Palm Springs Post Acute
40 Parkhurst Road, Chelmsford, MA 01824 · For profit - Corporation · 124 certified beds · (978) 256-3151 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- no federal fines or payment denials on record
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
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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 | 2 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 fell from 4 to 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
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 | 23.7% | 16.4% | 15.4% | worse |
| Long-stay residents who lose too much weight | 7.8% | 5.1% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.2% | 0.8% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.6% | 1.8% | 2.0% | better |
| Long-stay residents with depressive symptoms | 23.3% | 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 | 5.1% | 3.4% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 21.5% | 15.4% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 18.1% | 19.5% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 88.3% | 94.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.9% | 4.2% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 29.8% | 21.2% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 16.6% | 21.4% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 1.0% | 1.4% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 71.0% | 77.7% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 23.6% | 25.7% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 11.9% | 11.9% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 2.22 | 1.88 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.80 | 1.50 | 1.80 | typical |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
59.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 223 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 56.8% 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 148 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 0.30 therapist hours per resident per day in 2026Q1 — more than 49% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 42% 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 | 59.8%CMS range 52.1–65.5 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.4%CMS range 8.3–14.5 | 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 | 56.8% | 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 | 43.2% | 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 | 51.4% | 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 | 98.6% | 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 | 98.1% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.5% | 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 | 1.4% | 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 | 6.4%CMS range 3.8–9.6 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.80 | 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 124 beds and averages 112.3 residents a day — about 91% 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 3.62 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.50 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.09 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 3.13 hrs/resident/day on weekends vs 3.82 on weekdays — 18% thinner on weekends. RN hours go from 0.61 to 0.25 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 43% is about the same as the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
26 citations, most serious first. The 10 most serious are shown; the remaining 16 are one tap away and print in full.
- Potential for harm · D2026-03-26 · 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 records reviewed and interviews, for one of three sampled residents (Resident #1), whose physician's orders included wound care and dressing changes to a wound on his/her buttocks, the facility failed to ensure professional standards of practice were maintained when the nursing staff did not document specific wound characteristics, as well as effectiveness of treatment, in accordance with nursing best practice and facility policy.Findings include:Review of the Facility's Policy, titled Wound Care, with a revision date of October 2010, included the following:-The following information should be recorded in the resident's medical record:*The type of wound care given.*The date and time the wound care was given.*The position in which the resident was placed.*All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound.*Any change in the resident's condition.*How the resident tolerated the procedure.Resident #1 was admitted to the facility in January 2026, diagnoses included chronic kidney disease, polyosteoarthritis (affecting multiple…
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 before2026-03-26 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was admitted to the facility with an unstageable pressure injury (full tissue loss covered with slough or dead tissue), the facility failed to ensure they adequately managed his/her pain, when he/she displayed both verbal and non-verbal indicators of pain and analgesics were not offered or administered.Findings include:Review of the facility's Policy, titled Pain Assessment and Management, with a revision date of April 2025, indicated the following:-The purposes of this procedure are to help the staff identify pain in the resident, develop interventions consistent with the resident's goals and needs, and address the underlying causes of pain.-Pain management is a multidisciplinary process that includes the following:*identifying signs and symptoms of existing pain*recognizing situations and conditions with the potential for pain*identifying the underlying causes, intensity, duration, type, and characteristics of pain-Cognitive, cultural, familial, and gender-specific influences on 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 before2026-03-26 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the facility failed to ensure they maintained an accurate and complete medical record related to 1) the anatomical location of a pressure injury and 2) the frequency of repositioning.Findings include:Review of the Facility's Policy, titled Charting and Documentation, with a revision date of July 2017, included the following:-All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record.Review of the Facility's Policy, titled Prevention of Pressure Injuries, with a revision date of April 2020, included the following:-Reposition all residents with or at risk of pressure injuries on an individualized schedule, as determined by their interdisciplinary care team.Resident #1 was admitted to the facility in January 2026, diagnoses included chronic kidney disease, polyosteoarthritis (affecting multiple joints), and unstageable (full tissue loss…
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 before2025-12-09 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had a tracheostomy (a surgical procedure that creates and opening in the neck to facilitate breathing when the usual airway is obstructed or compromised) and required continual respiratory care and the administration of humidified oxygen, the facility failed to ensure that care and treatment provided were consistent with professional standards of practice, when physician's orders related to his/her respiratory equipment use/monitoring were not obtained by nursing.Findings include:Review of the Facility's Protocol and Procedure, titled Airvo and myAirvo Unit, undated, indicated the following:-Description: A humidifier, with adjustable flow settings, delivering high flow warm and humidified gases.-Fill the water chamber with sterile or distilled water. Do not allow the water chamber to run dry.-Set the airflow setting on the Airvo and the oxygen liters per minute to achieve the prescribed percentage of oxygen.-Documentation: *Airvo flow settings *Oxygen liter flow *Oxygen percentage…
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 before2025-12-09 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records reviewed and interviews for one of three sampled residents (Resident #1), the facility failed to ensure they maintained complete and accurate records related to 1) the care and services associated with his/her tracheostomy (a surgical procedure that creates and opening in the neck to facilitate breathing when the usual airway is obstructed or compromised) and 2) the recording of the events during his/her Cardiopulmonary Resuscitation (CPR) Code.Findings include:Review of the Facility's policy, titled Suctioning the Tracheostomy Tube, with a revision date of 10/2023, indicated the following:-The purpose of this procedure is to remove secretions, maintain a patent airway, and prevent infection of the lower respiratory tract.-The following information should be recorded in the resident's medical record: *The date and time the procedure was performed *The type and size of the catheter used. *The amount of negative pressure millimeters per mercury (mmHg) used to suction. *Amount, color 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 · Ecited before2025-11-20 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to provide supervision during meals for one Resident (#102) with an aspiration risk out of a total sample of 27 residents. Findings include: Review of the facility policy titled, Activities of Daily Living (ADL) Supporting, dated April 2025, indicated the following:-Residents are provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living.-Residents who are unable to carry out activities of daily living independently receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene.-Appropriate care and services are provided to residents who are unable to carry out ADLs independently, with the consent of the resident, and in accordance with the plan of care, including appropriate support and assistance with: d. dining (eating, including meals and snacks). Resident #102 was admitted to the facility in July 2025 with diagnoses 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 · E2025-11-20 · 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
Based on observation and interview, the facility failed to store and prepare food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure food was dated, stored off the floor, shelves on which food was stored were clean/free of possible contaminants, and that unpasteurized eggs were cooked thoroughly. Findings include: Review of the facility's policy titled Food Receiving and Storage, dated as revised November 2022, indicated, but was not limited to, the following:- Foods shall be received and stored in a manner that complies with safe food handling practices. - Dry foods that are stored in bins are removed from original packaging, labeled and dated ( use by date). Such foods are rotated using a first in-first out system.- All foods stored in the refrigerator or freezer are covered, labeled and dated ( use by date).- Refrigerators/walk-ins are not overcrowded. Foods in the walk-in are stored off the floor. Review of the facility's policy titled Food Preparation and Service, dated as revised November 2022, indicated, but was not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-11-20 · tag F0604 — failed to not use physical restraints improperly — isolatedEnsure that each resident is free from the use of physical restraints, unless needed for medical treatment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record review and interviews, the facility failed to ensure one Resident (#36) was free from restraints, out of a total sample of 27 residents.Findings include:Review of the facility policy titled, Restraints, dated September 2021, indicated the following:- -All residents have the right to be free of physical and chemical restraint used in violation of applicable regulations and standard of practice.- - Residents may not be physically restrained for discipline or convenience.- - Residents may not be physically restrained without an order from a physician to treat the resident's symptoms or medical conditions.Resident #36 was admitted to the facility in October 2025 with the diagnosis including Parkinson's disease and transient alteration of awareness.Review of Resident #36's most recent Minimum Data Set (MDS) assessment, dated 11/3/25, indicated the Resident scored 7 out of 15 on the Brief Interview for Mental Status exam indicating he/she was severely cognitively impaired. The MDS also indicated Resident #36 was dependent on staff for all care.On 11/18/25 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-11-20 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to accurately code in the Minimum Data Set (MDS) for one Resident (#7) out of 27 total sampled residents. Specifically, for Resident #7, the facility failed to accurately document a fall resulting in a right humeral fracture. Findings include:Review of the MDS 3.0 Resident Assessment Instrument (RAI) Manual, dated October 2025, indicated:-Review any follow-up medical information received pertaining to the fall, even if this information is received after the ARD (e.g., emergency room x-ray, MRI, CT scan results) and ensure that this information is used to code the assessment.-If the level of injury directly related to a fall that occurred during the look-back period is identified after the ARD and is at a different injury level than what was originally coded on an assessment that was submitted to the Internet Quality Improvement and Evaluation System (iQIES), the assessment must be modified to update the level of injury that occurred with that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-11-20 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure one Resident (#5), out of a total sample of 27 residents, was referred for a Level II Preadmission Screening and Resident Review (PASRR) evaluation (an evaluation to determine if a resident needs specialized services to address his/her new diagnosis of schizoaffective disorder, which is a serious mental illness (SMI)) as required.Findings include: Review of the facility policy titled Behavioral Assessment, Intervention, and Monitoring, dated as revised February 2025, indicated:-New onset or changes in behavior that indicate newly evident or possible serious mental disorder, intellectual disability, or a related disorder are referred for a PASARR Level II evaluation.Resident #5 was admitted to the facility in November 2025 with diagnoses including diabetes and heart failure.Review of the most recent Minimum Data Set (MDS) assessment, dated 11/7/25, indicated Resident #5 was cognitively intact as evidenced by a Brief Interview for Mental Status exam score of 14 out of 15. This MDS also indicated Resident #5 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.
Show the remaining 16 citations
- Potential for harm · D2025-11-20 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record review, and interviews, the facility failed to ensure one Resident (#87) who was fed by enteral means (artificially via a tube), out of a total sample of 27 residents, received appropriate treatment to prevent complications of enteral feeding. Specifically, the facility failed to ensure that Resident #87's enteral nutrition formula was administered at the physician-prescribed rate. Findings include:Review of the facility policy, titled Enteral Nutrition, revised November 2018, indicated, but was not limited to, the following:- Adequate nutritional support through enteral nutrition is provided to residents as ordered.- The dietitian monitors residents who are receiving enteral nutrition and makes appropriate recommendations for interventions to enhance tolerance and nutritional adequacy of enteral feedings.- Enteral feedings are scheduled to try to optimize resident independence whenever possible (e.g., at night or during hours that do not interfere with the resident's ability to participate in facility activities).- The nurse confirms that orders 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.
- Potential for harm · D2025-11-20 · 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
Based on observations and interviews the facility failed to ensure drugs and biologicals were stored in accordance with acceptable professional standards of practice. Specifically,1.The facility failed to ensure that expired medications were removed from medication carts and medication rooms on 2 out of 3 units.2.The facility failed to ensure medication carts were locked while unattended.Findings include:Review of the facility policy titled Medication Storage, dated August 2021, indicated the following: -Facility will ensure that medications are safely and appropriately stored. -Discontinued or expired medications will be destroyed within 30 days, or if unopened and properly labeled, returned to the pharmacy for credit if allowed. -The storage area will be kept locked when not in use. 1. On 11/19/25 at 6:35 A.M., the surveyor and Nurse#2 observed the following in the C-wing medication cart and medication room. -A bottle of Maalox with expiration date of 10/2025 -A bottle of Metamucil with expiration date of 3/2025 -A bottle of ear wax with expiration date of 10/2025 -A bottle 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 · D2024-10-18 · tag F0552 — isolatedEnsure that residents are fully informed and understand their health status, care and treatments.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record and policy review, the facility failed to inform in advance of changes to the plan of care relative to the use of psychotropic (medication that affects how the brain works and causes changes in mood, awareness, thoughts, feelings or behavior) medications for two Residents (#9 and #29) out of a total sample of 20 residents. Specifically, the facility failed to obtain written consent for the use of psychotropic medications before administering Lorazepam (Ativan - anti-anxiety medication) medication to Residents #9 and #29. Findings include: Review of the facility policy titled Psychoactive Medication Use, dated 2015 and revised December 2022, indicated: -A psychotropic medication is any medication that affects the brain activity associated with mental processes and behavior. -Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring and review requirements specific to psychotropic medications .anti-anxiety medications . -Written…
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 before2024-10-18 · tag F0604 — failed to not use physical restraints improperly — isolatedEnsure that each resident is free from the use of physical restraints, unless needed for medical treatment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record and policy review, the facility failed to ensure that devices utilized for two Residents (#50 and #103), were assessed and consent was obtained by the Resident Representative, when used as physical restraints (defined as any manual method, physical or mechanical device, equipment, or material that meets all of the following criteria: is attached or adjacent to the resident's body, cannot be removed easily by the resident; and restricts the resident's freedom of movement or normal access to his/her body), for two applicable Residents who had gastrostomy tubes (G-tube: tube inserted through the stomach that delivers nutrition/hydration), out of a total sample of 20 residents. Specifically, the facility failed to: 1. For Resident #50, obtain written consent for a restraint, and assess the need for an abdominal binder (wide compression belt that hook and loop fastens and encircles the abdomen) to cover Resident #50's G-tube site in order to prevent him/her from pulling 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 · Dcited before2024-10-18 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record and policy review, and interview, the facility failed ensure a Resident who was dependent for activities of daily living (ADL's- personal care activities including but not limited to, eating, grooming, and personal hygiene) received the necessary care and services to maintain grooming for one Resident (#94) out of a total sample of 20 residents. Specifically, for Resident #94, the facility failed to provide assistance for grooming of facial hair per the Resident's preference. Findings include: Review of the facility policy titled Activity of Daily Living (ADL's)- Supporting, dated 2001 with revision date of 3/2018, indicated: -Residents will be provided with care, treatment and services .to carry out ADL's. -Residents who are unable to carry out ADL's independently will receive the services necessary to maintain good .grooming and personal care. Resident #94 was admitted to the facility in June 2024, with diagnoses including fall, fracture (a complete or partial break of a bone) 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 · Dcited before2024-10-18 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, policy and record review, and interview, the facility failed to provide respiratory care and services consistent with professional standards of practice for one Resident (#29) out of a total sample of 20 residents. Specifically, the facility failed to obtain Physician's orders for oxygen administration and maintenance of oxygen and respiratory equipment. Findings include: Review of facility policy titled Oxygen Administration, dated 2001 with revision date of 10/2022, indicated: -Verify that there is a physician's order for oxygen administration. -Adjust the Oxygen delivery device so that it is comfortable for the resident and the proper flow of Oxygen is being administered. Review of the facility policy titled Respiratory Equipment/Supply Cleaning/Disinfecting, undated with revision date of 7/15/2024, indicated: -Schedule for supply changes of Nasal Cannula (NC - a clear, soft flexible tube with prongs which are positioned in the nose for oxygen delivery) should occur every seven days and as needed for soiling. Review of the AARC (American Association 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.
- Potential for harm · D2024-10-18 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop 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, record and policy review, the facility failed to ensure that an Influenza (Flu) vaccine was administered to one Resident (#16) out of five applicable residents, out of a total sample of 20 residents. Specifically, the facility failed to administer the Influenza vaccine for Resident #16 who had signed a consent for the vaccine to be administered. Findings include: Review of the facility policy titled Respiratory Protection Program Policy, (not dated), indicated: -The Center will ensure that all center staff and Residents/Patients have the opportunity to receive the respiratory illness vaccinations in accordance with the Centers for Disease Control and Prevention (CDC)recommendations and federal/state regulations . -Provide resident/resident representative with the current vaccine administration sheet as education regarding risks/benefits of vaccination if unvaccinated and document education. -Obtain consent. -Document exemptions/declinations. -Obtain a physician's order. -Administer vaccine.…
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 · E2023-08-24 · tag F0578 — failed to honor advance directives / code status — patternHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure the Advance Care Planning and Advance Directive rights for one Resident (#79), out of 21 sampled residents, to have a designated Health Care Agent make healthcare related decisions were upheld when the Resident was unable to make his/her own health care decisions. Specifically, the facility failed to arrange for Resident #79 to obtain a legally designated Health Care Agent when the Resident was incapacitated and his/her designated Health Care Agent was permanently unavailable to make healthcare related decisions for the Resident, resulting in facility communication of sharing confidential information and discussing health care related decision making, with an individual who was not the Resident's designated Health Care Agent. Findings include: Review of the facility's policy, titled Guardianship, revised 2/28/21, indicated: - A guardian may be appointed when a patient/resident (hereinafter patient) has been deemed incapacitated. - A court appointed guardian's responsibilities and duties may include, but are not…
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 · D2023-08-24 · tag F0636 — isolatedAssess 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 accurate comprehensive assessment of one Resident's (#79) functional capacity, out of 21 sampled residents according to the Centers for Medicare and Medicaid Services' (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual instructions. Specifically, the facility failed to comprehensively assess Resident #79's cognitive patterns when the Resident did not require an interpreter and was identified to have: clear speech, the ability to make him/her self understood, and the ability to understand others. Findings include: Review of the CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2019, indicated the following for Section C, Cognitive Patterns: -Intent: The items in this section are intended to determine the resident's attention, orientation and ability to register and recall new information. These items are crucial factors in many care planning decisions. -The Brief 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.
- Potential for harm · Dcited before2023-08-24 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to complete a Resident review (Level I (initial pre-screening) screening form required if Significant Change in Condition: newly indicated Serious Mental Illness [SMI]) for one Resident (#29) out of a total sample of 21 residents. Specifically, the facility failed to compete a Resident review for Resident #29 or refer the Resident to the PASRR (pre-admission screening and resident review) Office for a Level II (comprehensive evaluation) Evaluation, as required, when the Resident was identified to have Bipolar Disorder (mental disorder characterized by periods of depression and periods of abnormally elevated mood) after his/her admission to the facility. Findings include: Resident #29 was admitted to the facility in March 2022 with diagnoses including Major Depressive Disorder. Review of Resident #29's PASRR Level I Screening, dated 1/28/22, indicated the Resident had a negative Screen for SMI and that a Level II PASRR Evaluation was not indicated due to no diagnosis or suspicion of SMI. Review of Resident #29's Psychiatric…
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 · D2023-08-24 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to develop a comprehensive care plan for one Resident (#39), out of a total sample of 21 residents. Specifically, the facility failed to develop a care plan for urinary incontinence when Resident #39 was newly assessed as being occasionally incontinent of bladder on the Minimum Data Set (MDS) assessment and the decision was made to develop a care plan for urinary incontinence. Findings include: Resident #39 was admitted to the facility in July 2015 with a diagnosis of Dementia (a group of symptoms affecting memory, thinking and social abilities). Review of the MDS assessment dated [DATE], indicated Resident #39 was always continent of urine. Review of the MDS assessment dated [DATE], indicated Resident #39 was occasionally incontinent of urine. Further review of the MDS assessment indicated Resident #39 triggered for urinary incontinence and the decision was made to develop a urinary incontinence care plan. Review of Resident #39's clinical 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 · D2023-08-24 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to provide one Resident (#76) out of a total sample of 21 residents, who had oropharyngeal phase Dysphagia (weakened throat muscles, making it difficult to move food from your mouth into your throat and esophagus when you start to swallow, and could result in choking, gagging or coughing, and could lead to pneumonia) with adequate supervision and setup of adaptive devices to ensure the Resident's safety while eating. Specifically, the facility failed to provide Resident #76 with straws for all drinks and continual supervision while he/she drank, when he/she required the use of straws and continual supervision for safety, when the Resident rapidly consumed liquids and increased his/her risk for choking. Findings include: Resident #76 was admitted to the facility in October 2021 with diagnoses including Progressive Bulbar Palsy (PBP: motor neuron disease that can result in difficulty talking and swallowing) and oropharyngeal phase Dysphagia.…
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 before2023-08-24 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to provide one Resident (#21) out of a total sample of 21 residents, with pain management that was consistent with professional standards of practice. Specifically, the facility failed to ensure that its staff: (1) offered non-pharmacological approaches for pain management. (2) consistently assessed the Resident's location and description of pain, and factors that worsen or improve pain, prior to administering narcotic pain medications. Findings include: Resident #21 was admitted to the facility in March 2023 with diagnoses including pain in left ankle and joints of left foot, complete traumatic amputation of left great toe, Osteomyelitis (bone infection) of ankle and foot, history of alcohol overuse syndrome and Diabetes Mellitus. Review of the facility's policy for Pain Management, dated October 2022, included the following: -Policy: Patients will be evaluated as part of the nursing assessment process for the presence of pain upon admission/readmission, quarterly, with change in condition or change in pain status, and as…
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 · D2023-08-24 · 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
Based on interview and record review, the facility failed to follow Physician's orders related to pain medication for one Resident (#21) out of a total sample of 21 residents. Specifically, the facility failed to ensure that its staff did not administer more pain medication than was Physician ordered, which resulted in Resident #21 receiving more opioid (substances that act on opioid receptors to produce morphine-like effects) medication than ordered. Findings include: Resident #21 was admitted to the facility in March 2023 with diagnoses including pain in left ankle and joints of left foot, complete traumatic amputation of left great toe, Osteomyelitis (bone infection) of ankle and foot. Review of the facility's policy for Pain Management, dated October 2022, included the following: -Policy: Patients will be evaluated as part of the nursing assessment process for the presence of pain upon admission/readmission, quarterly, with change in condition or change in pain status, and as required by state regulations. -Purpose: to maintain the highest possible level of comfort for patients…
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 · E2023-08-15 · tag F0880 — failed to prevent and control infections — patternProvide 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 interview, the facility failed to implement infection control measures as required to prevent the spread of COVID- 19 infection during an outbreak on two out of three residents care units. Specifically, the bedroom doors of COVID-19 positive Resident rooms were left open on four out of nine applicable rooms on Unit A per facility policy. Findings include: Review of the facilities current COVID-19 cases, undated, indicated that 27 residents were positive for COVID-19 throughout all three units as of 8/15/23. Ten Residents out of the 27 COVID-19 positive residents resided on Unit A. Review of the facility's policy titled, Infection Control Policies and Procedures, revised, 6/30/23 included: -Special Droplet and Contact Precautions requires wearing a N95 respirator upon entry into the patient's room, in addition to the recommended personal protective equipment (PPE), and keeping the door to the patient's room closed, when safe to do so. -The Company follows CDC published guidelines for patient and/or healthcare personnel (HCP) with suspected…
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 · Bcited before2024-10-18 · tag F0641 — patternEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to complete an accurate assessment to reflect resident status for one Resident (#106) out of a total sample of 3 closed resident records. Specifically, for Resident #106, the facility failed to accurately enter in Minimum Data Set (MDS) Assessment that the Resident was discharged to the hospital and not to home/community resulting in an inaccurate medical record. Findings include: Resident #106 was admitted to the facility in July 2024. Review of the Resident's comprehensive medical record included: -A Provider order to transfer the Resident to the hospital on 7/22/24. -A Nursing progress note dated 7/22/24 that indicated the Resident was in the hospital due to abnormal laboratory (blood) work. -A Social Service progress note dated 7/23/24, which indicated Resident #106 had a change in condition and was sent to the hospital for evaluation on 7/22/24. -A Minimum Data Set (MDS) assessment dated [DATE], which indicated Resident #106 had been discharged 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.
“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.
Part of a chain
This home belongs to MARQUIS HEALTH SERVICES — 87 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 3.0 | -1.0 vs chain |
| Health inspection | 2 of 5 | 2.6 | -0.6 vs chain |
| Staffing | 2 of 5 | 2.3 | -0.3 vs chain |
| Quality measures | 3 of 5 | 4.3 | -1.3 vs chain |
The other 86 homes this chain runs (chain average 3.0★, per CMS)
Showing 40 of 86; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| PALM SPRINGS HOLDCO LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 100% | since 05/28/2025 |
| POPULAR BANK | Organization | 5% OR GREATER SECURITY INTEREST | — | since 05/28/2025 |
| CROWLEY, JEFFREY | Individual | MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | — | since 05/28/2025 |
| PATEL, RUCHI | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/28/2025 |
| VIROJA, YOGESH | Individual | MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | — | since 05/28/2025 |
| POSEN, MINDEE | Individual | CORPORATE OFFICER; ADP OF THE SNF | — | since 05/28/2025 |
| MARQUIS LIMITED LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/07/2025 |
| NUTRACO LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/08/2025 |
| RELIANT PRO REHAB LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/07/2025 |
| SIRAKOV, DIMITRE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/28/2025 |
| FLAGLER, OSHER | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 05/07/2025 |
| KAHANOW, AVIVA | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 05/07/2025 |
| LEVOVITZ, TZVI | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 05/07/2025 |
| ROKEACH, FRAIDE | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 05/08/2025 |
| ROKOWSKY, YITZCHOK | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 05/08/2025 |
| NFR 2020 IRRV TR | Organization | ADP OF THE SNF | — | since 05/28/2025 |
| PALM SPRINGS PROPERTY LLC | Organization | ADP OF THE SNF | — | since 05/28/2025 |
| QUINTO NEXGEN LLC | Organization | ADP OF THE SNF | — | since 05/28/2025 |
| RSBRMK HOLDINGS LLC | Organization | ADP OF THE SNF | — | since 05/28/2025 |
| SK NEXGEN TR | Organization | ADP OF THE SNF | — | since 05/28/2025 |
| TRYKO NEXGEN HOLDINGS LLC | Organization | ADP OF THE SNF | — | since 05/28/2025 |
| UAK 2020 IRRV TR | Organization | ADP OF THE SNF | — | since 05/28/2025 |
| UKR NEXGEN LLC | Organization | ADP OF THE SNF | — | since 05/28/2025 |
| YK NEXGEN TR | Organization | ADP OF THE SNF | — | since 05/28/2025 |
| YR NEXGEN TR | Organization | ADP OF THE SNF | — | since 05/28/2025 |
CMS files one row per role, so the 36 rows in the source record cover these 25 parties — each is shown once here with every role it holds. Nothing is omitted.
15 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.
About 72% 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. This home reported $1.3M paid to related parties — landlords or management companies under common ownership — equal to about 11% 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
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 225508. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-11-20, 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 →
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