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The Massachusetts Veterans Home At Chelsea

100 Summit Street, Chelsea, MA 02150 · Government - State · 154 certified beds · (617) 887-7115 Medicare only — no Medicaid

Call the home — (617) 887-7115 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Jul 2024Behavioral-health or dementia-care citation — no harm found (F0740)
Insights

This home has serious findings on its record. Read them closely before you consider it.

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
  • a high payroll-based staffing rating (4/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Jul 2024
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0609) — 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 (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags

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) 4 of 5
Quality measuresSelf-reported by the facility 3 of 5

Location & what’s nearby

Urgent care / clinic
1000 Broadway Fl 2 · (617) 660-6360 · Call to confirm hours
Pharmacy
1010 Revere Beach Pkwy · (617) 884-1095 · Call to confirm hours
Grocery
177 Washington Ave · (617) 884-1888 · Call to confirm hours
Park
120 Summit Ave · (617) 466-4070 · Typically dawn to dusk
Place of worship
201 Washington Ave · (617) 884-4278

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 3 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 3 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 increased13.9%16.4%15.4%typical
Long-stay residents who lose too much weight3.6%5.1%5.4%better
Long-stay residents with a catheter left in their bladder2.0%0.8%0.9%worse
Long-stay residents with a urinary tract infection1.2%1.8%2.0%better
Long-stay residents with depressive symptoms1.2%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 injury1.9%3.4%3.3%better
Long-stay residents whose ability to walk worsened9.7%15.4%16.1%better
Long-stay residents on antianxiety or hypnotic medication7.6%19.5%18.9%better
Long-stay residents given the seasonal flu vaccine99.2%94.8%95.3%typical
Long-stay residents with pressure ulcers6.5%4.2%4.7%worse
Long-stay residents with worsening bladder/bowel control17.8%21.2%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table26.5%21.4%17.1%worse
Long-stay hospitalizations per 1,000 resident days2.081.881.67worse
Long-stay outpatient ER visits per 1,000 resident days1.371.501.80better

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.

0.24U.S. median 0.31
Therapy hours / resident / day
0.11hours / resident / day
Physical therapy
0.10hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.24 therapist hours per resident per day in 2026Q1 — more than 32% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 0% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNFnot reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNFnot reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identifiednot reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure.
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality 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 dischargenot reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF staynot reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure.
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFsnot reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality 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

1.63
RN hours/ resident / day
1.00
LPN hours/ resident / day
4.35
Aide hours/ resident / day
6.97
Total nurse hours/ resident / day
1.28
RN hoursweekends
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 154 beds and averages 120.1 residents a day — about 78% occupied, or roughly 34 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 6.97 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.63 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 4.35 is at or above 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 6.33 hrs/resident/day on weekends vs 7.24 on weekdays — 13% thinner on weekends. RN hours go from 1.77 to 1.28 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

3 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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

Inspection trend

3
deficiencies at the latest standard inspection (2025-09-19)
7
at the previous standard inspection (2024-10-09)

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.

24 citations, most serious first. The 10 most serious are shown; the remaining 14 are one tap away and print in full.

  • Potential for harm · Dcited before2025-09-19 · 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

    Based on interviews and records reviewed, the facility failed to ensure staff developed and implemented a comprehensive person-centered care plan for one Resident (#29) out of 25 total sampled residents. Specifically, for Resident #29, nursing failed to consistently implement the Resident's left hand palm guard and buddy loop finger splint to his/her right 4th and 5th digits (fingers). Findings include: Review of the facility policy titled Care Planning, dated 12/18/23, indicated:-The facility will develop and implement a plan for each resident that includes the instructions needed to provide effective and person-centered care of each resident that meets professional standards of quality care. Resident #29 was admitted to the facility in October 2023 with diagnosis cerebral infarction, diabetes, and depression. Review of the most recent Minimum Data Set (MDS) assessment, dated 9/10/25, indicated that Resident #29 had a moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 12 out of 15. This MDS indicated Resident #29 was dependent on 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-09-19 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, policy review and record review, the facility failed to maintain a safe environment for three Residents (#31, #52, and #45) out of 25 total sampled residents. Specifically,1.) for Resident #31, the facility failed to provide fall mats in accordance with the physician's order. 2a.) For Resident #52, the facility failed to ensure staff stored the Resident's smoking materials in a locked area.2b.) For Resident #45, the facility failed to re-evaluate Resident's ability to safely maintain his/her own smoking materials after staff noted half burned cigarettes stored directly on his/her desk and was issued two smoking violations. Findings include: 1.) Review of the facility policy titled, Falls Prevention, dated as last reviewed 5/27/25, indicated to ensure that the safety and health of the resident veteran is protected by establishing a consistent and thorough assessment of resident veteran risk for falls and associated injuries, monitoring and assessment post-fall, and implementing individualized interventions to prevent falls. Resident #31 was admitted…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-09-19 · 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 observations, interviews, and record review, the facility failed to store all drugs and biologicals in locked compartments for one Resident (#65) out of a 25 total sampled residents. Specifically, the facility failed to ensure Resident #65's neuriva capsules (a brain health supplement) were not stored unlocked at bedside. Findings include:Review of the facility policy titled Bedside Medication Storage and Self Administration of Meds, dated 12/18/23, indicated:-Procedures: A written order for the bedside storage of medication is present in the resident's medical record. -Procedures: Bedside storage of medication is indicated on the resident medication administration record (MAR) and in the care plan for appropriate medications. Resident #65 was admitted to the facility in January 2024 with diagnoses including quadriplegia (a condition where all four limbs experience paralysis). Review of the most recent Minimum Data Set (MDS) assessment, dated 7/1/25, indicated Resident #65 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out 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 · D2025-07-29 · tag F0604 — failed to not use physical restraints improperly — isolated
    Ensure 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 records reviewed and interview, for one of three sampled residents, (Resident #1) who had a history of being resistant and combative during care, the facility failed to ensure he/she was free from the use of physical restraint, when on 6/17/25, while Resident #1 was receiving foot care from the podiatrist, the Charge Nurse laid across his/her lap/leg area to prevent him/her from moving during the procedure.Findings include:Review of the Facility Policy titled Restraints and Safety Devices, dated 11/03/23, indicated physical restraints are used only after assessment by the Interdisciplinary Team (IDT), when an alternative to restraints has been determined to be ineffective by the IDT members, and when absolutely necessary to ensure the safety of the Veteran or others. Resident #1 was admitted to the Facility in January 2024, diagnoses included cognitive social or emotional deficits, cardiovascular disease, type 2 diabetes mellitus, hypertension, hyperlipidemia, and dementia.Review of Resident #1's Quarterly Minimum Data Set (MDS) indicated he/she was significantly…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-07-29 · 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

    Based on records reviewed and interviews, for one of three sampled residents (Resident #1) who had a history of combativeness and resistance with care, the Facility failed to ensure staff consistently implemented interventions identified in his/her plan of care, which indicated when Resident #1 refused care that staff shouldn't force him/her, but instead should reapproach him/her when he/she is more accepting of care. On 06/17/25, although Resident #1 told staff to leave his/her feet alone, exhibited combative behavior during foot care, staff continued with care and did not implement interventions to return later.Findings include: Review of the Facility's Care Planning Policy, dated 12/15/23, indicated that the Facility will develop and implement a plan for each resident that includes the instructions needed to provide effective and person-centered care of the residents that meets professional standards of quality care. Resident #1 was admitted to the Facility in January 2024, diagnoses included cognitive social or emotional deficits, cardiovascular disease, type 2 diabetes…

    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 before2024-10-09 · 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, interview, and record review for two Residents (#30, #264) out of 26 sampled residents, the facility failed to implement the plan of care. Specifically: 1. For Resident #30, the facility failed to follow the physician's order to apply heel protector booties. 2. For Resident #264, the facility failed to develop a plan of care for a pacemaker. Findings include: 1. Resident #30 was admitted to the facility in February 2024, and had diagnoses which included diabetes mellitus, hemiplegia, and peripheral vascular disease. Review of Resident #30's Minimum Data Set (MDS) assessment, dated 8/19/24, indicated he/she had a Brief Interview for Mental Status score of 15, signifying intact cognition, and was at-risk for the development of pressure ulcers. Review of Resident #30's most recent care plan indicated he/she was at risk for skin breakdown and required a pressure-relieving mattress. Review of Resident #30's physician order dated 9/30/24 indicated: - Please use heel protector booties while in…

    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 · D2024-10-09 · 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

    Based on record review and interview the facility failed to ensure they followed standards of practice for 1 Resident (#264) out of a total sample of 26 residents. Specifically the facility failed to obtain lab results for a lab obtained during a hospitalization which was still pending upon discharge of the Resident from the hospital. Findings include: Resident #264 was admitted to the facility in February 2024 with diagnoses including dementia, diabetes and weight loss. Review of the medical record failed to indicate the facility had acquired the lab results. Review of the hospital document titled Hospital Course, dated 9/27/24 indicated that there were pending labs for Legionella. Review of the nursing progress notes failed to indicate that the facility called the hospital for the results of the pending labs. Review of the physician progress notes failed to indicate the physician was notified of the pending lab results. During an interview on 10/08/24 at 10:40 A.M., Nurse #1 said she was not aware that there was a pending lab result from Resident #264's 9/27/24 hospital discharge.…

    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 before2024-10-09 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure one Resident (#40) was safe from accidents/hazards out of a total sample of 26 residents. Specifically, the facility failed to appropriately assess the Resident for safety and ensure a safety care plan was developed to prevent an elopement. Findings include: Review of the facility policy titled Soldier's Home Policy Guide: Code Yellow: Missing Veteran, revised 9/22/23, indicated the following: -Policy: Veterans who are cognitively impaired have the right to a safe environment. Veterans who wander, exit seek, and/or elope their assigned unit will be identified and returned to their unit utilizing an expedited procedure for searching the Soldier's Home premises and surrounding communities. Resident #40 was admitted to the facility in February 2024 with diagnoses including psychiatric disorder and depression. Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #40 scored an 8 out of a possible 15 on the Brief Interview for 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-09 · tag F0699 — isolated
    Provide care or services that was trauma informed and/or culturally competent.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to develop a trauma informed plan of care for 2 Residents (#109 and 92) out of a total sample of 26 residents. Findings include: Review of the facility policy titled Trauma Informed Care, revised 9/22/23, indicates the following: - It is the policy of the Massachusetts Veterans Home at [NAME] to provide care and services to residents that meet professional standards, are delivered using approaches which are culturally competent, account for experiences and preferences, and address the needs of trauma survivors by minimizing triggers and/or re-traumatization. - The Veterans Home will collaborate with resident trauma survivors, and as appropriate, the resident's family, friends, and primary care clinician, and any other health care professionals (such as psychologists and mental health professionals) to develop and implement individualized care plan interventions. 1. Resident #109 was admitted in 08/2024 with diagnoses including post traumatic stress…

    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 · D2024-10-09 · tag F0710 — isolated
    Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
    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 physician was notified of a recommendation from a consulting dentist for one Resident (#79) out of a total sample of 26 residents. Findings include: Resident #79 was admitted to the facility February 2024 with diagnoses including dementia, diabetes and cancer. Review of the dental consult dated 7/15/24 indicated a recommendation for Peridex mouth rinse twice daily, swab with a toothette using 1/4 ounce of Peridex after breakfast and at bedtime. Review of the physician's orders dated July 2024, August 2024, September 2024 and October 2024 failed to indicate an order for Peridex mouth rinse. Review of the nursing progress notes dated after 7/14/24, failed to indicate acknowledgement or notification of the physician regarding the recommendation for the Peridex mouth rinse made by the dentist on 7/15/24. Review of the physician's progress notes failed to indicate a note written after 7/12/24. During an interview on 10/08/24 03:21 PM the Deputy Superintendent said that she would expect that nursing would inform 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
Show the remaining 14 citations
  • Potential for harm · D2024-10-09 · tag F0740 — failed to provide behavioral / mental-health care — isolated
    Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide appropriate behavioral health services for 1 Resident (#40) out of a total sample of 26 residents. Findings include: Review of the facility policy titled Behavioral Management, revised 9/23/23, indicates the following: - The Massachusetts Veterans Home will maintain an interdisciplinary Behavioral Management Committee (BMC) designed to identify, intervene, and monitor isolated and ongoing behavioral events occurring within the facility. - Committee members will intervene as described below when behavioral events occur and will document all assessments and changes in designated sections of resident's medical record. - If psychotherapy is indicated, LICSW (licensed social worker) assessing the resident to determine the type of therapy, frequency, and duration of services recommended. - Documenting intervention and outcome in psychosocial section of the medical record, care plan, and ensuring this is reflected in the Minimum Data Set (MDS).…

    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 before2024-10-09 · 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, interviews, and record review, the facility failed to ensure prescribed medications were secured in locked compartments or under proper supervision for two Residents (#31 and #7) out of 26 total sampled residents. Specifically: 1.) For Resident #31, the nurse left two pills at bedside without proper supervision. 2.) For Resident #7, the nurse left topical prescription medication at bedside without proper supervision. Findings include: Review of the facility policy titled Medication Storage and Security, revised 9/26/22, indicated: - It is the policy of the facility that medications be kept secure. - Medications being administered must be under constant surveillance. - Medications removed from a medication storage area must always remain with the individual and are not to be left unattended. Review of the facility policy titled Bedside Medication Storage and Self Administration of Meds, revised 10/24/23, indicated: - Bedside storage of medications is indicated on the resident medication administration record (MAR) and in the care plan for the appropriate…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-17 · tag F0557 — isolated
    Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on records reviewed and interviews, for one of four sampled residents (Resident #1) who was cognitively intact, the Facility failed to ensure staff treated him/her in a respectful manner, when on 06/21/24 during the evening shift, Nurse #1 and Certified Nurse Aide (CNA) #1 were arguing in the hallway outside of Resident #1's room, they then enter his/her room to provide care, and continued their argument in front of him/her, which made him/her feel uncomfortable. Findings include: The Facility Policy, titled Resident Rights, has no date. The Facility will treat you with dignity and respect in full recognition of your individual rights. Resident #1 was admitted to the Facility in February 2024, diagnoses included paraplegia, spinal abscess, lumbar spinal stenosis, lumbar osteomyelitis, and neurogenic bladder/bowel. Review of Resident #1's Minimum Data Set (MDS) Assessment, dated 05/09/24, indicated that he/she had intact cognition, could communicate his/her needs, and was his/her own decision-maker. The MDS also indicated that Resident #1 required assistance from two 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-17 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on records reviewed, review of surveillance camera video footage, and interviews for one of four sampled residents (Resident #2), who had moderate cognitive impairment, a history of behaviors, and was dependent on staff for care, the Facility failed to ensure he/she was free from abuse from staff members, when 1) on 6/29/24. Certified Nurse Aide (CNA) #4 engaged in a verbal altercation with Resident #2 and responded by throwing an object at him/her and 2) on 7/01/24, CNA #3 also engaged in a verbal altercation with Resident #2, was intimidating and confrontational while engaging with him/her, which resulted in escalating his/her behaviors. Findings include: The Facility's Policy titled Patient, Complaints, Mistreatment, Abuse or Neglect, revised 09/2018, indicated that Abuse is an overt act or an omission of care that results in the physical or emotional trauma of a patient. Examples of alleged abuse would include: -The aggressive imposition of a caregiver on a patient in the manner of pushing, shoving or any other form of physical touching that would constitute an assault…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-14 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    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 alleged to have been subjected to verbal abuse by Certified Nurse Aide #1, the Facility failed to ensure they submitted a report to the Department of Public Health within the required timeframe (two hours), after being made aware of the allegation, when their report regarding the allegation was not submitted until seven days after administrative staff became aware of the allegation. Findings include: Review of the Facility's Policy titled Prevention/Identification of Abuse, Neglect or Mistreatment, dated October 13, 202, indicated the Compliance Officer or designee is responsible for reporting the incident to the appropriate regulatory agency or accreditation organization. The Policy indicated to notify the State Agency through the Health Care Facility Reporting System (HCFRS) for alleged violations involving Abuse immediately, but no later than 2 hours after the allegation is made if the events that cause the allegation involve abuse. Review of the Report submitted by 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-08-03 · tag F0865 — failed to run a quality-improvement (QAPI) program — widespread
    Have a plan that describes the process for conducting QAPI and QAA activities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, document review, and policy review, the facility failed to develop, implement, and maintain a Quality Assurance and Performance Improvement (QAPI) program that addressed the full range of care and services, was comprehensive and data-driven, and focused on indicators of outcomes of quality of life, care, and services to residents in the facility. Findings include: Review of the facility's policy titled Agency Quality Assurance Performance Improvement Committee (QAPI) dated 9/2018 indicated that the committee will review/analyze departmental reports and other QAPI data and discuss the need for improvement or change, make recommendations as appropriate to Executive Committee and perform follow-up analysis when indicted. Review of the facility document titled QAPI Program Meeting and dated 12/7/22, and 3/22/23, indicated the purpose of the meeting was to continually improve the quality of patient care at the Soldiers Home. To systematically and objectively monitor the effectiveness of care at the Soldiers Home. To identify and implement monitoring processes 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-08-03 · tag F0867 — failed to act on quality-improvement findings — widespread
    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview the facility failed to develop and implement policies addressing: (a) How they will use a systematic approach to determine underlying causes of problems impacting larger systems; (b) How they will develop corrective actions that will be designed to effect change at the systems level to prevent quality of care, quality of life, or safety problems; and (c) How the facility will monitor the effectiveness of its performance improvement activities to ensure that improvements are sustained. Findings include: Review of the facility policy titled Agency Quality Assurance Performance Improvement Committee (QAPI) and dated 9/2018 failed to indicate how the facility will (a) use a systematic approach to determine underlying causes of problems impacting larger systems; (b) how the facility will develop corrective actions that will be designed to effect change at the systems level to prevent quality of care, quality of life, or safety problems; and (c) how the facility will monitor the effectiveness of its performance improvement activities to ensure 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-08-03 · tag F0656 — failed to write and follow a full care plan — pattern
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility 1) failed to develop a dementia care plan for one Resident (#40), 2) failed to follow physician orders for two Residents (#22 and #2) and 3) facility failed to follow a physician order to ensure air mattress was maintained at the proper setting for one Resident (#37) out of a total sample of 17 residents. Findings include: 1. Resident #40 was admitted to the facility in March 2022 with diagnoses including dementia with behavioral disturbance. Review of Resident #40's most recent Minimum Data Set (MDS) dated [DATE], indicated that the Resident has a Brief Interview for Mental Status (BIMS) score of 9 out of a possible 15, indicating he/she has moderate cognitive impairment. The MDS also indicated that Resident #40 requires supervision for functional daily tasks. Review of Resident #40's care plans failed to indicate a dementia care plan or a care plan to address cognitive impairment. During an interview on 8/2/23, at 1:01 P.M., Nurse #3 said she is responsible…

    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 · D2023-08-03 · tag F0637 — isolated
    Assess the resident when there is a significant change in condition
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and interview the facility failed to identify and complete a Significant Change in Status assessment, Minimum Data Set assessment (MDS) for one Resident (#32), who elected to receive hospice care services, out of a total sample of 17 residents. Findings include: Resident #32 was admitted to the facility in November 2019 and has diagnoses that include congested heart failure, coronary artery disease, and a lung mass. Review of Resident #32's medical record indicated the following: *An election for hospice services document signed by Resident #32's health care proxy dated 2/1/23. *An end-of-life care plan related to terminal diagnosis of cancer dated 4/6/23, that Resident #32 admitted back on Hospice care dated 2/3/23. Review of the MDS assessments for Resident #32 failed to indicate a Significant Change in Status assessment, MDS was completed as required. During an interview on 8/2/23, at 4:13 P.M., Minimum Data Nurse #1 said he reviewed Resident #32's MDS records and said a significant change MDS was not completed and should have been after 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 · D2023-08-03 · 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 complete an Minimum Data Set assessment for a resident discharge/return anticipated and failed to complete an MDS assessment for a resident re-entry to the facility for one Resident (#32) out of a total sample of 17 residents, resulting in inaccurate MDS data and the possible failure to care plan for Resident #32's post hospital needs. Findings include: Resident #32 was admitted to the facility in November 2019 with diagnoses that included congested heart failure, coronary heart disease and lung cancer. Review of Resident #32's medical record indicated the following: *A nurse practitioner progress note dated 5/31/23, which indicated Resident #32 was in the hospital 5/24/23, through 5/31/23. *A care plan that indicated Resident #32 had an acute (hospital) admission 5/24/23, through 5/31/23. Review of Resident #32's MDS binder failed to indicate an MDS discharge return anticipated assessment was completed or an MDS re-entry assessment was completed as required. During an interview on 8/2/23, at 4:13 P.M., Minimum Data Set…

    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 · D2023-08-03 · 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 observations, record reviews and interviews, the facility failed to identify, assess and document a bruise for 1 Resident (#30) out of a total sample of 17 residents. Findings include: Resident #30 was admitted to the facility in March 2019 with diagnoses including congestive heart failure. Review of Resident #30's most recent Minimum Data Set (MDS) assessment dated [DATE], indicated he/she had a Brief Interview for Mental Status (BIMS) score of 13 out of a possible 15, indicating he/she is cognitively intact. The MDS also indicated Resident #30 requires assistance from staff for functional daily tasks. Review of Resident #30's medical record indicated the following: *The Resident had blood drawn on 7/20/23. *The latest skin assessment on 7/27/23, failed to indicate a bruise on the Resident's right hand. *The nursing notes written since the Resident had blood drawn failed to indicated new bruising to his/her right hand. During an interview on 8/3/23, at 9:05 A.M., Nurse #4 said all new skin impairments,…

    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 before2023-08-03 · 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, interview, and policy review, the facility failed to ensure medications once opened were dated as required on 1 of 3 sampled medication carts. Findings include: Review of the facility policy titled Medication Storage and Security dated reviewed June 2019, indicated that beyond use dating, after initially entering or opening multi-dose containers is 28 days unless otherwise specified by the manufacturer. On 8/3/23, at 11:00 A.M., the surveyor the surveyor observed the following in the 4 Center Unit medication cart: 1 Fluticasone Proprionate 250 mcg (micrograms) inhaler dated as opened on 7/31/23, and dated as will expire on 10/25/23. Review of the manufacturer's instruction indicated that the inhaler expires 2 months after opening not the 3 months as indicated on the inhaler. 1 Fluticasone Proprionate inhaler 250 mcg dated as opened 7/12/23, and dated as will expire 11/23/23. Review of the manufacturer's instruction indicated that the inhaler expires 2 months after opening not the 4.5 months as indicated on the inhaler. During an interview on 8/3/23, at 11:03…

    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 · D2023-08-03 · tag F0790 — failed to provide dental care — isolated
    Provide routine and 24-hour emergency dental care for each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to provide dental services for one Resident (#14) out of a total sample of 17 residents. Specifically, the facility failed to provide dental services to Resident #14 since admission to the facility. Findings include: Review of the facility policy titled Dental Examinations for Facility Patients, dated 5/13/14, indicated the following: *Annual Examination: Provide annual dental/oral examinations in accordance with VA (Veterans Affair) and CMS (Centers for Medicare and Medicaid Services) regulations. *Facility Responsibilities: Assign Facility contact within 14 days of effective date to coordinated with contracted dental services, assistance with enrollment of residents in services, assistance with obtaining physician orders and other authorizations necessary to commence the services. Resident #14 was admitted to the facility in May 2022 with diagnoses including dementia without behavioral issues, cerebral vascular accident, and depression.…

    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 · D2023-08-03 · 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, policy and record review the facility failed to ensure infection control was maintained by 2 out of 2 nurses observed during medication pass. Findings include: On 8/3/23, at 9:20 A.M., the surveyor asked the Director of Quality Management for the facility policy for infection control during medication pass. The surveyor was presented with a policy titled Medications dated as reviewed July 2018. Review of the facility policy titled Pass Medications dated as reviewed July 2018 failed to indicate any infection control procedures during medication pass. 1. On 8/3/23, at 8:20 A.M., the surveyor observed Nurse #5 administer a resident eye drops in both eyes. The surveyor then observed Nurse #5 take a tissue and wipe each eye several times using the same tissue, potentially contaminating both eyes. During an interview on 8/3/23, at 8:23 A.M., Nurse #5 said that she should have used a different tissue for each eye to prevent the potential spread of infection. 2. On 8/3/23, at 8:50 A.M., the surveyor observed Nurse #2 pushing medications out of a bubble pack dispenser…

    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
THE COMMONWEALTH OF MASSACHUSETTSOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL100%since 03/01/2023
COUILLARD, JOHNIndividualCORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/13/2020
BALDINI, CHRISTINEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/28/2024
BARASH, JEDIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/02/2025

CMS files one row per role, so the 10 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted.

1 organizational owner 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.

What families pay in MA

Paying with Medicaid

CMS lists this home as Medicare-certified only — it is not Medicaid-certified, so it generally cannot accept Medicaid as payment for a long-term stay. That makes it one of roughly 545 homes nationally where a Medicaid-funded placement is not an option. If you expect to rely on Medicaid, ask the home directly before you tour, and see the Massachusetts Medicaid page for homes that do.

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 225110. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-19, 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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