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Chicopee Rehabilitation And Nursing

44 New Lombard Road, Chicopee, MA 01020 · For profit - Limited Liability company · 68 certified beds · (413) 592-7738 Medicare & Medicaid certified

Call the home — (413) 592-7738 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
2 actual-harm citations$7,901 in federal fines
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • lower-than-typical staff turnover (32% vs 45% nationally) — better care continuity
Worth asking about
  • it has 2 actual-harm citations
  • a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $7,901 in federal fines (most recent 2023-09-28)
  • 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.

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

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1040 Sheridan St · (413) 612-2100 · Call to confirm hours
Pharmacy
155 Brookdale Dr · (413) 781-2996 · Call to confirm hours
Grocery
591 Memorial Dr · (413) 530-3115 · Call to confirm hours
Park
Burnett Rd · (413) 594-9416 · Typically dawn to dusk

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 5 of 5
Short-stay residentsrehab / post-hospital 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 held steady at 2 stars. From monthly CMS archive snapshots.

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

Overall rating2★
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 increased11.2%16.4%15.4%better
Long-stay residents who lose too much weight4.1%5.1%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.8%0.9%better
Long-stay residents with a urinary tract infection0.0%1.8%2.0%better
Long-stay residents with depressive symptoms31.7%15.5%6.5%worse than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury0.0%3.4%3.3%check this — see note marked star below the table
Long-stay residents whose ability to walk worsened9.3%15.4%16.1%better
Long-stay residents on antianxiety or hypnotic medication11.9%19.5%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%94.8%95.3%typical
Long-stay residents with pressure ulcers4.5%4.2%4.7%typical
Long-stay residents with worsening bladder/bowel control8.5%21.2%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table6.5%21.4%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.4%1.4%better
Short-stay residents given the seasonal flu vaccine93.9%77.7%79.4%better
Short-stay residents rehospitalized after admission32.0%25.7%22.6%worse
Short-stay residents with an outpatient ER visit14.5%11.9%12.0%worse
Long-stay hospitalizations per 1,000 resident days0.691.881.67better
Long-stay outpatient ER visits per 1,000 resident days1.901.501.80typical

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

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.

45.1% 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 146 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

45.1%U.S. median 51.5%
Got home and stayed home
13.2%U.S. median 10.7%
Went back to hospital
61.5%U.S. median 56.6%
Met the expected recovery
0.35U.S. median 0.31
Therapy hours / resident / day
0.18hours / resident / day
Physical therapy
0.15hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Met the expected recovery: 61.5% 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 52 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 0.35 therapist hours per resident per day in 2026Q1 — more than 59% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 28% 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 SNF45.1%CMS range 36.9–52.851.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF13.2%CMS range 10.2–16.510.7%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 discharge61.5%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 discharge48.1%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 discharge51.9%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 settingnot reported — The number of residents or resident stays is too small to report. 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 discharge100.0%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 stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened2.9%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 hospitalization8.1%CMS range 5.3–11.57.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.991.02Oct 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

0.28
RN hours/ resident / day
1.03
LPN hours/ resident / day
2.24
Aide hours/ resident / day
3.55
Total nurse hours/ resident / day
0.19
RN hoursweekends
32.1%
Total nursing turnover
20.0%
RN turnover

How full it usually is: this home is certified for 68 beds and averages 63.5 residents a day — about 93% occupied, or roughly 4 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.55 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.28 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.24 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.36 hrs/resident/day on weekends vs 3.63 on weekdays — 7% thinner on weekends. RN hours go from 0.32 to 0.19 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 32% is below the national median of 45%.

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

9
deficiencies at the latest standard inspection (2025-02-18)
10
at the previous standard inspection (2024-02-28)

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.

27 citations, most serious first. The 12 most serious are shown; the remaining 15 are one tap away and print in full.

  • Actual harm · Gcited before2023-09-28 · 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 observation, records reviewed and interviews for one of three sampled residents (Resident #1), who was assessed by nursing as being at an increased risk for falls and who required assistance of two staff members with the use of a mechanical lift for safe transfers, the Facility failed to ensure staff consistently implemented and followed interventions from his/her plan of care related to his/her individual care needs related to transfers. On 09/04/23 during the day shift, a Certified Nurse Aide transferred Resident #1 out of bed, alone, and without a mechanical lift, resulting in him/her being lowered to the floor. Resident #1 complained of right hip pain a few hours after the incident, an order for an x-ray was obtained, Resident #1 was diagnosed with a right proximal tibia and fibula (lower leg bones) fractures and was transferred to the Hospital Emergency Department (ED) for evaluation and further treatment. Findings include: Review of the Facility's Policy, titled Falls and Fall Risk-Managing, dated as revised March 2018, indicated based on previous evaluations and…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2023-09-28 · 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 records reviewed and interviews for one of three sampled residents (Resident #1), who was assessed by nursing as being at an increased risk for falls, and who required extensive assistance from two staff members with the use of a mechanical lift during transfers, the Facility failed to ensure he/she was provided with the necessary level of staff assistance and assistive device during a transfer to maintain his/her safety in an effort to prevent an incident and/or accident resulting in an injury. On 09/04/23, during the day shift, Certified Nurse Aide (CNA) #1 attempted to transfer Resident #1 without a mechanical lift and without a second staff member present to assist her, Resident #1's knees buckled, and she lowered him/her to the floor. Resident #1 complained of right hip pain a few hours after the incident, an order for an x-ray was obtained, Resident #1 was diagnosed with a right proximal tibia and fibula (lower leg bones) fractures and was transferred to the Hospital Emergency Department (ED) for…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-18 · 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

    Based on observation, interview, and record review, the facility failed to notify the Physician/Physician Assistant (PA) of changes in condition for two Residents (#35 and #58) out of a total sample of 17 residents. Specifically, the facility failed to: 1. For Resident #35, notify the Physician/ PA timely of significant weight loss experienced by the Resident. 2. For Resident #58, ensure the Physician/PA was notified when the Resident had a significant weight change and continued significant weight decline. Findings include: Review of the facility policy titled Change In a Resident's Condition or Status, revised February 2011, indicated the following: -The nurse will notify the resident's attending physician or physician on call when there has been a (an): ---Significant change in the resident's physical/emotional/mental condition, ---Refusal of treatment or medications two (2) or more consecutive times. Review of the facility policy titled Weighing and Measuring the Resident, revised March 2011, indicated the following: a. one month 5% weight loss is significant; greater than 5% is…

    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 · D2025-02-18 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure that Significant Change in Status Minimum Data Set [MDS] Assessments (SCSA) was completed for one Resident (#54) out of a total sample of 17 residents. Specifically, for Resident #54, the facility failed to ensure that a SCSA was completed when the Resident had a decline in activities of daily living (ADLs) and developed a new pressure ulcer. Findings include: Review of the facility policy titled Comprehensive Assessment, revised March 2022, indicated the following: -the SCSA is a comprehensive assessment for a resident that must be completed when the IDT (interdisciplinary team) has determined that a resident meets the significant change guidelines for either major improvement or decline. Resident #54 was admitted to the facility in November 2024 with diagnoses including Dementia and an intertrochanteric fracture of the right femur. Review of Resident #54's MDS assessment dated [DATE], indicated: -the Resident required supervision for oral…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-18 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, and record review, the facility failed to follow professional standards of practice relative to administering medication for one Resident (#42) out of a total sample of 17 residents. Specifically, for Resident #42, the facility failed to ensure that prescribed Insulin (medication used to treat diabetes) was administered within one hour before or one hour after the ordered time. Findings include: Review of the facility policy titled Administering Medications, revised April 2019, indicated the following: -Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). Resident #42 was admitted to the facility in January 2025 with diagnoses including Type 2 Diabetes. Review of the Physician's Order Recap Report, from 1/14/25 through 2/28/25, indicated: -Lantus SoloStar Subcutaneous Solution 100 unit/milliliter (ml) (Insulin Glargine), Inject 18 units subcutaneously at bedtime (8:30 PM) with a start date of 1/23/25 and end date of 2/6/25. -Lantus SoloStar Subcutaneous Solution 100…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-18 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to maintain acceptable parameters of nutritional status for one Resident (#35) out of a total sample of 17 residents. Specifically, for Resident #35, the facility failed to address significant weight loss and implement nutritional interventions when the Resident was identified to have greater than 10 percent (%) weight loss. Findings include: Resident #35 was admitted to the facility in July 2024 with diagnoses including Diabetes, small cell lung carcinoma (lung cancer) receiving chemotherapy, Chronic Obstructive Pulmonary Disease (COPD), C-Diff (Clostridium Difficile,) Chronic Kidney Disease, anxiety and depression. Review of the facility policy titled Weighing and Measuring the Resident, revised March 2011 indicated the following: a. one month 5% weight loss is significant; greater than 5% is severe. b. three months 7.5% weight loss is significant; greater than 7.5 is severe c. six months 10% weight loss is significant; greater than 10% is severe.…

    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 · D2025-02-18 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, and record review, the facility failed to ensure that recommendations made by the Consultant Pharmacist during a monthly Medication Regimen Review (MRR) were reviewed by the Physician as required for one Resident (#214), of five applicable residents reviewed for unnecessary medications, out of a total sample of 17 residents. Findings include: Resident #214 was admitted to the facility in December 2023 with diagnoses including Vascular Dementia. Review of Resident #214's Pharmacist Progress Notes indicated the following: -10/4/24: the Pharmacist indicated recommendations made, see Clinical Pharmacy Report -11/5/24: the Pharmacist indicated recommendations made, see Clinical Pharmacy Report Review of Resident #214's medical record did not provide evidence of the Pharmacy Recommendations and Clinical Pharmacy Reports indicated in the Pharmacist Progress Notes on 10/4/24 and 11/5/24. Further review of the medical record failed to indicate that the Physician had reviewed the 10/4/24 and 11/5/24 Pharmacy Recommendations. During an interview on 2/14/25 at 10:05 A.M.,…

    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 · D2025-02-18 · tag F0849 — isolated
    Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
    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 continuity of care related to Hospice Services for one Resident (#42) out of a total sample of 17 residents. Specifically, for Resident #42, the facility failed to: -designate a member of the interdisciplinary team (IDT) responsible for working with Hospice Representatives to coordinate care provided by the facility staff and Hospice staff. -obtain the most recent Hospice Plan of Care and ensure that it was readily available. Findings include: Review of the Hospice Nursing Facility Services Agreement dated May 31, 2023, indicated: -Nursing facility and Hospice shall develop procedures regarding communications and the documentation of such communications to ensure that the needs of the patient are addressed and met 24 hours a day. -Hospice will supply the facility a copy of the patient's plan of care which will specify the inpatient services to be provided. -The facility will have patient care policies consistent with those of hospice and agrees to abide by the palliative care protocols and plan of care established…

    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 · Dcited before2025-02-18 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that infection control practices were implemented to prevent the spread of infection on two Units (North Unit and [NAME] Unit) of two units observed. Specifically, the facility failed to: 1. For Resident #164 who resided on the North Unit, ensure that staff utilized proper Enhanced Barrier Precautions (EBP - set of infection control practices that uses Personal Protective Equipment (PPE) such as gowns and gloves to reduce the spread of multidrug resistant organism to residents who are at risk due to having a wound or indwelling medical device). 2. For Resident #35 who resided on the North Unit, ensure that staff utilized proper Contact Precautions (set of infection control practices that are used when a resident is diagnosed with a condition that can spread from person to person by touch or by direct contact with contaminated objects and surfaces) when entering the Resident's room. 3. For Resident #54 who resided on the [NAME]…

    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 · D2025-02-18 · tag F0908 — failed to keep essential equipment working — isolated
    Keep all essential equipment working safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, and interview, the facility failed to ensure that patient care equipment was maintained in a safe operating condition for one Resident (#3) out of a total sample of 17 residents. Specifically, for Resident #3, the facility failed to ensure that his/her wheelchair was maintained in safe condition when the left cushioned armrest of the Resident's wheelchair was missing leaving a metal bar and exposed screw and placing the Resident at risk of injury. Findings include: Resident #3 was admitted to the facility in May 2024 with diagnoses including Cerebral Infarct (Stroke) and Rheumatoid Arthritis. Review of Resident #3's Minimum Data Set (MDS) assessment dated [DATE], indicated: -the Resident had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status score of 9 out of a total possible score of 15 -the Resident was dependent for transfers to and from the chair During an observation on 2/12/25 at 2:00 P.M., the surveyor observed Resident #3 sitting up in his/her…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-02-28 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and policy review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, the facility staff failed to: 1a. Ensure kitchen cleanliness and store and prepare food in the main kitchen area in a manner that would prevent contamination and food-borne illnesses. 1b. Ensure food was stored in a manner to prevent food-borne illnesses in two out of two unit-based kitchen areas. 2. Ensure that a process was in place to safely reheat food and beverages for the residents. Findings include: Review of the facility policy titled; Cleaning Schedule from the Dietary Services Manual dated 6/10/20 indicated the following: -It is the responsibility of the Dietary Department to maintain all areas of the facility's kitchen and related areas in a clean and sanitary manner. -The Food Service Director (FSD) is responsible to identify, assign, monitor and manage the cleanliness of their department. -Cleaning schedules should be unique to each Dietary Department based on specific,…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-02-28 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and interviews, the facility failed to provide a resident environment that was free from potential hazards on one Unit (North Unit) out of two Units observed. Specifically, the facility staff failed to ensure that smoking materials were stored in a secured location, that was out of sight and not accessible to the residents. Findings include: On 2/27/24 between 8:00 A.M. and 9:13 A.M., the surveyor observed a box containing smoking materials (several packages of cigarettes and two lighters) sitting on top of a medication storage cart that was located next to the nursing station. The surveyor also observed that the smoking materials on the medication storage cart were visible and accessible to four residents who were congregated in the immediate area near the medication storage cart. During an interview on 2/27/24 at 8:45 A.M., Certified Nurses Aide (CNA) #1 said the resident smoking materials were stored in a box and kept on top of the medication storage cart near the nursing station. CNA #1 further said staff used to keep the smoking materials in the locked…

    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
Show the remaining 15 citations
  • Potential for harm · E2024-02-28 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and policy review, the facility failed to ensure medications and medical supplies were stored in a secure manner on two Units (North Unit and [NAME] Unit) out of two units observed and the main hallway of the facility. Specifically, the facility staff failed to ensure that: 1. Two treatment carts and one medication/medical supply storage cart were locked and not accessible to residents, non-authorized staff and visitors. 2. A medication storage closet located on the main hallway of the facility was locked. Findings include: Review of the facility policy titled, Storage of Medications, undated, included but was not limited to the following: -Drugs and biologicals used in the facility are stored in locked compartments .only persons authorized to prepare and administer medications have access to locked medications. -Compartments (including but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended. 1a. On 2/27/24 at 7:58…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-28 · 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 observation, interview and record review, the facility failed to develop a care plan for one Resident (#28) and implement the plan of care for two Residents (#41 and #57) out of a total sample of 15 residents. Specifically, the facility staff failed to: 1. Develop a care plan relative to monitoring the side effects of an anticoagulant medication (medication used to thin the blood) for Resident #28. 2. Obtain laboratory testing relative to anticonvulsant medication (medication used to control seizure activity) monitoring as ordered for Resident #41. 3. Perform fingerstick blood sugar (FSBS) monitoring (used to measure the amount of glucose in the blood) as ordered for Resident #57. Findings include: 1. Resident #28 was admitted to the facility in March 2023 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD- chronic lung disease that causes obstructed airflow making it hard to breathe) and Atrial Fibrillation (A-Fib-an irregular, often rapid heart rate that causes poor blood flow). Review of the Resident's February 2024 Order Summary Report indicated 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 · D2024-02-28 · 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, policy and interview, the facility failed to provide care and services for an indwelling urinary/Foley catheter (a flexible tube that passes through the urethra and into the bladder to drain urine outside the body) for one Resident (#53) out of a total sample of 15 residents. Specifically, the facility staff failed to verify the correct size indwelling urinary catheter as ordered by the Physician and ensure the verified size catheter was in place for Resident #53, to prevent catheter related complications. Findings include: Review of the facility policy for Indwelling (Foley Catheter, Urinary Catheter) Catheter Insertion, last revised August 2022, indicated to verify that there is a Physician's order for this procedure. Resident #53 was admitted to the facility in June 2022 with diagnoses including urinary tract infection (UTI: bacterial infection of the urinary tract), disorder of the kidney and ureter (tubes made of smooth muscle that propel urine from the kidneys to the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-28 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, policy and record review, the facility failed to provide appropriate care, services, and monitoring of a gastrostomy tube (G-tube- a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medication, also referred to as a feeding tube) for one Resident (#26) out of a total sample of 15 residents. Specifically, the facility staff failed to verify proper placement of a G-tube every shift as ordered by the Physician to prevent complications of enteral (passing through the gastrointestinal [GI] tract) feeding. Findings include: Review of the facility policy titled Administering Medication through an Enteral Tube, last revised November 2018, indicated to verify the placement of the feeding tube prior to administering medications or feeding. Resident #26 was admitted to the facility in November 2021 with a diagnosis of gastrostomy tube. Review of Resident #26's Minimum Data Set (MDS) assessment dated [DATE], indicated…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-28 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the facility failed to ensure that an accurate medication reconciliation was completed upon admission to the facility from a hospitalization for one Resident (#28) out of a total sample of 15 residents. Specifically, the facility staff failed to: -For Resident #28, ensure that Lasix (a medication used to rid the body of extra fluid) medication was not re-started when the Resident was re-admitted to the facility following a hospital stay with a diagnosis and Physician documentation that indicated the medication should be held (not administered). Findings include: Review of the facility policy titled Reconciliation of Medications on Admission, revised July 2017, indicated the following: -Medication reconciliation is the process of comparing pre-discharge medications to post-discharge medications by creating an accurate list of both prescription and over the counter medications .for the purpose of preventing unintended changes or omissions at transition points…

    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 · D2024-02-28 · tag F0742 — isolated
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure one Resident (#49) out of a total sample of 15 residents, received the recommended treatment to address his/her mental health conditions. Specifically, the facility staff failed to ensure that recommendations made by the Psychiatric Nurse Practitioner (NP) for medication changes were reviewed by the Resident's attending Physician and implemented. Findings include: Resident #49 was admitted to the facility in January 2024, with diagnosis of adjustment disorder with anxiety and depressed mood. Review of the Psychiatric NP Evaluation and Consultation note, dated 1/25/24 indicated the following recommendations: -Start Escitalopram (antidepressant medication) 10 milligrams (mg) daily in the morning. -Start Lorazepam (antianxiety medication) 0.5 mg every eight hours as needed (PRN) for 14 days. Review of the Resident's medical record indicated no documentation that the recommendations had been reviewed by the Resident's Physician or implemented. Review of the Consultant Pharmacist admission Medication Regimen Review,…

    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 before2022-09-14 · 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

    Based on interview and record review, the facility failed to ensure the staff notified the Attending Physician/Practitioner that scheduled medications were not administered as ordered for one Resident (#22) out of a total sample of 15 residents. Findings include: Resident #22 was admitted to the facility in April 2019 with diagnoses including Dementia with Lewy Bodies (abnormal protein deposits within the bran that can lead to problems with thinking, movement, behavior and mood), Parkinson's Disease (progressive neurological disease marked by tremor, muscular rigidity and slow imprecise movement) and sleep disorders. Review of the Physicians Orders indicated the following: -Carbidopa-Levodopa (medication used to treat Parkinson's Disease) 25-100 milligrams (mg) give 1.5 tablet by mouth four times daily for Parkinson's (initiated 4/25/19) -Trazodone 12.5 mg give by mouth in the morning (initiated 2/24/21) -Ready Care 2.0 (nutritional supplement with increased calories/protein) 180 milliliters (ml) four times daily (initiated 12/6/21) Review of the Nursing Electronic Medical Record…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-09-14 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility and its staff failed to maintain a sanitary and comfortable room interior for two Residents (#11 and #6), out of 15 sampled residents. Specifically, 1) Failure to provide needed repairs for the wall behind Resident's #11 bed, and 2) Failure to maintain a clean and safe room environment for Resident #6. Findings include: Review of the facility policy titled Resident Room Cleaning, dated 9/14/22, included the following: -Spot clean soiled wall, doors . -Make work order for any repair work needed. 1. On 9/08/22 at 10:06 A.M., the surveyor observed the wall behind the head of the bed for Resident #11 to be in disrepair with patches of unfinished areas. During an interview and observation on 9/08/22 at 10:42 A.M., Resident #6 and the surveyor observed the following: -Dust build up on the privacy curtain track located on the ceiling around the Resident's bed -Two large stains on the ceiling -Splatter marks about the Resident's bed -Bottom right corner of the headboard missing Resident #6 said that he/she was not sure what all of the spots…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-09-14 · 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 observations, interviews and record reviews, the facility failed to ensure that staff implemented the plan of care for one Resident (#22), out of a total sample of 15 residents. Specifically, the plan of care relative to: A) Obtaining weights as ordered by the Physician to monitor significant weight loss, and B) Providing nutritional interventions as ordered by the Physician and/or as recommended by the Dietitian per the Nutritional Plan of Care. Review of the facility policy titled Weighing and Measuring the Resident, revised 3/2011, indicated the purpose of the policy was to provide a baseline and ongoing record of the resident's body weight as an indicator of nutritional status and medical condition. The policy also included the following: -Weights is usually measured on admission and monthly during the resident's stay -Report any significant weight loss/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 then 5% is severe --3…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-09-14 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility and its staff failed to ensure a care plan was updated to accurately reflect the level of assistance required during Activities of Daily Living (ADLs), for one Resident (#35), out of 15 sampled residents. Findings include: Resident #35 was admitted to the facility in August 2021. Review of the Minimum Data Set (MDS) dated [DATE], indicated the following: -Transfers - extensive assist of one person -Walking in room - limited assistance of one person -Toilet use - extensive assist one-person physical assist -Balance - moving from seated to standing-not steady, only able to stabilize with staff assistance -Walking - not steady, only able to stabilize with staff assistance -Moving on and off the toilet - not steady, only able to stabilize with staff assistance Review of the ADL Care Plan, last revised on 9/9/22, indicated the following: -The Resident is independent to use the toilet, initiated on 1/5/22 -The Resident is independent with walk, with transfers,…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-09-14 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews and record reviews the facility failed to ensure that staff maintained complete and accurate medical records for two Residents (#24 and #17), out of a total sample of 15 residents. Findings include: Review of the facility policy titled Charting and Documentation, revised July 2017, indicated all services provided to the resident, progress towards the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The policy also included the following: -documentation in the record may be electronic, manual or a combination -the following information is to be documented in the resident medical record: --objective observations --medications administered --treatments or services performed --changes in the resident's condition --events, incidents, or accidents involving the resident; and --progress toward or changes in the care plan goals and objectives 1. For Resident #24, the facility failed to ensure the staff maintained an accurate medical record…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-09-14 · 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 and record review, the facility failed to ensure that its staff implemented proper hand hygiene during a dressing change, contaminating a clean procedure and encouraging the risk of infection for one Resident (#18), out of 15 sampled residents. Findings include: Review of the facility policy titled Dressing, Dry/Clean, dated September 2013, indicated the following under Steps in Procedure: -Position resident and adjust clothing to provide access to affected area. -Wash and dry your hand thoroughly. Put on clean gloves. -Loosen tape and remove soiled dressing. Wash and dry your hands thoroughly. -Open, dry, clean dressing(s) by pulling corners of the exterior wrapping outward, touching only the exterior surface. -Label tape or dressing with date, time, and initials. Place on clean field. Using clean technique, open other products. Wash and dry your hands thoroughly. Put on clean gloves. -Cleanse the wound with ordered cleanser. Apply the ordered dressing. Label with date and initial to the top of dressing. Resident #18 was admitted to the facility 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2025-02-18 · tag F0641 — pattern
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure that the Minimum Data Set (MDS) Assessment was coded accurately for one Resident (#35) out of a total sample of 17 residents. Specifically, the facility failed to ensure that the most recent MDS Assessment was coded accurately relative to weight loss for Resident #35. Findings include: Resident #35 was admitted to the facility in July 2024 with diagnoses including Diabetes, small cell lung carcinoma (lung cancer) receiving chemotherapy, Chronic Obstructive Pulmonary Disease (COPD), C-Diff (Clostridium Difficile), Chronic Kidney Disease (CKD), anxiety and depression. Review of the facility policy titled Weighing and Measuring the Resident, revised March 2011, indicated the following: a. one month 5% weight loss is significant; greater than 5% is severe. b. three months 7.5% weight loss is significant; greater than 7.5 is severe c. six months 10% weight loss is significant; greater than 10% is severe. Review of Resident #35's Weight Summary from…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2024-02-28 · tag F0623 — widespread
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    What the surveyor found here — 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 that the Resident and/or Resident Representative was notified in writing of a transfer or discharge and that a representative in the Office of the State Long Term Care Ombudsman was also notified for five Residents (#41, #39, #52, #46, and #57) out of six applicable residents, out of a total sample of 15 residents. Specifically, the facility staff failed to ensure: 1. For Resident #41, that the Resident and/or Resident Representative was notified in writing, and the reason given for a transfer or discharge. 2. that the Office of the State Long Term Care Ombudsman was notified of the transfer/discharges for Residents #41, #46, #57, #39, and #52. Findings include: Review of the facility policy titled Transfer or Discharge Documentation, revised December 2016, indicated the following: - .An appropriate notice was provided to the resident and/or legal representative 1. Resident #41 was admitted to the facility in November 2022 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2024-02-28 · tag F0625 — pattern
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the Bed-Hold Policy was provided at the time of transfer to a hospital or shortly thereafter to one Resident (#41) and/or the Resident's Representative, out of a total sample of 15 residents. Findings include: Review of the facility policy titled Bed-Holds and Returns, revised March 2022, indicated the following: -All residents/representative are provided written information regarding the facility bed-hold policies .at the time of transfer (or, if the transfer was an emergency, within 24 hours). Resident #41 was admitted to the facility in November 2022 with diagnoses including major depressive disorder, adjustment disorder with disturbance of conduct, and a mood disorder. Review of the Skilled Nursing Facility (SNF)/Nursing Facility (NF) to Hospital Transfer Form, dated 11/29/23 indicated Resident #41 was transferred to the hospital on [DATE]. During an interview on 2/27/24 at 12:02 P.M., Social Worker (SW) #1 said she provides a copy 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.

    Resident Rights 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

$7,901 in federal fines across 1 penalty.

  • $7,901 — penalty dated 2023-09-28

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Who owns this facility

Owner / managerTypeRoleSince
KACZYNSKI, KEVINIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/08/2025
STEINBERG, GERALDIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2025

CMS files one row per role, so the 5 rows in the source record cover these 2 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

Follow the money — this home’s finances

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

$7.7M
Net patient revenuemost recent cost report
+3.3%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 72%Medicare 13%Other / private 15%

About 72% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself.

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

$328per resident / day
operating cost
$9,959per month
≈ monthly operating cost
$339per 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 225539. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-02-18, 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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