New England Homes for the Deaf, Inc
154 Water Street, Danvers, MA 01923 · Non profit - Corporation · 81 certified beds · (978) 774-0445 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- a high payroll-based staffing rating (5/5)
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $3,174 in federal fines (most recent 2023-10-30)
- its payroll-based staffing score sits well above its independent inspection score
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 20.8% | 16.4% | 15.4% | worse |
| Long-stay residents who lose too much weight | 2.5% | 5.1% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.8% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 1.0% | 1.8% | 2.0% | better |
| Long-stay residents with depressive symptoms | 1.1% | 15.5% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 4.7% | 3.4% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 30.5% | 15.4% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 16.1% | 19.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 94.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.8% | 4.2% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 16.2% | 21.2% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 19.7% | 21.4% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.4% | 1.4% | better |
| Short-stay residents rehospitalized after admission | 24.5% | 25.7% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 12.8% | 11.9% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 3.40 | 1.88 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.23 | 1.50 | 1.80 | worse |
‡ 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.
Met the expected recovery: 70.8% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 24 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 0.50 therapist hours per resident per day in 2026Q1 — more than 81% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 1% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.1%CMS range 5.8–16.4 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 70.8% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 70.8% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 37.5% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 71.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not 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 discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.87 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 81 beds and averages 28.7 residents a day — about 35% occupied, or roughly 52 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 4.92 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.81 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.04 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 4.44 hrs/resident/day on weekends vs 5.12 on weekdays — 13% thinner on weekends. RN hours go from 0.89 to 0.64 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 42% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
22 citations, most serious first. The 10 most serious are shown; the remaining 12 are one tap away and print in full.
- Potential for harm · Ecited before2025-03-19 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to properly follow food storage and food handling practices to prevent the risk of foodborne illness in accordance with professional standards for food service safety. Specifically, A) the facility failed to properly store food items in the kitchen to prevent the risk of foodborne illness and B) the facility failed to properly handle food and dinnerware in accordance of professional standards of practice in the second-floor dining room. Findings include: A) During the initial walk-through of the kitchen on 3/18/25 at 7:04 A.M., the surveyor observed the following: In the walk-in refrigerator: - Three carafes containing a yellow liquid, red liquid and clear liquid with no labels indicating what the product was or with a date. - Opened containers with no identifier label with no dates for: three bottles of juice, one container of milk, one container of soy milk, one container of Lactaid milk, three containers of thickened juice, and eight containers of soda. - An opened bag of chocolate whipped cream with no identifier label or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-19 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor 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 observations and interviews, the facility failed to ensure staff treated residents in a dignified manner during the dining experience. Specifically, the facility failed to ensure staff were sitting at eye level when assisting a resident with feeding. Findings include: Review of the facility policy titled Quality of Life - Dignity, revised and dated August 2009, indicated the following: - Residents shall be treated with dignity and respect at all times. The surveyor made the following observations: - During the lunch service on 3/18/25 in the second-floor dining room, a staff member was standing over a resident in a Broda chair while assisting with feeding from 12:22 P.M. through 12:34 P.M. - During breakfast on 3/19/25 at 8:28 A.M., the same staff member was standing over the same resident who was in his/her bed while assisting with feeding. During an interview on 3/19/25 at 9:27 A.M., Unit Manager #1 said staff should not be standing over residents while assisting them with feeding. During an interview on 3/19/25 at 10:05 A.M., the Director of Nursing said staff should not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-19 · tag F0552 — isolatedEnsure that residents are fully informed and understand their health status, care and treatments.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview the facility failed to ensure for one Resident (#21), out of a total sample of 13 residents, that the Health Care Agent was provided the correct risks and benefits related to the administration of an antipsychotic medication. (An Invoked Health Care Proxy (HCP) allows the Health Care Proxy Agent to make medical decision, when a person is determined by a physician/nurse practitioner to lack the capacity to make health care decisions). Findings include: Review of the facility's policy, titled Informed Consent for Psychotropic Medication, not dated included but was not limited to the following: Consistent with the mission of the facility and the rights afforded patients by Massachusetts General Laws Chapter 111 Section 70E, the facility recognizes the right of its residents/patients to be free from physical or chemical restraints except to provide and to be involved in decisions about treatment and any changes in care and treatment. To that end, informed written consent will be obtained as provided in this policy whenever a psychotropic medication…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-19 · tag F0604 — failed to not use physical restraints improperly — isolatedEnsure that each resident is free from the use of physical restraints, unless needed for medical treatment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to assess the use of foam wedges as a potential restraint for one Resident (#14) out of a total sample of 13 residents. Findings include: The facility was unable to provide a policy related to restraints. Resident #14 was admitted to the facility in December 2020 with diagnoses that included dementia, legal blindness, deaf non speaking, and schizophrenia. Review of Resident #14's most recent Minimum Data Set (MDS), dated [DATE], indicated he/she was assessed by nursing staff to have severe cognitive impairment. On 3/18/25 at 7:18 A.M. and 1:26 P.M., the surveyor observed Resident #14 in bed with foam wedges lining the sides of his/her bed. Review of Resident #14's fall care plan, dated 6/16/22, indicated Foam wedge pads placed on each side of bed. Review of Resident #14's fall risk assessment, dated 2/13/25, indicated he/she scored a 19 and is at high risk for falls. Review of Resident #14's nursing progress note, dated 2/17/25, 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.
- Potential for harm · Dcited before2025-03-19 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure resident centered care plans were developed for one Resident (#27) out of a total sample of 13 residents. Specifically, for Resident #27, the facility failed to develop a comprehensive, resident centered care plan for a pacemaker. Findings include: Review of the facility policy titled Pacemaker, Care of a Resident with, revised and dated December 2015, indicated the following: - For each resident with a pacemaker, document the following in the medical record and on a pacemaker identification card upon admission, a. the name, address and telephone number of the cardiologist, b. type of pacemaker, c. type of leads, d. Manufacture and model, e. serial number, f. date of implant, g. paced rate. Resident #27 was admitted to the facility in January 2025 with diagnoses including acute and chronic respiratory failure with hypoxia, pneumonia, chronic obstructive pulmonary disease and presence of cardiac pacemaker. Review of Resident #27's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-19 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to follow professional standards of nursing practice for two Residents (#2 and #7) out of a sample of 13 residents. Specifically, 1. the facility failed to initiate a physician's order for Zofran (an anti-nausea medication) for Resident #2 and 2. the facility failed to specify what setting Resident #7's air mattress should be set to in the physician's order. Findings include: 1. Resident #2 was admitted to the facility in May 2023 with diagnoses including dementia and dysphagia. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #2 was significantly cognitively impaired evidenced by a score of one out of a possible 15 on the Brief Interview for Mental Status Exam. Review of the Nurse Practitioner progress note dated 2/17/25 indicated: Asked to f/u with patient regarding reports of vomiting x 1 today and some nausea. No sob (shortness of breath) or chest pain. Appetite is poor due to illness. No fever. BP (blood…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-03-19 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to provide treatment and care in accordance with professional standards of practice for two Residents (#28, and #15), out of a total sample of 13 residents. Specifically, 1. For Resident #28, the facility failed to notify the Medical Doctor or Nurse Practitioner to initiate a new order for an oral antibiotic medication to treat his/her osteomyelitis recommended by the infectious disease provider. 2. For Resident #15, the facility failed to obtain a urine specimen timely and failed to notify the Nurse Practitioner or Medical Doctor that the urine specimen was not obtained resulting in Resident #15 being transferred to the emergency department and treated for cystitis (inflammation of the bladder). Findings include: Resident #28 was admitted to the facility in February 2025 with diagnoses that included extradural and subdural abscess, osteomyelitis, sepsis, and mild cognitive impairment. Review of Resident #28's 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.
- Potential for harm · Dcited before2025-03-19 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interview, the facility failed to provide respiratory care services in accordance with professional standards of practice for one Resident (#27) out of a total sample of 13 residents. Specifically, the facility failed to ensure Resident #27 had a physician's order for the use of supplemental oxygen therapy while he/she was receiving supplemental oxygen. Findings include: Review of the facility policy titled Oxygen Administration, revised and dated October 2010, indicated the following: - Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Resident #27 was admitted to the facility in January 2025 with diagnoses including acute and chronic respiratory failure with hypoxia, pneumonia, chronic obstructive pulmonary disease and presence of cardiac pacemaker. Review of Resident #27's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident had a Brief Interview…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-19 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
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, policy review, and interview, the facility failed to ensure residents were free of unnecessary medications for one Resident (#14) out of a total of 13 sampled residents. Specifically for Resident #14, the facility failed to ensure there was an initial 14 day stop order or reevaluation to continue his/her as needed (PRN) Ativan. Findings include: Review of the facility policy titled Antipsychotic Medication Use, revised December 2016, indicated 14. The need to continue PRN orders for psychotropic medications beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the PRN order will be indicated in the order. Resident #14 was admitted to the facility in December 2020 with diagnoses that included dementia, legal blindness, deaf non speaking, and schizophrenia. Review of Resident #14's most recent Minimum Data Set (MDS), dated [DATE], indicated he/she was assessed by nursing staff to have severe cognitive impairment. Further review 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.
- Potential for harm · F2024-03-21 · tag F0909 — failed to maintain a comfortable temperature — widespreadRegularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
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 regularly inspect bed frames to identify areas of potential entrapment. Specifically, the facility failed to regularly inspect and document findings regarding zone 7 (the space between the mattress and the foot of the bed) for 27 of 27 Residents' beds in the facility for potential areas of entrapment, as evidenced by not providing an effective bed bolster for Resident #3. Findings include: According to The Guidance for Industry and FDA Staff Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment Document issued on March 10, 2006, by the U.S. Department of Health and Human Services Food and Drug Administration Center for Devices and Radiological Health, the HBSW (Hospital Bed Safety Workgroup) identified 7 potential entrapment zones for hospital beds. Resident #3 was admitted to the facility in December 2005 with diagnoses including traumatic brain injury with loss of consciousness and aphasia (loss of ability to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 12 citations
- Potential for harm · D2024-03-21 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview for one Resident (Resident #18) of 30 sampled residents, the facility failed to accurately complete a Medical Orders for Life Sustaining Treatment (MOLST) form. Findings include: Review of the facility's Advanced Directive Policy and Procedure, dated as revised on February 2017, indicated Nurses and other health care staff are educated to initiate CPR [cardiopulmonary resuscitation], as recommended by the American Heart Association (AHA) unless a valid Do Not Resuscitate order is in place. Resident #18 was admitted to the facility in [DATE] and his/her current diagnoses included deafness, blindness, and psychosis. Review of Resident #118's Minimum Data Set assessment dated [DATE], indicated he/she was unable to complete the Brief Interview for Mental Status examination and was represented by a legal guardian. Review of Resident #18's medical record profile indicated he/she elected Do Not Resuscitate status. Review of Resident #18's Medical Orders for Life Sustaining Treatment…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-21 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
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, for one Resident (#1) out of 13 sampled residents, the facility failed to ensure staff implemented policies and procedures related to personal privacy and confidentiality. Specifically, the facility used a personal cell phone to take a picture of the Resident's wound. Findings include: Review of the facility's Clinical Photography Policy, undated, indicated: *Clinical photography of residents may be appropriate for the diagnosis and treatment of medical conditions as well as professional education. *Clinical photography is defined as any photography or videotaping of a resident and includes but not limited to: pictures/videos of pressure ulcers, wounds, skin tears, bruises, abrasions, etc. Pictures/videos of abuse, neglect, assaults, or accidents. Pictures/videos of residents taken for the purpose of identification. *Clinical photography will only be done post completion of the Photography Consent Form as completed by the resident or the residents' guardian/HCP (health care…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-03-21 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to develop and implement the plan of care for two Residents (#81 and #3) out of a total sample of 13 residents. Specifically, the facility failed to: 1. For Resident #81, the facility failed to develop a plan of care for the diagnosis of post-traumatic stress disorder. 2. For Resident #3, the facility failed to implement the falls care plan for the use of fall mats while in bed. Findings include: 1. Resident #81 was admitted to the facility in May 2021 and had diagnoses which included post-traumatic stress disorder (PTSD). PTSD is a mental health condition that is triggered by a terrifying event, either by experiencing it or witnessing it. Symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event. Review of Resident #81's Minimum Data Set (MDS) assessment dated [DATE], indicated he/she had an active diagnosis PTSD. Review of Resident #81's current care plan indicated a diagnosis of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-03-21 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and observation for one Resident (#81) of 27 sampled residents, the facility failed to ensure his/her oxygen concentrator filter was free of significant dust. Findings include: Resident #81 was admitted to the facility in May 2021, and had diagnoses which included asthma and congestive heart failure. Review of Resident #81's Minimum Data Set assessment dated [DATE], indicated he/she received intermittent oxygen therapy. Review of Resident #81's respiratory care plan dated 12/9/23, indicated he/she had an altered respiratory status. The goal of care included no complications related to shortness of breath. The care plan did not reference Resident #81's asthma or intermittent use of oxygen therapy. Review of Resident #81's active physician orders dated 3/7/24, indicated Apply oxygen via nasal cannula at 1-2 liters to keep SPO2 (blood oxygen saturation) greater than 88%. Review of Resident #81's nursing progress notes indicated the oxygen concentrator was last used on 3/4/24 for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-21 · tag F0908 — failed to keep essential equipment working — isolatedKeep 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 interview and observation for one Resident (#18) of 27 sampled residents, the facility failed to ensure his/her wheelchair was in safe operating condition. Findings include: Resident #18 was admitted to the facility in January 2021 and his/her current diagnoses included deafness, blindness, and psychosis. Review of Resident #118's Minimum Data Set assessment dated [DATE], indicated he/she was unable to complete the Brief Interview for Mental Status examination, used a wheelchair for ambulation and was dependent on staff for wheelchair use. Review of Resident #18's current plan of care for mobility indicated he/she used a wheelchair. On 3/20/24 at 8:37 A.M., the surveyor observed Resident #18 in his/her room and sitting in a wheelchair. The wheelchair was missing the upper left chair handle, and the metal edges were exposed. The right arm rest was broken and loosely attached to the arm. The sling back fabric to the wheelchair was stretched and scratched. During an interview with Resident #18 on 3/20/24…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-10-27 · tag F0585 — failed to handle grievances — isolatedHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on a resident group meeting and interviews, the facility failed to ensure that residents knew the proper way to file a grievance and felt that they could not file one without fear of retaliation. Findings include: Review of the facility policy titled Resident Grievance/Complaint Procedures, undated indicated the following: *A resident, his/her representative, family member, visitor or advocate has the right to file a grievance either orally or in writing without fear of reprisal of any form. The resident or representative has the right to file a grievance anonymously. This right will be honored and protected by the facility grievance official/social worker, and facility staff The resident group meeting was held on 10/26/22 at 10:34 A.M., with seven residents present. Seven out of 7 participating group members felt staff would retaliate against them if they were to file a formal complaint to the facility. Seven out of 7 participating members said they felt comfortable discussing issues with the social worker verbally but were unaware they could write a formal grievance on a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-10-27 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
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, policy review and interviews, the facility failed to investigate a potential incident of abuse for 1 Resident (#18) out of a total sample of 12 residents. Findings include: Review of the facility policy titled, Abuse and Neglect Policy and Procedure, dated 7/19/21, indicated the following: *Allegations of abuse, mistreatment, neglect, and exploitation, misappropriation of property and injuries of unknown origin will be addressed immediately and aggressively and will involve Social Services Department, Director of Nurses, Administrator and any other applicable supervisor or department managers. Resident #18 was admitted to the facility in November 2021 with diagnoses including cerebral palsy. Review of Resident #18's most recent Minimum Data Set (MDS) dated [DATE] revealed the Resident had a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15, indicating he/she is cognitively intact. The MDS also indicated the Resident requires extensive assistance from staff for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-10-27 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record reviews, interviews and resident council meeting, the facility failed to provide necessary assistance for activities of daily living by failing to provide showers for 2 Residents (#18 and #23) out of a total sample of 12 residents. Findings include: During resident council meeting on 10/25/22 at 10:30 A.M., 7 out of 7 participating members said they would like more showers offered to them and 7 out of 7 members said they have repeatedly mentioned this to staff. 1. Resident #18 was admitted to the facility in November 2021 with diagnoses that included cerebral palsy, muscle weakness, schizophrenia, major depressive disorder and abnormalities of gait (walking) and mobility. Review of Resident #18's most recent Minimum Data Set (MDS) dated [DATE] indicated that Resident #18 had a Brief Interview for Mental Status score of 15 out of a possible 15, indicating he/she is cognitively intact. The MDS also indicated Resident #18 requires extensive assistance with all activities of daily…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-10-27 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to investigate a bruise of unknown origin for 1 Resident (#19) out of a total sample of 12 residents. Findings include: Resident #19 was admitted to the facility in March 2022 with diagnoses including dementia. Review of Resident #19's most recent Minimum Data Set, dated [DATE] revealed the Resident was not able to participate in the Brief Interview for Mental Status and staff had assessed him/her to be independent with decision making. The MDS also indicated Resident #19 requires extensive assistance from staff for all daily tasks. Review of Resident #19's nursing progress note dated 9/29/22 indicated the Resident had a small purple bruise on his/her left dorsum (back) of hand. The medical record failed to indicate a note explaining the possible cause of the bruise and the facility was unable to provide an incident report with an investigation into the cause of the bruise to Resident #19. During an interview on 10/26/22 at 8:07 A.M., the Unit Manager…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-10-27 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to follow its urinary incontinence policy and did not provide bladder retraining to two Residents (#3 and #9) of 12 sampled residents. Nursing staff assessed Resident #3 and #9 and determined they were good candidates for retraining but failed to refer them to rehabilitation therapists for the retraining. Findings include: Review of the facility's policy for Behavioral Programs and Toileting Plans for Urinary Incontinence, revised September 2010, indicated: * Complete a thorough assessment to determine causes of urinary incontinence * Provide treatment and services to address factors that are potentially modifiable * Monitor, record and evaluate information about the resident's bladder habits, and continence or incontinence * Assess the resident for appropriateness of behavioral programs * Document the result of the toileting trial * If behavioral interventions are unsuccessful, refer resident to the physician for consideration of additional therapies 1. Resident #3 was admitted to the facility in August 2021, and 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.
- Potential for harm · Dcited before2022-10-27 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to follow proper food storage practices to prevent the risk of foodborne illness. Findings include: During a kitchen observation on 10/25/22 at 7:40 A.M., the surveyor observed the following expired foods: *Mozzarella cheese labeled and dated October 2016, black olives labeled and dated 9/26/22 with visible white mold, rice labeled and dated 10/24/22, a bowl of white dressing unlabeled and undated, cucumbers in the walk-in refrigerator with visible white mold on them and were very soft to the touch. During a kitchen observation on 10/27/22 at 7:36 A.M., the surveyor observed the following: *Mozzarella cheese labeled and dated November 2016, black olives labeled and dated 9/26/22 with visible white mold, rice labeled and dated 10/24/22, green beans labeled and dated 10/24/22. During an interview on 10/27/22 at 7:42 A.M., the Food Service Director said food labels should have two dates written on them, the top one being when the product was prepared and the bottom one being its expiration date. If only one date is written, the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-10-27 · tag F0867 — failed to act on quality-improvement findings — isolatedSet up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of the Quality Assurance/Assessment Performance Improvement Plan and staff interviews, the facility failed to ensure the Quality Assurance Committee identified quality deficient areas and to develop and implement an appropriate corrective action plan, to ensure satisfactory outcomes for the delivery of bowel and bladder retraining programs, activity of daily living concerns and call light wait times concerns for the facility's residents. Findings include: Review of the facility policy titled, Quality Assurance/Assessment and Performance Improvement Plan, dated January 2021, indicated: New England Home for the Deaf will identify areas where gaps in performance may negatively affect resident or staff outcomes. Where areas for improvement are detected, the Quality Assurance and Performance Improvement Steering Committee with input from the Leadership Team will prioritize focus areas for Performance Improvement Projects. The team will utilize root cause analysis to identify the cause of the problem and any contributing factors. The Performance Improvement Project team…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$3,174 in federal fines across 1 penalty.
- $3,174 — penalty dated 2023-10-30
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 / manager | Type | Role | Since |
|---|---|---|---|
| IKOMI, EMMANUEL | Individual | W-2 MANAGING EMPLOYEE | since 04/26/2010 |
The source lists no ownership percentage for any party here — 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.
A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in MA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Massachusetts Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 225768. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-03-19, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.