Hathorne Hill Rehabilitation And Healthcare Center

Location & what’s nearby

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

Quality measures — how residents actually fare

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.

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.

65.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 739 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 51.9% 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 260 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 26% 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.

Staffing

How full it usually is: this home is certified for 120 beds and averages 114.8 residents a day — about 96% occupied, or roughly 5 beds typically open. It runs essentially full — expect a waiting list. 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 3.67 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.58 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.95 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 3.31 hrs/resident/day on weekends vs 3.81 on weekdays — 13% thinner on weekends. RN hours go from 0.65 to 0.40 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 54% is about the same as the national median of 45%.

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

Inspection trend

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

Inspection deficiencies

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

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

29 citations, most serious first. The 16 most serious are shown; the remaining 13 are one tap away and print in full.

• Immediate jeopardy · Kcited before2023-12-15 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — pattern
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 5. Resident #65 was admitted to the facility in March 2023, and had diagnoses which included dementia, cellulitis, cerebral ischemia, and dysphagia. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #65 scored a 7 out of 15 on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. Review of Resident #65's nursing skin check note dated 3/10/23, indicated he/she was admitted with a left lower extremity abrasion, pressure area to coccyx, and Prevalon heel protectors (a device used to reduce the risk of pressure injuries by keeping the heel floated, relieving pressure), applied to bilateral lower extremities. His/her skin was warm and dry. Review of Resident #65's nurse practitioner note dated 3/20/23, indicated the presence of pressure area to the Right buttock but failed to indicate the wound was evaluated or measured. There was no documentation of the left lower extremity abrasion and had no documented evaluations including measurements or observations…

  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
• Immediate jeopardy · J2023-12-15 · tag F0726 — failed to have competent, trained nursing staff — isolated
  Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, staff education and Facility Assessment review, the facility failed to ensure the nursing staff were trained and demonstrated the competencies and skillsets necessary to provide the level and types of care and services needed as outlined in the Facility Assessment. Specifically, the facility failed to: 1) Ensure the licensed nursing staff were trained and demonstrated competency to identify, assess, evaluate, intervene, and respond to a significant change in condition of a wound, for one Resident (#182), out of a total sample of 44 Residents. Resident #182 was admitted with a Stage 2 pressure ulcer that progressed and deteriorated to a Stage 4 pressure ulcer. Resident #182 developed a pressure ulcer to the midthoracic spine while in the facility. and; 2) Ensure 10 out of 10 staff education records reviewed, education and competencies were completed and documented annually, per Facility Assessment. Findings include: According to the Board of Registration in Nursing, 244 CMR…

  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
• Immediate jeopardy · J2023-12-15 · tag F0835 — failed to run the facility competently — isolated
  Administer the facility in a manner that enables it to use its resources effectively and efficiently.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review the facility failed to ensure its administration used its resources effectively to provide appropriate wound care. Specifically, the facility administration failed to: 1) provide nursing staff education and training to provide competent, safe, and effective wound care management; 2) provide continuation of the wound care program following the resignation of its Wound Nurse and implement an effective wound care program for pressure ulcer (wounds that occur when the skin and tissue are damaged by prolonged pressure, usually on bony areas like the hips, heels, or elbows) prevention and care per the Facility Assessment Tool. These failures resulted in the development of a Stage 4 pressure ulcer with purulent drainage and odor for one Resident (#182) out of a total sample of 44 residents. Findings Include: During the survey process it was identified that the Administration's failure to perform wound care competencies for nursing staff that were delegated to assume…

  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
• Actual harm · G2023-12-15 · tag F0655 — isolated
  Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
  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 it completed a baseline care plan for one Resident (#182) out of 44 sampled residents. Specifically, the facility failed to complete a baseline care plan to address a Stage 2 pressure ulcer present on admission. The baseline care plan failed to include goals and interventions. The Stage 2 coccyx pressure ulcer then developed into a Stage 4 pressure ulcer on 11/8/23. Findings include: Review of the facility's policy Skin Integrity and Wound Management dated 2/1/23, indicated: - Complete comprehensive evaluation, and risk evaluation on admission and weekly for the first month. - The plan of care for the patient will be reflective of assessment findings from the comprehensive patient assessment and wound evaluation. Staff will continuously observe and monitor patients for changes and implement revision to the plan of care as needed. - Review care plan and revise as needed. The Skin Integrity and Wound Management policy did not make…

  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 · G2023-12-15 · 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 interviews, the facility failed to provide supervision for one Resident (#94) out of a total sample of 44 residents. Specifically, the facility failed to implement the fall intervention, which resulted in the Resident falling and fracturing his/her left hip. Findings include: Review of the facility's policy titled 'Falls Management' with a revision date of 8/7/23, indicated the following: -Patients will be assessed for risk of falling as part of the nursing assessment process. -Interventions to reduce risk and minimize injury will be implemented as appropriate. -A fall is defined as unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force. -Patients experiencing a fall will receive appropriate care and post fall interventions will be implemented. Resident #94 was admitted to the facility in May 2022 with diagnoses including a history of falls and Parkinson's disease. A review of the most recent 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2023-12-15 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and records reviewed for one Resident (#381) of 44 sampled residents, the facility failed to provide mental health services to a Resident with a known history of trauma and a diagnosis of post-traumatic stress disorder (PTSD). Specifically, for Resident #381 the facility failed to implement a physician's order for a psychiatric evaluation or develop a comprehensive plan of care, resulting in increased depression, thoughts of being better off dead, and an emergent hospital evaluation. Findings include: Review of the facility policy titled Behavioral Health Care and Services, revised 1/1/22, indicated, but was not limited to the following: -Each patient/resident (hereinafter patient) must receive, and the Center must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Resident #381 was admitted in November 2023 with…

  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 before2025-12-04 · tag F0550 — failed to protect resident dignity and rights — isolated
  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interviews, observations, and policy review, the facility failed to ensure staff treated one Resident (#140) in a dignified manner during the dining experience out of a total sample of 26 residents. Specifically, for Resident #140 who was dependent on staff for assistance with meals, the facility failed to provide assistance when his/her meal was delivered.Findings include:Review of the facility policy titled Dignity, dated 2/21, indicated each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. When assisting with care, residents are supported in exercising their rights for example, residents are: provided with a dignified dining experience. Resident #104 was admitted to the facility in February 2021 with diagnoses that included dysphagia, cerebral infarction, and macular degeneration. Review of Resident #104's most recent Minimum Data Set (MDS) assessment, dated 10/23/25, indicated he/she scored a 11 out of a possible 15 on the Brief Interview 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-12-04 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
  Provide care and assistance to perform activities of daily living for any resident who is unable.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, record review and interviews, the facility failed to provide assistance with Activities of Daily Living (ADLs), for one Resident (#46) out of a total sample of 26 residents. Specifically, for Resident #46 the facility failed to provide assistance and/or supervision with meals as per the plan of care.Findings include:Review of the facility policy titled Activities of Daily Living (ADLs), dated 4/25, indicated Residents who are unable to carry out activities of daily living independently receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. A resident's ability to perform ADLs is measured using clinical tools, including the MDS. Functional decline and improvement are evaluated using the following MDS definitions: Supervision or touching assistance - if the helper provides verbal cues or touching/steadying/contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. Partial/moderate assistance - if the helper does less than half the effort.…

  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 · D2025-12-04 · tag F0887 — isolated
  Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review and interview the facility failed to ensure that for two out of five staff records reviewed (Nurse #2 and Additional Staff #2), who did not receive the covid vaccination, signed a statement certifying that they are exempt from vaccination and they received information about the risks and benefits of COVID-19 vaccine.Findings include:Review of Nurse #2's personnel health records indicated a facility document titled Covid-19 Vaccine Consent form had a check mark indicating the declination of the covid vaccine, but the document was not signed by the staff member.Review of Additional Staff #2's personnel health records indicated a facility document titled Covid-19 Vaccine Consent form had a check mark indicating the declination of the covid vaccine, but the document was not signed by the staff member.During an interview on 12/3/25 at 1:30 P.M. the Staff Development Coordinator/Infection Preventionist (SDC/IP) said that the Human Resource (HR) Director is responsible for the hiring process, including maintaining the staff employment records and ensuring documents…

  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 · Dcited before2024-12-05 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  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 implement interventions related to pressure ulcer care and prevention for one Resident (#46) out of a total of 23 sampled Residents. Specifically, the facility failed to implement an air mattress as recommended by the Wound Physician for Resident #46 after he/she developed a stage III pressure ulcer at the facility. Findings include: Review of the facility's Pressure Injury Prevention and Management Policy, dated May 2024, indicated: Evidenced based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include, but are not limited to: Redistribute pressure, minimize exposure to moisture and keep skin clean, provide appropriate, pressure redistributing support surfaces. Resident #46 was admitted to the facility in July 2024 with diagnoses including spinal stenosis and age related osteoporosis. Review of the Minimum Data…

  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 · D2024-12-05 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
  Provide safe and appropriate respiratory care for a resident when needed.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation and interview, the facility failed to maintain a sanitary oxygen filter for one Resident (#93) out of a total sample of 23 residents. Findings include: Review of the facility policy titled Oxygen Concentrator, dated 8/1/24, indicates the following: Care of Concentrator: Follow the manufacturer recommendations for the frequency of cleaning filters and servicing the device. Resident #93 was admitted in October 2023 with diagnoses including chronic obstructive pulmonary disorder. Review of the current physician's order indicated Resident #93 requires oxygen delivery continuously. There were no physicians orders related to the monitoring or maintenance of Resident #93's oxygen concentrator filter. During an observation on 12/3/24 at 8:07 A.M., Resident #93's oxygen filter was dirty and caked in dust. During an observation on 12/4/24 at 10:30 A.M., Resident #93's oxygen filter was dirty and caked in dust. During an interview on 12/4/24 at 10:30 A.M., Nurse #1 said she does not know who changes the filters. She said she is only responsible for changing the oxygen…

  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 · D2024-12-05 · tag F0805 — failed to prepare food in a form residents can eat — isolated
  Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
  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 follow the dietary plan for one Resident (#44) of 23 sampled residents. Specifically, the facility served Resident #44 fish, which was a documented allergen. Findings include: Resident #44 was admitted to the facility in December 2023 with the following active diagnoses: dementia and chronic pulmonary disorder. Review of Resident #44's Minimum Data Set assessment dated [DATE], indicated he/she required set-up assistance for meals. The Resident had a Brief Interview for Mental Status exam score of 9, signifying moderately impaired cognition. Review of Resident #44's allergens list dated 1/15/18, indicted he/she was allergic to fish containing products. Review of Resident #44's Nurse Practitioner note dated 1/26/24, indicated staff accidentally gave fish (not tuna) for his/her evening meal and reported an allergic reaction. The note indicated he/she experienced a tingling on his/her nose, but no other symptoms. Review of Nurse #3 written statement dated…

  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 · Past Non-Compliance
• Potential for harm · Dcited before2024-12-05 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to accurately document the completion of shaving for one Resident (Resident #22) of 23 sampled residents. Findings include: Resident #22 was admitted to the facility in May 2024, and has active diagnoses which include anxiety, depression, and esophageal cancer. Review of Resident #22's Minimum Data Set (MDS) assessment dated [DATE], indicated he/she required partial to moderate assistance with personal hygiene (includes shaves). The Resident had a Brief Interview for Mental Status exam score of 14, signifying intact condition. The Resident exhibited verbal and non-verbal behaviors and rejected care approximately 1 to 3 times per week. Review of Resident #22's care plan dated 1/2/24, indicated he/she required set-up and assist of one as needed for personal hygiene. The care plan also indicated he/she required two staff members present for all care related to accusatory statements. The care plan indicated he/she was verbally abusive toward…

  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 · E2023-12-15 · tag F0697 — failed to manage pain — pattern
  Provide safe, appropriate pain management for a resident who requires such services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and records reviewed for one Resident (#78) of 44 sampled residents, the facility failed to provide pain management that met professional standards of practice. Specifically, the facility failed to obtain a physician's order for pain medication prior to administration. Findings include: Review of the facility policy titled Pain Management revised 11/1/23, indicated, but was not limited to: -Staff will continually observe and monitor patients for comfort and presence of pain and will implement strategies in accordance with professional standards of practice, the patient-centered plan of care, and the patient's choices relating to pain management. -The nurse will notify the physician/advanced practice provider (APP) as appropriate to obtain treatment orders as indicated. -The care plan will be evaluated for effectiveness until satisfactory pain management is achieved. Resident #78 was admitted in March 2023 with the following diagnosis: osteoarthritis. Review of the most recent…

  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 · E2023-12-15 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and policy review for four Residents (#25, #93, #118, #381) of 39 sampled residents, the facility failed to ensure medications were dated and unexpired, and securely stored. Specifically: - For Resident #25, the facility failed to ensure outdated medications were not available for administration and ensure medications with shortened expiration dates after being opened were labeled with open dates. - For Resident #93, #118 and #381, the facility failed to secure medications found in their bedrooms. Findings include: 1. Review of the facility policy titled General Dose Preparation and Medication Administration revised [DATE], indicated, but was not limited to: -Facility staff should enter the date opened on the label of medications with shortened expiration dates (e.g., insulins, irrigation solutions, etc.) On [DATE], at 8:03 A.M., the surveyor observed Nurse #7 during the medication pass. The surveyor observed an insulin glargine-yfgn subcutaneous solution pen-injector open 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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2023-12-15 · tag F0880 — failed to prevent and control infections — pattern
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, policy review and interviews, the facility failed to maintain and implement an infection control program designed to help prevent and identify the development and transmission of disease and infection. Specifically: - The facility failed to monitor, track, and analyze infectious diseases during the month of November 2023. - For Resident #381, the facility failed to implement transmission-based precautions for the management of active Clostridioides difficile disease. Findings include: Review of the facility policy titled Infection Control Outcome and process Surveillance and Reporting dated 9/1/2004, and revised on 11/28/2017, indicated but was not limited to the following: - Outcome surveillance which consists of collecting/documenting data on individual cases and comparing the collective data of standard, written definitions of infection. The monthly infection control report will be used. - Process surveillance to review practices directly related to patient care. Examples…

  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.

Fines & penalties

$242,785 in federal fines across 1 penalty.

• $242,785 — penalty dated 2023-12-15

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.

Part of a chain

This home belongs to ATLAS HEALTHCARE — 29 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

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

Follow the money — this home’s finances

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

This home reported $3.6M paid to related parties — landlords or management companies under common ownership — equal to about 19% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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

Cost & finances

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

What families pay in MA