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East Longmeadow Skilled Nursing Center

305 Maple Street, East Longmeadow, MA 01028 · Non profit - Corporation · 131 certified beds · (413) 441-4576 Medicare & Medicaid certified

Call the home — (413) 441-4576 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0605) — cited Jul 2025Behavioral-health or dementia-care citation — no harm found (F0758)
Insights

On the public record, this home looks stronger than most — but visit before you decide.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605) — 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 (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags

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

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

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

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
175 Dwight Rd Ste 303C · (774) 392-2728 · Call to confirm hours
Pharmacy
746 Bliss Rd · (413) 567-8961 · Call to confirm hours
Grocery
696 Bliss Rd · (413) 372-8486 · Call to confirm hours
Park
1161 Williams St · (413) 565-4160 · Typically dawn to dusk
Place of worship
1280 Williams St · (413) 567-3210

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

Quality measures — how residents actually fare

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

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 4 stars. From monthly CMS archive snapshots.

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

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased23.2%16.4%15.4%worse
Long-stay residents who lose too much weight8.1%5.1%5.4%worse
Long-stay residents with a catheter left in their bladder1.4%0.8%0.9%worse
Long-stay residents with a urinary tract infection0.8%1.8%2.0%better
Long-stay residents with depressive symptoms9.9%15.5%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury2.3%3.4%3.3%better
Long-stay residents whose ability to walk worsened28.1%15.4%16.1%worse
Long-stay residents on antianxiety or hypnotic medication25.5%19.5%18.9%worse
Long-stay residents given the seasonal flu vaccine97.3%94.8%95.3%typical
Long-stay residents with pressure ulcers4.5%4.2%4.7%typical
Long-stay residents with worsening bladder/bowel control32.5%21.2%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table19.0%21.4%17.1%worse
Short-stay residents who newly got an antipsychotic medication1.7%1.4%1.4%worse
Short-stay residents given the seasonal flu vaccine90.5%77.7%79.4%better
Short-stay residents rehospitalized after admission30.6%25.7%22.6%worse
Short-stay residents with an outpatient ER visit9.4%11.9%12.0%better
Long-stay hospitalizations per 1,000 resident days1.271.881.67better
Long-stay outpatient ER visits per 1,000 resident days0.551.501.80better

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

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

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

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

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

52.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 475 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

52.4%U.S. median 51.5%
Got home and stayed home
14.6%U.S. median 10.7%
Went back to hospital
50.2%U.S. median 56.6%
Met the expected recovery
0.33U.S. median 0.31
Therapy hours / resident / day
0.14hours / resident / day
Physical therapy
0.15hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 50.2% 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 239 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 0.33 therapist hours per resident per day in 2026Q1 — more than 54% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 17% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF52.4%CMS range 46.7–55.551.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF14.6%CMS range 12.0–17.910.7%Oct 2022–Sep 2024worse than U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge50.2%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge46.0%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge49.0%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified97.7%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting96.3%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.3%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.7%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.0%CMS range 5.0–9.27.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.881.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.67
RN hours/ resident / day
1.08
LPN hours/ resident / day
2.47
Aide hours/ resident / day
4.22
Total nurse hours/ resident / day
0.43
RN hoursweekends
46.6%
Total nursing turnover
50.0%
RN turnover

How full it usually is: this home is certified for 131 beds and averages 127.4 residents a day — about 97% occupied, or roughly 4 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 4.22 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.67 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.47 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 3.84 hrs/resident/day on weekends vs 4.37 on weekdays — 12% thinner on weekends. RN hours go from 0.76 to 0.43 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 47% 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

8
deficiencies at the latest standard inspection (2025-07-22)
7
at the previous standard inspection (2024-05-07)

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.

ABCDEFGHIJKL

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

30 citations, most serious first. The 10 most serious are shown; the remaining 20 are one tap away and print in full.

  • Potential for harm · Ecited before2025-07-22 · 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, and interview, the facility failed to ensure infection control practices for cleaning medical equipment was maintained to prevent the potential spread of infection within the facility on two Units (100s and 400s), out of four units observed. Specifically, 1. On the 100s Unit, the facility failed to ensure staff cleaned and disinfected the portable vital signs machine (medical device that takes temperature, blood pressure, and blood oxygen readings) in between resident use. 2. On the 400s Unit, the facility failed to ensure that staff disinfected the glucometer machine while performing finger sticks, and portable vital signs machine in between residents, increasing the risk for the potential spread of infection between residents.Findings include: 1a. Review of the facility policy titled Policy for Environmental Surface Cleaning, approved 12/22/16, indicated the following: -PDI Super Sani Plus (type of disinfecting wipe)…should be used by nursing staff to clean all equipment used by multiple…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-22 · tag F0552 — isolated
    Ensure 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 interview and record review the facility failed to ensure the resident and/or their resident representative was fully informed about treatments being provided to one Resident (#5) out of a total sample of 26 residents. Specifically, for Resident #5, the facility failed to ensure the Resident's activated Health Care Proxy (HCP - representative designated by a resident to make decisions for him/her when he/she is no longer able to do so) was informed of the current dose and frequency of an antipsychotic medication (Seroquel) and an antidepressant medication (Zoloft) that were actively being administered to the Resident. Findings include: Review of the facility policy title Psychotropic Medications, revised 2/24/25, indicated the following: >Purpose: -To ensure psychotropic medication is used appropriately, with written informed consent, as part of the care of the resident's psychiatric/behavioral health care plan. >Procedure: -The written informed consent for each psychotropic medication shall be initiated with any newly prescribed psychotropic medication and renewed…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-22 · tag F0605 — failed to not use drugs as a restraint — isolated
    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record reviews, the facility failed to ensure that as needed (PRN) orders for antipsychotic medications were limited to 14 days for one Resident (#7), of five applicable residents reviewed for unnecessary medications, out of a total sample of 26 residents. Specifically, for Resident #7, the facility failed to ensure that Physician's orders for PRN Seroquel and Haldol medications were limited to 14 days.Findings include:Review of the facility policy titled Psychotropic Medications, revised 2/24/25, indicated in caring for residents with psychiatric/behavioral health conditions, properly ordered psychotropic medications may be used when non-pharmaceutical interventions are ineffective or inadequate. Psychotropic medications can affect mood and behavior and include but not limited to.antipsychotics. The policy further indicated:-As with all medications, psychotropics shall only be administered following an order by a physician.<As needed (PRN) medications will require a 14-day…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-22 · tag F0637 — isolated
    Assess the resident when there is a significant change in condition
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure that a Significant Change in Status Minimum Data Set [MDS] Assessment (SCSA) was completed for one Resident (#22) out of a total sample of 26 residents. Specifically, for Resident #22, the facility failed to ensure that a SCSA was completed when the Resident experienced a decline in the Activity of Daily Living (ADL) function, change in bowel and bladder continence, and experienced a significant weight decline (weight loss of 5% or more in the past 30 days or 10% or more in the last 180 days). Findings Include: Review of the CMS Resident Assessment Instrument (RAI) Version 1.19.1 dated October 2024, indicated the following: -A SCSA is a comprehensive assessment for a resident that must be completed when the Interdisciplinary Team (IDT) has determined that a resident meets the significant change guidelines for either major improvement or decline. -A significant change is a major decline or improvement in a resident's status that: 1. Will not normally resolve itself without intervention by staff or by implementing…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-07-22 · tag F0685 — isolated
    Assist a resident in gaining access to vision and hearing services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record reviews, the facility failed to provide care and services related to hearing devices for one Resident (#38), out of a total sample of 26 residents. Specifically, for Resident #38, the facility failed to ensure hearing aids were applied per recommendations from the Audiologist and the Resident's plan of care. Findings include:Review of the facility policy titled Activities of Daily Living (ADL), approved 12/22/16, indicated each resident will receive the necessary care and services to attain or maintain the highest practicable physical, mental, and psychological wellbeing, consistent with the resident's comprehensive assessment and plan of care.The policy also included the following:-the facility will provide care and services for the following activities of daily living .communication, including speech and language, functional communication systems .-the care and services for ADL will be based on the resident's ability as identified in Minimum Data Set (MDS) assessment, Rehabilitation evaluation, nursing assessment, and person-centered…

    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 before2025-07-22 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews, and record reviews, the facility failed to ensure that the medication regimen reviews (MRRs) performed by the Consultant Pharmacist were acted upon timely for one Resident (#28) out of a total sample of 26 residents. Specifically, for Resident #28, the Attending Physician failed to document in the Resident's medical record that irregularities identified by the Consultant Pharmacist during the MRRs performed on 6/26/24 and 7/23/24 were reviewed and addressed timely.Findings include: Review of the facility policy titled Drug Regimen Review/Medication Regimen Review dated 11/17/16 and revised on 10/6/22, indicated but was not limited to the following:>Policy:-In accordance with State and Federal Regulations, the Consultant Pharmacist will review each resident's clinical chart monthly, or more frequently depending on the resident's condition and the risks for adverse consequences related to current medications. This review of the clinical chart shall be comprehensive, and findings shall be documented on the Consultant Pharmacist Review/Signature sheet in the chart…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-07-22 · 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 observations, interviews, and records reviewed, the facility failed to maintain complete and accurate medical records for one Resident (#51), out of a total sample of 26 residents. Specifically, for Resident #51, the facility failed to ensure complete and accurate documentation was maintained for urinary catheter output (documentation indicating the volume of urine collected in a urinary drainage bag connected to a urinary catheter) as required. Findings include: Review of the facility policy titled Monitoring of Intake and Output (I & Os), revision date 10/30/18, indicated the following:>Procedure:-Record output amounts (in ccs [cubic centimeter]) including:*Urine-Total shift and daily intake and output records>Document >Intake and output; in resident's medical record Resident #51 was admitted to the facility in July 2025 with diagnoses including Neurologic Neglect Syndrome, Urine Retention, and history of Cerebral Infarction (Stroke). Review of Resident #51's July 2025 Physician's Orders indicated the…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-05-07 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a homelike environment was provided relative to dining for two Residents (#44 and #4) out of a total sample of 27 residents, on two of four units observed (Unit Three and Unit Four). Specifically, the facility failed to ensure: 1. -For Resident #44, that meals were provided timely when he/she was dining with other residents and that blood sugar (glucose) checks were not completed in the dining room. -that residents seated together in a dining area, were served their meals at the same time. 2. For Resident #4, that the Resident's preference for beverages was provided timely with meals. Findings include: 1. Resident #44 was admitted to the facility in February 2023 with diagnoses including Encephalopathy (disease in which the functioning of the brain is affected by some agent or condition such as a viral infection of toxins in the blood), Dementia with agitation (progressive or persistent loss of intellectual functioning and memory)…

    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 · Ecited before2024-05-07 · tag F0842 — failed to keep accurate, complete medical records — pattern
    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 4. Resident #42 was admitted to the facility in February 2024, with a diagnosis including Protein Calorie Malnutrition (state of inadequate intake of food including protein, calories and other essential nutrients). Review of the May 2024 Physician's orders included the following: -Keflex (an antibiotic) 500 milligrams (mg) every 8 hours daily (three times daily) for 10 days for infection, initiated 4/23/24 Review of the April 2024 and May 2024 Medication Administration Record (MARs) indicated Keflex 500 mg was administered three times daily to Resident #42 from 4/23/24 through 5/2/24, with the exception of 4/26/24 where an M was documented at 10:00 P.M. Review of the Resident's clinical record did not indicate why the Keflex medication was prescribed. During an interview on 5/3/24 at 11:10 A.M., Nurse #6 said Resident #42 was prescribed the Keflex because he/she had a root canal and had an abscess (a swollen area within the body tissue containing an accumulation of pus). During an interview on 5/3/24 at 11:34…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-07 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to coordinate an assessment with the Preadmission Screening and Resident Review (PASARR- a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care. PASRR requires that: 1) all applicants to a Medicaid-certified nursing facility be evaluated for a serious mental disorder and/or intellectual disability; 2) be offered the most appropriate setting for their needs [in the community, a nursing facility, or acute care setting]; and 3) receive the services they need in those settings) program for one Resident (#76) out of a total sample of 27 residents. Specifically, the facility failed to complete a new Level I assessment for a change in condition timely and refer Resident #76 for a Resident Review (person-centered assessment taking into account all relevant information) when he/she had a significant change in condition, a new diagnosis of Schizoaffective Disorder (serious chronic mental illness, characterized by…

    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
Show the remaining 20 citations
  • Potential for harm · D2024-05-07 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to communicate and implement a Physician's recommendation to start medication for one Resident (#2) out of a total sample of 27 residents. Specifically, for Resident #2, the facility failed to verify the ordered dosage and frequency and appropriately communicate the Physician recommendation of Tylenol medication for pain management for the Resident, resulting in potential delay in treatment. Findings include: Resident #2 was admitted to the facility in October 2019 with the following diagnoses: Vascular Dementia (dementia resulting from impaired blood flow to the brain), Spinal Meningioma (a tumor in the thin membranes that cover the spinal cord), Idiopathic Peripheral Neuropathy (sensory disturbances in the limbs causing numbness, tingling, burning and/or weakness with no known cause) and Renal Mass (an undefined abnormal growth in the kidney that may or may not be cancerous). Review of Lippincott Manual of Nursing Practice - 11th Ed.…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-07 · 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

    Based on observation, interview, record and policy review, the facility failed to ensure that Physician's orders were implemented for one Resident (#10), of seven applicable residents identified with pressure ulcers (injury to underlying tissue resulting from prolonged pressure on the skin), out of a total sample of 27 residents. Specifically, the facility failed to ensure that the Physician orders for the setting of a pressure reducing mattress (air mattress) was implemented for Resident #10, who had an existing pressure ulcer and remained bedbound (confined in bed). Findings include: Review of the Operation Manual for the Relief Alternating Pressure System with Low Air Loss, undated and provided by the facility, included the following: -the alternating pressure system with low air loss was designed to treat and prevent wounds by facilitating blood circulation and decreasing pressure of each tissue's contact area. -Always consult the Physician before using the mattress system. -Press the weight button to adjust the patient's weight from 100 pounds (lbs.) to 325 lbs. according 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-07 · 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 observation, interview, and policy review, the facility failed to provide an environment that was free of potential accidents and hazards for one Resident (#384), out of a total sample of 27 residents. Specifically, for Resident #384, the facility staff allowed the Resident to smoke in an undesignated area on the sidewalk in front of the building without any smoking safety equipment available for use in the event of an accidental fire in the vicinity. Findings include: Review of the facility's policy titled Resident Smoking, last revised 7/15/22, indicated the following: -The facility strived to maintain a safe, injury-free environment while respecting those residents who have expressed a desire to smoke. -Smoking is allowed only in designated locations to be determined in collaboration with the facility leadership and local fire chief. -Educate staff regarding the facility's smoking policy, designated smoking location and smoking schedule. -Adaptive equipment (cigarette holder, etc.) will be provided…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-07 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record and policy review, the facility failed to ensure that Enhanced Barrier Precautions (EBP- targeted gown and glove use during high contact resident care activities, designed to reduce transmission of infections) were adhered to for three Residents (#12, #17, #42), of five applicable residents, out of a total sample of 27 residents, to prevent the spread of infections. Specifically, the facility staff failed to: 1. For Resident #12, ensure that the required personal protective equipment (PPE) was worn when providing high contact wound care when the Resident was identified as being on EBP. 2. For Resident #17, ensure the required PPE was worn when assisting the Resident with toileting activities. 3. For Resident #42, ensure the required PPE was worn when assisting the Resident with repositioning when in bed. Findings include: Review of the facility policy titled Enhanced Barrier Precautions, dated 1/10/23, indicated: Enhanced Barrier Precautions will be used in these…

    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 · E2022-12-19 · tag F0550 — failed to protect resident dignity and rights — pattern
    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 observation and interview, the facility failed to ensure its staff kept patient specific protected health information in a private location for Resident #89, and provided a dignified environment on three units (200s Unit, 300s Unit, and 400s Unit) out of four units observed. Findings Include: 1. For Resident #89, the facility staff failed to ensure patient specific protected health information was kept in a location not readily visible in a public area to non-clinical staff and visitors on the 400's Unit. Resident #89 was admitted to the facility in May 2022. During an observation on 12/13/22 at 9:44 A.M., the surveyor observed a white board/bulletin board on the wall in the Resident's room visible from the doorway. The white board had instructions regarding toileting and activities of daily living (ADLs) and indicated that the Resident used pull-ups diapers. On the bulletin board there was also a sheet of paper that was titled Therapy Communication to Nursing which had the Resident's full name on it, and in the Problems/Needs section there was a hand written note…

    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 · E2022-12-19 · tag F0758 — failed to limit and justify psychotropic drugs — pattern
    Implement 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

    3. For Resident #92 the facility failed to ensure its staff monitored changes or side effects for the use of Seroquel (an antipsychotic used to treat certain mental/mood conditions and Remeron (an antidepressant). Resident #92 was admitted to the facility in September 2022. Review of the Active Order Report indicated the following: -Seroquel 25 milligram (mg) give 12.5 mg oral twice daily at 2:00 P.M. and 6:00 P.M. for distressing delusions with a start date of 12/2/22. -Remeron 15 mg tablet give one-half tablet oral at bedtime for Major Depressive Disorder with a start date of 10/26/22. During an interview on 12/14/22 at 3:06 P.M., UM #2 said that residents who are on psychotropic medications are monitored for changes and side effects. She said that the information is documented on a flow sheet and there should be an order to do so. She said there was no order in place to monitor changes and side effects for Resident #92 and there should have been as required. Based on observation, interview, and record review, the facility and its staff failed to ensure that psychotropic…

    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 · D2022-12-19 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that its staff provided access to the call bell system that alert staff to resident needs, for one Resident (#17), out of a sample of 27 residents. Findings include: Review of a facility policy titled: Call Light, Answering, dated 5/2/05, indicated the call light should be placed within reach of the resident. Resident #17 was admitted to the facility in May 2021. Review of the Minimum Data set Assessment (MDS) dated [DATE], indicated Resident #17 scored 6 out of 15 on the Brief Interview of Mental Status (BIMS), was cognitively impaired, and required extensive assist with activities of daily living (ADLs) including transfers. During an observation on 12/13/22 at 9:56 A.M., the surveyor observed Resident #17 seated in an armchair in his/her room. The Resident's call bell was attached to the transfer rail on the bed, out the Resident's reach, approximately four feet away from where the resident was sitting. During subsequent…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-12-19 · tag F0622 — isolated
    Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure its staff completed the required transfer documentation and communicated the appropriate information to the receiving health care institution for two Residents (#117 and #36), out of a sample of 27 residents, putting the Residents at risk for complications and adverse events upon transfer to the receiving facility. Findings include: Review of the facility policy titled Admission/Transfer/Discharge Rights, last reviewed on 10/24/22, indicated the following in part: Emergency Transfer: - Complete emergency transfer form specific to facility (Situation, Background, Assessment, Recommendation) (SBAR) .if unable to complete the information, verbally communicate the necessary information and fax when complete. Information provided to the receiving provider must include at a minimum: -Special instructions or precautions for ongoing care, as appropriate. -Copy of resident discharge summary 1. Resident #117 was admitted to the facility in August 2022 with diagnoses including Acute Respiratory Failure, and Sepsis (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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-12-19 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure its staff developed and implemented a comprehensive person-centered plan of care for two Residents (#89, and #103), out of a sample of 27 residents. Specifically, the facility failed to: 1. develop and implement a care plan for a Resident (#89) with Dementia, and 2. failed to implement a mood and psychotropic medication care plan for a Resident (#103) with Dementia with behavioral disturbance. Findings include: 1. For Resident #89, the facility failed to monitor mood and affect daily and also failed to develop a care plan for cognition. Resident #89 was admitted to the facility in May 2022 with a diagnosis of Parkinson's Disease. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated the Resident scored 13 out of 15 on the Brief Interview of Mental Status (BIMS), had non-Alzheimer's Dementia, and Parkinson's Disease. Review of the nursing progress notes indicated Resident with the following behaviors on the…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-12-19 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility failed to ensure its staff provided quality of care according to the plan of care, facility protocols, and professional standards of practice for two Residents (#104 and #78), out of a total sample of 27 residents. Specifically, the facility failed to ensure that a medicated cream/lotion for both Residents' #104 and #78 was applied by licensed staff only. Findings include: Review of the facility policy titled Medication Storage in the Facility dated 6/1/10 indicated the following: -Only licensed nurses, pharmacy personnel and those lawfully authorized to administer medications (such as medication aides) are allowed to access medications. -Medication rooms, carts and medication supplies are locked or attended by persons with authorized access. 1. Resident #104 was admitted to the facility in April 2021 with diagnoses including dermatitis (inflammation of the skin, typically characterized by itchiness, redness, and a rash). Review of the Minimum…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-12-19 · tag F0685 — isolated
    Assist a resident in gaining access to vision and hearing 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 observation, interview, and record review, the facility and its staff failed to ensure that routine assessments and devices used to maintain hearing were provided for one Resident (#78), out of 27 sampled residents. Specifically, the facility staff failed to offer and encourage the use of hearing aids when Resident #78 complained of difficulty hearing. Findings include: Resident #78 was admitted to the facility in October 2019. During an observation on 12/13/22 at 8:28 A.M., the surveyor observed Resident #78 in his/her room. When the surveyor asked if she could enter the room, the Resident indicated the surveyor should come closer as he/she had a hard time hearing. The Resident said that his/her hearing is poor on his/her left side and when asked, indicated that there had not been a recent audiological (hearing) exam. During an observation and interview on 12/15/22 at 8:33 A.M., Resident #78 said he/she had a hard time hearing, had hearing aids but gave them back to the nurses because they never…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-12-19 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, policy review, and interviews, the facility and its staff failed to maintain an environment that was free from accident hazards by leaving medications at the Residents bedside, for three Residents (#8, #104 and #78), out of a sample of 27 residents. Findings include: Review of the facility policy titled Medication Storage in the Facility, dated 6/1/10, indicated the following: -Only licensed nurses, pharmacy personnel and those lawfully authorized to administer medications (such as medication aides) are allowed to access medications. Medication rooms, carts and medication supplies are locked or attended by persons with authorized access. -Except for those requiring refrigeration, medications intended for internal use are stored in a medication cart or other designated area. 1. Resident #8 was admitted to the facility in October 2021. Review of the Resident's clinical record indicated no documented evidence that he/she had been assessed to self-administer medication. During an interview on…

    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 · D2022-12-19 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure its staff stored a feeding tube syringe (syringe used to administer a nutrition supplement into a feeding tube) per Physicians' orders and failed to store and/or dispose of unused nutrition supplement per manufacturers guidelines for one Resident (#50), out of 27 sampled residents. Findings Include: Review of the facility policy titled: Enteral Therapy Feeding Administration via Pump, Continuous Pump, Gravity Bag, and via Syringe, revised June 10, 2022, indicated the following: - .ensure feeding administration are administered per Medical Doctor orders . Review of the IsoSource (nutrition supplement used by the Resident) instructions indicated the following: -Once opened, unused portions should be tightly covered, refrigerated, and used within 24 hours. Resident #50 was admitted to the facility in February 2020 with diagnoses including Dementia, Gastrostomy status (the Resident had a Gastrostomy Tube/G-tube a tube that brings nutrients from outside the body directly into the stomach), and dysphagia…

    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 · D2022-12-19 · 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 interview and record review, the facility and its staff failed to ensure the attending Physician reviewed recommendations from the Behavioral Health care team to aid in treating increased anxiety and depression for one Resident's (#107), out of 27 sampled residents. Findings include: Resident #107 was admitted to the facility in October 2021 with diagnoses including Anxiety Disorder and Depressive Disorder. During an interview on 12/13/22 at 9:16 A.M., the Resident expressed feeling down and having a bout of seasonal depression, he/she further could not remember when he/she last saw Behavioral Health services, and said he/she thought he/she would like to talk to someone more about how he/she was feeling. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident scored a 14 out of 15 on the Brief Interview of Mental Status (BIMS) indicating the Resident was cognitively intact. Further review of the MDS Assessment indicated a Patient Health Questionnaire-9 (PHQ9)…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-12-19 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure its staff had the Physician review and respond to monthly medication regimen reviews (MRRs) for two Residents (#36 and #89), out of 27 sampled residents. Findings include: Review of the facility policy titled: Drug Regimen Review/Medication Regime Review, revised 10/6/22, indicated the following: -Any non-urgent recommendation(s)/irregularities must be addressed within 30 days of the consultant Pharmacist monthly visit. 1. Resident #36 was admitted to the facility in May 2014. Review of the MRR dated 4/22/22 indicated no documentation that the Physician had reviewed and responded to the MRR. During an interview on 12/19/22 at 11:08 A.M., Unit Manager (UM) #1 said the MRR from 4/22/22 did not appear to have been reviewed and responded to by the Physician, as required. 2. For Resident #89, the facility failed to ensure that pharmacy recommendations were reviewed, completed and filed in the Resident record. Resident #89 was admitted to the facility in May 2022. Review of the Resident's clinical record indicated that…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-12-19 · tag F0791 — failed to provide routine dental services — isolated
    Provide or obtain dental services for each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that its staff arranged for routine dental care for one Resident (#49), out of 27 sampled residents. Findings include: Resident #49 was admitted to the facility in November 2020. During an interview on 12/13/22 at 10:07 A.M., Resident #49 told the surveyor he/she had some missing teeth and wanted to see the dentist. He/she was unable to say when he/she had last seen the dentist. Review of the Resident's most recent Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident had scored a 13 out of 15 on the Brief Interview of Mental Status (BIMS), indicating he/she was cognitively intact. Further review of the MDS assessment indicated the resident had obvious or likely cavities and/or broken natural teeth. Review of the HealthDrive Dental Group (company that provided dental services to the facility) note dated 4/22/21, indicated a recommendation for an Annual Exam. Further review of the Resident's medical record provided no evidence…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-12-19 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure its staff maintained complete and accurate medical records for two Residents (#100 and #36) of 27 sampled residents. Specifically, the facility failed to ensure that its staff: 1. provided complete and accurate documentation relative to transfer/discharge/bed hold rights for Resident #100, and 2. that a) meal intakes and b) pharmacy consultation documentation were accurate for Resident #36. Findings include: 1. For Resident #100 the facility failed to ensure documentation relative to transfer/discharge/bed hold rights was complete and accurate. Resident #100 was admitted to the facility in November 2021. Review of the Resident's medical record included INTERACT SBAR Communication Forms (INTERACT- an acronym for Interventions to Reduce Acute Care Transfers, SBAR- an acronym for Situation, Background, Assessment, Recommendation, a tool used to communicate pertinent patient information between members of the health care team about a patient's condition) indicating the Resident was sent to the hospital on the following…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-12-19 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to ensure that its staff maintained a hygienic environment and performed hand hygiene at recommended intervals during wound care for one Resident (#103), out of 27 sampled residents. Specifically, the facility staff failed to create an aseptic (free from contamination) work area to place wound care supplies and perform hand hygiene between the removal of gloves after removal of old dressings and donning (putting on) new gloves for placement of new dressings during wound care. Findings include: Review of the facility policy titled Aseptic Dressing Change and Wound Measurement, effective date June 2010, indicated: -that the facility will adhere to the Nursing Standard of Practice, Centers for Disease Control and Infection Control Standards and provide a safe, hygienic environment for residents who need dressing application -a work area will be cleaned of personal items -the work area will be cleaned with facility approved wipes -a drape will be set up if no wrapping exists to provide a barrier -once old dressings are removed 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • No harm found · Bcited before2025-07-22 · tag F0640 — pattern
    Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, and interview, the facility failed to ensure the timely completion and transmission of the Minimum Data Set (MDS) Assessments as required for four Residents (#29, #135, #141, #95), out of a total sample of 26 residents. Specifically, the facility failed to ensure that the components of the MDS Assessments were completed and electronically transmitted within the required timeframes when: 1. For Resident #29, the Comprehensive MDS Assessment was transmitted 141 days after the completion of the MDS Assessment. 2. For Resident # 135, the Entry Tracking MDS Assessment was transmitted 140 days after the completion of the MDS Assessment. 3. For Resident # 141, the Discharge Tracking MDS Assessment was completed 19 days after the ARD (Assessment Reference Date). 4. For Resident #95, the Entry Tracking MDS Assessment was completed 27 days after the ARD.Findings include: Review of the Center for Medicare & Medicaid Services Resident Assessment Instrument (RAI) Version 1.19.1 dated October 2024, included the following: -ARD refers to the specific endpoint for the…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • No harm found · Bcited before2022-12-19 · tag F0640 — pattern
    Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to ensure that its staff transmitted a Minimum Data Set (MDS) assessment within the required 14 days of the MDS Assessment completion for one Resident (#7), out of three sampled residents. Findings include: Resident #7 was admitted to the facility in July 2017. Review of the Resident's MDS assessment indicated a required MDS Assessment was completed by the facility on 10/20/22. During an interview on 12/14/22 at 4:59 P.M., the Clinical Reimbursement Coordinator (CRC) said the MDS Assessment in question was completed by the facility accordingly but had not been transmitted within 14 days of completion, as required.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to INTEGRITUS HEALTHCARE — 14 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 →

RatingThis homeChain avg
Overall 4 of 52.8+1.2 vs chain
Health inspection 4 of 52.9+1.1 vs chain
Staffing 4 of 53.4+0.6 vs chain
Quality measures 3 of 52.7+0.3 vs chain
The other 13 homes this chain runs (chain average 2.8★, per CMS)

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

Owner / managerTypeRoleShareSince
FAIRVIEW EXTENDED CARE SERVICES INCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF100%since 02/01/2022
INTEGRITUS HEALTHCARE INCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST; 5% OR GREATER SECURITY INTEREST100%since 02/01/2022
JONES, WILLIAMIndividualCORPORATE DIRECTOR; CORPORATE OFFICER; ADP OF THE SNFsince 02/01/1993
GINGRAS, MARCIE JOIndividualCORPORATE OFFICER; ADP OF THE SNFsince 02/01/2022
INTEGRITUS HEALTHCARE MANAGEMENT SERVICES INCOrganizationOPERATIONAL/MANAGERIAL CONTROL; TRUSTEE OF THE SNF; ADP OF THE SNFsince 02/01/2022
LEBEAU, ASHLEYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/01/2024
ELDER, ANN MARIAIndividualADP OF THE SNFsince 02/01/2022

CMS files one row per role, so the 16 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted.

3 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.

$16.9M
Net patient revenuemost recent cost report
-7.0%
Operating marginrevenue minus expenses
$1.0M
Related-party expense6% of expenses
Who pays — share of resident-days
Medicaid 64%Medicare 14%Other / private 22%

This home reported $1.0M paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

Cost & finances

$392per resident / day
operating cost
$11,904per month
≈ monthly operating cost
$366per day
avg. revenue, all payers

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

What families pay in MA

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 225331. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-07-22, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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