Oak Knoll Rehabilitation And Healthcare Center
9 Arbetter Drive, Framingham, MA 01701 · For profit - Corporation · 123 certified beds · (508) 877-3300 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- 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 (F0604) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 2 immediate-jeopardy problems — the most serious level
- a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $211,819 in federal fines (most recent 2025-06-12)
- its payroll-based staffing rating is low (2/5)
- its facility-reported quality-measure rating is low (2/5)
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) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 2 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 | 2 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 1 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.
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 | 10.0% | 16.4% | 15.4% | better |
| Long-stay residents who lose too much weight | 9.1% | 5.1% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.8% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 2.0% | 1.8% | 2.0% | typical |
| Long-stay residents with depressive symptoms | 60.1% | 15.5% | 6.5% | worse 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 | 12.6% | 15.4% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 15.2% | 19.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 84.8% | 94.8% | 95.3% | worse |
| Long-stay residents with pressure ulcers | 3.5% | 4.2% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 12.5% | 21.2% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 20.7% | 21.4% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 1.4% | 1.4% | 1.4% | typical |
| Short-stay residents given the seasonal flu vaccine | 87.6% | 77.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 25.3% | 25.7% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 14.6% | 11.9% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.88 | 1.88 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.05 | 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.
47.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 220 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 37.9% 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 95 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 0.24 therapist hours per resident per day in 2026Q1 — more than 31% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 19% 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 | 47.9%CMS range 42.2–55.5 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.3%CMS range 8.8–14.1 | 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 | 37.9% | 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 | 36.8% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 39.0% | 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 | 99.3% | 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 | 97.9% | 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 | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS 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 stay | 0.7% | 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 | 2.7% | 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 | 8.0%CMS range 5.4–11.4 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.88 | 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 123 beds and averages 110.7 residents a day — about 90% occupied, or roughly 12 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 3.79 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.33 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.08 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.33 hrs/resident/day on weekends vs 3.98 on weekdays — 16% thinner on weekends. RN hours go from 0.38 to 0.19 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%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are 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.
27 citations, most serious first. The 12 most serious are shown; the remaining 15 are one tap away and print in full.
- Immediate jeopardy · Jcited before2025-06-12 · 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 records reviewed and interviews, for one of three sampled residents (Resident #1), who had a history of dysphagia (difficulty swallowing) with several episodes of choking which required nursing staff to perform the Heimlich Maneuver (a first-aid procedure for dislodging an obstruction from a person's windpipe in which sudden strong pressure is applied on the abdomen, between the navel and the rib cage), the Facility failed to ensure his/her Dysphagia Care Plan was reviewed and/or revised related to effectiveness of interventions, when he/she remained on the same diet but continued to experience choking episodes and despite recommendations from Speech Therapy to implement a new intervention for direct supervision by staff during all meals, he/she was only supervised from a distance by staff. On 5/02/25, Resident #1 choked on his/her meal and died. Findings include: Review of the Facility's policy, titled Comprehensive Person-Centered Care Plans, with a revision date of March 2022, included the following: -A comprehensive, person-centered care plan that includes measurable…
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.
- Immediate jeopardy · J2025-06-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 records reviewed and interviews, for one of three sampled residents (Resident #1), who had a history of dysphagia (difficulty swallowing), was identified to be at increased risk for aspiration, with multiple choking episodes which required the nursing staff to perform the Heimlich Maneuver (a first-aid procedure for dislodging an obstruction from a person's windpipe in which sudden strong pressure is applied on the abdomen, between the navel and the rib cage), and for whom Speech Therapy had recommended the need for direct supervision by nursing staff while eating, the Facility failed to ensure they provided an adequate level of staff supervision for Resident #1 in an effort to maintain a safe environment, when on 5/02/25, he/she choked again on his/her meal, and although nursing staff performed the Heimlich Maneuver, Resident #1 died. Findings include: Review of the Facility's policy, titled Accidents and Incidents, with a revision date of April 2024 included the following: -It is the policy of the Facility to provide a safe and healthful work environment. -Definition of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-02-13 · 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, and interview, the facility failed to adhere to infection control and prevention standards related to multi-resident medical equipment use for one Unit (Sub Acute) out of two units observed, to mitigate the development and transmission of communicable diseases and infections. Specifically, the facility failed to:1. ensure that facility staff cleaned and disinfected a blood glucose monitor (BGM - device used to measure the amount of glucose [sugar] in the blood) between multi-resident use after Nurse #2 used the BGM to obtain finger stick blood sugar (FSBS) levels on two residents and before storing the BGM device in the medication cart with clean equipment.2. ensure the facility staff cleaned and disinfected a wrist blood pressure cuff (machine used to check blood pressure) between multi-resident use when Nurse #2 used the wrist blood pressure cuff to obtain blood pressure readings on three residents, placed the wrist blood pressure cuff in her pocket after use on the three residents, and placed the contaminated device on the surface of the medication…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-30 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, policy review, and interview, the facility failed to accurately execute Advance Directives (legal documents that provide instructions for medical care and only go into effect if you are unable to communicate your own wishes) for one Resident (#94) out of a total sample of 23 residents. Specifically, for Resident #94, the facility failed to ensure that the MOLST (Massachusetts Medical Order for Life-Sustaining Treatment) form was valid and reflected the signature of Resident #94's invoked (made active by a Physician) Health Care Proxy (HCP- the person chosen as the healthcare decision maker when the individual is unable to do so for themself). Findings include: Review of the facility policy for Advance Directives, last revised February 2022, indicated: -capacity to make health care decisions is the ability to understand and appreciate the nature and consequences of health care decisions, including the benefits and risks of and alternatives to any proposed health care, and to reach an informed decision. -In Massachusetts, the determination of a patient's lack…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-30 · tag F0604 — failed to not use physical restraints improperly — isolatedEnsure that each resident is free from the use of physical restraints, unless needed for medical treatment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure that one Resident (#98), was free from physical restraints, out of a total sample of 23 residents. Specifically, for Resident #98, the facility failed to: -appropriately assess and re-assess the use and need of wedge cushions (a triangular shaped cushion used to aid in positioning for health issues or comfort) as a restraint that was being used in the place of an ordered scoop mattress (a mattress with raised edges on all four sides to prevent accidental rolling out of bed). -obtain informed consent and review the risk/benefits with the Resident's Representative for the use of wedge cushions while the Resident was in bed to prevent him/her from exiting the bed, increasing the potential risk of accidental falls and injury. Findings include: Review of the facility policy titled Guidelines for the Use of a Restraint, revised 11/2016, indicated it was the policy of the facility to provide care and services to assist each resident to attain and maintain his/her highest practicable well-being in an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-30 · tag F0640 — isolatedEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview the facility failed to ensure that Minimum Data Set (MDS) assessments were transmitted within 14 days after the completion date for 17 Residents (#4, #43, #57, #90, #95, #102, #103, #18, #51, #54, #65, #80, #81, #82, #100, #116, and #118) out of a total sample of 23 residents. Specifically, the facility failed to ensure that: 1) Comprehensive MDS assessments for Resident's #4, #43, #57, #90, #95, #102, #103 were not submitted late with submission dates more than 14 days after the completion date. 2) Non comprehensive MDS assessments for Residents #18, #51, #54, #65, #80, #81, #82, #100, #116, and #118 were not submitted late with submission dates more than 14 days after the completion date. Findings include: Review of The Centers for Medicare and Medicaid (CMS) MDS 3.0 Resident Assessment Instrument (RAI) Manual dated October 2024, indicated: -Comprehensive assessments (Omnibus Budget Reconciliation Act (OBRA)-required comprehensive assessments include the completion of both the MDS Assessment and the Care Area Assessment (CAA) process, as well…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-30 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, and record review, the facility failed to ensure that a Preadmission and Resident Review Level I (initial PASRR - initial pre-screening completed prior to admission to a Nursing Facility that assess for Serious Mental Illness[SMI] or Developmental Disabilities[DD]) screen was completed prior to admission to the facility for one Resident (#85), out of a total sample of 23 residents. Findings include: Resident #85 was admitted to the facility in April 2023, with diagnoses including Major Depressive Disorder (symptoms lasting greater than two weeks of a persistently low or depressed mood and a loss of interest in activities that a person used to enjoy) and Psychotic Disorder (serious mental disorders characterized by a disconnection from reality which results in strange behaviors often accompanied by disturbances of thought [excessive suspiciousness, guilt] and perception [hearing voices, seeing things, feeling things] with hallucinations [an experience involving the apparent perception of something not present]). Review of the PASRR Level I Screening, dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-30 · tag F0646 — isolatedNotify the appropriate authorities when residents with MD or ID services has a significant change in condition.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, and record review, the facility failed to notify the State Mental Health Authority for a Resident Review (person-centered assessment taking into account all relevant information) after a significant change in mental condition occurred for one Resident (#98), out of a total sample of 23 residents. Specifically, the facility failed to request a Preadmission Screening and Resident Review Level II screen (PASRR- an evaluation done to determine if a resident has an intellectual or developmental disability and/or serious mental illness [SMI] and if a Resident is in need of additional specialized support services at the facility) after Resident #98 received emergency mental health interventions and was transferred to the hospital for a psychiatric evaluation. Findings include: Resident #98 was admitted to the facility in May 2024, with diagnoses including Severe Dementia (a group of symptoms that affects memory, thinking and interferes with daily life) with agitation, Adjustment Disorder (a disorder characterized by a group of symptoms such as stress, anxiety, feeling…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-30 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and policy review, the facility failed to provide treatments in accordance with professional standards of practice for one Resident (#78) out of a total sample of 23 residents. Specifically, the facility failed to implement and perform care and treatment consistent with the Physician orders and professional standards of practice for a Resident with Diabetes Type II (DM II- a chronic medical condition where the body cannot effectively use insulin [hormone that regulates blood glucose/sugar] or produce enough insulin and has trouble controlling blood sugar levels), placing the Resident at risk for side effects of hyperglycemia (high blood sugar). Findings include: Review of the National Library of Medicine document titled, Management of Diabetes and Hyperglycemia in hospitalized Patients, dated October 2024, https://www.ncbi.nlm.nih.gov/books/NBK279093/ indicated: -hyperglycemia . is defined as blood glucose greater than 140 mg/dL (milligrams per deciliter) -for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-30 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, policy and record review, the facility failed to ensure that respiratory care and services consistent with professional standards of practice, were provided for two Residents (#87 and #24), out of a total sample of 23 residents. Specifically, the facility failed to: 1. For Resident #87, routinely maintain the oxygen concentrator (a device used to deliver supplemental oxygen) air intake gross particle filter in accordance with Physician orders and manufacturers guidelines, placing Resident #87 at risk for equipment malfunction, impaired oxygen delivery and contamination. 2. For Resident #24, ensure that the Resident had an active Physician's order for nebulizer (delivery device used to administer medication in the form of an aerosol that is inhaled into the lungs) equipment care, handling, and storage, to prevent contamination and the spread of infections. Findings include: Review of the facility policy titled Oxygen and Respiratory Equipment Management, dated September 2009,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-30 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record and policy review, the facility failed to ensure that professional standards of practice relative to dialysis (the process of cleansing the blood by passing it through a special machine, necessary when the kidneys are unable to filter the blood) care and services for one Resident (#32), of two applicable residents reviewed for dialysis, out of a total sample of 23 Residents. Specifically, for Resident #32, the facility failed to: 1. Monitor and assess the Physician's ordered fluid restriction to ensure adequate fluid intake. 2. Provide food items prior to dialysis as indicated in the plan of care and per the Resident's preferences. Findings include: Review of facility policy titled Guidelines for Initiating, Maintaining, and Removing Residents from Intake & Output Recording, dated 1/2016, indicated the following: -It is the policy of this facility to monitor the intake and output of residents as needed based on the resident's clinical condition and physician orders. -Conditions for which a resident must be put on I & O (intake and output) include 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 · D2024-10-30 · 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 record review, interview, and policy review, the facility failed to ensure that one Resident (#84), out of a total sample of 23 residents, was free from the risks of side effects resulting from the unnecessary use of psychotropic medications. Specifically, the facility failed to ensure that appropriate monitoring for adverse consequences and side effects of antipsychotic medications using the Abnormal Involuntary Movement Scale (AIMS) assessment (a rating scale used to measure involuntary movements of the face, mouth, trunk, or limbs known as Tardive Dyskinesia (TD) in a resident taking antipsychotic medications) was completed timely in accordance with standards of practice. Findings include: Review of the facility policy titled Guidelines for Completing AIMS Testing, revised 10/2019, indicated: -All residents receiving antipsychotics (neuroleptics) will have an AIMS test completed prior to initiation of the medication and at least every six (6) months thereafter to monitor for movement disorder. -The AIMS aids in early detection of tardive dyskinesia as well as provides a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 15 citations
- Potential for harm · Dcited before2024-10-30 · 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 record review, the facility failed to adhere to infection control standards to prevent contamination and stop the spread of infections for one Resident (#54), out of a total sample of 23 residents. Specifically, the facility failed to: 1. For Resident #54, perform appropriate hand washing/hygiene for five opportunities, during a wound care procedure which increased the Resident's risk for wound contamination and infection. 2. For Resident #54, Adhere to Enhanced Barrier Precautions (EBP: infection control guidelines that use Personal Protective Equipment [PPE] to reduce the spread of multidrug-resistant organisms [MDROs]) during medication and fluid administration through a gastrostomy tube (G-tube: a tube surgically inserted through the abdominal wall and into the stomach to provide nutrition, fluids and medications by bypassing the mouth and esophagus). Findings include: Review of the facility policy titled Handwashing, dated June 2012 with revision date of January 2016, indicated the following: -It is the policy of this facility to follow 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 · E2023-08-28 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to maintain professional standards relative to food storage and sanitation in one of three nourishment kitchens. Findings include: Review of the facility's Nourishment policy dated January 2016, indicated the following: -Dietary is responsible for monitoring and recording the temperatures of both the refrigerator and freezer of the nourishment refrigerators. -All non-nourishment food will be discarded immediately Review of the 2022 United States Food and Drug Administration Food Code indicated the following: *Food shall be protected from contamination by storing the food: -In a clean, dry location. -Where it is not exposed to splash, dust, or other contamination. -At least 15 centimeters (six inches) above the floor. *Time/Temperature control for safety, cold holding: -Except during preparation, cooking, or cooling, or when time is used as the public health control, food shall be maintained at 5°Celsius (41°Fahrenheit) or less. During an observation of the first floor nourishment kitchen on 8/24/23 at 8:38 A.M., the following…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-08-28 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, policy reviews and interviews, the facility failed to adhere to Infection Control policies/practices during a COVID-19 outbreak. Specifically the facility staff failed to: 1) utilize the appropriate precaution signs on one out of three units during an outbreak of COVID-19 infection. 2) use appropriate personal protective equipment (PPE) by staff in a manner that would minimize the spread of COVID-19 infection during an active outbreak for one Resident (#96) out of four applicable residents, out of a sample of 21 residents. 3) to ensure staff were tested for COVID-19 as required when the facility was experiencing an outbreak of COVID-19 infections. Findings include: Review of the facility policy titled, COVID-19 Control Plan, revised 5/14/23, indicated the following: *Residents in whom a diagnosis of COVID-19 is suspected or confirmed will be separated from non-infected residents. The following measures will be implemented: -An Isolation Precautions sign will be placed on the door and necessary personal protective equipment (PPE) will be utilized immediately.…
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 · D2023-08-28 · tag F0552 — isolatedEnsure that residents are fully informed and understand their health status, care and treatments.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure that residents and/or their representatives were informed and given necessary information to make health care decisions including the risks and benefits of psychotropic (any drug that affects behavior, mood, thoughts, or perception) medications prior to their use for two Residents (#8, and #102), out of a total sample of 21 Residents. Specifically: 1. For Resident #8, the facility staff failed to ensure the correct medication dose was documented on the Informed Consent for the use of an antidepressant (medicine used to treat clinical depression) medication. 2. For Resident #108, the facility staff failed to ensure the Resident was: a) was given the right to be informed of the risk and benefits of the use of an antipsychotic (medication which are to treat psychosis) medication. b) an Informed Consent was signed by the Resident or the Resident's Representative/Health Care Proxy (HCP) for the use of an antianxiety (medication that help reduce 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 · D2023-08-28 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to assess one Resident (#70), out of a total sample of 21 residents, for self-administration of medications. Specifically, the facility staff failed to determine if self-administration of medications was clinically appropriate for Resident #70 while at the Dialysis Clinic. Findings include: Review of the facility policy titled, Self-Administration of Medications, revised 3/2022, included but was not limited the following: -Residents who desire to self-administer medications may do so if the interdisciplinary team (IDT) has determined that the practice would be safe for the resident and other residents of the facility. -If the resident desires to self-administer medication, an assessment is conducted by the IDT of the resident's cognitive, physical and visual ability to carry out this responsibility. -The IDT determines the resident's ability to self- administer medications by means of a skills assessment. -The results of the IDT assessment…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-08-28 · tag F0646 — isolatedNotify the appropriate authorities when residents with MD or ID services has a significant change in condition.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure a Level II [comprehensive evaluation that identifies the specialized services required] Preadmission Screening and Resident Review (PASRR- evaluation done if it was determined by the Level I [initial pre-screening] screen that a resident had an intellectual or developmental disability and/or serious mental illness [SMI] and if a resident was in need of additional support services at the facility) was submitted for one Resident (#48) out of a total sample of 21 residents. Specifically, for Resident #48, the facility staff failed to request a Level II PASRR evaluation when the Resident demonstrated an increase in behavioral, psychiatric, and mood-related symptoms resulting in a change to the Resident's plan of care. Findings Include: Resident #48 was admitted to the facility in November 2022 with diagnoses including Wernicke's Encephalopathy (a neurological disorder often associated with chronic alcoholism). Review of Resident #48's Level I PASRR screen dated 11/29/22, indicated that he/she had a history of alcohol…
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 before2023-08-28 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to implement a comprehensive person-centered care plan for one Resident (#35), out of a total sample of 21 Residents. Specifically, for Patient #35, the facility staff failed to implement a care plan with interventions related to a re-occurring health problem that resulted in required hospitalizations. Findings include: Review of the facility Interdisciplinary Care Planning policy dated January 2022, indicated the following: -The care plan process is not limited to developing a written plan but also addresses the ongoing execution of care, treatment, and services with a person-centered approach. The plan is continually reevaluated and modified to ensure the resident's needs are met. Resident #35 was admitted to the facility in August 2014 with diagnoses including Angiodysplasia (a bleeding disorder in which one or more blood vessels in the gastrointestinal tract become dilated or stretched beyond their normal size) of the colon with hemorrhage (bleeding)…
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 · D2023-08-28 · 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 record review and interview, the facility failed to include one Resident (#21) and/or their Resident Representative in the care planning process out of a total sample of 21 residents. Specifically, the facility staff was unable to provide evidence that Resident #21, and/or their Resident Representative had been invited to, and/or were included in care plan meetings as required. Findings include: Review of the facility policy titled Interdisciplinary Care Planning revised 1/2022, included: -The care planning process provides the resident and their representative with information on the plan for delivery of care and services and a means to remain actively engaged. -Responsible parties are notified by phone or mail in advance of the meeting which is scheduled based on the Medicare/MDS (MDS - Minimum Data Set) review. -The resident is invited to attend the scheduled meeting or the meeting can be held at the bedside if elected to do so by this resident. -The plan includes .involving residents and their representative in the planning process. Resident #21 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 · D2023-08-28 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record and policy review, the facility failed to provide care and treatment consistent with professional standards of practice to prevent the development and worsening of a pressure injury for one Resident (#96), out of a total sample of 21 residents. Specifically, the facility staff failed to: 1) Follow a Physician order for air mattress setting as an intervention to prevent pressure injury. 2) Follow a Physician ordered treatment to a pressure ulcer on the Resident's sacral region (the portion of the spine between the lower back and tailbone), lower medial coccyx (base of the spine, also known as the tail bone). Findings include: Review of the facility policy titled, Dressing Change Procedure, revised 11/16, indicated the following: -The dressing of choice, according to physician order, will be applied -All dressing changes are completed utilizing a clean technique unless ordered otherwise by the physician -Obtain/check Physician order -Apply dressing as ordered -Document 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 · D2023-08-28 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and interview, the facility failed to follow the plan of care for an indwelling urinary catheter/Foley (a flexible tube that passes through the urethra and into the bladder to drain urine) for one Resident (#96) out of five applicable residents who required an indwelling urinary catheter, out of a total sample of 21 Residents. Specifically, the facility staff failed to ensure the correct size indwelling urinary catheter was in place for Resident #96 as ordered. Findings include: Resident #96 was admitted to the facility in May 2023, with diagnoses including bladder cancer. On 8/24/23 at 2:48 P.M., the surveyor and Nurse #3 observed Resident #96 lying in bed with a urinary catheter drainage bag that was hooked to the left side of the bed. During an interview at the time, Nurse #3 said that the Resident had a 16 French (FR)/ 10 cubic centimeter (cc) indwelling urinary catheter inserted. Review of the August 2023 Physician's orders indicated an order with a start date of 8/7/23: -22 FR/10 cc balloon. Review of the Indwelling Catheter Care plan, dated…
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 before2023-08-28 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure dialysis (a process by which waste substances are removed from a patient's body) care and services were provided for one Resident (#70), out of five applicable resident who received dialysis out of a total sample of 21 residents. Specifically, the facility failed to ensure that its staff maintained ongoing communication and documentation with the dialysis center, including medication management, and assessment of the residents' condition before and after dialysis treatment, including site care, vital signs and weights. Findings include: Review of the facility policy titled, Dialysis Treatment, Care and Transportation of Residents Requiring [sic], revised 1/8/2019, indicated the following: -The facility shall communicate with the designated dialysis center to identify the schedule of services for the resident. -The facility will initiate a communication book to accompany the resident to scheduled dialysis appointments. -Pertinent medication information will be recorded in this book by both 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.
- Potential for harm · D2023-08-28 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, policy and record review, the facility failed to ensure one Resident (#96) was free of significant medication errors, out of a total sample of 21 residents. Specifically, the facility failed to ensure that its staff followed Physician's orders for: 1. Scheduled morphine (medication is used to treat severe pain) prior to a pressure ulcer dressing change as ordered. 2. By administering Morphine more frequently than ordered. Findings include: Resident #96 was admitted to the facility in May 2023, with following the diagnoses: Encephalopathy (medical term used to describe a disease that affects brain structure or function which causes altered mental state and confusion), failure to thrive (describes a syndrome of wide spread decline), status post transurethral resection of bladder tumor (TURBT) due to a bladder mass (the procedure done to diagnose and to treat early stage bladder cancer at the same time) and unspecified pressure ulcer of sacral region, Stage 4 (-full-thickness skin and tissue…
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 · D2023-08-28 · tag F0772 — isolatedHave an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to obtain Physician ordered laboratory specimens for one Resident (#11) out of a total sample of 21 residents. Specifically, the facility staff failed to obtain a Hemoglobin A1C (Hgb A1C - a blood test that measures the average blood sugar level over the past three months) level for Resident #11 as ordered by the Physician. Findings include: Resident #11 was admitted to the facility in March 2023 with a diagnosis of Type 2 Diabetes Mellitus (a chronic condition that affects the way the body processes blood sugar). Review of the Resident's Physician's orders included: -5/31/23 Please check A1C (Hgb A1C) -6/1/23 May have labs done .A1C .(due to blood clots at the lab) -6/5/23 May have STAT (immediately) .A1C today (patient refused on 6/2/23) Review of the Resident's clinical record nursing progress notes included: -6/1/23 .phone call received from the lab, they couldn't run .A1C due to blood clotting, will be added to the next lab day, NP notified. -6/5/23 patient refused (labs) .on Friday .draw labs STAT today . Review of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-28 · tag F0801 — isolatedEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
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 Food Service Director (FSD) held the required qualifications. Specifically, the facility failed to ensure there was a full-time Registered Dietitian (RD) when the FSD: -was not a certified dietary manager. -was not a certified food service manager. -did not have a similar national certification in food service management and safety. -did not have an Associate's degree or higher in food service management or in hospitality. -did not have two or more years of experience in the position of Director of food and nutrition services in a nursing facility setting. Findings include: Review of the facility Director of Culinary Services (the FSD) job description indicated the following prerequisites: -High School Diploma and graduate of state approved course that provides 90 hours or more classroom instruction in food service supervision including Food Service Management, Nutrition and Sanitation, or -Any Bachelor's degree with 90 hours of State approved courses, or -Any Associates or Bachelor's degree in Nutrition,…
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 · D2023-08-28 · 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 document review and interview, the facility failed to offer and administer a Pneumococcal Immunization when requested, for one Resident (#8), out of total sample of 21 Residents. Findings include: Review of the facility's Immunization and Vaccination of Residents policy, dated March 2021, indicated the following: -All residents will be offered the Influenza, Prevnar13, Pneumovax23, COVID-19 and Tetanus and Diphtheria Toxoid, or Tetanus, Diphtheria Pertussis Vaccines at the time of admission. -Vaccination consent forms will be completed by the resident /responsible person at the time of admission or prior to administration and maintained in the medical record. Resident #8 was admitted to the facility in August 2020 with diagnoses including Cerebral Palsy (a disorder of movement, muscle tone or posture), Anemia and history of Cancer. Review of the clinical record indicated no Pneumococcal Immunization Consent or documentation that the Resident was administered the Pneumococcal Vaccine. Review of a Minimum…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“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
$211,819 in federal fines across 1 penalty.
- $211,819 — penalty dated 2025-06-12
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 ATLAS HEALTHCARE — 29 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 3.6 | -0.6 vs chain |
| Health inspection | 3 of 5 | 3.1 | -0.1 vs chain |
| Staffing | 2 of 5 | 2.3 | -0.3 vs chain |
| Quality measures | 2 of 5 | 4.4 | -2.4 vs chain |
The other 28 homes this chain runs (chain average 3.6★, 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 / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| WHITTIER MOP OPERATIONS HOLDINGS LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 02/28/2025 |
| JMH FAMILY LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; LIMITED PARTNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 02/28/2025 |
| JMH FAMILY TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; LIMITED PARTNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 02/28/2025 |
| MLS FAMILY LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; LIMITED PARTNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 02/28/2025 |
| MLS FAMILY TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; LIMITED PARTNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 02/28/2025 |
| SGS FAMILY LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; LIMITED PARTNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 02/28/2025 |
| SGS FAMILY TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; LIMITED PARTNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 02/28/2025 |
| WHITTIER 6 OPERATIONS HOLDINGS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; LIMITED PARTNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 02/28/2025 |
| MILLER, NACHUM | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; LIMITED PARTNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 02/28/2025 |
| BAK, PINCHOS | Individual | CORPORATE OFFICER; ADP OF THE SNF | — | since 02/28/2025 |
| WHITTIER OPCO MANAGER LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/28/2025 |
| GILANI, AHMED | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/28/2025 |
| WANGANGA, STELLA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/28/2025 |
| WRISTON, ANTHONY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/28/2025 |
| GLEN OAK 11, LLC | Organization | LIMITED PARTNERSHIP INTEREST | — | since 02/28/2025 |
| MALT FAMILY TRUST | Organization | LIMITED PARTNERSHIP INTEREST | — | since 02/28/2025 |
| SGS 2010 FAMILY TRUST | Organization | LIMITED PARTNERSHIP INTEREST | — | since 02/28/2025 |
| TYH 2017 TRUST | Organization | LIMITED PARTNERSHIP INTEREST | — | since 02/28/2025 |
| GOLDBERGER, SHLOMO | Individual | ADP OF THE SNF | — | since 02/28/2025 |
| SONNENSCHEIN, MOSHE | Individual | ADP OF THE SNF | — | since 02/28/2025 |
CMS files one row per role, so the 34 rows in the source record cover these 20 parties — each is shown once here with every role it holds. Nothing is omitted.
13 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $1.3M 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 225682. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-13, 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.