Champion Rehabilitation And Nursing Center
2 Beaumont Avenue, Brockton, MA 02302 · For profit - Limited Liability company · 123 certified beds · (508) 588-8550 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- lower-than-typical staff turnover (32% vs 45% nationally) — better care continuity
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has a citation for mishandling residents’ money or property (F0565)
- a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing rating is low (1/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 1 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 21.2% | 16.4% | 15.4% | worse |
| Long-stay residents who lose too much weight | 9.7% | 5.1% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.8% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.0% | 1.8% | 2.0% | better |
| Long-stay residents with depressive symptoms | 25.3% | 15.5% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 1.3% | 3.4% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 12.4% | 15.4% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 22.0% | 19.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 96.8% | 94.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.8% | 4.2% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 11.7% | 21.2% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 24.0% | 21.4% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.9% | 1.4% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 78.3% | 77.7% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 21.4% | 25.7% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 14.9% | 11.9% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 0.95 | 1.88 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.00 | 1.50 | 1.80 | better |
‡ 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.
46.3% 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 61 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 39.3% 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 56 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 0.19 therapist hours per resident per day in 2026Q1 — more than 20% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 48% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 46.3%CMS range 35.4–58.1 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.5%CMS range 7.2–14.6 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 39.3% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 35.7% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 23.2% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 3.8% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.1%CMS range 4.3–12.1 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.95 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 123 beds and averages 115.2 residents a day — about 94% occupied, or roughly 8 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 3.13 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.35 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.88 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 2.86 hrs/resident/day on weekends vs 3.24 on weekdays — 12% thinner on weekends. RN hours go from 0.39 to 0.24 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 32% is below 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
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
28 citations, most serious first. The 10 most serious are shown; the remaining 18 are one tap away and print in full.
- Potential for harm · Ecited before2025-09-16 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure it provided an environment free of potential safety hazards for seven Residents (#27, #55, #81, #8, #30, #98, and #15), out of a total sample of 26 residents. Specifically, the facility failed:1. For Residents #27, #55, and #81, to ensure safe smoking practices were implemented; 2. For Resident #8, to complete a smoking evaluation prior to him/her smoking on facility property; and 3. For Residents #30, #98, and #15, to ensure falls were investigated thoroughly and interventions were developed and implemented to prevent future falls and/or mitigate risk of injury. Findings include: 1. Review of the facility's policy titled Resident Smoking Policy and Procedure, dated 2020, indicated but was not limited to the following: -The facility shall conduct an assessment to determine whether the resident requires a smoking apron and shall document this in the resident's care plan and in a smoking log to be kept on each residential floor.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-09-16 · tag F0698 — failed to provide proper dialysis care — patternProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed for one Resident (#13), out of a total sample size of 24 residents, to collaborate with the dialysis center on the Resident's care and services. Specifically, the facility failed to ensure the facility's Dietitian monitored Resident #13's Dialysis lab communication report cards and addressed abnormal laboratory results. Findings include:Review of the facility's policy titled End Stage Renal Disease, Care of the Resident with, revised September 2010, indicated but was not limited to the following:-Residents with end stage renal disease (ESRD) will be cared for according to currently recognized standards of care.-Staff caring for residents with ESRD, including residents receiving dialysis care outside the facility, shall be trained in the care and special needs of these residents.-Education and training of staff include, specifically: The nature and clinical management of ESRD (including infection prevention and nutritional needs). Resident #13 was admitted…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-09-16 · tag F0883 — failed to offer flu and pneumonia vaccines — patternDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide pneumococcal immunizations for three eligible Residents (#7, #15, and #30), out of a total sample of five residents.Findings include:Review of the facility's policy titled Pneumococcal Vaccine, last revised March 2023, indicated but was not limited to:-All residents are offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections.-Prior to or upon admission, residents are assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, are offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated.-Administration of the pneumococcal vaccines are made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination. Review of the CDC guidance titled Pneumococcal Vaccine Timing for Adults, dated October 2024, indicated but was not limited to the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-09-16 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to immediately notify the physician and/or registered dietitian of a significant weight loss for one Resident (#98), out of a total sample of 24 residents, to determine if a change in treatment was necessary. Findings include: Review of the facility's policy titled Weight Assessment and Intervention, dated as last revised March 2022, indicated but was not limited to the following:-Weights are monitored for undesirable or unintended weight loss or gain.-Any weight change of 5% or more since the last weight assessment is retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the dietician in writing.-The threshold for significant unplanned and undesirable weight loss will be based on the following criteria: 1 month - 5% weight loss is significant and greater than 5% is severe; 3 months - 7.5% weight loss is significant and greater than 7.5% is severe; and 6 months - 10% weight loss is significant and greater than 10% is severe.-Undesirable weight change is evaluated by the treatment…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-09-16 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interview, and record review, the facility failed to maintain acceptable parameters of nutritional status for one Resident (#98) with an unplanned significant weight loss, out of a total sample of 24 residents. Specifically, the facility failed to assess and evaluate after a severe weight loss (11.62% weight loss in one month and 13.61% in six months) had been identified for two weeks resulting in no interventions being implemented and he/she continued to lose weight. Findings include: Review of the facility's policy titled Weight Assessment and Intervention, dated as last revised March 2022, indicated but was not limited to the following:-Weights are monitored for undesirable or unintended weight loss or gain.-Any weight change of 5% or more since the last weight assessment is retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the dietician in writing.-The threshold for significant unplanned and undesirable weight loss will be based on the following criteria: 1 month - 5% weight loss is significant and greater…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-08-30 · tag F0656 — failed to write and follow a full care plan — patternDevelop 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
Based on observation, interview, and record review, the facility failed to develop and implement a person-centered comprehensive care plan for three Residents (#43, #2, and #36), out of a total sample of 18 residents. Specifically, the facility failed: 1. For Resident #43, to develop and implement a care plan for the Resident's smoking needs; 2. For Resident #2, to develop and implement a care plan for epilepsy (seizure disorder); and 3. For Resident #36, to develop and implement a care plan for the Resident's suicidal ideation. Findings include: 1. Review of Resident Smoking Policy and Procedure, dated 2022, indicated but was not limited to the following: -Resident deemed to need assistance to smoke should have the designation noted in the care plan. -The determination of the smoking assessment should be noted in the Resident's care plan. Resident #43 was admitted to the facility in August 2021 with diagnoses which included: hypertension, ambulatory dysfunction, and asthma. Review of the Minimum Data Set (MDS) assessment, dated 7/30/24, indicated Resident #43 scored 15 out of 15 on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-08-30 · tag F0699 — patternProvide care or services that was trauma informed and/or culturally competent.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interviews, the facility failed to ensure three Residents (#36, #51, and #89), out of a total sample of 18 residents, received culturally competent, trauma-informed care in accordance with professional standards of practice. Specifically, the facility failed to assess and identify triggers of trauma to prevent potential re-traumatization. Findings include: Trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being. Trauma. SAMHSA-HRSA Center for Integrated Health Solutions. Substance Abuse and Mental Health Services Administration, 11/30/2016. Review of the facility's policy titled Trauma Informed Care and Culturally Competent Care, dated revised 8/2022, indicated but was not limited to: -Perform universal screening of residents, which includes a brief, non-specialized identification of possible exposure to traumatic…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-08-30 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and policy review, the facility failed to store, prepare, and serve food in accordance with 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 perform hand hygiene during meal service on two of three units observed. Findings include: Review of the facility's policy titled hand washing/hand hygiene, revised August 2019, indicated but was not limited to the following: -The facility considers hand hygiene the primary means to prevent the spread of infections. -All personnel shall follow the hand washing/hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. -Use an alcohol-based rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: a. Before and after direct contact with residents; b. Contact with objects (e.g.,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-08-30 · tag F0840 — patternEmploy or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure for one Resident (#2), out of a total sample of 18 residents, recommended specialist appointments were scheduled. Specifically, the facility failed to ensure Inpatient Epilepsy (seizure disorder)and Neurology appointments were scheduled. Findings include: Review of the facility's policy titled Consultation Follow (sic), dated 2/2/24, indicated the facility will schedule the appointment and arrange transportation. Resident #2 was admitted to the facility in April 2024 with diagnoses including epilepsy. Review of the Minimum Data Set (MDS) assessment, dated 7/31/24, indicated Resident #2 scored 9 out of 15 on the Brief Interview for Mental Status (BIMS) indicating he/she had moderate cognitive impairment, he/she had epilepsy, and had been hospitalized recently. Review of the medical record indicated Resident #2 was having frequent seizures. Review of the Appointment Communication Form, dated 5/28/24, indicated Electro-encephalogram (EEG) (test to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-08-30 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record review, the facility failed to ensure one Resident (#53), out of a total sample of 18 residents, received care and treatment to promote healing of a pressure ulcer. Specifically, the facility failed for Resident #53, to implement treatments as ordered for an unstageable pressure ulcer (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough (necrotic (dead) tissue that is green, yellow, tan, or brown and may be moist, loose, or stringy) or eschar (dry, thick, leathery tissue)) on the sacrum (lower spine area). Findings include: Review of the facility's policy titled Pressure Ulcers/Skin Breakdown- Clinical Protocol, dated as revised in December 2023, indicated the following: -the physician will order pertinent wound treatments including dressings and application of topical agents -the nurses shall describe and document current treatments Resident #53 was admitted to the facility in July 2022 with a diagnosis of dementia and was on hospice…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 18 citations
- Potential for harm · Dcited before2024-08-30 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 interview, the facility failed to ensure the environment was free from accident hazards for one Resident (#51), out of a total sample of 18 residents. Specifically, the facility failed to implement interventions on the comprehensive care plan to ensure safety precautions were taken for resident safety related to smoking, and to complete quarterly smoking evaluations. Findings include: Review of the facility's policy titled Resident Smoking Policy and Procedure, dated 2022, indicated but was not limited to the following: -The facility will maintain an environment that remains as free from accidental hazards as possible. The facility will ensure that each resident receives adequate supervision and assistance to prevent accidents. The facility will provide accommodation of individual needs and preferences without endangering the health or safety of any resident in the facility. -Residents deemed to need assistance should have this designation noted in the care plan. RESIDENTS: -Each resident should be individually assessed to determine whether…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-30 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
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 provide indwelling catheter (a flexible tube inserted into the bladder to drain urine outside of the body) care and management consistent with professional standards for one Resident (#2), out of a total sample of 18 residents. Specifically, the facility failed to ensure the Foley catheter was assessed for removal as soon as possible after returning from the hospital and failed to ensure he/she followed up with Urology as recommended. Findings include: Resident #2 was admitted to the facility in April 2024 with diagnoses including overactive bladder and epilepsy (seizure disorder). Review of the Minimum Data Set (MDS) assessment, dated 7/31/24, indicated Resident #2 scored 9 out of 15 on the Brief Interview for Mental Status (BIMS) indicating he/she had moderate cognitive impairment, had epilepsy, had been hospitalized recently, and had a Foley catheter. Review of the active Physician's Orders indicated but were not limited to the following: -Foley…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-08-30 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, record review, and policy review, the facility failed to monitor the nutritional status for one Resident (#18) with an unplanned gradual weight loss, in a total sample of 18 residents. Specifically, the facility failed for Resident #18, to obtain weekly weights as ordered and to monitor the gradual weight loss of 9.68% over six months. Findings include: Review of the facility's Weight Management policy, undated, indicated the healthcare staff will perform the following best practice guidelines to manage risk of significant unplanned weight change: -residents are weighed a minimum of monthly with more frequent weights obtained as ordered or deemed necessary Review of the facility's Clinical Assessment policy, dated 3/17/23, indicated it was the policy of the facility to complete appropriate assessments on residents on admission, quarterly, significant change, annually and at any time an assessment would be indicated. The purpose of the assessments is to get an accurate picture/evaluation of the resident to ensure the development of an appropriate…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-08-30 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to ensure for one Resident (#42), out of a total sample of 18 residents, that the Resident's drug regimen was free from unnecessary drugs. Specifically, the facility failed to ensure Azithromycin (antibiotic) was not administered without an adequate indication for use for an excessive duration of time (one year). Findings include: Resident #42 was admitted to the facility in December 2022 with diagnoses which included chronic respiratory failure, chronic obstructive pulmonary disease (COPD), and pneumonia. Review of the Minimum Data Set (MDS) assessment, dated 6/26/24, indicated Resident #42 scored 12 out of 15 on the Brief Interview for Mental Status (BIMS), was cognitively intact, and was taking an antibiotic. Review of the medical record indicated Resident #42 had been admitted to the hospital in August 2023. Review of the hospital Discharge summary, dated [DATE], indicated the Resident was discharged back to the facility on a 5-day course of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-30 · tag F0808 — failed to follow doctor-ordered diets — isolatedEnsure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure the physician ordered therapeutic diet was followed for one Resident (#29), in a total sample of 18 residents. Findings include: Resident #29 was admitted to the facility in July 2015 with diagnoses which included: dysphagia oropharyngeal phase (an impairment in the ability to swallow), pneumonitis due to inhalation of other solids and liquids, gastrostomy status (presence of a feeding tube), and hemiplegia and hemiparesis following cerebrovascular disease affecting right dominant side. Review of Resident #29's Minimum Data Set (MDS) assessment, dated 6/11/24, indicated the staff assessed the Resident to be severely cognitively impaired. Review of the Physician's Orders for Resident #29 indicated the following: regular diet, puree texture, thin consistency. Review of the care plan for Resident #51 indicated the following: Focus: Resident #29 has an ADL self-care performance deficit. Goal: Resident #29 will maintain current level…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-30 · tag F0880 — failed to prevent and control infections — isolatedProvide 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, record review, and interviews, the facility failed to ensure for one Resident (#53), out of a total sample of 18 residents, infection prevention and control measures were implemented to prevent the potential transmission of infections. Specifically, the facility failed to ensure staff followed basic infection control practices, including hand hygiene, resulting in potential cross contamination (transfer of pathogens from one surface to another). Findings include: Review of the facility's policy titled Handwashing/Hand Hygiene, dated as last revised August 2019, indicated but was not limited to the following: -This facility considers hand hygiene the primary means to prevent the spread of infections. -Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap and water for the following situations: a. Before and after direct contact with a resident. b. Before performing any non-surgical invasive procedures. c. Before handling clean or soiled dressings, gauze pads, etc. d. Before moving from a contaminated body site to a clean body site…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-07-12 · tag F0565 — failed to support the resident council — patternHonor 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, interview, policy review, and document review, the facility failed to ensure grievances and concerns brought forward by the Resident Council were addressed and/or responded to. Findings include: Review of the facility's policy titled Resident Council, dated as revised February 2021, indicated but was not limited to the following: - The purpose of the Resident Council is to provide a forum for discussion for concerns, communication between residents and staff, and to gather feedback. - a resident council response form will be utilized to track issues and their resolutions. Review of the facility's policy titled Resident and family concerns and grievance policy, dated 2020, indicated but was not limited to the following: - residents may voice a grievance to the facility staff in person, by phone, or written communication - a formal investigation of the grievance will occur as soon as is practicable - the facility will document all steps of the grievance resolution, including whether or not the residents were satisfied with the resolution Review of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-07-12 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure the resident environment was clean, comfortable, and homelike for the residents residing on two of three units. Specifically, 1. For the Astoria Unit (2nd floor), multiple areas in the environment were found to be dirty and/or in disrepair; and 2. For the [NAME] Unit (4th floor), multiple concerns were identified with regard to the cleanliness of resident rooms and equipment. Findings include: 1. The surveyor observed the Astoria Unit and made the following observations of the residents' environment: On 7/6/23 from 10:51 A.M. to 11:15 A.M., the surveyor observed the following: -An air conditioner in room [ROOM NUMBER] had a black mold-like substance material at the louvered side panels that meet the sides of the windows. -An air conditioner in room [ROOM NUMBER] had a black mold-like substance at the louvered side panels that meet the sides of the window and in the air conditioner vents. A soiled glove was observed on the floor between the beds.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-07-12 · tag F0656 — failed to write and follow a full care plan — patternDevelop 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
Based on observations, interviews, policy review, and record review, the facility failed to ensure an individualized plan of care was developed and implemented for three Residents (#66, #28, and #77), in a total sample of 19 residents. Specifically, the facility failed: 1. For Resident #66, a. to develop a care plan for an indwelling urinary catheter, an intravenous (IV) catheter, and an active infection, and b. to ensure the air mattress settings were implemented per the plan of care; 2. For Resident #28, to develop a care plan for edema; and 3. For Resident #77, to ensure the air mattress settings were implemented per the plan of care. Findings include: Review of the facility's policy titled Comprehensive Person-Centered Care Plans, dated March 2022, indicated but was not limited to: -A comprehensive, person-centered care plan that includes measurable objective and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. - The comprehensive, person-centered care plan describes the services that are 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.
- Potential for harm · Ecited before2023-07-12 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — patternProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record reviews, the facility failed to ensure one Resident (#16) with a pressure ulcer received treatment and services to promote wound healing, in a sample of five residents with pressure ulcers. Specifically, the facility failed to ensure for Resident #16, a. wound treatment recommendations were implemented, and b. the pressure-relieving air mattress was utilized following professional standards. Findings include: Resident #16 was admitted to the facility in August 2022 and had diagnoses including re-occurring c-diff (clostridium difficile- a bacteria that causes diarrhea) and diabetes; hospice services were initiated in March 2023. Review of the Minimum Data Set (MDS) assessment, dated 5/17/23, indicated Resident #16 scored a 7 out of 15 on the Brief Interview for Mental Status, indicating severe cognitive impairment. Review of the Care Plans indicated Resident #16 had a skin impairment related to incontinence and a mobility deficit, initiated February 2023. The goal was to reduce the size of the pressure ulcer through interventions of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-07-12 · tag F0757 — failed to avoid unnecessary drugs — patternEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure the resident's drug regimen was free from unnecessary drugs without adequate monitoring for signs/symptoms of adverse consequences (i.e., side effects) to ensure the safe administration of medications for four Residents (#19, #42, #40, and #28), in a total sample of 19 residents. Specifically, the facility failed to ensure Residents #19, #42, #40 and #28 were monitored for signs/symptoms of adverse complications/side effects (signs and symptoms of hypo/hyperglycemia) and effectiveness related to the administration of antidiabetic medications. Findings include: 1. Resident #19 was admitted to the facility in March 2020 with diagnoses including diabetes mellitus. Review of the July 2023 Physician's Orders indicated the following: Glipizide (anti-diabetic medication) tablet 5 milligrams (mg). Give 1 tablet by mouth two times a day (start date 12/16/22). Metformin (anti-diabetic medication) tablet 1000 mg. Give 1000 mg by mouth two times a day (start date 5/19/22). Review of the current Medication Administration Record…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-07-12 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to notify the physician of changes in condition, to re-evaluate the potential need to alter the treatment plan for two Residents (#16 and #19), from a total sample of 19 residents. Specifically, the facility failed to notify the primary physician when: 1. Resident #16 developed an open area on the sacrum (lower back near the pelvis) and a new dressing was applied; and 2. Resident #19 had recommendations from the consultant Ophthalmologist. Findings include: Review of the facility's policy titled Change in a Resident's Condition or Status, dated as revised in February 2021, indicated the following: - The nurse will notify the resident's attending physician (or physician on call) when there has been a need to alter the resident's medical treatment significantly. 1. Resident #16 was admitted to the facility in August 2022. Review of the Care Plans indicated Resident #16 was at risk for skin breakdown related to incontinence, impaired mobility and a diagnosis of diabetes (initiated August 2022). Review of the Weekly…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-07-12 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and policy review, the facility failed for one Resident (#85), out of five residents observed during medication administration, to verify the prescribed dose of medication prior to administering the medication to the Resident. Findings include: Review of the facility's policy titled Administering Medications, dated as revised March 2023, indicated but was not limited to the following: - the individual administering the medication checks the label three times to verify the right medication, resident, route, time and dose - nurses adhere to the seven rights of medication administration: right medication, right patient, right time, right route, right reason, right documentation, right dose Review of the current Physician's Orders for Resident #85 included but were not limited to the following: - Folic Acid 1 milligram (mg), once a day, 9:00 A.M. (12/14/22) - Thiamine hydrochloride (HCL) 100 mg, once a day, 9:00 A.M. (12/14/22) - Vitamin B12 500 micrograms (mcg), once a day, 9:00 A.M. (12/14/22) - Calcium 600 mg, twice a day, 9:00 A.M. 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.
- Potential for harm · D2023-07-12 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to provide activities of daily living, including getting out of bed to a wheelchair and receiving a shower, for one Resident (#16) who was dependent for care, in a total sample of 19 residents. Findings include: Resident #16 was admitted to the facility in August 2022. Review of the most recent Minimum Data Set (MDS) assessment, dated 5/17/23, indicated Resident #16 was totally dependent on two staff members for transfers between surfaces (in and out of bed) and totally dependent on staff for bathing. Review of the Care Plans indicated Resident #16 had a self-care performance deficit, impaired mobility related to weakness, decreased activity tolerance and poor endurance with interventions including requiring extensive physical assist and dependent of one to two staff for bed mobility, toileting and transfers (between surfaces), requiring extensive physical assist and dependent on staff for grooming and hygiene, and requiring extensive physical assist for bathing. Review of the electronic medical record indicated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-07-12 · tag F0685 — isolatedAssist a resident in gaining access to vision and hearing services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, observations, and interviews, the facility failed to ensure one Resident (#59) received his/her hearing aids daily, to maintain hearing ability, out of a total sample of 19 residents. Findings include: Resident #59 was admitted to the facility in June 2022 with diagnoses which included dementia and need for assistance with personal care. Review of the Minimum Data Set (MDS) assessment, dated 6/6/23, indicated Resident #59 had a Brief Interview for Mental Status score of 2 out of 15, which indicated Resident #59 had severe cognitive impairment. Further review of the MDS indicated Resident #59 had minimal difficulty hearing with the use of hearing aids. Review of the medical record for Resident #59 included a care plan indicating he/she had a potential for communication problem related to being hard of hearing and having impaired cognition. Care plan interventions included bilateral hearing aids as ordered. Review of Resident #59's current Physician's Orders included: -Bilateral hearing aids in A.M. remove at HS (hour of sleep). Store in medication room 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.
- Potential for harm · D2023-07-12 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and policy review, the facility failed to ensure compartments containing drugs and biologicals were locked when not in use for 2 of 6 medication carts in use by the facility. Findings include: Review of the facility's policy titled Storage of Medications, dated as revised November 2020, indicated but was not limited to the following: - facility stores all drugs and biologicals in a safe, secure and orderly manner - compartments, including carts, containing drugs and biologicals are locked when not in use - unlocked medication carts are not left unattended On 7/6/23, the surveyor made the following observations on the [NAME] unit: - 1:45 P.M., Nurse #1 sitting behind the nurses' station with the medication cart parked, unlocked in front of the nurses' station. - 1:47 P.M., Nurse #1 leaves the nurses' station and walks down the hallway to assist a resident behind a closed door. The medication cart remained unlocked, and now unattended by staff in the hallway in front of the nurses'…
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.
- No harm found · B2023-07-12 · tag F0623 — patternProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — the official record, unedited, may be distressing
Based on interview and record review, the facility failed to provide a written notice of discharge prior to transferring one Resident (#6) to the hospital on two occasions, out of 19 sampled residents. Findings include: Resident #6 was admitted to the facility in August 2020. Review of the medical record indicated Resident #6 was transferred to the hospital on 5/13/23 and 5/23/23. Review of the paper and electronic medical records failed to indicate evidence that a Notice of Intent to Transfer Resident was completed on 5/13/23 or 5/23/23. During an interview on 7/11/23 at 2:43 P.M., the Social Worker said nursing staff completes the Notice of Intent to Transfer Resident when they are transferring a resident to the hospital. During an interview on 7/11/23 at 4:32 P.M., the Director of Nurses (DON) reviewed Resident #6's medical record and was unable to locate a Notice of Intent to Transfer Resident for either hospitalization. The DON said the expectation was for a transfer notice to be completed any time a resident was transferred to the hospital.
- No harm found · B2023-07-12 · tag F0625 — patternNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to provide a bed-hold notice upon transfer to the hospital on two occasions for one Resident (#6), out of 19 sampled residents. Findings include: Resident #6 was admitted to the facility in August 2020. Review of the medical record indicated Resident #6 was transferred to the hospital on 5/13/23 and 5/23/23. Review of the paper and electronic medical records failed to indicate evidence that written notice of the bed-hold policy was provided to Resident #6 when he/she was transferred to the hospital on 5/13/23 or 5/23/23. During an interview on 7/11/23 at 2:43 P.M., the Social Worker said nursing staff provides the written notice of the bed-hold policy when they are transferring a resident to the hospital. During an interview on 7/11/23 at 4:32 P.M., the Director of Nurses (DON) reviewed Resident #6's medical record and was unable to locate evidence that written notice of the bed-hold policy had been completed on 5/13/23 or 5/23/23. The DON said the expectation was for written notice of the bed-hold policy to be provided any…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| REYNOLDS, MATTHEW | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/03/2025 |
| ASAKER, BAHIGE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2025 |
CMS files one row per role, so the 5 rows in the source record cover these 2 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 82% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in MA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Massachusetts Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 225221. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-16, 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 →
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