall be administered in a safe and timely manner and as prescribed. 7. The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method of administration before giving the administration. 1.) For Resident # 11, Nurse #1 administered the incorrect dose of calcium with vitamin d, the incorrect dose and incorrect form of metoprolol (cardiac medication) and opened a zonisamide (seizure medication) capsule that indicated to swallow whole. On 10/19/23 at 8:09 A.M. the surveyor observed Nurse #1…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-11-03 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and policy review, the facility failed to ensure controlled medications were locked appropriately, medications were stored in clean/sanitary conditions, medications were labeled/dated appropriately and medications that had a shortened expiration date were not available for use in two out of two observed medication carts and one medication storage room. Findings include: Findings include: Review of the facility policy titled Storage of Medications undated included the following: -The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. -Drugs for external use, as well as poisons, shall be clearly marked as such, and shall be stored separately from other medications. -Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use. On 10/20/23 at 9:14 A.M., the surveyor observed the following on the 2nd Floor B side Medication Cart: -Opened and undated bottle of Prostat. During an interview on 10/20/23 at 9:14 A.M.,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-11-03 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on resident group meeting, interview and test tray results, the facility failed to ensure foods provided to the residents were prepared by methods that conserve nutritional value, flavor, palatability and at appetizing temperatures on two of two units. Findings include: During the initial Resident screening process, numerous residents voiced concerns and displeasure about the overall food quality, temperature, and variety they are provided. During the resident council group meeting on 10/19/23 at 10:00 A.M., 15 out of 15 participating residents said they did not like the food quality, and everything is always covered in chicken gravy. On 10/19/23 at 12:20 P.M., the second-floor unit test tray arrived. After all residents received this lunch tray, the surveyor received the test tray at 12:26 P.M. The following was recorded: *Baked ham with brown gravy and pineapple: temperature 134 degrees Fahrenheit. Warm to taste, not hot. Tasted very bland, was rubbery and salty. *Spinach: 118 degrees Fahrenheit. Warm to taste, not hot. Mushy in texture and was very salty. *Cheesy Potatoes:…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-03 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately 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 observation, record review and interview, the facility failed to notify the physician of a change in status for one Resident (#23) out of a total sample of 30 Residents. Specifically, the facility failed to notify the physician when the Resident was observed to have vomited significantly while in bed. Findings include: Resident #23 was admitted to the facility in December 2022 with diagnoses including cerebral infarction and hemiplegia/hemiparesis. Review of Resident #23's most recent Minimum Data Set Assessment (MDS) indicated that the Resident had a Brief Interview for Mental Status score of 13 out of a possible 15 indicating that he/she is cognitively intact. Further review of the MDS indicated that the Resident requires extensive assistance with all activities of daily living. On 10/17/23 at approximately 8:35 A.M., the surveyor walked into Resident #23's room and observed a large amount of vomit on the floor next to his/her bed. Upon entering, a nurse entered the room and asked for assistance to clean up Resident #23. Review of Resident #23's physician's orders…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-03 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to provide a homelike environment, specifically, failed to address a chirping fire alarm. Findings include: During an observation on 10/17/23 at 8:15 A.M., the surveyor observed a fire alarm in room [ROOM NUMBER] chirping repeatedly. During an observation on 10/20/23 at 8:16 A.M., the surveyor observed the same fire alarm in room [ROOM NUMBER] chirping repeatedly. During an interview on 10/20/23 at 8:16 A.M., the Maintenance Director said that he is usually told about an issue in the building via the log book or is called if there is an emergency. The Maintenance Director said that he was not aware or told of the chirping fire alarm in room [ROOM NUMBER].
- Potential for harm · D2023-11-03 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond 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 record review and interview, the facility failed to 1. investigate a bruise of uknown origin for one Resident (#35) and 2. failed to investigate injury of unknown origin (laceration to head) for one Resident (#34) out of a total sample of 30 residents. Findings include: 1. Review of the facility policy titled Resident Rights and Ethics- Abuse/Neglect, dated 09/2023, indicated the following: - Injuries of uknown source: * the source of the injury was not observed by any person * the source of the injury could not be explained by the resident * the injury is suspicious because of the extent of the injury or the location of the injury Resident #35 was admitted in 03/2023 with diagnoses including depression and hypertension. Review of the Minimum Data Set (MDS), 9/27/23, indicated that Resident #35 is rarely/never understood. Resident #35 requires extensive assist with toilet use, personal hygiene, bed mobility, and transfers. Review of the progress note, dated 5/22/23, indicated that staff had discovered a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-03 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interviews, the facility failed to provide a written notice of discharge prior to transferring Two Residents (#1 and #20) to the hospital, out of a total sample of 30 residents. Findings include: 1. Resident #1 was admitted to the facility in August 2023, with diagnoses including repeated falls. Review of medical record for Resident #1 indicated he/she was transferred to the hospital on 7/26/23, 8/21/23 and 9/7/23. Review of the paper and electronic medical records failed to indicate evidence that a Notice of Intent to Transfer Resident was completed on 7/26/23, 8/21/23 and 9/7/23. 2. Resident #20 was admitted to the facility in January 2023 with diagnoses including type two diabetes and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. Review of medical record for Resident #20 indicated he/she was transferred to the hospital on 3/9/23 and 9/20/23. Review of the paper and electronic medical records failed to indicate evidence that a Notice of Intent to Transfer Resident was completed on 3/9/23 and 9/20/23. During an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-03 · tag F0625 — isolatedNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record reviews and interviews, the facility failed to provide a bed-hold notice upon transfer to the hospital for Two Residents (#1 and #20), out of a total sample of 30 residents. Findings include: 1. Resident #1 was admitted to the facility in August 2023 with diagnoses including repeated falls. Review of medical record for Resident #1 indicated he/she was transferred to the hospital on 7/26/23, 8/21/23 and 9/7/23. Review of the paper and electronic medical records failed to indicate evidence that a written notice of the bed-hold policy was provided to Resident #1 when he/she was transferred to the hospital on 7/26/23, 8/21/23 and 9/7/23. 2. Resident #20 was admitted to the facility in January, 2023 with diagnoses including type two diabetes and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. Review of medical record for Resident #20 indicated he/she was transferred to the hospital on 3/9/23 and 9/20/23. Review of the paper and electronic medical records failed to indicate evidence that a written notice of bed-hold policy was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-03 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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 interview, the facility failed to update the plan of care for one Resident (#67). Specifically, the plan of care was not updated after the Resident swallowed lotion and was hospitalized . 2. develop and implement a complete plan of care for a resident with a pace maker (a cardiac device used to control and monitor heart rate) for one Resident (#1), out of a total sample of 30 residents. Findings include: 1. Resident #67 was admitted in 03/2023 with diagnoses including dysphagia and dementia. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #67 scored a 1 out of a possible 15 on the Brief Interview for Mental status (BIMS), indicated severe cognitive impairment. Review of the MDS indicated that Resident #67 requires extensive assistance with all activities of daily living and is independent with eating. Review of the progress note, dated 10/13/23, indicated the following: - Situation: Resident was caught in room drinking bottle with lotion in it. - Response:…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-11-03 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to 1. obtain weekly weights as ordered for one Resident (#25) and 2. failed to provide follow up on a pharmacy recommendation for one Resident (#47) out of a total sample of 30 residents. Findings include: 1. Resident #25 was admitted in 12/2021 with diagnoses including dementia and dysphagia. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #25 scored a 11 out of a possible 15 on the Brief Interview for Mental status (BIMS), indicated moderate cognitive impairment. Resident #25 require dependence with eating. Review of the progress note, dated 8/17/23, indicated the following: - Resident current weight is 98.8 pounds, NP (nurse practitioner) made aware orders given for weekly weight x4 weeks, obtain dietitian consultation. Attempts to notify HCP (health care proxy) unable to leave message. Review of the physician's orders indicated that Resident #25 had an order for weekly weights. Review of the weight record did not indicate…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-11-03 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide assistance with Activities of Daily Living (ADLs) for dependent residents, specifically, the facility failed to 1)provide assistance with showers for two Residents (#65 and #23) and 2) provide supervision with meals for one Resident (#23) out of a total sample of 30 Residents. Findings include: Review of the facility policy titled Activities of Daily Living (ADL), Supporting, dated and revised 2018, indicated the following: *Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain food nutrition, grooming and personal and oral hygiene. *Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: *Hygiene (bathing, dressing, grooming, and oral care) *Dining (meals and snacks) 1a) Resident #65…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-03 · tag F0687 — failed to care for feet properly — isolatedProvide appropriate foot 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 Based on observation, record review and interviews, the facility failed to ensure staff obtained necessary podiatry (foot care) services for One Resident (#20) out of a total sample of 30 residents. Findings include: Review of facility admission packet titled 'admission Notifications, Authorizations and Consents' indicated the following but not limited to: Professional services Authorization: *I understand that the choice of professional services provider is my right and the center will assist me in the obtaining professional services. I choose to use the nursing center's professional services. Resident #20 was admitted to the facility in January 2023, with diagnoses including type two diabetes and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. Review of Resident #20's Minimum Data Set (MDS) dated [DATE], indicated the Resident scored a 3 out of a possible 15 on the Brief Interview for Mental Status indicating he/she was severely cognitively impaired. Further 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.
- Potential for harm · D2023-11-03 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to 1. address a significant weight loss for One Resident (#25), and 2. implement a dietician recommendations to prevent a significant weight loss for one Resident (#34) out of a total sample of 30 residents. Findings include: 1. Resident #25 was admitted in 12/2021 with diagnoses including dementia and dysphagia. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #25 scored a 11 out of a possible 15 on the Brief Interview for Mental status (BIMS), indicated moderate cognitive impairment. Resident #25 require dependence with eating. Review of the weight record for Resident #25 indicated the following: - 6/27/23: 108.2 pounds - 7/2/23: 108 pounds - 8/17/23: 98.8 pounds - 9/14/23: 100.2 pounds Review of the weights indicated that Resident #25 had lost 9.2 pounds, or 8.5% in one month from 7/2/23 to 8/17/23. Review of the progress note, dated 8/17/23, indicated the following: - Resident current weight is 98.8 pounds, NP (nurse…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-11-03 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record review and interviews, the facility failed to obtain a physician's order for the use of a CPAP machine (a machine for Continuous Positive Airway Pressure to treat sleep apnea) for one Resident (#13) with a diagnosis of sleep apnea out of a total sample of 30 residents. Findings include: Review of the facility policy titled, Care and Treatment CPAP, dated as reviewed September 2023, indicated to verify physician's orders. Resident #13 was admitted to the facility in May 2020 with diagnoses including anxiety, myalgia, obstructive sleep apnea and rheumatoid arthritis. Review of the Minimum Data Set (MDS) assessment, dated 9/28/23, indicated Resident #13 did not require a non-invasive mechanical ventilator (any type of CPAP or BiPAP respiratory support devices that prevent airways from closing by delivering slightly pressurized air through a mask or other device continuously or via electronic cycling throughout the breathing cycle. The BiPAP/CPAP mask/device enables the individual to support their own spontaneous respiration by providing enough pressure…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-03 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on policy review, observation and staff interview, the facility failed to ensure pharmaceutical services met the needs of each resident. Specifically, the facility failed to ensure an antibiotic kit was replaced by the pharmacy after being opened. Finding include: Review of the facility policy titled, Emergency Drug Supply, dated 2012, indicated in order to assure that emergency supplies of certain infusion medications and supplies are maintained for STAT use within nursing facilities, the pharmacy will provide sealed supplies of these medications and solutions for the purpose of assuring their prompt administration. The nursing facility must notify the pharmacy so that these emergency supplies can be promptly replenished and the appropriate resident account is invoiced. F. When an Emergency Supple Box is opened, the nurse notifying the pharmacy of the resident's infusion orders will request a replacement Emergency dose or Emergency Supply Box as per usual protocol. On 10/19/23 at 8:10 A.M. during the medication pass, Nurse #1 attempted to obtain doxycycline from the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-03 · tag F0805 — failed to prepare food in a form residents can eat — isolatedEnsure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
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 provide a diet to meet one Resident (#40)'s specific dietary needs, as indicated on the Resident's tray ticket, out of a total sample of 30 residents. Findings include: Resident #40 was admitted in 03/2022 with diagnoses including end stage renal disease and hypertension. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #40 scored a 10 out of a possible 15 on the Brief Interview for Mental status (BIMS), indicated moderate cognitive impairment. Review of the facility policy titled Therapeutic Diets, dated 09/2023, indicated the following: - A therapeutic diet is considered a diet ordered by a physician, practitioner, or dietitian as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet. During an observation on 10/19/23 at 8:30 A.M., Resident #40 was sitting in bed eating breakfast with 4 ounces of orange juice on his/her tray. Review…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-11-03 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records reviewed and interviews, the facility failed to ensure they maintained a complete and accurate medical record for two Residents (#18) and (#5) out of a total sample of 30 Residents. Specifically, 1. For Resident # 18, nursing failed to document showers given on the Activities of Daily Living (ADLs) flow sheets and 2. For Resident #5, the facility failed to complete documentation for monitoring a bed alarm on each shift as ordered. Findings include: 1. For Resident # 18, nursing failed to document showers given on the Activities of Daily Living (ADL) flow sheets Resident #18 was admitted to the facility in June 2020 with diagnoses including multiple sclerosis, immobility and depression. Review of the Minimum Data Set (MDS) assessment, dated 8/9/23, indicated Resident #18 was totally dependent of staff of two for bathing. On 10/19/23 at 11:00 A.M., Resident #18 said he/she does not always get his/her showers. Review of the Documentation Survey Report v2 (ADL flow sheets), dated September and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$200,070 in federal fines across 1 penalty.
- $200,070 — penalty dated 2023-11-03
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.
Part of a chain
This home belongs to MARQUIS HEALTH SERVICES — 87 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 3.0 | ≈ chain avg |
| Health inspection | 3 of 5 | 2.6 | +0.4 vs chain |
| Staffing | 2 of 5 | 2.3 | -0.3 vs chain |
| Quality measures | 4 of 5 | 4.3 | -0.3 vs chain |
The other 86 homes this chain runs (chain average 3.0★, per CMS)
Showing 40 of 86; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| KAHANOW, AVIVA | Individual | INDIRECT OWNERSHIP INTEREST | since 09/03/2025 |
| ROKEACH, FRAIDE | Individual | INDIRECT OWNERSHIP INTEREST | since 09/03/2025 |
| ISRAEL DISCOUNT BANK OF NEW YORK - IDB BANK OF YORK | Organization | 5% OR GREATER SECURITY INTEREST | since 09/03/2025 |
| ALGHAZAWNEH, BASHAR | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/07/2026 |
| COHEN, DAVID | Individual | MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | since 09/29/2025 |
| VIROJA, YOGESH | Individual | MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | since 09/03/2025 |
| MARQUIS LIMITED LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/05/2025 |
| RELIANT PRO REHAB LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 09/16/2025 |
| POSEN, MINDEE | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 09/03/2025 |
| WEINREB, YAAKOV | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 09/29/2025 |
| FLAGLER, OSHER | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 08/05/2025 |
| LEVOVITZ, TZVI | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 08/05/2025 |
| ROKOWSKY, YITZCHOK | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 08/05/2025 |
| BRIGHTON REAL PROPERTY LLC | Organization | ADP OF THE SNF | since 09/03/2025 |
| NFR 2020 IRRV TR | Organization | ADP OF THE SNF | since 09/03/2025 |
| QUINTO NEXGEN LLC | Organization | ADP OF THE SNF | since 09/03/2025 |
| RSBRMK HOLDINGS LLC | Organization | ADP OF THE SNF | since 09/03/2025 |
| SK NEXGEN TR | Organization | ADP OF THE SNF | since 09/03/2025 |
| TRYKO NEXGEN HOLDINGS LLC | Organization | ADP OF THE SNF | since 09/03/2025 |
| UAK 2020 IRRV TR | Organization | ADP OF THE SNF | since 09/03/2025 |
| UKR NEXGEN LLC | Organization | ADP OF THE SNF | since 09/03/2025 |
| YK NEXGEN TR | Organization | ADP OF THE SNF | since 09/03/2025 |
| YR NEXGEN TR | Organization | ADP OF THE SNF | since 09/03/2025 |
CMS files one row per role, so the 30 rows in the source record cover these 23 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.
13 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $514K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in MA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Massachusetts Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 225770. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-11-14, 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.