Baker-Katz Skilled Nursing And Rehabilitation Ctr
194 Boardman Street, Haverhill, MA 01830 · For profit - Limited Liability company · 77 certified beds · (978) 373-5697 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- a high number of inspection citations overall (17) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- 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 | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 3 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 | 2 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 3 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 | 9.4% | 16.4% | 15.4% | better |
| Long-stay residents who lose too much weight | 3.8% | 5.1% | 5.4% | better |
| 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 | 3.6% | 1.8% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 0.0% | 15.5% | 6.5% | check this* — see note marked star 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 | 1.5% | 3.4% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 6.3% | 15.4% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 22.5% | 19.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 98.0% | 94.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 11.4% | 4.2% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 8.6% | 21.2% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 40.7% | 21.4% | 17.1% | worse |
| Short-stay residents rehospitalized after admission | 22.5% | 25.7% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 14.3% | 11.9% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.28 | 1.88 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.68 | 1.50 | 1.80 | worse |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
§ 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.
Met the expected recovery: 46.1% 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 26 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 0.21 therapist hours per resident per day in 2026Q1 — more than 24% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 10% 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.4%CMS range 5.7–15.3 | 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 | 46.1% | 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 | 38.5% | 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 | 42.3% | 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 | 92.7% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 | 0.0% | 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 | 2.4% | 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 | 7.8%CMS range 4.4–15.4 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.22 | 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 77 beds and averages 52.3 residents a day — about 68% occupied, or roughly 25 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 3.58 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.42 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.49 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.40 hrs/resident/day on weekends vs 3.65 on weekdays — 7% thinner on weekends. RN hours go from 0.45 to 0.37 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 43% 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 more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
17 citations, most serious first. The 10 most serious are shown; the remaining 7 are one tap away and print in full.
- Potential for harm · D2025-05-21 · 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
Based on observation, record review and interview, the facility failed to provide treatment and care in accordance with professional standards of practice for two Residents (#24 and #199) who were assessed to be at high risk for developing pressure ulcers, out of a total sample of 14 residents. Specifically, 1. For Resident #24, the facility failed to implement a physician's order for a treatment and plan for monitoring a blister. 2. For Resident #199, the facility failed to ensure his/her plan of care was implemented related to skin integrity. Findings include: Review of the facility's policy, not titled, revised 11/1/20 indicated the following: Purpose: To minimize the development of any type of ulcer and other skin issues through the systematic and regular inspections of the resident's skin, and to ensure early detection and interventions for all skin problems. Policy: 2. Residents will undergo a weekly body check by the licensed nurse. The facility will utilize the weekly body check form. 3. Certified Nursing Assistants will inspect the skin of each resident during daily 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 before2025-05-21 · 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, record review and interviews, the facility failed to ensure that respiratory care services, consistent with professional standards of practice, were implemented for two Residents (#16 and #18), out of a total sample of 14 residents. Specifically, facility staff failed to change oxygen and nebulizer tubing in accordance with the physician's orders. Findings include: Review of the facility's policy titled Oxygen Administration and Storage, not dated, indicated the following: -Purpose: Administration of oxygen as ordered by the physician. Ensure safe storage and proper handling of oxygen. -Procedure: 8. Change cannula, humidifier, tubing, and other disposable equipment weekly and as needed. Date, time, and initial tubing when changed. 1a. Resident #16 was admitted to the facility in August 2021 and has diagnoses that include but are not limited to cerebral infarction, chronic diastolic heart failure, and atrial fibrillation. Review of the Minimum Data Set (MDS) assessment, dated 4/24/25,…
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 · D2025-05-21 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and interviews, the facility failed to ensure nursing staff stored drugs and biologicals in accordance with State and Federal requirements. Specifically, the facility failed to ensure two of two treatment carts were locked while a nurse was not present. Findings include: Review of the facility policy titled Storage of Medications, dated 2017, indicated The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized with authorized access. On 5/20/25 from 7:06 A.M. to 7:49 A.M., the surveyor observed the treatment cart unlocked and unsupervised in the A hall. Multiple staff members and residents were observed walking by the treatment cart. On 5/20/25 from 7:45 A.M. to 8:11 A.M., the surveyor observed the treatment cart unlocked and unsupervised in the B hall. Multiple staff members and residents were observed walking by the treatment cart. The surveyor was able to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-05-21 · 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, record review and interview, the facility failed to implement infection control practices to prevent the spread of infection. Specifically, two housekeeping staff failed to perform hand hygiene, and one entered a resident's room wearing potentially contaminated gloves. Findings include: Review of the facility's policy titled Handwashing/Hand Hygiene, not dated indicated the following: This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation included but was not limited to: 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors. 6. In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, use alcohol-based rub containing 60-95% ethanol or isopropanol for all the following situations: b. before donning sterile gloves, j. After removing gloves. During an observation in the B hall on 5/21/25 at 9:14 A.M., the surveyor observed…
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 · D2024-11-20 · 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 records reviewed and interviews, for one of three sampled residents (Resident #1), who on 10/26/24 was found lying on the floor by Nurse #1 after an unwitnessed fall, the Facility failed to ensure nursing reported the incident to the Physician, his/her Guardian, Administrative staff and to the oncoming Nurse as required, and per Facility policy. Findings Included: Review of the Facility's policy, titled Resident Assessment, revised 08/30/24, indicated the Facility shall promptly notify the resident, his/her attending Physician and representatives of changes in the residents medical/mental condition and/or status including an accident or incident involving the resident. Review of the Facility's policy, titled Accident and Incident Reports, undated, per Director of Nurses (DON) reviewed annually in December, indicated all accidents or incidents involving residents to notify the following; the attending Physician and follow any orders promptly, the DON within 24 hours of the incident or accident, the oncoming nurse, the family or responsible party and that it is imperative…
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 · D2024-11-20 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who on 10/26/24, was found lying on the floor by Nurse #1 after an unwitnessed fall, the Facility failed to ensure he/she was provided with nursing care and treatment that met professional standards of quality care, when although Nurse #1 said she assessed Resident #1 prior to moving him/her off of the floor, there was no documentation to support she adequately assessed Resident #1 after his/her fall for potential injury. Findings include: Standard Reference: Standard of Practice Reference: Pursuant to Massachusetts General Law (M.G.L), chapter 112, individuals are given the designation of registered nurse and practical nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a registered nurse and practical nurse bear full responsibility for systematically assessing health status and recording the related health status and recording the related…
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 before2024-06-05 · 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 record reviews, observations and interviews, the facility failed to ensure resident centered care plans were implemented for one Resident (#43) out of a total sample of 14 residents. Specifically, for Resident #43, the facility failed to implement TED hose (compression stockings) as ordered by the Physician. Findings include: Resident #43 was admitted to the facility in November 2022 with diagnoses that included cerebral infarction due to embolism of right middle cerebral artery, aortic aneurysm, and essential primary hypertension. Review of Resident #43's most recent Minimum Data Set (MDS) assessment, dated 3/21/24, indicated Resident #43 scored a 2 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating he/she has severe cognitive impairment. On 6/03/24 at 12:15 P.M., the surveyor observed Resident #43 seated in the dining room eating his/her lunch. Resident #43 was not wearing compression stocking on his/her legs. On 6/05/24 at 7:43 A.M., the surveyor observed Resident #43 seated in his/her room waiting to go to breakfast. Resident #43 was not…
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 · D2024-06-05 · tag F0699 — isolatedProvide care or services that was trauma informed and/or culturally competent.
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 ensure a plan of care was developed for Trauma Informed Care with individualized interventions, for two Residents (#3 and #41) who have a history of Post Traumatic Stress Disorder (PTSD), out of a total sample of 14 residents. Findings include: The facility policy titled Trauma Informed Care, undated, indicated the following: -Traumatic event(s) cause an over-reactive adrenaline response influencing receptor sites. This creates biological changes in the brain. These biological changes persist long after the traumatic event(s). Future situations can make the person be hyper-responsive to these situations. Stress hormones suppress hypothalamic activity which can then create symptoms. Essentially maladaptive learning has been created in the brain. Interventions include: -Utilize all team resources to identify areas of trauma ad triggering events-stimuli -Identify and avoid behavioral triggers -Decrease stimuli that have negative effects 1. Resident #3 was admitted to the facility in January 2018 and had…
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 · D2023-04-25 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to maintain resident's rights after the removal of shaving razors from 1 Resident's (#29) room, out of a total sample of 19 residents. Findings include: Review of the facility policy, titled Dignity and Respect, dated 8/1/22, indicated the following: -The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. -Grooming residents as they wish to be groomed (e.g., hair combed and styled, beards shaved and trimmed, nails clean and clipped). (A care plan will be added if unable to safely groom themselves) Resident #29 was admitted in July 2013 with diagnoses including hypertension. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #29 scored a 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. Additional review of the MDS indicated that Resident #29 required one person physical…
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 · D2023-04-25 · 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 interviews, the facility failed to obtain consent to administer a psychotropic medication for one Resident (#20) out of a sample of 19 Residents. Findings include: Review of the facility policy titled 'Psychotropic Medication Management' effective 10/14/2017 indicated the following: *Obtain physicians order for each psychoactive medication. Ensure that supportive diagnosis and target behaviors are documented and clearly identify the use of the medication is necessary and warranted. *Notify resident or responsible party of initiation of psychoactive medications, and with any changes to dose, and document in record. Resident #20 was admitted to the facility in February 2020 with diagnoses including anxiety disorder and major depressive disorder. Review of the most recent Minimum Data Set (MDS) dated [DATE] indicated that Resident #20 had a Brief Interview for Mental Status (BIMS) score of 13 out of a possible 15, indicating intact cognition. A review of Resident #20's Health Care Proxy…
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 7 citations
- Potential for harm · Dcited before2023-04-25 · 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, the facility failed to develop and implement a comprehensive person-centered care plan for a fluid restriction for 1 Resident (#10) who had a diagnosis of heart failure and end stage renal disease, out of a total sample of 19 residents. Specifically, Resident #10's physician's ordered fluid restriction did not have a break down for fluids per shift and staff were not aware of Resident #10's nursing fluid allowance. Findings include: Review of the facility policy titled, Fluid Restrictions, undated, indicated the total amount of fluids may need to be restricted in residents who have renal failure or congestive heart failure. All residents who are on fluid restrictions should be on daily intake and output. A nurse and a dietician can divide the total fluids allowed per day in the amount to be used on the 3 meal trays and an amount for nursing to utilize between meals and at night. Resident #10 was admitted to the facility in July 2012 with diagnoses including acute kidney injury, congestive heart failure and end stage renal disease. Review of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-04-25 · 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 observation, record review and interviews, the facility failed to revise the plan of care for 1 Resident (#38) out of a total sample of 19 residents. Specifically, the facility failed to ensure that nursing revised a treatment order after Resident #38 who had a diagnosis of heart failure and edema was unable to wear his/her physician's ordered compression stockings (TEDs) on the left leg because Resident #38 sustained an injury. Findings include: Resident #38 was admitted to the facility in October 2019 with diagnosis including heart failure, atrial fibrillation and edema. Review of the Minimum Data Set assessment, dated 4/3/23, indicated Resident #38 can make himself/herself understood and that he/she understands others. The MDS indicated he/she required one person physician assist with dressing which included applying and removing TED hose. Review of the physician's order, dated 10/22/22, indicated for TEDs to be applied in the morning and removed at bedtime for edema. Review of the Nursing Note, dated 4/4/23, indicated Resident #38 was bleeding heavily from his/her left…
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 · D2023-04-25 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record review and interviews, the facility failed to provide assistance with Activities of Daily Living (ADLs), specifically providing assistance with nail care, for one Resident (#17) out of a total sample of 19 residents. Finding included: Review of the facility policy titled, Activities of Daily Living, dated as 1/1/15, indicated Resident's self image is maintained. Resident #17 was admitted to the facility in August 2021 with diagnosis including heart failure, major depression and anxiety. Review of the Minimum Data Set assessment, dated 4/10/23, indicated Resident #17 can make self understood, he/she can understand others and Resident #17 does not have any behaviors. The MDS indicated that indicated Resident #17 required total dependence of one staff member for personal hygiene which included applying makeup and washing hands. During an interview on 4/23/23 at 8:59 A.M., Resident #17 said he/she wanted his/her finger nails trimmed, filed, cleaned and painted. Resident #17 said the staff used to do finger nail care but they have not done his/her nails in 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.
- Potential for harm · D2023-04-25 · tag F0685 — isolatedAssist a resident in gaining access to vision and hearing services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and interviews, the facility and its staff failed to ensure that routine assessments and devices used to maintain hearing were provided for one Resident (#17), out of 19 sampled residents. Specifically, the facility staff failed to provide and implement a treatment plan for chronic ear wax and failed to implement the use of hearing aids when Resident #17 complained of difficulty hearing. Findings include: Review of the facility policy titled, Hearing Aide: Care of, dated 9/1/04, indicated to maintain the resident's hearing aide in optimal condition: -periodically check the auditory canal for irritation, drainage, and soreness. -check ear piece for wax build up -over the ear style: if wax build up, use hearing aide cleaning kit to remove wax. If kit no available forward to hearing aide specialist. -in the care plan document the need, and care of the hearing aide. Resident #17 was admitted to the facility in August 2021 with diagnosis including heart failure, diabetes, major depression and anxiety. Review of the Minimum Data Set assessment, 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 · D2023-04-25 · 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 observations, record reviews and interviews, the facility failed to 1.) ensure an air mattress was on the correct setting for 1 Resident (#41) who had actual skin breakdown and 2.) the facility failed to ensure that an air mattress was on the correct setting and his/her foot was elevated per the plan of care for 1 Resident (#2) with actual skin break down out of a total sample of 19 residents. Review of the facility policy titled Alternating Pressure Air Mattress dated 6/20/2022 indicated the following: Policy: To maintain adequate circulation, to relieve pain due to pressure and aide in healing and prevention of pressure ulcers. Procedures: *Verify MD (Medical Doctor) order and settings in according to manufacturer guidelines. *Check setting and function regularly 1.) For Resident #41, he/she had an actual pressure injury to his/her sacrum (tailbone) and right calf (back part of leg), the facility failed to ensure staff provided treatment and services consistent with professional standards of practice…
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 before2023-04-25 · 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 observations, record review and interview, the facility failed to 1.) ensure Residents received oxygen according to professional standards of practice and in accordance with physician's orders for 2 Residents (#22 and #20) and 2.) failed to maintain a continuous positive airway pressure (CPAP) face mask according to professional standards of practice in a way to prevent possible infections for 1 Resident (#17) out of a total of 19 sampled Residents. Findings include: Review of the facility policy titled 'Oxygen Administration', undated, indicated the following: *A physician order is required for continuous administration of oxygen. The order must include the percentage of oxygen concentration to be delivered expressed as liters/minute. *When oxygen therapy is ordered, the licensed clinician will verify the physician's order. Review of the facility policy titled 'Concentrator Maintenance', undated, indicated the following: Filter Cleaning: *Filters can be cleaned by manually removing dust by wiping 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 · D2023-04-25 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to 1. accurately document a blood sugar vital sign and 2. a meal percentage for 1 Resident (#27) out of a total sample of 19 residents. Findings include: Resident #27 was admitted in April 2018 with diagnoses including type 2 diabetes. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #27 scored a 13 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. 1. Review of the Medication Administration Record (MAR) for 4/19/23 indicated that Resident #27 was scheduled to receive a Novolog Insulin (a medication used to treat high blood sugar) injection after a blood sugar vital was obtained at 7:30 A.M. Review of the MAR indicated that Resident #27 had a blood sugar of 245 and received 2 units of Novolog. Review of the record indicated that the blood sugar was obtained at 9:45 A.M., 2 hours and 15 minutes after the scheduled time. During an interview on 4/24/23 at 9:18 A.M., Nurse #2 said that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“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 |
|---|---|---|---|
| BLAKE, MARK | Individual | DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 10/01/2018 |
| KHAN, AMIR | Individual | DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 10/01/2018 |
| QURESHI, TARIQ | Individual | DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 10/01/2018 |
CMS files one row per role, so the 9 rows in the source record cover these 3 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
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.
About 82% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $600K paid to related parties — landlords or management companies under common ownership — equal to about 11% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
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 225743. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-21, 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.