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Kimwell Nursing And Rehabilitation

495 New Boston Road, Fall River, MA 02720 · For profit - Limited Liability company · 124 certified beds · (508) 679-0106 Medicare & Medicaid certified

Call the home — (508) 679-0106 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
1 actual-harm citation$8,278 in federal fines
Insights

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

Worth asking about
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $8,278 in federal fines (most recent 2025-10-07)
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (2/5)
  • its facility-reported quality-measure rating is low (1/5)

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

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

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 1 of 5

Location & what’s nearby

Urgent care / clinic
1030 President Ave · (508) 676-3411 · Call to confirm hours
Pharmacy
187 New Boston Rd · (508) 672-2472 · Call to confirm hours
Grocery
18 Pear St · (410) 430-9264 · Call to confirm hours
Park
Robeson Street & President Ave · Typically dawn to dusk
Place of worship
709 Hanover St · (508) 679-6732

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 1 of 5
Long-stay residentspeople who live here 1 of 5
Short-stay residentsrehab / post-hospital 2 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 fell from 2 to 1 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 rating1★
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 increased25.0%16.4%15.4%worse
Long-stay residents who lose too much weight5.3%5.1%5.4%typical
Long-stay residents with a catheter left in their bladder0.9%0.8%0.9%typical
Long-stay residents with a urinary tract infection1.8%1.8%2.0%typical
Long-stay residents with depressive symptoms6.5%15.5%6.5%typical
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury6.1%3.4%3.3%worse
Long-stay residents whose ability to walk worsened31.2%15.4%16.1%worse
Long-stay residents on antianxiety or hypnotic medication27.1%19.5%18.9%worse
Long-stay residents given the seasonal flu vaccine84.4%94.8%95.3%worse
Long-stay residents with pressure ulcers4.9%4.2%4.7%typical
Long-stay residents with worsening bladder/bowel control30.5%21.2%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table11.1%21.4%17.1%better
Short-stay residents who newly got an antipsychotic medication1.1%1.4%1.4%better
Short-stay residents given the seasonal flu vaccine55.0%77.7%79.4%worse
Short-stay residents rehospitalized after admission33.1%25.7%22.6%worse
Short-stay residents with an outpatient ER visit16.6%11.9%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.571.881.67worse
Long-stay outpatient ER visits per 1,000 resident days3.191.501.80worse

§ 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.

60.3% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 156 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

60.3%U.S. median 51.5%
Got home and stayed home
9.6%U.S. median 10.7%
Went back to hospital
36.6%U.S. median 56.6%
Met the expected recovery
0.26U.S. median 0.31
Therapy hours / resident / day
0.09hours / resident / day
Physical therapy
0.13hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 36.6% 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 82 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 0.26 therapist hours per resident per day in 2026Q1 — more than 37% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 14% 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 SNF60.3%CMS range 53.9–67.951.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.6%CMS range 6.7–12.610.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge36.6%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 discharge35.4%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 discharge35.4%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%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 discharge97.4%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 stay1.6%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 worsened3.9%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.5%CMS range 4.0–10.97.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.911.02Oct 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

0.52
RN hours/ resident / day
1.05
LPN hours/ resident / day
2.01
Aide hours/ resident / day
3.58
Total nurse hours/ resident / day
0.41
RN hoursweekends
40.0%
Total nursing turnover
50.0%
RN turnover

How full it usually is: this home is certified for 124 beds and averages 105.8 residents a day — about 85% occupied, or roughly 18 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 3.58 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.52 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.01 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 3.13 hrs/resident/day on weekends vs 3.76 on weekdays — 17% thinner on weekends. RN hours go from 0.56 to 0.41 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 40% 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

7
deficiencies at the latest standard inspection (2026-03-16)
8
at the previous standard inspection (2024-12-16)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

24 citations, most serious first. The 11 most serious are shown; the remaining 13 are one tap away and print in full.

  • Actual harm · Gcited before2025-10-07 · 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 records reviewed and interviews, for one of three sampled residents (Resident #1), who became unsteady during a transfer and was lowered to the floor by staff, the Facility failed to ensure staff provided quality of care consistent with professional standards of practice, when on 08/30/25, after Resident #1 was lowered to the floor, two Certified Nurse Aides (CNAs) transferred him/her up off the floor without informing and having the nurse assess him/her first for the potential for physical injury, Resident #1 exhibited a sudden change in his/her condition, with signs and symptoms of severe pain, was transferred to the Hospital Emergency Department (ED) for evaluation and was diagnosed with a fracture of his/her left hip.Findings include:Review of the Facility's Policy, titled Falls and Fall Risk, Managing, dated as revised March 2018 indicated the following:-a fall is defined as: unintentionally coming to rest on the ground, floor or other lower level; an episode where a resident lost his/her balance…

    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 · E2026-03-16 · 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 observations and interviews, the facility failed to ensure residents had a homelike environment on three of three units. Specifically, the facility failed to: 1. Repair water damaged ceiling tiles on the K3 unit; 2. Ensure Resident #18 had a bedroom with walls, blinds, and durable medical condition in good repair; and 3. Ensure residents' bedrooms were homelike and free from holes and damaged window treatments on the K1 and K2 units.Findings include:Review of the facility's policy titled Homelike Environment, dated 2001, indicated but was not limited to the following:-the facility staff and management maximize to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These include a clean, sanitary, and orderly environment.-the maintenance director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner.During an interview on 3/11/26…

    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 · E2026-03-16 · 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

    Based on interview and document review, the facility failed to implement a comprehensive infection control program to include timely surveillance data and a comprehensive analysis which identified interventions when patterns and trends were identified. Specifically, the facility failed to ensure timely and accurate surveillance data for all infection types to identify a pattern of E-Coli Urinary Tract Infections (UTI) (bacterial infection, caused by E-Coli bacteria, typically originating from the gut, entering the urinary tract, and causing inflammation, often due to improper wiping/perineal care) and implement interventions to decrease the risk of residents developing E-Coli UTIs. Findings include:Review of the facility's policy titled Surveillance for Infections, dated as last revised September 2017, indicated but was not limited to the following:-The Infection Preventionist (IP) will conduct ongoing surveillance for healthcare associated infections (HAIs) and other epidemiologically significant infections that have substantial impact on potential resident outcomes and that may…

    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 · E2026-03-16 · tag F0881 — failed to use antibiotics responsibly — pattern
    Implement a program that monitors antibiotic use.
    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 document review, the facility failed to implement an antibiotic stewardship program which included a system to monitor antibiotic use, including prophylactic antibiotic use, to ensure appropriate antibiotics were utilized to prevent antibiotic resistance. Specifically, the facility failed:1. For Resident #56, to document the rationale for antibiotic treatment of an infection not meeting the criteria of an infection;2. For Resident #2, to ensure he/she was prescribed an antibiotic susceptible to the organism growth and to document rationale for antibiotic treatment of an infection not meeting the criteria of an infection;3. For Resident #35, to ensure he/she was prescribed an antibiotic susceptible to the organism growth and not treated with a prophylactic antibiotic concurrently and to document rationale for antibiotic treatment of an infection not meeting the criteria of an infection;4. For Resident #21, to document the rationale for antibiotic treatment from a Hospice recommendation 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-03-16 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review, and interviews, the facility failed to ensure activities of daily living (ADL) care was provided to maintain good personal hygiene for one Resident (#35), in a total sample of 21 residents. Specifically, the facility failed to ensure showers were offered and provided per his/her shower schedule. Findings include: Review of the facility's policy titled Activities of Daily Living (ADL) Support, dated as last revised March 2018, indicated but was not limited to the following:-Residents who are unable to carry out ADLs independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene.-Refusal of care and information are documented in the resident's clinical record.-Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with consent of the resident and in accordance with the plan of care, including support and assistance with hygiene (bathing, dressing, grooming, and oral care). Resident #35 was admitted to the facility in June 2025 with…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-03-16 · 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 record review and interview, the facility failed to ensure a resident at with an alteration in skin integrity related to a wound, specifically chronic venous ulcers, received necessary treatment and services to promote healing for one Resident (#74), out of a total sample of 21 residents. Specifically, the facility failed to transcribe and implement wound care per the Hospital Discharge Summary for seven days. Findings include: Review of the facility's policy titled Medication Orders, dated as last revised November 2014, indicated but was not limited to the following:-A current list of orders must be maintained in the clinical record of each resident.-Treatment Orders: When recording treatment orders, specify the treatment, frequency, and duration of the treatment. Review of the facility's policy titled Charting and Documentation, dated as last revised July 2017, indicated but was not limited to the following:-All services provided to the resident, progress toward the care planned goals, or any changes…

    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 before2026-03-16 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and document review, the facility failed to ensure all drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles. Specifically, the facility failed to:1. Properly monitor medication refrigeration temperatures in one of three medication storage rooms reviewed to ensure the safety and integrity of vaccines stored; and2. Provide a permanently affixed compartment and separate from all other medications for the storage of schedule IV (low potential for misuse and dependence) controlled substance in two of three medication room refrigerators reviewed. Findings include:Review of the facility's policy titled Medication Storage in the Facility, dated November 2021, indicated but was not limited to the following:-Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations.-Controlled substances that require refrigeration are stored within a locked box within the refrigerator.-This box must be attached to the inside of the refrigerator.-The facility…

    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 before2026-03-16 · 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 record review and interview, the facility failed to ensure a complete and accurate medical record was maintained for two Residents (#74 and #35), out of a total sample of 21 residents. Specifically, the facility failed to ensure:1. For Resident #74, the Medical Orders for Life Saving Treatment (MOLST) in the Electronic Medical Record (EMR) matched the active Do Not Resuscitate, Intubate, or Ventilate physician's order; and2. For Resident #35, with a diagnosis of dysphagia (difficulty swallowing), he/she did not have conflicting therapeutic diet orders of Regular texture versus Mechanical Soft/Ground texture in the active medical record. Findings include: 1. Review of the facility's policy titled Electronic Medical Record (EMR), dated 12/19/22, indicated but was not limited to the following:-The EMR's quality and integrity shall be maintained by adhering to identified standards in entering complete, concise, accurate and updated information that produces clear and useful medical record.-Staff making entry into the EMR are responsible for checking for contradictory…

    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 · Ecited before2024-12-16 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and maintenance record review, the facility failed to ensure the environment was free from accident hazards for two out of three units in the facility. Specifically, the facility failed to ensure water temperatures were maintained at safe and comfortable levels in resident bathrooms and shower rooms. Findings include: Review of the facility's policy titled Water Temperatures, Safety of, dated 2001, included but was not limited to the following: -Policy Statement: Tap water in the facility shall be kept within a temperature range to prevent scalding of residents. -Policy Interpretation and Implementation: 1. Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than 115 degrees Fahrenheit, or the maximum allowable temperature per state regulation. 2. Maintenance staff is responsible for checking thermostats and temperature controls in the facility and recording these checks in a maintenance log. 3.…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-12-16 · tag F0883 — failed to offer flu and pneumonia vaccines — pattern
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to provide the Pneumococcal and Influenza immunizations as requested/consented for three Residents (#94, #90 and #11), out of a total sample of five residents. Findings include: Review of the facility's policy titled Influenza Vaccine, dated as revised in September 2024, indicated the following: -between as early as August 1st through March 31st of the following year, the influenza vaccine shall be offered to residents, unless the vaccine is medically contraindicated, or the resident has already been immunized -residents admitted between August 1st (or when the vaccine is available) and March 31st of the following year shall be offered the vaccine within five (5) working days of the resident's admission to the facility Review of the facility's policy titled Pneumococcal Vaccine, dated as revised in March 2023, indicated the following: -all residents are offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections -prior to or upon admission, residents are assessed for eligibility to receive 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-16 · tag F0551 — isolated
    Give the resident's representative the ability to exercise the resident's rights.
    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 Court Order of Appointment of Guardian for an Incapacitated Person was followed for one Resident (#77), in a sample of 20 residents. Specifically, the facility failed to ensure for Resident #77 that the Massachusetts Medical Orders for Life Sustaining Treatment (MOLST) form, which was signed by the previous Health Care Proxy (HCP), was voided with the appointment of a court designated guardian (a professional guardian who is unrelated to the incapacitated adult) who revoked the previous HCP and did not have authority to make advanced directive treatment decisions. Findings include: Review of the facility's policy titled Resident Representative, dated as last revised February 2021, indicated the following: -If the resident is determined to be incompetent under the laws of the state by a court of competent jurisdiction, the rights of the resident devolve to and are exercised by the resident representative appointed to act on the resident's behalf. -The court-appointed resident representative will exercise 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
Show the remaining 13 citations
  • Potential for harm · D2024-12-16 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure that a required Preadmission Screening and Resident Review (PASARR) was completed for one Resident (#2) with a diagnosed mental condition, out of a total sample of 20 residents. Findings include: Review of the facility's policy titled Behavioral Assessment, Intervention and Monitoring, revised March 2019, indicated but was not limited to the following: 1. As part of the initial assessment, the nursing staff and attending physician will identify individuals with a history of impaired cognition, altered behavior, substance use disorder, or mental disorder. a. All residents will receive a Level 1 PASARR screen prior to admission. Resident #2 was admitted to the facility in November 2024 with diagnoses including: bipolar disorder, anxiety, depression, and schizophrenia. Review of the Hospital Discharge summary, dated [DATE], indicated the Resident's past medical history included schizoaffective disorder, schizophrenia, and bipolar disorder. Review…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-16 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interview, and record review, the facility failed to follow professional standards of practice to administer oxygen therapy as ordered for one Resident (#68), in a total sample of 20 residents. Specifically, the facility administered Oxygen at 5 liters (L) per minute for Resident #68 with an order for Oxygen at 2L. Findings include: Resident #68 was admitted to the facility in May 2024 with a diagnosis of chronic obstructive pulmonary disease (COPD- a lung disease that blocks airflow and makes it difficult to breathe) and had an active diagnosis of pneumonia during the survey period. Review of the Physician's Orders included an order to administer Oxygen at 2L via nasal cannula effective 11/10/24. Review of the Nurse Practitioner (NP) Progress Note, dated 11/11/24, indicated Resident #68 had COPD and to continue Oxygen at 2 to 3L. Review of the NP Progress Note, dated 11/14/24, indicated Resident #68 had COPD and to continue Oxygen at 2 to 3L. Review of the nursing progress notes indicated the following: -12/6/24: Resident's oxygen saturation increased from…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-16 · tag F0727 — failed to provide required RN coverage — isolated
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to utilize the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, as required placing all residents at risk for not having their clinical needs met either directly by the RN or indirectly by the Licensed Practical Nurse (LPN) or Certified Nurse Aides (CNA) that the RN was responsible for overseeing with provision of resident care. Specifically, the facility failed to provide the services of a RN for at least eight consecutive hours a day, seven days a week when no staffing waivers were in place on four days for the period of 7/1/24 to 9/30/24. Findings include: 1. Review of the Payroll Based Journal (PBJ) Staffing Data Report, dated Quarter 4: 2024 (July 1 - September 30), indicated the following: -One Star Staffing Rating Triggered = Star Staffing Rating Equals 1 -No RN Hours Triggered = Four or More Days Within the Quarter with no RN Hours Review of the as worked nursing schedule provided by the facility failed to indicate that a RN worked for eight hours in the facility 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-16 · tag F0745 — failed to provide medically-related social services — isolated
    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

    Based on record review and interview, the facility failed to provide medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one Resident (#77), in a total sample of 20 residents. Specifically, the facility failed to obtain a social history for Resident #77 which included complicated family relations, possible lack of care in the community from a family member, and a history of substance use disorder. Findings include: Review of the facility's policy titled Social Services, dated as revised in September 2021, indicated but was not limited to the following: -the facility staff are able to identify and address factors that have potentially negative effect on psychosocial functioning of a resident; examples include: situations that impede the resident's dignity and sense of control, lack of family/community support system, substance abuse; -the social worker/social service staff are responsible for: identifying and seeking ways to support residents needs through the assessment and care planning process Review 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-29 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had an activated Health Care Proxy (HCP), the Facility failed to ensure nursing promptly notified his/her Health Care Agent (HCA), when on 09/05/24, Resident #1 was found sitting on the floor against the bed after an unwitnessed fall. Findings include: Review of the Facility's Policy, titled Change in a Resident's Condition or Status, dated as revised February 2022, indicated the following: -our facility promptly notifies the resident's attending physician, the resident representative of change in the resident's medical/mental condition and/or status; -a nurse will notify the resident's representative when the resident is involved in any accident or incident that results in an injury including injuries of unknown source; -the nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. Review of the Facility Policy, titled Accidents and Incidents - Investigating and Reporting, dated as revised July 2022, indicated…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-10-29 · 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 records reviewed and interviews for one of three sampled residents (Resident #1), who was found sitting on the floor against his/her bed after an unwitnessed fall, the Facility failed to ensure they maintained complete and accurate medical/clinical records, when there was no nursing documentation in the Medical Record related to Resident #1's unwitnessed fall. Finding Include: Review of the Facility Policy titled, Charting and Documentation, dated as revised July 2017, indicated that all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition should be documented in the resident's medical record. The Policy further indicated that the following information is to be documented in the resident medical record: -objective observations; -treatments or services performed; -changes in the resident's condition; -events, incidents or accidents involving the resident; Review of the Facility Policy, titled Accidents and Incidents - Investigating and Reporting, dated as revised July…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-08-18 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and staff interview, the facility failed to ensure that pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) met the needs of each resident. Specifically, the facility failed to: a. Ensure medication kits were replaced by the pharmacy after being opened with medications removed, and not accounted for; b. Ensure proper handling of extra unused medications; and c. Ensure prescriptions for controlled substances were logged into the narcotic register. Findings include: On 8/17/23 at 1:52 P.M., the surveyor, with Nurse #6 present, inspected the K-1 medication storage room, and identified the following issue: a. An emergency Super Kit of medications was lying directly on the floor in the K-1 medication storage room. The 2nd and 3rd drawers of the emergency kit were opened indicating medications had been removed for resident use. During an interview at this time, Nurse #6 said that whenever the emergency kit is opened, the nurse must fill out a form that indicates what…

    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 · Ecited before2023-08-18 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and staff interview, the facility failed to ensure that all medications and biologicals were labeled in accordance with currently accepted principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable. Specifically, the facility failed to label medication stored in the medication storage room. Findings include: On 8/17/23 at 1:52 P.M., the surveyor inspected the K-1 medication room and observed the following: A plastic bag containing multiple glass vials of the antibiotics Ertapenem and Cefepime (powder requiring reconstitution) were in a drawer to the right of, and below, the shelf of over the counter (OTC) medications. Neither the plastic bag, nor the vials of antibiotic powder, were labeled with a resident name, the medication, or any other information typically contained on medication dispensed to the facility from the pharmacy. During an interview on 8/17/23 at 1:55 P.M., Nurse #6 said that the nurses keep the extra antibiotics that go unused by residents and use them while they wait for the pharmacy…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-08-18 · tag F0943 — pattern
    Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and review of training documentation, the facility failed to ensure 5 out of 5 sampled employees were provided training on prevention of abuse, neglect, exploitation, misappropriation of resident property, and dementia management. Findings include: Review of the Staff Training/education and competency section of the Facility Assessment, dated 8/7/23) indicated staff were to have the following education upon hire and annually: -abuse, neglect, exploitation -care/management for persons with dementia and resident abuse prevention -caring for residents with dementia, Alzheimer's and cognitive impairments (8 hours training upon hire and 4 hours upon annual recertification) 1. Certified Nursing Assistant (CNA) #6: Review of the education file failed to include abuse, neglect, exploitation, care/management for persons with dementia and resident abuse prevention, and caring for residents with dementia, Alzheimer's and cognitive impairments (8 hours training upon hire and 4 hours upon annual recertification). 2. Nurse #7: Review of the education file failed to include…

    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 · D2023-08-18 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to meet professional standards of care for two Residents (#36, #22), out of a total sample of 24 residents. Specifically, the facility failed: 1. For Resident #36, to ensure three of the physician prescribed morning medications were not continuously scheduled to conflict with the Resident's scheduled dialysis treatment, when the Resident was known to be out of the facility; and 2. For Resident #22, to ensure the nurse administered medication following the facility's policy. Findings include: Review of the facility's policy titled Administering Medications, revised April 2022, indicated but was not limited to the following: -Medication administration times are determined by resident's need and benefit, not staff convenience. Factors that are considered include: a. Enhancing optimal therapeutic effect of medications; b. Preventing potential medication or food interactions; and c. Honoring resident choices and preferences, consistent with his or her care plan. -New personnel authorized to administer medications are…

    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 before2023-08-18 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure Activity of Daily Living (ADL) assistance was provided to one dependent Resident (#14), out of a total sample of 23 residents. Specifically, the facility failed to provide assistance with grooming and supervision while eating. Findings include: Review of the facility's policy titled Activities of Daily Living (ADL), Supporting, last revised March 2018, included but was not limited to: -Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan or care, including appropriate support and assistance with hygiene (bathing, dressing, grooming, and oral care) and dining (meals and snacks). Review of the facility's policy titled Fingernails, Care Of, last revised February 2018, included but was not limited to: -The purpose of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. -Nail care includes daily cleaning and regular trimming. Resident #14 was…

    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 before2023-08-18 · 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

    Based on observation, interview, and policy review, the facility failed to ensure there was adequate supervision and assistance during smoking sessions for two Residents (#1 and #32), and the resident designated smoking area complied with the Centers for Medicare and Medicaid Services (CMS) guidance for a safe smoking area. Specifically, the facility failed to: 1. Provide adequate supervision for Resident #1 and #32 when attempting to ignite and extinguish their cigarettes; and 2. Provide all smoking residents with a dignified smoking experience, including protection from the elements and have readily available safety equipment in the designated smoking area. Findings include: Review of the CMS circular letter, dated November 10, 2011, titled Smoking Safety in Long Term Care Facilities indicated but was not limited to the following: -The facility is obligated to ensure the safety of designated smoking areas which includes protection of residents from weather conditions and non-smoking residents from second hand smoke. -The facility is also required to provide portable fire…

    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
  • No harm found · B2024-12-16 · tag F0582 — pattern
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on the Beneficiary Protection Notification Review, the facility failed to issue the Notice of Medicare Non-Coverage (NOMNC) to two of three sampled Residents (#207 and #208) and failed to issue the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) to two of three sampled Residents (#208 and #86). Findings include: The NOMNC, Form CMS-10123, is given by the facility to all Medicare beneficiaries at least two days before the end of a Medicare covered Part A stay or when all of Part B therapies are ending. The NOMNC informs the beneficiaries of the right to an expedited review by a Quality Improvement Organization. The SNF ABN, CMS-10055, is only issued if the beneficiary intends to continue services and the SNF believes the services may not be covered under Medicare. It is the facility's responsibility to inform the beneficiary about potential non-coverage and the option to continue services with the beneficiary accepting financial liability for those services. Review of the Beneficiary Protection Notification Review indicated Resident #208 was receiving Medicare…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

$8,278 in federal fines across 1 penalty.

  • $8,278 — penalty dated 2025-10-07

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 BEST CARE SERVICES — 10 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 1 of 52.3-1.3 vs chain
Health inspection 2 of 52.4-0.4 vs chain
Staffing 2 of 53.0-1.0 vs chain
Quality measures 1 of 52.4-1.4 vs chain
The other 9 homes this chain runs (chain average 2.3★, 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 / managerTypeRoleSince
CHAPLER, YAAKOVIndividualINDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROLsince 08/01/2022
STEINBERG, MOSHEIndividualINDIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROLsince 02/01/2024
BONADIO & CO LLPOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/26/2025
RELIANT PRO REHAB, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2023
TWOMAGNETS LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/26/2025
AL-MADI, SAMIIndividualOPERATIONAL/MANAGERIAL CONTROLsince 08/01/2022
HINEDI, TAMIMIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/01/2022
MCNAUGHTON, JAMESIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/01/2022

CMS files one row per role, so the 16 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

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.

$13.6M
Net patient revenuemost recent cost report
-2.5%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 55%Medicare 10%Other / private 35%

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

$353per resident / day
operating cost
$10,721per month
≈ monthly operating cost
$344per 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 225194. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-16, 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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