Fall River Healthcare

Location & what’s nearby

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

Quality measures — how residents actually fare

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

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

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

53.4% 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 110 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 22.8% 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 57 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: not reported. This home filed no therapist hours at all in its payroll data for this quarter. That is a gap in what it reported, and we do not read it as an absence of therapy — the homes that file nothing here include ones that discharged hundreds of Medicare rehab patients in the very same period, who plainly received therapy from someone. Because we cannot tell a home that under-reports from one that genuinely provides little, this home is left out of the comparison above rather than scored at zero. Ask it directly how many therapist hours a rehab resident gets, and on which days.

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

Staffing

How full it usually is: this home is certified for 176 beds and averages 157.3 residents a day — about 89% occupied, or roughly 19 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.42 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.51 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.08 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.11 hrs/resident/day on weekends vs 3.54 on weekdays — 12% thinner on weekends. RN hours go from 0.57 to 0.38 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 50% is about the same as the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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

Inspection trend

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.

54 citations, most serious first. The 20 most serious are shown; the remaining 34 are one tap away and print in full.

• Actual harm · Gcited before2025-03-31 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was alert and oriented, frequently incontinent and dependent on staff to meet his/her care needs, the Facility failed to ensure he/she was free from verbal abuse by staff members when, during the night shift (11:00 P.M. to 7:00 A.M.) on 03/09/25, Certified Nurse Aide (CNA) #1 and CNA #2 yelled at, made insulting and ridiculing comments to Resident #1, who said he/she was upset, humiliated and cried after the incident. Findings include: Review of the Facility Policy titled Abuse Investigation and Reporting, last revised February 2024, indicated that each resident has the right to be free from verbal, sexual, physical and mental abuse. Review of the Facility Policy titled Resident Rights, last revised January 2024, indicated employees shall treat all residents with kindness, respect and dignity. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 3/12/25, indicated that Resident #1 reported that Certified Nurse Aide (CNA) #1 and CNA #2…

  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 · Past Non-Compliance
• Actual harm · Gcited before2025-02-27 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on records reviewed and interviews, for three of three sampled residents (Resident #1, #2, and #3), who were dependent on staff to meet their care needs, the Facility failed to ensure they were free from verbal and mental abuse by a staff member when, during the night shift (11:00 P.M. to 7:00 A.M.) on 01/29/25 into 01/30/25, Certified Nurse Aide (CNA) #1 was witnessed by two staff members as she yelled at, swore at, and berated Residents #1, #2, and #3, who became embarrassed, upset, and cried. Resident #1 also reported to staff that he/she was afraid of CNA #1. Findings include: Review of the Facility's Policy titled, Abuse Investigation and Reporting, dated as revised February 2024, indicated the following: -verbal abuse is defined as any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within hearing distance, to describe residents, regardless of a resident's age, ability to comprehend or mental and/or physical disability, and -staff will maintain a manner of courtesy and respect toward…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-02-27 · tag F0607 — failed to have anti-abuse policies — isolated
  Develop and implement policies and procedures to prevent abuse, neglect, and theft.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on records reviewed and interviews, for three of three sampled residents (Residents #1, #2, and #3), who were dependent on staff to meet their care needs, the Facility failed to ensure staff implemented and followed their Abuse Policy to prevent the potential for further abuse, when on 01/30/25 during the night shift, although Nurse #1 witnessed and was therefore aware [sometime around 12:30 A.M.], that Certified Nurse Aide (CNA) #1 had verbally abused Residents #3, she did not immediately report the abuse to facility management, as required. CNA #1 was not put on administrative leave after the first incident that night and worked the entire night shift on the same unit providing care and having access to other residents. As a result, CNA #1 verbally and mentally abused Resident #1 and #2, later that same night. Nurse #1 waited and reported all three incidents of abuse to the Director or Nurses (DON) at the end of the night shift, sometime around 7:00 A.M., more than six hours after the first incident occurred. Findings include: Review of the Facility's Policy, titled, Abuse…

  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
• Actual harm · Hcited before2025-02-05 · tag F0600 — failed to protect residents from abuse and neglect — pattern
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, interviews, and record review, the facility failed to protect Resident #141's right to be free from verbal abuse by Resident #105. The total sample was 33 residents. Specifically, after the facility staff witnessed Resident #105 use racial slurs to verbally abuse Resident #141, the facility failed to develop and implement effective interventions to prevent further resident-to-resident verbal abuse, resulting in the verbal abuse continuing for three weeks and Resident #141 crying and verbalizing wanting to decrease their socialization. Findings include: Review of the facility's policy titled Abuse Investigating and Reporting, revised in February 2024, indicated the following: -Verbal abuse is defined as any use of oral, written, or gestured language that willfully include disparaging and derogatory terms to residents or their families, or within their hearing distance, to describe residents, regardless of a resident's age, ability to comprehend or mental and/or physical disability -alleged violations are reported to the Administrator and to other officials in…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Hcited before2025-02-05 · tag F0607 — failed to have anti-abuse policies — pattern
  Develop and implement policies and procedures to prevent abuse, neglect, and theft.
  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 implement their abuse policy and procedures to prevent further verbal abuse for one Resident (#141), in a total sample of 33 residents. Specifically, after the facility staff witnessed Resident #105 use racial slurs to verbally abuse Resident #141, the facility failed to implement their policy to initiate effective interventions to prevent further resident-to-resident verbal abuse, resulting in the verbal abuse continuing for three weeks and Resident #141 crying and verbalizing wanting to decrease their socialization. Findings include: Review of the facility's policy titled Abuse Investigating and Reporting, revised in February 2024, indicated the following: -Verbal abuse is defined as any use of oral, written, or gestured language that willfully include disparaging and derogatory terms to residents or their families, or within their hearing distance, to describe residents, regardless of a resident's age, ability to comprehend or mental and/or physical disability -alleged violations are reported to the…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · H2025-02-05 · tag F0610 — failed to investigate and act on abuse reports — pattern
  Respond appropriately to all alleged violations.
  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 implement their policy and procedures to investigate and prevent further verbal abuse for one Resident (#141), in a total sample of 33 residents. Specifically, after the facility staff witnessed Resident #105 use racial slurs to verbally abuse Resident #141, the facility failed to implement their policy to conduct a thorough investigation and initiate effective interventions to prevent further resident-to-resident verbal abuse, resulting in the verbal abuse continuing for three weeks and Resident #141 crying and verbalizing wanting to decrease socialization. Findings include: Review of the facility policy titled Abuse Investigating and Reporting, revised in February 2024 indicated the following: -Verbal abuse is defined as any use of oral, written, or gestured language that willfully include disparaging and derogatory terms to residents or their families, or within their hearing distance, to describe residents, regardless of a resident's age, ability to comprehend or mental and/or physical disability -alleged…

  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
• Actual harm · H2025-02-05 · tag F0740 — failed to provide behavioral / mental-health care — pattern
  Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to provide effective and appropriate treatment and services to attain the highest practicable mental and psychological well-being for one Resident (#105) with anxiety, demonstrated behaviors, and active substance use, out of a total sample of 33 residents. Specifically, the facility failed to develop, implement, and update the plan of care to meet the Resident's behavioral needs, including interventions for verbal abuse to Resident #141, interventions for intermittent explosive disorder, and interventions for active substance use resulting in emergency room visits. Findings include: Review of the facility's policy titled Behavioral Assessment, Intervention and Monitoring, revised in November 2017, indicated but was not limited to the following: -behavioral symptoms will be identified using facility-approved behavioral screening tools and the comprehensive assessment. -the interdisciplinary team will evaluate behavioral symptoms in residents…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · H2025-02-05 · tag F0745 — failed to provide medically-related social services — pattern
  Provide medically-related social services to help each resident achieve the highest possible quality of life.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to provide social services to attain the highest practicable mental and psychological well-being for two Residents (#105 and #141), out of a total sample of 33 residents. Specifically, the facility failed 1. For Resident #105, to assess, develop, implement, and update the plan of care to meet the Resident's behavioral needs, including interventions for verbal abuse to Resident #141, interventions for intermittent explosive disorder and interventions for active substance use resulting in emergency room visits; and 2. For Resident #141, to follow up after being verbally abused by Resident #105 to ensure effective interventions were implemented to prevent additional incidents of verbal abuse resulting in Resident #141 crying and verbalizing wanting to decrease socialization. Findings include: Review of the facility's policy titled Behavioral Assessment, Intervention and Monitoring, revised in November 2017, indicated but was not limited to the…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-02-27 · 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 records reviewed and interviews, for one of three sampled residents (Resident #1), whose Plan of Care indicated that he/she required the physical assistance of two staff members with bed mobility and was assessed by nursing as being at high risk for falls, the Facility failed to ensure nursing staff consistently implemented and followed interventions identified in his/her Plan of Care while meeting his/her care needs. On 01/28/24, Certified Nurse Aide (CNA) #1 provided care to Resident #1 who was in bed, without the assistance of another staff member, Resident #1 rolled and fell out of bed on the opposite side of the bed where CNA #1 was standing, and sustained a laceration to his/her right lower eyelid. Resident #1 was transferred to the Hospital Emergency Department (ED) for evaluation and required five sutures to close the wound to his/her right lower eyelid. Findings include: Review of the Facility's Policy, titled Care Plans, dated as revised January 2024, indicated the following: -a comprehensive,…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-02-27 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was assessed by nursing to be at high risk for falls, and required the physical assistance of two staff members with bed mobility, the Facility failed he/she was provided with the required level of staff assistance in an effort to prevent an accident resulting in an injury. On 01/28/24, Certified Nurse Aide (CNA) #1 provided care to Resident #1, who was in bed, without the assistance of another staff member, Resident #1 rolled and fell out of bed, on the opposite side of the bed where CNA #1 was standing, and sustained a laceration to his/her right lower eyelid. Resident #1 was transferred to the Hospital Emergency Department (ED) for evaluation and required five sutures to close the wound to his/her right lower eyelid. Findings include: Review of the Facility's Policy, titled Assessing Falls and Their Causes, dated as revised January 2018, indicated the following: -review the resident's care plan to assess for any…

  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 · D2026-06-29 · tag F0628 — isolated
  Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who required transfer to the Hospital Emergency Department for an evaluation, the Facility failed ensure they sent a copy of their Notice of Intent to Discharge him/her to a representative of the Office of the Long-Term Care Ombudsman, as required. Findings include: The Facility Transfer or Discharge Notice Policy, last revised 11/2024, indicated that a resident and/or his/her representative, will be given a thirty-day written notice of an impending transfer or discharge from the Facility. The Policy indicated that a copy of the notice would be sent to the Office of the State Long-Term Care Ombudsman. Review of Resident #1's clinical record indicated he/she was admitted to the Facility during July 2025 and his/her diagnoses included multiple sclerosis, major depressive disorder, anxiety disorder and tobacco use. Resident #1's Care Plan related to resident's wish to discharge to the community, dated as initiated 7/16/25, indicated that Resident #1 would communicate an understanding of the…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-06-29 · tag F0760 — failed to prevent significant medication errors — isolated
  Ensure that residents are free from significant medication errors.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records reviewed and interviews for one of three sampled residents (Resident #1), who required an atypical antipsychotic medication for major depressive disorder and anxiety disorder, the Facility failed to ensure he/she was free from a significant medication error, when upon re-admission to the facility following a hospitalization, his/her medication orders were not accurately reconciled by nursing resulting in him/her being administered four extra doses of his/her antipsychotic in error. Findings include: Review of the Reconciliation of Medication on admission Policy, dated 11/20/24, indicated that the purpose of the procedure was to ensure medication safety by accurately accounting for the resident's medications, routes and dosages upon admission or readmission to the facility. The Guidelines for the Policy indicated that medication reconciliation is the process of comparing pre-discharge medications to post-discharge medications by creating an accurate list of both prescription and over the counter…

  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 · D2026-02-09 · tag F0557 — isolated
  Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on records reviewed and interviews, for two of three sampled residents (Residents #2 and #3) who were severely cognitively impaired, the Facility failed to ensure they were treated in a dignified and respectful manner, when in January 2026 they both experienced an incident involving physical contact initiated by Resident #1 (who was also severely cognitively impaired), which was unwanted and without their consent.Findings include:Review of the Facility Policy titled Resident Rights, dated as revised 1/2024, indicated the residents had the right to a dignified existence and to be treated with respect and dignity.Resident #1 was admitted to the Facility in October 2025, diagnoses included psychotic disorder and Alzheimer's Disease.Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 1/23/26, indicated Resident #1's cognitive patterns were severely impaired.Review of Resident #1's Medical Record indicated his/her Health Care Proxy had been activated by the physician on 1/19/26.Resident #2 was admitted to the Facility in December 2022, diagnoses included unspecified…

  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 · E2025-12-22 · tag F0565 — failed to support the resident council — pattern
  Honor the resident's right to organize and participate in resident/family groups in the facility.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on a resident group meeting, staff interviews, and document review, the facility failed to ensure grievances and concerns from the Resident Council regarding long call light wait times were acted upon to resolve the issue.Findings include:Review of the facility's policy titled Resident Council, dated as revised in February 2024, indicated the facility would establish and maintain an active Resident Council with the basic goal of promoting the highest Quality of Life for each resident. The process included Department Heads responding to grievances addressed in the minutes in writing before the next meeting. Review of the Resident Council Minutes, dated 7/16/25, indicated call lights continued to be monitored and when asked the residents responded that they could not get help or care without waiting a long time and call lights were not answered in a timely manner. Review of the Resident Council Minutes, dated 8/13/25, indicated call lights continued to be monitored, and the residents added that on weekends call lights were not answered in a timely manner; the residents requested…

  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 · E2025-12-22 · tag F0567 — failed to protect residents' money held by the home — pattern
  Honor the resident's right to manage his or her financial affairs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on document review and interviews, the facility failed to ensure residents had access to their personal funds. Specifically, the facility failed to make funds available for Resident #10 within three banking days for requests in the amount of $50 or more and failed to make funds available for same day requests for cash amounts less than $50.Findings include:Review of the facility's Resident Handbook, undated, indicated the facility could assist with the management of Personal Funds. The Handbook indicated Deposits into these accounts may be made by mail or in person during normal business office hours. For withdrawals from a resident's personal funds account after the Business Office hours, the resident may contact his/her unit supervisor who will assist the resident with the transaction. Review of the facility's Resident Handbook failed to indicate a process for withdrawals during business office hours, how much personal funds could be withdrawn at a time, or what the business office hours were. During an interview on 12/15/25 at 10:00 A.M., the Ombudsman said there were…

  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 · E2025-12-22 · tag F0692 — failed to prevent malnutrition and dehydration — pattern
  Provide enough food/fluids to maintain a resident's health.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, interview, and record review, the facility failed to evaluate and assess one Resident (#97), out of a total sample of 34 residents after an unplanned 11.29% significant weight loss in six months had been identified. Specifically, the facility failed to assess and evaluate the resident for more than two months after the significant weight loss had been identified. Findings include: Review of the facility's policy titled Weight Measurement, dated as last revised 11/2025, indicated but was not limited to the following:-Weights will be obtained monthly at the beginning of the month.-All residents with significant weight changes will be reweighed to ensure accuracy of the weight. If the reweight indicates significant weight change, the resident and/or representative and interdisciplinary team (IDT) will be notified, and plan of care will be revised as warranted. Resident #97 was admitted to the facility in April 2025 with diagnoses which include abnormal weight loss, muscle wasting and atrophy, and diabetes mellitus. Review of the Minimum Data Set (MDS) Assessment,…

  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 · E2025-12-22 · tag F0759 — failed to keep medication error rate low — pattern
  Ensure medication error rates are not 5 percent or greater.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, interviews, and records reviewed, the facility failed to ensure it was free from a medication error rate of greater than 5% when one of three nurses observed during the medication pass made three errors out of 31 opportunities, resulting in a medication error rate of 9.68%. Those errors impacted two Residents (#77 and #62). Findings include:Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice dated and revised April 11, 2018, indicated but was not limited to the following: Nurses Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescribers.Review of the facility's policy titled Administering Medications, dated as revised September 2024, indicated but was not limited to the following:-Medications are administered in a safe and timely manner, and as prescribed.-Medications are administered in accordance with prescriber orders, including any required time frame.-Medications may be administered one (1) hour before or after the prescribed time, unless…

  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 · E2025-12-22 · tag F0803 — failed to meet residents' dietary needs — pattern
  Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, interviews, and menu review, the facility failed to ensure that menus posted were followed. Findings include:Review of the lunch menu for 12/17/25 indicated the residents should have received chicken cacciatore as a main entree. On 12/17/25 at 11:20 A.M., the surveyor observed the lunch tray line and a test tray was conducted. The surveyor along with a second surveyor observed the chicken cacciatore to be red in color and have no sauce or topping. The chicken had a cumin-like flavor. Review of the chicken cacciatore recipe included, but was not limited to, the following ingredients: yellow onions, green peppers, sliced mushrooms, diced tomatoes with juice, oregano, ground thyme, chicken stock, flour, and water. The recipe instructed to mix water and flour and add to boiling chicken and vegetable mixture, stir until thickened. Review of the lunch menu for 12/18/25 indicated residents should have received Harvard beets as a side dish. On 12/18/25 at 11:30 A.M., the surveyor observed the lunch tray line and a test tray was conducted. The surveyor and a second…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-12-22 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
  Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and test tray results, the facility failed to ensure staff served palatable, attractive, and flavorful food for 2 out of 2 test trays conducted. Findings include:During the initial resident screening on 12/16/25, the residents expressed the following concerns about the food at the facility:-Taste of the food is not good; it's overcooked, dry, mushy vegetables;-Food is awful, does not taste good, no flavor;-Flavor is awful, I usually just ask for a peanut butter and jelly sandwich instead of the food;-Food sucks;-Food is not good, poor quality, odd pairings that don't go together;-Food is terrible;-Food is lousy;-Food is gross. On 12/17/25 at 11:20 A.M., the surveyor conducted Test Tray #1 (regular texture). The meal consisted of chicken cacciatore, penne pasta, cauliflower, chilled baked apples, milk, and juice. APPEARANCE: The chicken cacciatore was a red colored chicken thigh with no sauce; the penne pasta was white; and the cauliflower was white. TEXTURE: The cauliflower was overall mushy and could be easily crushed between the tongue and roof 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.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-12-22 · 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

  Based on record review and interview, the facility failed to ensure a complete and accurate medical record was maintained for five Residents (#97, #106, #17, #46, and #6), out of a total sample of 34 residents. Specifically, the facility failed:1. For Resident #97, to:a) ensure medications and treatments were accurately documented during a leave of absence (LOA), and tob) ensure the percentage of lunch consumed was accurately documented after the meal was provided and consumed on 17 of 31 days reviewed; 2. For Resident #106, to ensure the percentage of lunch consumed was accurately documented after the meal was provided and consumed on 16 of 31 days reviewed; 3. For Residents #17 and #46, to ensure volumes of tube feeding and water flushes being administered to the Residents were accurately documented in the Medication Administration Record (MAR); and4. For Resident #6, to accurately document wound care provided on the TAR per the physician's orders. Findings include:Review of the facility's policy titled Charting and Documentation dated as last revised November 2024 indicated but…

  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

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

Fines & penalties

$385,062 in federal fines across 4 penalties.

• $14,905 — penalty dated 2025-03-31
• $197,905 — penalty dated 2025-02-05
• $157,160 — penalty dated 2024-05-14
• $15,092 — penalty dated 2024-02-27

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

Part of a chain

This home belongs to NEXT STEP 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 →

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

CMS files one row per role, so the 9 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

This home reported $826K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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