Jml Care Center INC
184 Ter Heun Drive, Falmouth, MA 02540 · Non profit - Corporation · 132 certified beds · (508) 457-4621 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing rating is low (1/5)
- 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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 1 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
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 4 to 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 28.8% | 16.4% | 15.4% | worse |
| Long-stay residents who lose too much weight | 10.0% | 5.1% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 1.3% | 0.8% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 5.8% | 1.8% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 0.8% | 15.5% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 4.0% | 3.4% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 21.9% | 15.4% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 11.4% | 19.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 91.1% | 94.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 8.2% | 4.2% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 35.2% | 21.2% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 18.7% | 21.4% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 1.2% | 1.4% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 71.8% | 77.7% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 28.8% | 25.7% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 16.2% | 11.9% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.40 | 1.88 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.01 | 1.50 | 1.80 | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
63.0% 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 622 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 44.1% 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 365 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 0.51 therapist hours per resident per day in 2026Q1 — more than 82% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 34% 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 63.0%CMS range 58.5–66.3 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.6%CMS range 9.5–13.4 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 44.1% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 41.1% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 54.5% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 98.2% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS 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 discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.2% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 3.1% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.2%CMS range 4.0–7.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.70 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 132 beds and averages 89.4 residents a day — about 68% occupied, or roughly 43 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 2.92 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.63 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.63 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 2.70 hrs/resident/day on weekends vs 3.00 on weekdays — 10% thinner on weekends. RN hours go from 0.72 to 0.42 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 41% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
23 citations, most serious first. The 10 most serious are shown; the remaining 13 are one tap away and print in full.
- Potential for harm · Ecited before2026-03-24 · tag F0883 — failed to offer flu and pneumonia vaccines — patternDevelop 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 ensure up to date pneumococcal immunizations were offered and/or administered after consent had been obtained for 4 out of 5 Residents (#7, #5, #48, and #99) reviewed for immunizations. Findings include: Review of the facility's policy titled 2026 Infection Control Plan, dated as last revised 12/2025, indicated the need for Pneumococcal vaccines will be assessed for all residents and offered if needed. Staff will offer up to date vaccines when available. Licensed staff will follow the Centers for Disease Control and Prevention (CDC) and the Association for Professionals in Infection Control (APIC) guidelines for all vaccines. Review of the facility's policy titled Pneumococcal Immunization Program, undated, indicated the facility follows CDC's Advisory Committee on Immunization Practices (ACIP) and Massachusetts Department of Public Health (MDPH) and the ACIP recommends all persons living in a long-term care (LTC) facility are assessed for and receive the pneumococcal immunization if eligible. The Infection Control…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-03-24 · tag F0887 — patternEducate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to offer the COVID-19 2025/2026 vaccination when it became available to 4 out of 5 Residents (#7, #5, #48, and #99) reviewed for immunizations. Findings include: Review of the facility's policy titled 2026 Infection Control Plan, dated as last revised 12/2025, indicated the need for COVID-19 vaccines will be assessed for all residents and offered if needed. Staff will offer up to date vaccines when available. Licensed staff will follow the Centers for Disease Control and Prevention (CDC) and the Association for Professionals in Infection Control (APIC) guidelines for all vaccines. Review of the facility's policy titled COVID-19 Vaccinations, dated as last revised 11/2023, indicated residents are protected from COVID-19 disease by vaccination per the CDC, Centers for Medicare and Medicaid Services (CMS), and Massachusetts Department of Public Health (MDPH) guidelines and all residents will be assessed as new COVID-19 vaccines are authorized for use. Residents who may not have been fully vaccinated may be vaccinated during…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-24 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately 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 document review and interview, the facility failed to notify the Health Care Proxy (HCP- health care agent designated by the resident when competent who has the authority to consent for health care decisions when a resident has been declared, by a physician, not to be competent to make his/her own health care decisions) in a timely manner when the Resident was found ingesting pieces of a Styrofoam plate resulting in a need to alter the plan of care to reduce the risk of reoccurrence, for one Resident (#8), out of a total sample of 19 residents.Findings include:Review of the facility's policy titled Change in a Resident's Condition or Status, dated as revised February 2021, indicated but was not limited to the following:Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status.-A nurse will notify the resident's representative when:a. The resident is involved in any accident or incident that results in an injury including injuries of an unknown source.b.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-24 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
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 that individualized, comprehensive care plans were reviewed and revised for one Resident (#8), out of 19 sampled residents. Specifically, the facility failed to ensure the care plan was revised to reflect removal of all non-food items from meal tray after the Resident was found ingesting a Styrofoam plate. Findings include:Review of the facility's policy titled Care Plans, Comprehensive Person-Centered, last revised March 2022, indicated but was not limited to:-The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.-The comprehensive, person-centered care plan:-Describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including-Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.-The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-24 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, document review, and interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment for two Residents (#104 and #120), out of a total sample of 19 residents. Specifically, the facility failed to:1. Ensure the correct personal protective equipment (PPE) was used when staff provided care and services for Resident #104 who was on isolation precautions for COVID-19; and2. Adhere to standard infection control practices including hand hygiene in between glove changes and practices on disinfecting the hub connector during connecting or flushing the peripherally inserted central line catheter (PICC) for Resident #120. Findings include:1. Review of the facility's policy titled 2026 Infection Control Plan, dated as revised December 2025, indicated but was not limited to the following:-Use of PPE is based on Centers for Disease Control and Prevention (CDC) and Massachusetts (MA) Department of Public Health (DPH) guidance. Review of the sign in use by the facility titled…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-02-06 · tag F0656 — failed to write and follow a full care plan — patternDevelop 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
Based on observation, interview, and record review, the facility failed to develop and implement an individualized, person-centered care plan to meet the physical, psychosocial, and functional needs for four Residents (#40, #48, #84, and #33), out of a total sample of 19 residents. Specifically, the facility failed to ensure a comprehensive care plan was developed: 1. For Resident #40, to address the use of antidepressant medication (used to treat obsessive compulsive disorder) that identified target behaviors, individualized, measurable non-pharmacological interventions and measurable goals of treatment; 2. For Resident #48, to address the use of antianxiety, antidepressant, and antipsychotic medication that identified target behaviors and individualized, measurable non-pharmacological interventions and measurable goals of treatment; 3. For Resident #84, to address a wound to the Resident's right medial calf; and 4. For Resident #33, to address an antipsychotic medication that identified target behaviors and individualized, measurable non-pharmacological interventions and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-02-06 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure 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 and interview, the facility failed to provide an environment that was free from accidents and hazards on three of three units. Specifically, the facility failed: 1. For the Naushon Unit, to ensure that medicated treatment supplies and an unlocked treatment cart in the Clean Utility Room were accessible only to licensed staff; 2. For the Nobska Unit, to ensure that: a. medicated treatment supplies and an unlocked treatment cart in the Clean Utility Room were accessible only to licensed staff, and b. the daily supply closet door was locked and not accessible to residents; 3. For Resident #33, (Nobska Unit) that sharps were properly placed in the sharps container to decrease the risk of needlestick injuries and exposure to bloodborne pathogens; and 4. For Resident #73 (Penzance Unit), to ensure sharps containers were replaced routinely and not overfilled to decrease the risk of needlestick injuries and exposure to bloodborne pathogens. Findings include: Review of the facility Matrix (used to identify pertinent care categories for residents) provided to surveyors by…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-02-06 · tag F0758 — failed to limit and justify psychotropic drugs — patternImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure three Residents' (#33, #40, and #48) drug regimen was free from unnecessary psychotropic medications, out of a total sample of 23 residents. Specifically, the facility failed: 1. For Resident #33, to adequately identify and monitor target behaviors related to his/her antipsychotic use; 2. For Resident #40, to adequately monitor for potential side effects of fluvoxamine (antidepressant used in the treatment of obsessive-compulsive disorder); and 3. For Resident #48, to adequately monitor for potential side effects for the use of Ativan (antianxiety), Depakote (anticonvulsant used as a mood stabilizer), Escitalopram (antianxiety), Remeron (antidepressant), Zyprexa (antipsychotic), and Strattera (norepinephrine reuptake inhibitor (SNRI) used to treat attention deficit hyperactivity disorder). Findings include: Review of the facility's policy titled Antipsychotic Medication Use, last revised July 2022, indicated but was not limited to: - Policy Statement: Antipsychotic medications can be considered for residents 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.
- Potential for harm · Dcited before2025-02-06 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately 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 record review and interview, the facility failed to ensure the Resident Representative was notified of a fall for one Resident (#48), out of a total sample of 19 residents. Specifically, the facility failed to ensure the activated Health Care Proxy (health care agent designated by the resident when competent who has the authority to consent for health care decisions when a resident has been declared, by a physician, not to be competent to make his/her own health care decisions) was notified of one fall resulting in a large bruise. Findings include: Review of the facility's policies, Notification of Changes Policy/Incident Reporting Process and Fall Prevention and Management Program Policy, undated, indicated but was not limited to: -The MD (physician) and responsible party MUST be notified at the time of the occurrence. Document in both incident report and the nurse's note this was completed. -The Nurse and/or Physician will notify and involve the family or significant others. Resident #48 was admitted to the facility in 10/2023 and had diagnoses including Alzheimer's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-06 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to report an allegation of physical abuse to the State Agency (SA) within the mandated timeframes as required for one Resident (#13), out of a total sample of 19 residents. Findings include: Review of the facility's policy titled Abuse Policy, undated, indicated but was not limited to the following: -It is the policy that each resident will be free from Abuse. Abuse can include verbal, mental, sexual, or physical abuse, corporal punishment or involuntary seclusion. Additionally, residents will be protected from abuse, neglect, and harm while they are residing at the facility. -The facility will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but no later than 2 hours after the allegation is made. -The Administrator or designee will inform the resident or resident's representative of the report of an incident and that an investigation is being conducted. -Covered individuals 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.
Show the remaining 13 citations
- Potential for harm · D2025-02-06 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure staff provided the resident and/or their representative with a summary of the baseline care plan for one Resident (#291), out of a total sample of 19 residents. Specifically, the facility failed to provide the Resident with a written summary of the baseline care plan and document receipt of the information within the Resident's clinical record. Findings include: Review of the facility's policy titled Care Plans - Baseline indicated but was not limited to the following: -The baseline care plan includes instructions needed to provide effective, person-centered care of the residents that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the residents including, but not limited to the following: a. Initial goals based on admission orders and discussion with the resident/representative; b. Physician orders; c. Dietary orders; d. Therapy Services; e. Social Services; and f.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-06 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to provide respiratory care consistent with professional standards of practice for one Resident (#50), out of a total sample of 19 residents. Specifically, the facility failed to ensure a physician's order was obtained for the administration of oxygen (O2). Findings include: Review of Lippincott Nursing Procedures, Eighth Edition [Philadelphia: Wolters Kluwer, (2019)] indicated but was not limited to the following: Oxygen Administration: -Verify the practitioner's order for the oxygen therapy, because oxygen is considered a medication or therapy and should be prescribed. Review of the facility's policy titled Oxygen Administration, revised October 2012, indicated but was not limited to the following: -Verify that there is a physician's order for this procedure. Review the physician's order or facility protocol for oxygen administration. -The nasal cannula is a tube that is placed approximately one-half inch into the resident's nose. It is held in place by an elastic band placed around the resident's head. -Turn…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-02-06 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
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 two Residents (#33, #67), out of a total sample of five residents reviewed for immunization, were screened for eligibility to receive the recommended pneumococcal vaccination, were educated on the benefits and potential side effects of the vaccine and were offered and administered (if applicable) the vaccine in a timely manner. Specifically, the facility failed to ensure Residents #33 and #67 were offered the Pneumococcal Conjugate Vaccine (PCV-a vaccine that helps protect against diseases caused by pneumococcal bacteria) at the time of admission or shortly thereafter, putting the Residents at risk for developing facility acquired pneumonia. Findings include: Review of the facility's policy titled Pneumococcal Immunization Program: Pneumococcal Vaccination, undated, indicated but was not limited to the following: - Purpose: to reduce morbidity and mortality from pneumococcal disease by vaccinating all patients who meet the criteria established…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-12-14 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and policy review, the facility failed to store and serve food in accordance with professional standards for food safety in three out of three nourishment kitchens. Specifically, the facility failed to properly label and date opened beverages and maintain safe and clean equipment. Findings include: Review of the facility's policy titled Unit Pantry Stock, dated as revised 1/2023, indicated but was not limited to: - Service and stock pantries daily or as needed per community specifications. - Label, date and discard outdated items per food storage policy. - Ensure all items are covered, labeled, and dated. - Procedure and responsibilities for cleaning and care of pantry area must be assigned. The responsible department(s) will maintain equipment temperature and cleaning logs per record retention policy. Responsibilities may include, but are not limited to: (a) cleaning and sanitizing of refrigerator/pantry: Food Service. Review of the facility's policy titled Food and Supply…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-12-14 · tag F0585 — failed to handle grievances — patternHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews, policy review, and observations, the facility failed to have information on how to file a grievance in resident care and public areas and have forms accessible, so residents and/or visitors were able to anonymously notify the facility of their concerns. Findings include: Review of the facility's policy titled Grievance (undated) indicated but was not limited to: -The right to file grievances verbally or in writing; -The right to file grievances anonymously During the Resident Group interview on 12/13/23 at 10:00 A.M., which consisted of 11 residents from all three open units, the residents said they would speak to the Social Worker or the Ombudsman if they had a grievance/concern. The residents said they were unsure of how to file a grievance when the Social Worker and/or Ombudsman were unavailable. The residents were unaware of where information on filing a grievance or grievance forms were located. During a tour on 12/13/23 at 11:58 A.M., the surveyor was unable to locate information on how to file a grievance verbally or anonymously, or any grievance forms 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.
- Potential for harm · E2023-12-14 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and policy review, the facility failed to ensure all drugs and biologicals were secured in locked compartments with only authorized personnel having access. Specifically, the facility failed: 1A. For Resident #212, to ensure prescription medicated treatment powder and cream were not left unattended in the Resident's room, and B. For Resident #51, to ensure a bottle of vitamin supplement and a prescription cream were not left unattended in the Resident's room; and 2. To ensure staff kept the Medication Cart locked when not in use or under direct supervision of the nurse. Findings include: Review of the facility's policy titled Medication Storage Policy, undated, with attachment titled Omnicare: Common Medication Storage Guidance and Terminology, dated March 2020, indicated but was not limited to the following: -All medications stocked and packaged and labeled in accordance with federal and state regulations. Review of the facility's policy titled Administering Medications,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-12-14 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, policy review, and record review, the facility failed to implement a person-centered care plan for the use of multiple psychotropic medications for one Resident (#54), out of a total sample of 17 residents. Findings include: Review of the facility's policy titled Unnecessary Drug Therapy, undated, indicated but was not limited to the following: -Based on a comprehensive assessment of each resident, the facility must ensure that antipsychotic drug therapy is used to treat a specific condition as diagnosed and documented in the clinical record. -Residents who use antipsychotic drugs receive gradual dose reductions and behavioral interventions in an effort to discontinue these drugs. -It is the policy of this facility to encourage multidisciplinary efforts to determine factors responsible for resident behavior changes and recommend consideration of alternate (non-drug) means of treating those factors. -Behavioral symptoms and the development of a plan of care designed to attempt to reduce or eliminate the cause of harmful behavior. Resident #54 was admitted 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.
- Potential for harm · D2023-12-14 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide 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 observation, interview, and record review, the facility failed to consistently implement the nutritional care plan interventions for one Resident (#23), out of a total sample of 17 residents, resulting in a gradual progressive weight loss. Findings include: Review of the facility's policy titled Clinical Nutritional Services: Interdisciplinary Care Plans, dated as revised January 2023, indicated but was not limited to the following: - each resident will have a person-centered comprehensive care plan developed and implemented to meet his or her preferences and goals - the comprehensive care plan includes but is not limited to: measurable goals, needs and nutritional problems; nutritional interventions and approaches as needed; the prevention of unintentional weight loss Review of the facility's policy titled Nutritional Interventions, dated as revised October 2022, indicated but was not limited to the following: - the dietitian identifies residents that are at risk or potential risk for nutritionally related problems and recommends interventions to improve the resident's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-12-14 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, policy review, and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary psychotropic drugs without adequate monitoring for one Resident (#54), out of a total sample of 17 residents. Specifically, the facility failed to monitor for side effects of multiple psychotropic medications and to implement behavioral interventions in an effort to discontinue these drugs. Findings include: Review of the facility's policy titled Unnecessary Drug Therapy, undated, indicated but was not limited to the following: -According to The Centers for Medicare and Medicaid Services (CMS), an unnecessary drug is one that is: in excessive dose; for excessive duration; without adequate monitoring; without adequate indication for use; in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combination of the reasons above. -Based on a comprehensive assessment of each resident, the facility must ensure that antipsychotic drug therapy is used to treat a specific condition as diagnosed and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-12-14 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and policy review, the facility failed to maintain and consistently implement an infection prevention and control program to provide a safe, sanitary, and comfortable environment and to help prevent the development and potential transmission of communicable diseases and infections for one Resident (#208). Specifically, the facility failed to ensure Enhanced Barrier Precautions (EBP), including gown and glove use were consistently implemented during care. Findings include: Review of the facility's policy titled Policy for Enhanced Barrier Precautions, dated 1/1/23, indicated but was not limited the following: -Care Center will follow the recommendations of the Centers for Disease Control and Prevention (CDC) regarding the utilization of EBP for residents during these situations: Indwelling catheters. -Person Protective Equipment (PPE) will consist of gloves, gowns after hand sanitizing by staff for any of the following activities: Dressing, Bathing/Showering, Transferring, Hygiene Care, Linen Changing, Toileting assists or brief changes, Device care:…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-11-08 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and document review, the facility failed to maintain an infection prevention and control program to help prevent the potential transmission of a communicable disease when the facility was experiencing an outbreak of COVID-19 infections. Specifically, the facility failed to: 1. Ensure proper COVID-19 outbreak testing procedures were implemented for two of two facility staff reviewed (Staff #1, Staff #2); and 2. Ensure staff followed infection control guidelines for doffing (taking off) personal protective equipment (PPE) when exiting a COVID-19 positive resident's room. Findings include: During an interview on 11/8/23 at 8:57 A.M., the Administrator and Director of Nursing (DON) said the facility was experiencing a COVID-19 outbreak that began on 10/21/23 affecting the Nobska and Naushon (10/31/23) Units. They said the expectation for PPE was for staff to wear an N95 facemask, gown, face shield/goggles, and gloves prior to entering a COVID-19 positive resident's room and that the facility followed Department of Public Health (DPH), Centers for Disease…
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.
- No harm found · B2025-02-06 · tag F0641 — patternEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to accurately complete the Minimum Data Set (MDS) assessment for three Residents (#70, #6, #33), out of 19 sampled residents. Specifically, the facility failed: 1. For Resident #70, to ensure the MDS assessment was accurately coded for dialysis; 2. For Resident #6, to ensure the MDS assessment was accurately coded for hospice; and 3. For Resident #33, to ensure the MDS assessment was accurately coded for a diagnosis of dementia. Findings include: 1. Resident #70 was admitted to the facility in August 2023 with diagnoses including end stage renal disease, dependence on renal dialysis and vascular dementia. Review of Resident #70's Physician's Orders indicated but were not limited to the following: - 5/13/24: [Name of Dialysis Center] scheduled Tuesday/Thursday/Saturday with 6:35 A.M. arrival time Review of the MDS assessment, dated 12/9/24, failed to indicate Resident #70 was receiving dialysis. During an interview on 2/5/25 at 7:23 A.M., MDS Nurse #1 said Resident #70 was the only resident in the facility receiving dialysis.…
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.
- No harm found · B2025-02-06 · tag F0712 — patternEnsure that the resident and his/her doctor meet face-to-face at all required visits.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record review, the facility failed to ensure five Residents (#84, #6, #76, #47, #31), in a sample of 19 residents, had been seen by a physician every 60 days and had the required visits alternated between the Physician and the Nurse Practitioner (NP). Findings include: Review of the facility's policy titled Physician Visits, dated April 2013, indicated but was not limited to the following: - The attending physician must make visits in accordance with applicable state and federal regulations. - The attending physician will visit residents in a timely fashion, consistent with applicable state and federal requirements, and depending on the individual's medical stability, recent and previous medical history, and the presence of medical conditions or problems that cannot be handled readily by phone. - After the first ninety (90) days, if the attending physician determines that a resident need not be seen by him/her every thirty (30) days, an alternate schedule of visits may be established, but not to exceed every sixty days. A physician assistant or nurse…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| MCDONOUGH ANASTOS, MARY | Individual | W-2 MANAGING EMPLOYEE | since 01/11/2011 |
| SPOFFORD, ROBIN | Individual | W-2 MANAGING EMPLOYEE | since 04/16/1998 |
| PINO, COLLEEN | Individual | CORPORATE DIRECTOR | since 04/16/2016 |
| LAUF, MICHAEL | Individual | CORPORATE OFFICER | since 03/17/2022 |
The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $88K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in MA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Massachusetts Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 225369. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-24, 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.