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Brockton Post Acute Care

50 Christy Place, Brockton, MA 02301 · For profit - Limited Liability company · 169 certified beds · (508) 580-6800 Medicare & Medicaid certified

Call the home — (508) 580-6800 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Resident-funds citation (F0565)
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has a citation for mishandling residents’ money or property (F0565)
  • a high number of inspection citations overall (33) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure score sits well above its independent inspection score
  • 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.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
200 Westgate Dr · (508) 584-8962 · Call to confirm hours
Pharmacy
610 Pleasant St · (508) 427-6223 · Call to confirm hours
Grocery
753 Pleasant St · (508) 588-9731 · Call to confirm hours
Park
44 Palmer St · (508) 587-5096 · Typically dawn to dusk
Place of worship

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 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 improved from 2 to 4 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased18.8%16.4%15.4%worse
Long-stay residents who lose too much weight4.3%5.1%5.4%better
Long-stay residents with a catheter left in their bladder1.0%0.8%0.9%typical
Long-stay residents with a urinary tract infection0.6%1.8%2.0%better
Long-stay residents with depressive symptoms56.1%15.5%6.5%worse 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 injury2.1%3.4%3.3%better
Long-stay residents whose ability to walk worsened13.8%15.4%16.1%better
Long-stay residents on antianxiety or hypnotic medication17.4%19.5%18.9%typical
Long-stay residents given the seasonal flu vaccine100.0%94.8%95.3%typical
Long-stay residents with pressure ulcers2.7%4.2%4.7%better
Long-stay residents with worsening bladder/bowel control20.4%21.2%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table19.0%21.4%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.8%1.4%1.4%better
Short-stay residents given the seasonal flu vaccine71.7%77.7%79.4%typical
Short-stay residents rehospitalized after admission26.6%25.7%22.6%worse
Short-stay residents with an outpatient ER visit6.7%11.9%12.0%better
Long-stay hospitalizations per 1,000 resident days1.021.881.67better
Long-stay outpatient ER visits per 1,000 resident days0.811.501.80better

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.

56.2% 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 328 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

56.2%U.S. median 51.5%
Got home and stayed home
10.8%U.S. median 10.7%
Went back to hospital
55.9%U.S. median 56.6%
Met the expected recovery
0.23U.S. median 0.31
Therapy hours / resident / day
0.08hours / resident / day
Physical therapy
0.14hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Met the expected recovery: 55.9% 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 143 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 0.23 therapist hours per resident per day in 2026Q1 — more than 29% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 51% of this home’s weekday level — it runs therapy at close to weekday levels right through the weekend. 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 SNF56.2%CMS range 50.0–61.551.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.8%CMS range 8.4–14.210.7%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 discharge55.9%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 discharge49.0%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 discharge48.2%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 identified99.5%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 setting100.0%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 discharge95.7%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 stay1.0%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 hospitalization6.8%CMS range 4.3–9.67.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.951.02Oct 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

0.58
RN hours/ resident / day
0.80
LPN hours/ resident / day
2.10
Aide hours/ resident / day
3.47
Total nurse hours/ resident / day
0.39
RN hoursweekends
37.5%
Total nursing turnover
45.5%
RN turnover

How full it usually is: this home is certified for 169 beds and averages 156.9 residents a day — about 93% occupied, or roughly 12 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 3.47 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.58 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.10 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 3.11 hrs/resident/day on weekends vs 3.62 on weekdays — 14% thinner on weekends. RN hours go from 0.65 to 0.39 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 38% is about the same as the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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 (2025-04-16)
13
at the previous standard inspection (2024-02-21)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

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.

33 citations, most serious first. The 10 most serious are shown; the remaining 23 are one tap away and print in full.

  • Potential for harm · Dcited before2025-07-30 · 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 record reviews and interviews for one of three sampled residents (Resident #1), the Facility failed to ensure nursing provided care and services that met professional standards of practice, when upon admission his/her medications were not reconciled accurately, and medications were administered at doses and intervals that were not consistent with Physicians Orders.Findings include:Review of the Facility Policy titled Reconciliation of Medication on Admission, dated as last revised 07/2017, indicated that the purpose of medication reconciliation is to ensure medication safety by accurately accounting for the resident's medications, routes and dosages upon admission or readmission to the Facility.The Policy indicated that all prescription medications, including those taken only as needed are obtained from all sources prior to reconciliation as well as dose, route, frequency and last doses taken.Resident #1 was admitted with Hospice Services from the community to the Facility in April 2025 for a five (5) day respite stay, diagnoses include Chronic Obstructive Pulmonary Disease…

    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 · D2025-04-16 · tag F0676 — failed to keep up residents' daily-living abilities — isolated
    Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
    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 ensure appropriate treatment and services were provided to maintain or improve his or her ability to carry out the activities of daily living and attain or maintain the highest practical physical, mental, and psychosocial well-being for two Residents (#37 and #38 out of a sample of 27 residents. Specifically, the facility failed to ensure: 1. For Resident #37 with a diagnosis of Aphasia (communication disorder that affects speech, writing and language understanding) was assessed for communication 2. For Resident #12 to ensure Speech Therapy (SLP) evaluation was completed timely after admission and to ensure Physical Therapy (PT) visits were completed per physician order/plan of care. Review of the facility policy titled Scheduling of Therapy Services dated as last revised July 2013 indicated but was not limited to the following: -Therapy Services shall be scheduled in accordance with the residents treatment plan. -A listing of residents…

    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 before2025-04-16 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interviews, the facility failed to provide residents with adequate supervision and effective interventions to prevent avoidable accidents. Specifically, the facility failed to develop and consistently implement effective interventions to prevent four unwitnessed falls, resulting in three injuries on 11/2/24, 11/30/24 and 1/26/25, for one Resident (#16), out of a total sample of 27 residents. Findings include: Review of the facility's policies titled Fall and Fall Risk Managing last revised March 2018, indicated but was not limited to the following: Based on previous evaluations and current data, the staff will identify interventions related to the resident specific risks and causes to try to prevent the resident from falling -The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. -If falling recurs despite initial interventions, staff will implement additional or different interventions…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-16 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record 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 one Residents (#29) with a history of trauma, out of a total sample of 27 residents. Findings include: Review of the facility policy titled Trauma Informed Care and Culturally Competent Care dated as last revised 8/2022 indicated but was not limited to the following: -Trauma results from an event, series of events, or set of circumstances that is experiences 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. -Trauma-informed care is an approach to delivering care that involves understanding, recognizing, and responding to the effects of trauma. A trauma-informed approach to cate delivery recognizes the widespread impact and signs and symptoms of trauma…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-16 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide 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 observation, and interview, the facility failed to ensure that pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) were implemented to ensure that emergency Kits were replaced timely. Five out of five drawers of Supper Kit #51001 were impacted and 1of 1 Cubex Kit was also impacted. Specifically, the facility failed to ensure that emergency medication kits (E-Kits) were re-ordered and replaced timely by the Pharmacy after being opened. Findings Include: Review of the facility Pharmacy policy titled Emergency Medication dated April 2025, indicated but was not limited to the following: - The facility shall maintain a supply of medications typically used in emergencies - The pharmaceutical services/quality assurance and performance improvement committee, with the input of the consultant pharmacist, director of nursing services, and medical director, shall approve the contents of the emergency medication kit, and the dispensing pharmacy will stock it. - The emergency medication…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-16 · tag F0804 — failed to serve food at safe, palatable temperature — isolated
    Ensure 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 observation, interview, and test tray results, the facility failed to provide food to residents that was served at appetizing temperatures for one of two test trays. Findings include: On 4/14/25 at 2:20 P.M., the Resident Council meeting was conducted with 17 residents in attendance. During the meeting the residents collectively expressed the kitchen continues to be problematic, with specific complaints that the food is cold, especially eggs in the morning and the plates are cold not heated. On 4/16/25 at 7:55 A.M., the surveyor observed breakfast tray line service and made the following observations: -The surveyor felt the dishes in the plate warmer to be slightly warm, not hot. -Food Service Manager measured the temperature at the bottom of the plates to be 130 degrees Fahrenheit (F). He then turned up the temperature of the plate warming unit. During an interview on 4/11/25 at 8:00 A.M., the [NAME] #1 said she turned on the plate warmer when she first came in in the morning. She said the plates were not hot. On 4/16/25 at 7:59 A.M., the surveyor requested a test tray,…

    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 · D2024-08-08 · tag F0553 — failed to let residents help plan their care — isolated
    Allow resident to participate in the development and implementation of his or her person-centered plan of care.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on records reviewed and interviews for one of three sampled resident (Resident #1), the Facility failed to ensure that the resident and/or his/her family member or legal representative participated in the development and implementation of their person-center care plans, which included conducting and inviting the resident and/or their legal representative to an interdisciplinary care plan meeting following the completion of any Comprehensive Minimum Data Set (MDS) Assessment, including the Admission, Quarterly, and Annual MDS. Findings include: Review of the Facility Policy titled, Care Plans, dated as last revised 02/2022, indicated that each resident in the facility shall be involved in the development and review of his/her plan of care along with his/her family member. The Policy further indicated that the Interdisciplinary Team (IDT) conferences shall be held for each resident at 90-day intervals and the IDT shall; -Evaluate the resident's progress toward meeting the goals outlined in the care plan; -Revise the plan of care, and services; -Collaborate with the resident 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-08 · tag F0559 — isolated
    Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on records reviewed and interviews for one of three sampled residents (Resident #1), who was alert, oriented and his/her own decision maker, the facility failed to ensure Resident #1 and/or his/her Representative were provided with a written explanation of the need to change his/her room, when on 06/26/24 Resident #1's was moved to a new room despite his/her wishes to remain in his/her original room. Findings include: Review of the Facility Policy tilted, Room Change, dated as last revised 10/2022, indicated that a room change or change in roommate shall be made when the resident or their representative requests the change or the facility deems it necessary. The Policy further indicated the following; -When a resident room change is occurring, the resident being moved or their representative, will be informed of the room change; and -The notice of change in a room or roommate assignment will be both verbal and in writing and will include the reason(s) for the change. Resident #1 was admitted to the facility in April 2024, diagnoses included both lower extremity necrotizing…

    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 · Dcited before2024-08-08 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records reviewed and interviews for one of three sampled residents (Resident #1) who had been admitted with three pressure injuries, the Facility failed to ensure they maintained complete and accurate medical/clinical records including but not limited to documentation related to the completion and accuracy of skin assessments. Findings include: Review of the Facility Policy titled, Charting and Documentation, dated as last revised 01/2023, indicated that all services provided to the resident, progress toward the care plan goals, or any changes in the resident's condition medical, physical, functional or psychosocial condition, shall be documented in the resident's medical records. The Policy indicated that the medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Review of the Facility Policy titled, admission Assessment, dated 10/2022, indicated the purpose of the admission procedure is to gather information about 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 · E2024-02-21 · tag F0583 — failed to protect personal privacy — pattern
    Keep residents' personal and medical records private and confidential.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and staff interview, the facility failed to ensure, for four Residents (#336, #110, #25, and #100), out of a total sample of 24 residents, the right to personal privacy of his/her own physical body during medical treatment was maintained. Findings include: On 2/14/24 at 9:18 A.M., the surveyor observed a lab technician enter Resident #336's room with a rolling cart and begin to prepare supplies to draw blood. The surveyor observed the technician cleanse the Resident's right arm, apply a tourniquet, and draw blood from the Resident's arm. The Resident was in full view of his/her roommate and any passerby in the hallway. On 2/14/24 at 9:45 A.M., the surveyor observed a lab technician enter Resident #110's room with a rolling cart and begin to prepare supplies to draw blood. The surveyor observed the technician cleanse the Resident's arm, apply a tourniquet, and draw blood from the Resident's arm. The Resident was in full view of his/her roommate and any passerby in the hallway. On 2/14/24 at 9:49 A.M., the surveyor observed a lab technician enter Resident #25's…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 23 citations
  • Potential for harm · Ecited before2024-02-21 · 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 observation and interview, the facility failed to ensure residents were provided with an environment which was free from accident hazards on two (Arborwood and Cedarwood) of three units in the facility. Specifically, the facility failed to ensure potentially hazardous items were not left unsecured and easily accessible to residents. Findings include: Review of the Matrix for Providers completed by the Director of Nursing and provided to the survey team on 2/14/24 indicated: - 25 out of 53 residents residing on the Arborwood Unit had a diagnosis of Alzheimer's dementia/dementia Residents of the Arborwood and Cedarwood units were observed independently ambulating or self-propelling in wheelchairs at various times and dates of the survey. On the following dates the surveyor observed: -2/14/24 at 11:52 A.M., the Arborwood treatment cart was unlocked and unattended at the nurses' station with two caddies on top of the treatment cart. The contents of the caddies included alcohol swabs and lancets (a device that contains a small needle to poke a small hold in the skin of a finger…

    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 before2024-02-21 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure 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, interview, and policy review, the facility failed to ensure all drugs and biologicals were stored in a safe and secure manner as required on three of three units in the facility. Specifically, the facility failed to: 1. Ensure all medication and treatment carts were locked when unattended and unsupervised; and 2. Provide separately locked, permanently affixed compartments for storage of controlled substances. Findings include: Review of the facility's policy titled Medication Storage, dated 10/2022, indicated but was not limited to: -all medications will be stored in a locked cabinet, cart or medication room that is accessible only to authorized personnel, as defined by facility policy. 1. On the following dates/times of survey the surveyor observed the following medication/treatment carts to be unlocked and unattended: -2/14/24 at 9:44 A.M. through 9:51 A.M., a Cedarwood medication cart was unlocked and unattended in the hallway. At 9:51 A.M., Nurse #3 emerged from a resident room and went…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-02-21 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure 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 observation and interviews, the facility failed to ensure each resident received food prepared by methods that conserve nutritive value, flavor, and appearance, and was palatable, attractive, and at a safe and appetizing temperature for one of two test trays. Findings include: During the initial tour of the facility, residents on all three units made the following statements to the surveyors: -Smaller portions, sometimes the food is cold. -The food could be served faster, and it can be lukewarm, not hot. -Food is cold. -Hot foods are lukewarm, oatmeal is always hot. -Cold food. -Food is awful, mostly dinner, cold at times. -A family member reports food is awful. -Today the chicken was so tough I could not bite it. -Food is usually cold. -Concerned with food temperatures. -Food could be better. -Cold at times. -Two residents eating breakfast complained the food was cold. On 2/15/24 at 1:20 P.M., the surveyor conducted a Resident Council Meeting with nine residents in attendance, who voiced concerns regarding the quality and palatability of the meals provided to them. Nine 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-02-21 · 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

    Based on observation, policy review, and interview, the facility failed to follow their policy and 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: 1. Ensure the main kitchen was maintained in a sanitary condition; 2. Ensure all food items were properly labeled and dated in the main kitchen refrigerators; 3. Ensure the food/drinks stored in the reach-in single door refrigerator maintained a safe temperature of below 41 degrees Fahrenheit (F); 4. Handle ready-to-eat food (food which does not require cooking or further preparation prior to consumption) utilizing proper hand hygiene to prevent cross contamination (transfer of pathogens from one surface to another). In addition, to ensure the use of gloves was limited to a single use task; 5. Ensure the concentration of the sanitizer in the third bay (of the three-bay sink) was at the correct concentration to properly sanitize pots, pans and utensils to reduce potential pathogens; 6. Ensure 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 · D2024-02-21 · 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

    Based on interview, record review, and policy review, the facility failed to ensure the residents and/or their representatives were informed and given necessary information to make health care decisions, including the risks and benefits of psychotropic medications and obtain consent for their use, prior to administration for one Resident (#57), out of total sample of 24 residents. Findings include: Review of the facility's policy titled Psychotropic Med Consents, last revised 1/2023, indicated but was not limited to: - Psychotropic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review. Prior to administering psychotropic medications, consent should be obtained for their use. - Facility should obtain informed consent prior to administering psychotropic medication. - Informed consent shall include the prescribed medication, dosage, range if needed and frequency; and any known effect or side effect of the psychotropic medication. Resident #57 was admitted to the facility in December 2023 with…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-21 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review, and interview, the facility failed to ensure staff developed and implemented a baseline care plan within 48 hours of the resident's admission, which included the instructions needed to provide effective and person-centered care to the resident which meet professional standards of quality care for two Residents (#100 and #235), in a total sample of 24 residents. Specifically, the facility failed to ensure: 1. For Resident #100, a baseline care plan was developed for the Resident's dialysis treatment; and 2. For Resident #235, a baseline care plan was developed for the Resident's cardiac pacemaker (an implanted medical device used to control an irregular heart rhythm). Findings include: Review of the facility's policies titled Care Plans-Baseline, last revised 10/2022, and Comprehensive Care Plan, last revised 10/22/22, included but was not limited to: - A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-21 · 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 interview and record review, the facility failed to follow professional standards of practice for two Residents (#48, #235), out of a total sample of 24 residents. Specifically, the facility failed: 1. For Resident #48, a. To ensure a physician's order was obtained prior to collecting a urine sample via straight catheterization (removing urine from the bladder by placing a tube into the bladder), and b. To notify a physician or nurse practitioner (NP) of an abnormal urinalysis result in a timely manner to avoid a three-day delay in administering antibiotics for a urinary tract infection (UTI); and 2. For Resident #235, to monitor for signs/symptoms for pacemaker complications, monitor the function of the pacemaker, and document the model, make, and date of insertion per facility policy from admission until 12/23/23. Findings include: 1. Resident #48 was admitted to the facility in May 2014 with the following diagnoses: retention of urine, frequency of micturition (urinary frequency), and cognitive…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-21 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on records reviewed and interviews, for two Residents (#100 and #336), from a sample of 24 residents, the facility failed to ensure complete and accurate medical records were maintained according to professional standards of practice related to documentation of critically high laboratory testing results. Findings include: Review of the facility's policy titled Lab Services, last revised 1/2023, indicated but was not limited to: - Licensed staff will document in the resident's chart and on the 24-hour report that the results were sent to the physician. - When the physician responds, document the response in the resident's chart. -The nurse receiving the lab result is responsible for ensuring the nursing supervisor and MD (physician) are made aware promptly and must document same in the medical record. 1. Resident #100 was admitted to the facility in January 2024 with diagnoses which included bacteremia and end stage renal disease. Review of the medical record indicated a physician's order for laboratory testing as follows: -Weekly Complete Blood Count (CBC) with differential,…

    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 · Fcited before2022-05-17 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, policy review, and interview, the facility failed to properly store and label food in the facility kitchen and on two out of three unit nourishment kitchens in accordance with professional standards of practice to ensure food safety. Specifically, the facility failed to: 1. properly label and store food items in the dry storage room and kitchen refrigerators, 2. ensure food was properly stored in the kitchen freezer to allow for circulation, 3. properly label resident food in two out of three unit nourishment kitchens, and 4. ensure staff followed the facility's policy for storage of personal food items. Finding include: 1. Review of a facility document provided to the surveyor by the Dietary Manager titled, Eight Guidelines for Quality Food, undated, indicated, but is not limited to the following: -3 days or older, throw it out -A label and a date must be on all open/prepped/pulled product -Never use food that has expired On 5/11/22 at 8:02 A.M., the surveyor reviewed the kitchen dry…

    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 · E2022-05-17 · tag F0565 — failed to support the resident council — pattern
    Honor the resident's right to organize and participate in resident/family groups in the facility.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on a resident group meeting, staff interviews and document review, the facility failed to ensure grievances and concerns from the Resident Council regarding residents feeling they were not being treated respectfully, were acted upon timely. Findings include: Review of the Resident Council minutes dated 2/22/22 indicated residents had the following concerns: - residents don't feel they are being treated respectfully on the Baywood unit Residents were encouraged to meet with their unit manager to address their concerns. Review of the Resident Council minutes dated 3/22/22 indicated residents had the following concerns: - residents don't feel they are being treated respectfully on the Baywood unit Residents met with their unit manager to discuss their concerns and are still awaiting resolution. Review of the Resident Council minutes dated 4/19/22 indicated under the section of old business residents had not received resolution on their concerns from their meeting with the unit manager on the Baywood unit. A group meeting was held on 4/12/22 at 11:00 A.M., with the Resident…

    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 · E2022-05-17 · tag F0656 — failed to write and follow a full care plan — pattern
    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, policy and record review, the facility failed to ensure staff developed an individualized comprehensive care plan 3 Residents (#43, #58, #30), out of a total sample of 25 Residents. Specifically, the facility failed to: 1. for Resident #43, develop a care plan for a midline catheter and transmission-based precautions (TBP), 2. for Resident #58, develop a care plan for the management of the Resident's chronic obstructive pulmonary disease (COPD), including the use of nebulizer treatments, and 3. for Resident #30, develop a care plan for mobility care needs. Findings include: Review of the facility's policy titled, Comprehensive Care Plan, reviewed 1/28/22, indicated, but was not limited to the following: -Point Group Care shall provide an individualized, interdisciplinary plan of care for all residents that shall be appropriate to the resident's needs, strengths, results of diagnostic testing limitations and goals. -Results of assessments shall be used to develop, review, 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-05-17 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure 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 observations and staff interview, the facility failed to ensure all drugs and biologicals were labeled and stored in accordance with currently accepted professional principles and the facility policy. Findings include: On [DATE] at 1:39 P.M., the Arborwood Unit medication storage areas were inspected with Nurse #1 and Unit Manager #1. -The bottom shelf of the medication refrigerator was observed to be stained and dirty. -A vial of Vitamin B-12 was observed in the medication refrigerator, open and not dated. -The side 2 medication cart was observed to have a significant amount of scattered, dried spills and a sticky substance in the third drawer. -A bottle of timolol maleate, ophthalmic drops were observed to be not dated. -Another bottle of fluticasone nasal spray was observed to be dated [DATE]. (discard one month after removal from protective overwrap or when indicator reads 0 whichever comes first). Insulin Vials in Medication Cart -A vial of Novolog insulin was observed to be dated [DATE] when…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-05-17 · 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

    Based on observation, interview, policy and record review, the facility failed to ensure standards of practice were followed for infection control practices. Specifically, the facility failed to: 1. limit the movement and prioritize cleaning and disinfection for a Resident (#43) on contact precautions for extended spectrum beta lactamase (ESBL) (bacterial infection resistant to many antibiotics), 2. ensure staff wore the appropriate personal protective equipment (PPE) in the facility kitchen and in patient care areas, and 3. perform proper hand hygiene during a Resident's (#30) dressing change. Findings include: 1. Review of the facility's policy titled, Transmission-Based Precautions (Isolation Precautions) indicated, but is not limited to the following: -Transmission-based precautions are to be used in addition to standard precautions for residents with documented or suspected infection or colonization with highly transmissible or epidemiologically important pathogens for which additional precautions are needed to prevent transmission. -Contact precautions shall be used for…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-05-17 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, record review and policy review the facility failed to determine the competency of the Resident to self administer medication, for 1 Resident (#93) out of a total sample of 25 Residents. Findings include: Resident #93 was admitted to the facility in April 2022 with osteomyelitis of the vertebra, discitis and lower back pain. On 5/11/22 at 10:23 A.M., the surveyor observed a roll on bottle of Biofreeze (a menthol muscle cream) on the Resident's over bed table. During an interview on 5/11/22 at 10:23 A.M., Resident #93 said he/she had their spouse bring in the muscle cream and it had been on the over the bed table. He/she said no one has asked him/her about the medication or discussed with him/her the need for a physician order or how often it should be used. On 5/12/22 at 7:41 A.M., the surveyor observed a roll on bottle of Biofreeze on the over the bed table of Resident #93. During an interview with observation on 5/12/22 ay 10:48 A.M., the surveyor observed a roll on of Biofreeze on the over the bed table of Resident #93. Resident #93 said he/she uses it for…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-05-17 · tag F0636 — isolated
    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to conduct an interview with the responsible party to ensure that a timely activity comprehensive assessment was completed for one Resident (# 86) out of a total of 25 sampled residents. Findings include: 1. Resident # 86 was admitted to the facility in July 2021 with medical diagnoses including anoxic brain damage, functional quadriplegia, dysphagia, cortical blindness, cognitive communication deficit, contracture left elbow. Review of the Minimum Data Set (MDS), assessment dated [DATE], indicated Resident # 86 had a Brief Interview for Mental Status (BIMS) score of 04 out of a possible 15, which indicated he/she is severely cognitively impaired. The MDS indicated that Resident #86 is totally dependent on staff for all functional tasks. The MDS indicated no daily and activity preferences from Resident, family or significant other, as no interview was completed. During an interview on 05/16/22 at 12:27 A.M., the Activities Director said the social worker…

    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 · D2022-05-17 · 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, interview, and record review the facility failed to ensure a PICC line dressing was dated and maintained in accordance with the current physician orders for one Resident (#93), out of a total sample of 25 Residents. Findings include: Resident #93 was admitted to the facility in April 2022 with osteomyelitis of the vertebra, discitis and lower back pain. On 5/11/22 the surveyor observed a single lumen peripherally inserted central line (PICC) in the right arm of Resident #93. There was no date on the dressing indicating the last time the dressing was changed. Review of the current physician orders dated indicated the following order: - PICC Line dressing change: Change dressing 24 hours after insertion of the line and then weekly and as needed if compromised. Label with date and time. During an interview with observation on 5/12/22 Unit Manager (UM) #3 said PICC line dressings are to be changed initially upon admission and then weekly and as needed. She said the dressing should be dated at the time of the dressing change. UM #3 observed the PICC line dressing…

    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 · D2022-05-17 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview the facility failed to maintain the nebulizer tubing and set up for one Resident (#58) out of a total sample of 25 residents. Findings include: Resident #58 was admitted to the facility in March 2022 with diagnoses that include: Chronic obstructive pulmonary disease (COPD) with acute exacerbation and shortness of breath on exertion. Review of the current physician orders dated 5/13/22 indicated Resident #53 had an order for albuterol sulfate (a respiratory medication used to treat wheezing or shortness of breath) nebulizer treatment every four hours as needed for wheezing or shortness of breath since 3/16/22 and a second order for Nebulizer change device and tubing weekly on Thursday. On 5/11/22 the surveyor observed Resident #58 to have two nebulizer tubing and set up devices (small cup and mouth piece or mask) in his/her room dated March 2022. On 5/12/22 the surveyor observed the hand held mouth piece nebulizer tubing and set up at the Resident's bedside to be dated 3/24/22 and the mask nebulizer tubing and set up at the Resident's bedside to be…

    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 · D2022-05-17 · tag F0908 — failed to keep essential equipment working — isolated
    Keep all essential equipment working safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, document review, and interview, the facility failed to ensure that all electrical equipment on one of three unit nourishment kitchens were maintained and in safe operating condition. Findings include: On 5/11/22 at 3:01 P.M., the surveyor reviewed the Baywood Unit nourishment kitchen and observed the inner coating of the microwave to be stained brown on the bottom and sides. The upper right top coating, approximately three to four inches in length, was actively peeling and no longer intact, exposing the microwave's cavity wall underneath. The bottom outer panel of the microwave was rusted. Review of the unit maintenance log, dated January through May 2022, failed to indicate staff had identified a problem with the unit microwave for maintenance review. During an interview on 5/12/22 at 11:40 A.M., the Dietary Manager reviewed the unit kitchen with the surveyor and said the microwave needed to be taken out of service. During an interview on 5/16/22 at 9:03 A.M., the Maintenance Director said the microwave was disgusting and dirty, and there was potential for…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • No harm found · Bcited before2025-04-16 · tag F0641 — pattern
    Ensure each resident receives an accurate assessment.
    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 the Minimum Data Set (MDS) assessment was complete and accurate to reflect the status of one Resident (#16), out of a sample of 27 residents. Specifically, the facility failed to ensure an MDS was accurately coded for a fall with injury. Findings include: Review of the Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated 10/2024, indicated but was not limited to the following: 1) J1800: Any Falls Since Admission/Entry or Reentry or Prior Assessment OBRA (Omnibus Budget Reconciliation Act) or Scheduled PPS (Prospective Payment System), whichever is more recent -If this is not the first assessment/entry or reentry, the review period is from the day after the ARD (Assessment Reference Date) of the last MDS assessment to the ARD of the current assessment. -Code 0, no: if the resident has not had any fall since the last assessment. -Code 1, yes: if the resident has fallen since the last assessment. Continue to Number of Falls Since Admission/Entry…

    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
  • No harm found · B2024-02-21 · tag F0637 — pattern
    Assess 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 interviews and records reviewed, for two Residents (#89 and #107), of six residents reviewed, the facility failed to conduct significant change comprehensive assessments through completion of Minimum Data Set (MDS) assessments as required. Findings include: Review of the MDS 3.0 Resident Assessment Instrument (RAI) Manual, dated October 2019, indicated a Significant Change in Status Assessment (SCSA) comprehensive assessment must be completed by the end of the 14th calendar day following determination that a significant change has occurred. Review of the facility's policy titled Resident Assessment Instrument (RAI) Process, 6/2021, indicated but was not limited to: -The RAI process has multiple regulatory requirements -Staff will follow the rules and regulations of the RAI process per the RAI manual Review of the medical record for Resident #89 indicated the SCSA MDS assessment had an Assessment Reference Date (ARD) of 1/25/24. Review of the electronic medical record indicated as of 2/20/24 the SCSA MDS had not been completed, 26 days after the ARD. Review of the medical…

    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
  • No harm found · B2024-02-21 · tag F0638 — pattern
    Assure that each resident’s assessment is updated at least once every 3 months.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews and records reviewed, for two Residents (#86 and #235), of six residents reviewed and 24 sampled residents, the facility failed to conduct quarterly assessments through completion of Minimum Data Set (MDS) assessments as required. Findings include: Review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual indicated for Quarterly Assessments: The MDS completion date (item Z0500B) must be no later than 14 days after the Assessment Reference Date (ARD + 14 calendar days). Review of the facility's policy titled Resident Assessment Instrument (RAI) Process, 6/2021, indicated but was not limited to: -The RAI process has multiple regulatory requirements -Staff will follow the rules and regulations of the RAI process per the RAI manual 1.Review of the medical record for Resident #86 indicated the quarterly MDS assessment had an ARD of 1/11/24. Review of the electronic medical record indicated that as of 2/20/24 the quarterly MDS had not been completed, 40 days after the ARD. During an interview…

    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
  • No harm found · B2024-02-21 · tag F0640 — pattern
    Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on Minimum Data Set (MDS) assessment review and staff interview, the facility failed to ensure an MDS assessment was completed timely as required for three Residents (#77, #5, and #78), out of six records reviewed and 24 sampled residents. Specifically, the facility failed to ensure completion of an MDS discharge assessment within the required timeframe. Findings include: Review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) 3.0 Manual Chapter 2: Assessments for the RAI, dated October 2023, indicated but was not limited to: -a Discharge Assessment when return is anticipated must be completed no later than 14 calendar days after the discharge date . 1. Record review for Resident #77 indicated the Resident was discharged on 1/31/24. Review of Resident #77's MDS Discharge Return Anticipated encounter, dated 1/31/24, indicated section K was completed and signed; all other sections were incomplete or not completed. Further review of Resident #77's record indicated the MDS Discharge Return Anticipated encounter, dated 1/31/24, had 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • No harm found · Bcited before2024-02-21 · tag F0641 — pattern
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure a Minimum Data Set (MDS) assessment was accurately completed to reflect the status for two Residents (#4 and #100), in a total sample of 24 residents. Specifically, the facility failed: 1. For Resident #4, to ensure the MDS accurately reflected his/her preferences for customary routine and activities; and 2. For Resident #100, to ensure the MDS accurately reflected his/her dialysis status. Findings include: 1. Resident #4 was admitted to the facility in January 2013 with diagnoses including generalized weakness. Review of section F-preferences for customary routine and activities of the MDS assessment, dated 12/7/23, indicated sections F0300 through F0800 were blank and did not reflect the Resident's preferences for customary routine and activities. During an interview on 2/15/24 at 2:00 P.M., MDS Nurse #2 reviewed the 2/16/24 MDS and said section F was incomplete and did not reflect the Resident's activity preferences. 2. Resident #100 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.

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

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

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 →

RatingThis homeChain avg
Overall 4 of 53.0+1.0 vs chain
Health inspection 3 of 52.6+0.4 vs chain
Staffing 2 of 52.3-0.3 vs chain
Quality measures 5 of 54.3+0.7 vs chain
The other 86 homes this chain runs (chain average 3.0★, per CMS)
1 of 5Avalon Rehabilitation And Healthcare CenterHamilton, NJ 1 of 5Bay Harbor Post Acute Healthcare CenterSalisbury, MD 1 of 5Blueberry Hill Rehabilitation And Healthcare CtrBeverly, MA 1 of 5Canterbury Rehabilitation And Healthcare CenterRichmond, VA 1 of 5Cape Cod Post Acute CareBrewster, MA 1 of 5Crest Pointe Rehabilitation And Healthcare CenterPt Pleasant, NJ 1 of 5Highland Park Rehabilitation And Healthcare CenterChelsea, MA 1 of 5Mount Holly Rehabilitation & Healthcare CenterLumberton, NJ 1 of 5Nashua Post Acute CareNashua, NH 2 of 5Arbor Ridge Rehabilitation And Healthcare CenterWayne, NJ 2 of 5Atlantic View Post AcuteNewport News, VA 2 of 5Bayview Rehabilitation and Healthcare CenterNorth Kingstown, RI 2 of 5Collingswood Rehabilitation And Healthcare CenterRockville, MD 2 of 5Elmhurst Rehabilitation and Healthcare CenterProvidence, RI 2 of 5Graduate Post AcutePhiladelphia, PA 2 of 5Heritage Hills Nursing & Rehabilitation CenterSmithfield, RI 2 of 5Laurel Brook Rehabilitation And Healthcare CenterMount Laurel, NJ 2 of 5Lawrence Rehab & Hcc/The Meadows At LawrenceLawrenceville, NJ 2 of 5Lawrence Rehabilitation HospitalLawrenceville, NJ 2 of 5Lighthouse Rehabilitation And Healthcare CenterRevere, MA 2 of 5Lincolnwood Rehabilitation and Healthcare CenterNorth Providence, RI 2 of 5North End Rehabilitation And Healthcare CenterBoston, MA 2 of 5Orchard Hill Rehabilitation And Healthcare CenterTowson, MD 2 of 5Palm Springs Post AcuteChelmsford, MA 2 of 5Riverview Healthcare CommunityCoventry, RI 2 of 5Roosevelt Rehabilitation And Healthcare CenterPhiladelphia, PA 2 of 5Southampton Rehabilitation And Healthcare CenterRichmond, VA 2 of 5Springfield Rehabilitation And Healthcare CenterSpringfield, PA 2 of 5West Chester Rehabilitation And Healthcare CenterWest Chester, PA 2 of 5Westgate Hills Rehab & Healthcare CtrBaltimore, MD 2 of 5Willow Brook Rehabilitation And Healthcare CenterWilmington, MA 2 of 5YORK Post AcuteYorktown, VA 3 of 5Alexandria Rehabilitation And Healthcare CenterAlexandria, VA 3 of 5Aspen Hill Rehabiliation & Healthcare CenterHaverhill, MA 3 of 5Belmont Bay Rehabilitation And Healthcare CenterWoodbridge, VA 3 of 5Brighton Post Acute CareBrighton, MA 3 of 5Cambridge Rehabilitation And Healthcare CenterMoorestown, NJ 3 of 5Capitol Rehabilitation And Healthcare CenterHarrisburg, PA 3 of 5Chelsea Rehabilitation And Healthcare CenterGoochland, VA 3 of 5Exton Post AcuteExton, PA

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 / managerTypeRoleSince
QUINTO NEXGEN LLCOrganizationDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 04/01/2025
SKILLED VENTURE LLCOrganizationDIRECT OWNERSHIP INTERESTsince 04/01/2025
UKR NEXGEN LLCOrganizationDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 04/01/2025
NFR 2020 IRRV TROrganizationINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 04/01/2025
RSBRMK HOLDINGS LLCOrganizationINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 04/01/2025
SK NEXGEN TROrganizationINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 04/01/2025
TRYKO NEXGEN HOLDINGS LLCOrganizationINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 04/01/2025
UAK 2020 IRRV TROrganizationINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 04/01/2025
YK NEXGEN TROrganizationINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 04/01/2025
YR NEXGEN TROrganizationINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 04/01/2025
WALKER & DUNLOP MULTIFAMILY INCOrganization5% OR GREATER SECURITY INTERESTsince 04/01/2025
COHEN, DAVIDIndividualMANAGING CONTROL - GOVERNING BODY; ADP OF THE SNFsince 04/01/2025
MARIOS, PAULIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/10/2025
VIROJA, YOGESHIndividualMANAGING CONTROL - GOVERNING BODY; ADP OF THE SNFsince 04/01/2025
MARQUIS LIMITED LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/20/2025
RELIANT PRO REHAB LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/20/2025
PARAYATH, PADMAJAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2025
POSEN, MINDEEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2025
FLAGLER, OSHERIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 03/20/2025
KAHANOW, AVIVAIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 07/07/2025
LEVOVITZ, TZVIIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 03/20/2025
ROKEACH, FRAIDEIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 03/20/2025
ROKOWSKY, YITZCHOKIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 03/20/2025
BROCKTON PROPERTY LLCOrganizationADP OF THE SNFsince 04/01/2025

CMS files one row per role, so the 41 rows in the source record cover these 24 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.

14 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.

$17.7M
Net patient revenuemost recent cost report
-6.3%
Operating marginrevenue minus expenses
$2.8M
Related-party expense15% of expenses
Who pays — share of resident-days
Medicaid 59%Medicare 10%Other / private 30%

This home reported $2.8M paid to related parties — landlords or management companies under common ownership — equal to about 15% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$423per resident / day
operating cost
$12,867per month
≈ monthly operating cost
$398per 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 225690. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-16, 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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