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Sunny Acres Skilled Nursing And Rehabilitation Ctr

254 Billerica Road, Chelmsford, MA 01824 · For profit - Limited Liability company · 93 certified beds · (978) 256-0231 Medicare & Medicaid certified

Call the home — (978) 256-0231 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
No harm-level citations or fines — but 23 lower-level deficiencies on record (see below)
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing rating is low (2/5)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

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

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
228 Billerica Rd · (978) 250-6000 · Call to confirm hours
Pharmacy
VA CMOP0.5 mi
10 Industrial Ave · (978) 244-1300 · Call to confirm hours
Grocery
299 Chelmsford St · (978) 250-4102 · Call to confirm hours
Park
60 Carlisle St · (351) 322-7498 · Typically dawn to dusk
Place of worship
275 Billerica Rd · (978) 256-2626

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 3 of 5
Short-stay residentsrehab / post-hospital 4 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 4 stars. From monthly CMS archive snapshots.

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

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased21.6%16.4%15.4%worse
Long-stay residents who lose too much weight4.9%5.1%5.4%typical
Long-stay residents with a catheter left in their bladder0.4%0.8%0.9%better
Long-stay residents with a urinary tract infection2.3%1.8%2.0%worse
Long-stay residents with depressive symptoms12.0%15.5%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury1.8%3.4%3.3%better
Long-stay residents whose ability to walk worsened16.9%15.4%16.1%typical
Long-stay residents on antianxiety or hypnotic medication21.1%19.5%18.9%worse
Long-stay residents given the seasonal flu vaccine83.6%94.8%95.3%worse
Long-stay residents with pressure ulcers7.2%4.2%4.7%worse
Long-stay residents with worsening bladder/bowel control23.5%21.2%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table18.7%21.4%17.1%typical
Short-stay residents who newly got an antipsychotic medication0.7%1.4%1.4%better
Short-stay residents given the seasonal flu vaccine73.3%77.7%79.4%typical
Short-stay residents rehospitalized after admission26.9%25.7%22.6%worse
Short-stay residents with an outpatient ER visit10.5%11.9%12.0%better
Long-stay hospitalizations per 1,000 resident days2.231.881.67worse
Long-stay outpatient ER visits per 1,000 resident days1.121.501.80better

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

55.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 265 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

55.5%U.S. median 51.5%
Got home and stayed home
11.9%U.S. median 10.7%
Went back to hospital
74.1%U.S. median 56.6%
Met the expected recovery
0.40U.S. median 0.31
Therapy hours / resident / day
0.22hours / resident / day
Physical therapy
0.14hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 74.1% 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 116 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 0.40 therapist hours per resident per day in 2026Q1 — more than 70% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 29% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF55.5%CMS range 49.6–61.551.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.9%CMS range 9.6–14.410.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge74.1%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge67.2%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge54.3%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting98.1%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge98.2%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.5%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened3.6%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.7%CMS range 4.3–10.47.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.821.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.51
RN hours/ resident / day
0.96
LPN hours/ resident / day
1.87
Aide hours/ resident / day
3.33
Total nurse hours/ resident / day
0.20
RN hoursweekends
41.7%
Total nursing turnover
50.0%
RN turnover

How full it usually is: this home is certified for 93 beds and averages 78.1 residents a day — about 84% occupied, or roughly 15 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.33 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.51 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.87 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 2.93 hrs/resident/day on weekends vs 3.50 on weekdays — 16% thinner on weekends. RN hours go from 0.63 to 0.20 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 42% is about the same as the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

3
deficiencies at the latest standard inspection (2025-05-06)
5
at the previous standard inspection (2024-06-26)

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

Inspection deficiencies

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

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

23 citations, most serious first. The 10 most serious are shown; the remaining 13 are one tap away and print in full.

  • Potential for harm · Dcited before2025-05-06 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide 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 observation, record review, and interview, the facility failed to provide appropriate treatment and services relative to an indwelling urinary catheter (a thin, flexible tube inserted into the bladder to drain urine outside the body) for one Resident (#32) out of a total sample of 18 residents. Specifically, for Resident #32, the facility staff failed to follow the Physician order's relative to the foley (type of indwelling urinary catheter) catheter size, increasing the Resident's risk for indwelling urinary catheter complications. Findings include: Review of the facility policy titled, Catheter Care, Changing Foley Catheter, revised May 2020, indicated the following: -the Foley catheter will be changed only when needed, unless otherwise specified by the Physician, Nurse Practitioner (NP) or Physician Assistant (PA). -Foley catheters should be changed when: <urinary tract infection is suspected <clogged or unable to irrigate <displaced (balloon [retention balloon- a tiny balloon at the end of the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-06 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, and interview, the facility failed to ensure that medications were stored in a safe and secure manner for one unit (Unit 1) out of a total of two units. Specifically, the facility failed to ensure that six over-the-counter medications were not stored in an unlocked drawer at the nurses station where the medications were readily accessible to unauthorized individuals and were at risk for improper temperature, humidity, and light controls. Findings include: Review of the undated facility policy titled Medication Labeling and Storage indicated the following: -The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. -Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use . On 5/6/25 at 8:37 A.M., the surveyor observed Unit Manager (UM) #1 open an unlocked drawer at the nurses station on Unit 1 where the following medications were observed to be stored in the drawer: -one 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-06 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record reviews, the facility failed to administer Pneumococcal Vaccinations for one Resident (#44) of five applicable residents, out of a total sample of 18 residents. Specifically, for Resident #44, the facility failed to administer Pneumococcal Vaccines when the Resident was eligible to receive, and consented to, the Pneumococcal immunization, putting the Resident at risk of acquiring pneumococcal illnesses. Findings include: Review of the facility's policy titled Resident Pneumococcal Vaccine, undated, indicated the following: -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 days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. -Pneumococcal vaccines are administered to residents (unless medically contraindicated, already given, or refused) per our facility's physician approved pneumococcal vaccination…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-26 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to honor the rights of two Residents (#33 and #49) out of a total sample of 18 residents, to formulate Advanced Directives (an individual's wishes regarding medical treatment). Specifically, 1. For Resident #33, the facility staff executed a Medical Order for Life-Sustaining Treatment (MOLST - a medical order form that converts an individual's wishes regarding life-sustaining treatment into medical orders) form that was signed by the Residents' Health Care Proxy (HCP- the person chosen as the healthcare decision maker when the individual is unable to do so for themself) when the Resident continued to be capable of making his/her own health care decisions. 2. For Resident #49, the facility staff executed a MOLST form that was signed by the HCP, which should have been signed by the Resident because the Resident's HCP was not invoked (put into effect - evaluation of capacity by a Physician indicating that a resident is unable to make medical decisions) and…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-26 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record and policy review, the facility failed to provide care in accordance with professional standards of practice for two Residents (#56 and #58) out of a total sample of 18 residents. Specifically, the facility staff failed to: 1. off-load (minimizing or removing weight placed on the foot to help prevent and heal ulcers) Resident #58's heels when the Resident was in bed, had been identified as being at risk for skin breakdown, and had an active Physician's order to off-load his/her heels when in bed, increasing the Resident's risk for developing a pressure injury (PI: meaning an area of damage to skin or underlying soft tissue, usually over a bony prominence, as a result of prolonged pressure). 2. follow the Physician's order for Resident #56 not to exceed three grams (3 g: 3,000 milligrams [mg]) of Acetaminophen administration in a 24-hour period when facility staff administered 3,650 mg of Acetaminophen to the Resident in one 24-hour period. Findings include: 1. Review of…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-06-26 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and policy review, the facility failed to provide treatments in accordance with professional standards of practice for one Resident (#64) out of a total sample of 18 residents. Specifically, the facility staff failed to manage hypoglycemic (low blood sugar) episodes as required and implement and perform care and treatment consistent with the Physician orders and professional standards of practice for a Resident with Diabetes Type 1 (DM I - a chronic autoimmune disease that prevents the pancreas from making insulin), when the Resident's blood glucose levels decreased to less than 70 mg/dL on multiple occasions. Findings include: Resident #64 was admitted to the facility in September 2023 with diagnoses including Diabetes Type 1 and hypoglycemia. Review of the facility policy titled Nursing Care of the Older Adult with Diabetes Mellitus, undated, indicated the following: -the Provider will order the frequency of glucose monitoring and establish appropriate glycemic…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-26 · tag F0727 — failed to provide required RN coverage — isolated
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week as required, placing all residents at risk for not having their clinical needs met either directly by the RN or indirectly by the Licensed Practical Nurse (LPN) or Certified Nurses Aides (CNA) that the RN was responsible for overseeing with provision of resident care. Specifically, review of the facility's Licensed Nurses schedule and interviews indicated that the facility failed to have an RN working at least eight consecutive hours over a 24-hour period for four days between 5/26/24 - 6/22/24, when no nursing staff waivers were in place. Findings include: Review of the Nursing Staff Schedule provided by the facility dated 5/26/24 - 6/8/24, indicated no evidence of any RN coverage in the facility on 6/1/24, 6/2/24, and 6/8/24. Further Review of the Nursing Staff Schedule dated 6/9/24 - 6/22/24, indicated there was no evidence of any RN coverage in the facility on 6/16/24. During an interview for the facility…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-06-26 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record and policy review, the facility failed to implement Contact Precautions (use of gloves and a gown for all interactions with a resident and their environment) to prevent the potential transmission of communicable diseases (a disease or infection that is easily spread from one individual to another) and infections within the facility for two Residents (#49 and #58), out of a total sample of 18 residents. Specially, the facility failed to: 1) For Resident #49, ensure that staff: -wore the required Personal Protective Equipment (PPE - items used to prevent the spread of infection such as gowns, gloves, face masks) while caring for the Resident with Clostridium difficile (C. diff- a bacterium that causes an infection of the colon [the longest part of the large intestine]. Symptoms can range from diarrhea to life-threatening damage to the colon) and Contact Precautions were indicated. -performed the appropriate hand hygiene (hand washing with soap and water) for C. diff after exiting the Resident's room. 2) For Resident #58, ensure that staff:…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-02-27 · tag F0882 — widespread
    Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, the facility failed to ensure its staff designated an Infection Preventionist (IP) who had completed specialized training in infection prevention and control prior to assuming the role of IP at the facility. Specifically, the facility designated an IP in November 2022 who had not completed specialized training in infection prevention and control before assuming the IP role, still had not completed the specialized training by the time survey began in February 2023 and continued to work as the designated IP at the facility. Findings include: During an interview on 2/22/23 at 7:52 A.M., the Director of Nurses (DON) said the facility's designated IP had not yet completed specialized training in infection prevention and control as required. During an interview on 2/24/23 at 11:07 A.M., the IP said she started working at the facility in November 2022, was designated as the facility's IP at that time, and that she continued to work in that role. The IP said she had not completed specialized training in infection prevention and control prior to starting at the facility…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-02-27 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, policy review, and interview, the facility failed to ensure its staff maintained a clean and sanitary environment in the kitchen where food items were stored for resident consumption. The facility also failed to ensure its staff adhered to food storage requirements in the kitchen. Specifically, the facility failed to ensure its staff: 1) labeled and dated all open food stored for resident consumption, in the kitchen's reach-in refrigerator and freezer, 2) kept scoops from directly touching the ice and rice, 3) maintained a sanitary surface where clean dishes and pans were stored, and 4) maintained the microwave to be free of dried food and debris. Findings include: Review of the facility's policy, Food Use and Storage, dated 10/2022, indicated the following: It is the policy of the facility to provide safe and sanitary storage of all foods. The food service workers, cooks, dietary aides, dishwashers, food prep aides, and any person working in the kitchen is responsible to adhere to the food safety requirements. -Leftovers should be labeled, dated, and used…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
Show the remaining 13 citations
  • Potential for harm · Ecited before2023-02-27 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure its staff implemented infection control practices relative to 1) the facility's water management program, to provide a safe, sanitary, and clean water supply, for all residents and staff, and 2) required hand hygiene practices during care of a pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure) for one Resident (#54), out of a total sample of 18 residents. Specifically, the facility failed to ensure its staff: a) cleaned the ice machine every three months, as indicated in the facility's water management program, as an intervention to prevent waterborne pathogens, and b) implemented proper hand hygiene practices before and after glove use during a dressing change for Resident #54's pressure ulcer. Findings include: 1. The facility failed to ensure a safe, sanitary, and clean water supply for residents and staff when its staff failed to clean the ice machine every three months, as required, when the ice from the ice machine was used for resident and staff consumption.…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-27 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure its staff notified the Physician/Non-Physician Practitioner (NPP) of unavailability and missed doses of an ordered medication for one Resident (#124), out of a total sample of 18 residents. Specifically, the facility failed to ensure its staff notified the Physician/NPP when ordered doses of Xarelto (anticoagulant-medication used to treat and prevent blood clots) was: a) unavailable for administration, and b) not administered to Resident #124 as ordered for three consecutive days. Findings include: Review of the undated facility protocol, titled What to do When Medication is Unavailable, included the following: - If the Pharmacy was out of a medication or did not deliver the medication, facility staff were required to: 1) contact the Physician/NPP, to advise on an alternative medication and 2) document this in a progress note. - If a medication dose was missed, facility staff were required to notify the Physician/NPP and a progress note needed…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-27 · tag F0636 — isolated
    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to ensure its staff completed a Comprehensive Minimum Data Set (MDS) Assessment in a timely manner for one Resident (#39), out of a sample of five applicable residents. Specifically, the facility failed to ensure its staff completed a Comprehensive admission MDS Assessment for Resident #39 within 14 days after the Resident's admission to the facility. Findings include: Resident #39 was admitted to the facility in March 2022. Review of the Resident's clinical record indicated a Comprehensive admission MDS Assessment with an assessment reference date (ARD) of 3/16/22. Review of the MDS Transmission Report, dated 4/8/22, indicated Resident #39's Comprehensive MDS Assessment was not completed until 4/3/22 (more than 14 days following the Resident's admission to the facility). During an interview on 2/24/23 at 2:24 P.M., the MDS Nurse said Resident #39's Comprehensive admission MDS Assessment, dated 3/16/22, was not completed within 14 days following the Resident's admission to the facility, as required.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-27 · tag F0638 — isolated
    Assure that each resident’s assessment is updated at least once every 3 months.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to complete Quarterly Minimum Data Set (MDS) Assessment timely for two Residents (#5 and #48), out of a sample of five applicable residents. Specifically, the facility failed to ensure its staff completed the Quarterly MDS Assessments no later than 14 days following the assessment reference dates (ARDs) for each assessment. Findings include: 1) Resident #5 was admitted to the facility in December 2020. Review of the clinical record indicated a Quarterly MDS Assessment with an ARD of 3/16/22. 2) Resident #48 was admitted to the facility in June 2021. Review of the clinical record indicated a Quarterly MDS Assessment with an ARD of 3/16/22. Review of the facility's MDS Transmission Report, dated 4/8/22, indicated the Quarterly MDS Assessments with ARDs of 3/16/22 for Residents #5 and #48 were not completed until 4/3/22 (more than 14 days following the ARD for each Assessment). During an interview on 2/24/23 at 2:24 P.M., the MDS Nurse said the Quarterly MDS Assessments for Residents #5 and #48 were not completed within the…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-27 · tag F0640 — isolated
    Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure that its staff electronically submitted timely Minimum Data Set (MDS) data to the Centers for Medicare and Medicaid Services (CMS) system for two Residents (#25 and #39), out of a sample of five applicable residents. Specifically, the facility failed to ensure its staff electronically submitted MDS data as required for: 1) Resident #25 relative to discharge tracking, and 2) Resident #39 relative to entry tracking within 14 days of completing the MDS assessments. Findings include: Resident #25 was admitted to the facility in June 2021. Resident #39 was admitted to the facility in March 2022. Review of the facility's MDS Transmission Report, dated 4/8/22, indicated: -discharge tracking MDS data, dated 3/10/22, for Resident #25, and -entry tracking MDS data, dated 3/16/22, for Resident #39 was not submitted to the CMS system until 4/8/22 (more than 14 days following the completion of both assessments). During an interview on 2/24/23 at 2:24 P.M., the MDS Nurse said the MDS data for Resident #25 and Resident #39 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-27 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — the official record, unedited, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure that its staff accurately completed a Minimum Data Set (MDS) Assessment for one Resident (#24) out of a total sample of 18 residents. Specifically, the facility staff failed to accurately code for an unplanned weight loss of 5% or more in one month for Resident #24. Findings include: Resident #24 was admitted to the facility in March 2018. Review of the Resident's monthly weights indicated the following: -1/5/2023 113 pounds -2/4/2023 107.2 pounds This represented a 5.13% weight loss over a one month period. Review of the MDS assessment dated [DATE] Section K, did not indicate an unplanned weight loss of 5% or more in the last month. During an interview on 2/27/23 at 2:35 P.M., the MDS nurse said that the Resident's unplanned weight loss of 5% or more in the last month should have been indicated on the MDS dated [DATE] but it was not.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-27 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure that its staff implemented the plan of care for two Residents (#26 and #36), out of a total sample of 18 residents. Specifically, the facility staff failed to implement: 1) the use of fall mats for Resident #26, and 2) the plan of care relative to meals for Resident #36. Findings Include: 1) Resident #26 admitted to the facility in December 2016 with diagnosis of Dementia (group of symptoms affecting memory, thinking and social abilities severely enough to interfere with daily life). Review of the facility policy for Updating and Revising Care Plans, last revised 12/2022, indicated that the facility will develop and implement a comprehensive person-centered care plan to meet each resident's preferences and goals, and address the resident's medical, mental and psychosocial needs. Review of Resident #26's Minimum Data Set Assessment (MDS), dated [DATE], indicated that the Resident was unable to complete the Brief Interview of Mental…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-27 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interview, and record review, the facility failed to ensure its staff re-evaluated positioning concerns timely for one Resident (#36), out of a total sample of 18 residents. Specifically, decline in Resident #36's positioning that did not receive timely treatment to address the decline. Findings include: Review of the facility policy titled Rehabilitation Screening & Referrals, revised 11/2022, indicated all residents will be screened by rehabilitation for possible therapy intervention. These screenings will be completed upon admission/readmission, upon facility request, or upon resident change in functional status. The policy also included the following: -all screens will consist of a brief review of the medical record, interview of the resident/staff/family and observation of the resident -residents . will be reviewed during the routine Medicare meeting regarding the results of the screen . -rehabilitation staff will be required to attend daily clinical meetings in order to remain aware of falls, new physician orders and changes in status such as confusion,…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-02-27 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure its staff provided wound treatment and care in accordance with professional standards of practice for one Resident (#274), out of five sampled Residents. Specifically, the facility staff failed to ensure: 1) obtained wound treatment orders on admission to identify all wound areas and initiate treatment. 2) failed to implement wound treatment as ordered for several days to promote healing. 3) failed to implement an updated care plan for wound treatments. Findings include: Review of the facility policy, titled, Skin Integrity and Wound Care Policy, dated, January 2023, indicated the following: -Document all wounds initially on the admission assessment in MatrixCare (computer software for medical charting) by the admitting nurse. - The admitting nurse will document/ include: the anatomical part, site, staging if pressure ulcer, depth, drainage type and amount, odor, perimeter involvement and wound type. -Assessment will be prompt 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-02-27 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide 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

    Based on observation, record review, and interview, the facility failed to ensure that its staff provided appropriate care and services related to the use of an indwelling urinary catheter (a flexible tube passed through the urethra and into the bladder to drain urine) for one Resident (#63), out of a total sample of two applicable residents. Specifically, the facility staff failed to follow Physician's orders and ensure that the ordered urinary catheter was in place for Resident #63. Findings include: Resident #63 was admitted to the facility in November 2021 with diagnoses including Benign Prostatic Hyperplasia with lower urinary tract symptoms (BPH- swelling of the prostate gland, which squeezes the urethra and limits the flow of urine) and Chronic Kidney Disease Stage 2 (the kidneys are losing their ability to do their job effectively). On 2/24/23 at 9:05 A.M., the surveyor observed Resident #63 lying in bed. A urinary catheter, in a privacy bag was hooked to the left side of the bed at this time. Certified Nurses Assistant (CNA #1) viewed the catheter with this surveyor 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-27 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide 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 record review and interview, the facility failed to ensure that its staff monitored and implemented interventions to address an unplanned significant weight loss for one Resident (#24), out of a total sample of 18 residents. Specifically, the facility staff failed to report and address an unplanned weight loss of greater than 5% for Resident #24. Findings include: Review of the facility policy titled Weighing and Measuring the Resident revised 1/2023 indicated: -report significant weight loss/weight gain to the nurse supervisor. -the threshold for significant unplanned and undesired weight loss/gain will be based on the following criteria -1 month - 5% weight loss is significant; greater than 5% is severe. Resident #24 was admitted to the facility in March 2018. Review of the Resident's weights indicated: -1/5/2023 113 pounds -2/4/2023 107.2 pounds This represented a 5.13% weight loss over a one month period. Review of the Resident's clinical record did not indicate any recorded reweigh of the Resident or notification to the nurse supervisor of the greater than 5% unplanned…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-27 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    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 and its staff failed to ensure that one Resident (#124), was free of significant medication errors. Specifically, facility staff failed to implement necessary action when: a) daily administration of Xarelto was ordered by the Physician/NPP, and b) Xarelto was omitted from the Resident's medication administration for three consecutive days, increasing his/her risk for development of blood clots. Findings include: Review of the undated facility protocol, titled What to do When Medication is Unavailable, included the following: - If the Pharmacy was out of a medication or did not deliver the medication, facility staff were required to: 1) contact the Physician/NPP to advise on an alternative medication, and 2) document this in a progress note. - If a medication dose was missed, facility staff were required to notify the Physician/NPP and a progress note needed to be completed. Resident #124 was admitted to the facility in February 2023 with diagnoses…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-27 · tag F0886 — failed to test for COVID-19 as required — isolated
    Perform COVID19 testing on residents and staff.
    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 its staff implemented the process for employee COVID-19 surveillance testing, according to current guidance for one Employee (#1), out of three sampled employees. Specifically, the facility failed to ensure its staff implemented the once per week COVID-19 surveillance testing procedure when the Employee (who had not been positive for COVID-19 in the previous 30 days) returned to work following a time-off leave, worked at the facility five days over a seven-day period of time, and was not tested for COVID-19, as required. Findings include: Review of the Executive Office of Health and Human Services Massachusetts (MA) Department of Public Health (DPH) memorandum, titled Updates to Long-Term Care (LTC) Surveillance and Outbreak Testing, dated 12/1/22, included the following: - All LTC facility staff who are up to date (UTD) with COVID-19 vaccines must conduct weekly testing. - Staff surveillance testing is not required to be conducted onsite; however, a LTC facility must develop and maintain policies to document staff…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

Owner / managerTypeRoleShareSince
EISENSTEIN, ROBERTIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF100%since 12/01/2023
GREYSTONE CRE NOTES 2024-HC3, LLCOrganization5% OR GREATER MORTGAGE INTERESTsince 12/01/2023
EATON, SHIRLEYIndividual5% OR GREATER SECURITY INTERESTsince 12/01/2023
FLAHERTY, PATRICKIndividualCORPORATE OFFICER; INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF; ADP OF THE SNFsince 12/01/2023
EF SENIOR LIVING MANAGEMENT LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/01/2023
BAIN, KARENIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/01/2023
BERTOS, MICHAELIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2014
KAUFMAN, DANIELLEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/01/2023
MCGUIRE, FRANCISIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/02/2021
VENO, JOSEPHIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/01/2023
BAKER TILLY ADVISORY GROUP LPOrganizationADP OF THE SNFsince 01/07/2025
BAKER TILLY US LLPOrganizationADP OF THE SNFsince 02/17/2025
EF AND ASSOCIATES LLCOrganizationADP OF THE SNFsince 12/01/2023
EF INVESTMENT COMPANY LLCOrganizationADP OF THE SNFsince 12/01/2023
EF LLCOrganizationADP OF THE SNFsince 12/01/2023
EFSAIC LLCOrganizationADP OF THE SNFsince 12/01/2023
MATHEW MURATORE REVOCABLE TRUSTOrganizationADP OF THE SNFsince 12/01/2023
MICHAEL J. NICKOLAUS AND TRACY NICKOLAUS REVOCABLE TRUSTOrganizationADP OF THE SNFsince 12/01/2023
PATRICK J. FLAHERTY LIVING TRUST DATED JUNE 17, 2021OrganizationADP OF THE SNFsince 12/01/2023
SUNNY ACRES PROPCO LLCOrganizationADP OF THE SNFsince 12/01/2023
THE EISENSTEIN FAMILY TRUSTOrganizationADP OF THE SNFsince 12/01/2023
TWOMAGNETS LLCOrganizationADP OF THE SNFsince 03/26/2023
MURATORE, MATHEWIndividualADP OF THE SNFsince 12/01/2023
NICKOLAUS, MICHAELIndividualADP OF THE SNFsince 12/01/2023

CMS files one row per role, so the 34 rows in the source record cover these 24 parties — each is shown once here with every role it holds. Nothing is omitted.

14 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$9.5M
Net patient revenuemost recent cost report
-12.7%
Operating marginrevenue minus expenses
$548K
Related-party expense5% of expenses
Who pays — share of resident-days
Medicaid 35%Medicare 15%Other / private 50%

This home reported $548K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

Cost & finances

$441per resident / day
operating cost
$13,400per month
≈ monthly operating cost
$391per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in MA

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Massachusetts Medicaid page.

Typical monthly cost in Massachusetts
$14,448/mo
Nursing home (semi-private)
$15,817/mo
Nursing home (private)
$9,600/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 225494. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-06, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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