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Penacook Place, Inc

150 Water Street, Haverhill, MA 01830 · Non profit - Church related · 160 certified beds · (978) 374-0707 Medicare & Medicaid certified

Call the home — (978) 374-0707 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0604, F0607, F0609) — most recent Jan 2026Behavioral-health or dementia-care citation — no harm found (F0744)1 actual-harm citation CMS recorded as corrected before the inspection ended (past non-compliance)$10,868 in federal fines
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • a high payroll-based staffing rating (4/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0607, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $10,868 in federal fines (most recent 2025-04-29)

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.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 3 of 5

Location & what’s nearby

Hospital
Urgent care / clinic
600 Primrose St · (978) 373-6557 · Call to confirm hours
Pharmacy
Walgreens0.3 mi
68 S Main St · (978) 373-0292 · Call to confirm hours
Grocery
2 Water St · (978) 372-0576 · Call to confirm hours
Park
S River St · Typically dawn to dusk
Place of worship

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 3 of 5
Long-stay residentspeople who live here 3 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 improved from 1 to 4 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased15.4%16.4%15.4%typical
Long-stay residents who lose too much weight2.1%5.1%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.8%0.9%better
Long-stay residents with a urinary tract infection0.3%1.8%2.0%better
Long-stay residents with depressive symptoms0.5%15.5%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury4.6%3.4%3.3%worse
Long-stay residents whose ability to walk worsened19.9%15.4%16.1%worse
Long-stay residents on antianxiety or hypnotic medication30.9%19.5%18.9%worse
Long-stay residents given the seasonal flu vaccine99.2%94.8%95.3%typical
Long-stay residents with pressure ulcers2.3%4.2%4.7%better
Long-stay residents with worsening bladder/bowel control24.3%21.2%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table27.6%21.4%17.1%worse
Short-stay residents who newly got an antipsychotic medication3.3%1.4%1.4%worse
Short-stay residents given the seasonal flu vaccine53.7%77.7%79.4%worse
Short-stay residents rehospitalized after admission20.2%25.7%22.6%better
Short-stay residents with an outpatient ER visit20.0%11.9%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.051.881.67worse
Long-stay outpatient ER visits per 1,000 resident days2.071.501.80worse

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.

53.9% 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 133 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

53.9%U.S. median 51.5%
Got home and stayed home
11.4%U.S. median 10.7%
Went back to hospital
48.0%U.S. median 56.6%
Met the expected recovery
0.08U.S. median 0.31
Therapy hours / resident / day
0.03hours / resident / day
Physical therapy
0.06hours / resident / day
Occupational therapy

Met the expected recovery: 48.0% 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 50 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 0.08 therapist hours per resident per day in 2026Q1 — more than 4% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 4% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF53.9%CMS range 45.7–60.851.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.4%CMS range 8.6–14.910.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge48.0%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge48.0%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge32.0%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified91.7%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot 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 dischargenot 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 stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.0%CMS range 2.8–11.27.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.751.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.64
RN hours/ resident / day
0.79
LPN hours/ resident / day
2.32
Aide hours/ resident / day
3.76
Total nurse hours/ resident / day
0.38
RN hoursweekends
39.0%
Total nursing turnover
30.8%
RN turnover

How full it usually is: this home is certified for 160 beds and averages 101.8 residents a day — about 64% occupied, or roughly 58 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 3.76 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.64 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.32 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 3.63 hrs/resident/day on weekends vs 3.81 on weekdays — 5% thinner on weekends. RN hours go from 0.75 to 0.38 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 39% 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

0
deficiencies at the latest standard inspection (2025-06-04)
5
at the previous standard inspection (2024-05-08)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

26 citations, most serious first. The 11 most serious are shown; the remaining 15 are one tap away and print in full.

  • Actual harm · G2025-04-29 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure he/she was free from a significant medication error, when on 03/18/25 he/she was administered the incorrect dose of long acting insulin. Resident #1 experienced an adverse reaction, including lethargy and malaise, for which he/she required treatment and increased monitoring by nursing until his/her blood sugar level stabilized. Findings include: The Facility Policy, titled Insulin Administration, dated revised 09/2014, indicated nursing would verify the type of insulin, dosage requirements, strength, and method of administration before administration, to confirm it corresponds with the physician's orders. The Facility Policy, titled Adverse Consequences and Medication Errors, dated revised 02/2023, indicated that a medication error was defined as the preparation or administration of drugs or biologicals which was not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principals of the professional providing…

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

    Pharmacy Service Deficiencies · Past Non-Compliance
  • Potential for harm · D2026-01-20 · tag F0607 — failed to have anti-abuse policies — isolated
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was severely cognitively impaired and dependent on staff to meet his/her care needs, the facility failed to ensure staff consistently implemented and followed their abuse policy related to protection and reporting abuse allegations, when on 12/13/25 Certified Nurse Aide (CNA) #2 witnessed, but did not immediately report, that Resident #1 was allegedly verbally abused by a staff member, and waited until 12/16/25 (three days later) to report the incident, therefore placing Resident #1 and other residents on the unit at risk for potential abuse.Findings include:Review of the Facility Policy titled Compliance with Reporting Allegations of Abuse/Neglect/Exploitation, dated 03/01/25, indicated it is the policy of this facility to report all allegations of abuse/neglect/exploitation or mistreatment immediately to the Administrator of the facility. The Policy indicated the facility will develop and operationalize policies and procedures for the protection of residents and for the reporting 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-01-20 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on records reviewed and interviews for one of three sampled residents (Resident #1), who was severely cognitively impaired, the Facility failed to ensure staff consistently implemented and followed policies and procedures to immediately report an altercation of abuse to Administrative staff as required, so the Facility could report the incident to the State Survey Agency, within the required time frames. On 12/13/25 although a staff member witnessed Certified Nurse Aide (CNA) #1 engage in a suspected verbally abusive altercation with Resident #1, it was not reported to Administration until 12/16/25, and therefore not reported to their State Survey Agency, until three days later.Findings include: Review of the Facility Policy titled Abuse, Exploitation or Misappropriation-Reporting and Investigating, dated September 2022, indicated all reports of resident abuse are reported to local, state and federal agencies (as required by current regulations). The Policy indicated that if abuse is suspected, the suspicion must be reported immediately to the administrator and to other…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-08 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview and record review, the facility failed to follow the plan of care for one Resident (#100) by not following a doctor's order to offload heels, out of a total sample of 24 residents. Findings include: Resident #100 was admitted to the facility in August 2023 with diagnoses including dementia and pain in both feet. Review of Resident #100's most recent Minimum Data Set (MDS) assessment, dated 5/2/24, indicated the Resident had a Brief Interview for Mental Status exam score of 3 out of a possible 15, which indicated he/she had severe cognitive impairment. The MDS also indicated Resident #100 is dependent on staff for all bed mobility tasks. On 5/06/24 at 8:37 A.M., Resident #100 was observed lying in bed with both heels directly on the bed. There was no pillow present in the bed or in the room to offload pressure from Resident #100's heels. On 05/07/24 at 7:36 A.M., 8:37 A.M., and 1:47 P.M., Resident #100 was observed lying in bed with both heels directly on the bed. There was no…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-08 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility staff failed to provide supervision with meals for one Resident (#37) out of a total sample of 24 residents. Findings include: Resident #37 was admitted to the facility in October 2021 with diagnoses including dementia. Review of the most recent Minimum Data Set (MDS) assessment, dated 4/25/24, indicated that Resident #37 could not participate in the Brief Interview for Mental Status exam and was assessed by staff to have severely impaired cognition. The MDS further indicated that Resident #37 requires supervision with eating. Review of Resident #37's current activities of daily living care plan indicated that Resident #37 requires supervision after setup with eating. Review of the most recent Functional Abilities and Goals Assessment, dated 4/26/24, indicated that Resident #37 requires supervision or touching assistance with meals. Review of the task performance documentation for the last 30 days indicated that Resident #37 required varying assistance levels between independence and dependence with meals. During 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-08 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review, and policy review, the facility failed to ensure that one Resident (#57), out of 24 total sampled residents, received treatment and care in accordance with professional standards of practice. Specifically, the facility failed to obtain weekly wound measurements and failed to obtain recommendations for wound treatments from a follow-up physician appointment for Resident #57. Findings include: The facility policy titled Skin Tears - Abrasions and Minor Breaks, Care of, revised September 2013, indicated, but was not limited to: -Obtain a physician's order as needed. Document physician notification in medical record. -Review the resident's care plan, current orders, and diagnoses to determine resident's needs. -Generate a Non-Pressure form and complete. Resident #57 was admitted to the facility in October 2022 with diagnoses including peripheral vascular disease and diabetes. Review of the most recent Minimum Data Set (MDS) assessment, dated 3/07/24, indicated that Resident #57 was cognitively intact as evidenced by a Brief Interview 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-08 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record reviews and interviews, the facility failed to provide respiratory care services in accordance with professional standards of practice. Specifically, the facility failed to ensure oxygen administration was in accordance with the medical plan of care for one Resident (#5) out of a total sample of 24 residents. Findings include: The facility policy titled Oxygen Administration, undated, indicated the following but not limited to: -The purpose of this procedure is to provide guidelines for safe oxygen administration. -Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Resident #5 was admitted to the facility in June 2023 with diagnoses including chronic obstructive pulmonary disorder, neoplasm of bronchus or lung, chronic respiratory failure and dependent on supplemental oxygen. Review of Resident #5's most recent Minimum Data Set (MDS) assessment, dated 4/18/24, indicated Resident #5 scored a 10 out of 15 on the Brief Interview for Mental Status exam indicating 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-08 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, policy reviews and interviews, the facility failed to provide care and services consistent with professional standards for two Residents (#103 and #57) who required renal dialysis (a life sustaining treatment that helps the body remove extra fluid and waste products from the blood when the kidneys are not able to) out of a total sample of 24 residents. Specifically, the facility failed to ensure that clamps and pressure dressings were kept with the Resident's #103 and #57 in case of an emergency related to a tunneled hemodialysis catheter (a plastic tube used for exchanging blood between a patient and a hemodialysis machine). Findings include: The facility policy titled End-Stage Renal Disease, Care of a Resident with (sic), dated as revised September 2023, indicated the following but not limited to: -Residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care. -Staff caring for residents with ESRD, including residents receiving…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-12-12 · tag F0604 — failed to not use physical restraints improperly — isolated
    Ensure 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records reviewed, interviews and review of surveillance camera video footage, for one of three sampled residents (Resident #1), who had a diagnosis of Alzheimer's disease and was cognitively impaired, the Facility failed to ensure he/she was treated in a respectful and dignified manner which included being free from the use of restraints, when on 11/20/23, Certified Nurse Aide (CNA) #1 used a plastic bag to secure one of the wheels of Resident #1's wheelchair to restrict his/her movement and limit his/her ability to self propel the wheelchair on his/her own. Findings include: Review of the Facility Policy titled Use of Restraints, no date, indicated that examples of devices that are/might be considered physical restraints include leg restraints, arm restraints, hand mitts, soft ties or vests, wheelchair safety bars, Geri-chairs, lap cushions and lap trays that the resident cannot remove. Resident #1 was admitted to the Facility in April 2022, diagnosis included chronic kidney disease, Meniere's disease,…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
  • Potential for harm · E2023-03-20 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor 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

    Based on observations, record reviews, policy reviews and interviews the facility failed to 1) provide a dignified dining experience for the residents on the Dementia Care Specialty Unity (DSCU) and 2a) failed to provide a dignified experience for 1 Resident (#188) by not providing a privacy bag for a foley catheter and 2b) For Resident #188 leaving him/her without a top sheet or blanket, leaving genitals exposed, out of a total sample of 35 residents. Findings include: 1. Review of the facility policy, Quality of Life - Dignity undated, indicated the following: *Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. *Staff shall speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not labeling or referring to the resident by his or her room number, diagnosis or care needs. During observation of the breakfast meal on 3/16/23 at 8:17 A.M., the following was observed: *A Certified Nursing Assistant (CNA) passed out a breakfast tray to a Resident in his/her…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-03-20 · tag F0656 — failed to write and follow a full care plan — pattern
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. Resident #239 was admitted in 03/2023 with diagnoses including localized edema. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #239 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. Review of the physician's orders indicated that an order was initiated on 3/10/23 for ace wrap to left lower extremity daily prior to getting out of bed. Review of the behavior tracking documentation does not indicate that Resident #239 has any behaviors. During an observation on 3/15/23 at 7:54 A.M., Resident #239 was not wearing ACE wraps on his/her left lower extremity. During an observation on 3/17/23 at 11:26 A.M., Resident #239 was out of bed and not wearing ACE wraps on his/her left lower extremity. During an interview on 3/17/23 at 11:26 A.M., Resident #239 said that he/she has not had any ACE wraps on since admission. During an interview on 3/17/23 at 2:49 P.M., the Director of Nursing said that if there was an order for ACE wraps then it…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
Show the remaining 15 citations
  • Potential for harm · E2023-03-20 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure 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, interview and policy review, the facility failed to 1) properly store food items to prevent the risk of foodborne illness and 2) follow proper food handling practices to prevent the risk foodborne illness and contamination. Findings include: Review of the facility policy titled Food Storage, undated, indicated the following: *Leftover food will be stored in covered containers or wrapped carefully and securely and clearly labeled and dated before being refrigerated. Leftover food must be used within 72 hours or discarded. *Refrigerated food storage: Cooked foods will be stored above raw foods to prevent contamination. Raw animal foods must be separated from each other and stored on lower shelves (below cooked foods or raw fruits and vegetables) and in drip proof containers. Review of the facility policy titled General Food Preparation and Handling, undated, indicated the following: *Bare hands must never touch ready to eat raw food directly. Disposable gloves are a single use item and must be discarded after each use. Employees must wash hands prior to putting…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-03-20 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interviews, the facility failed to appropriately wear Personal Protective Equipment (PPE) to prevent the spread of infection on 2 out of 4 units. Findings include: Throughout the days of survey, the following was observed: On 3/15/23 at 7:30 A.M., two nurses were observed at the 2 North nursing station. One nurse was wearing a mask on her chin, not covering her mouth or nose and the second nurse was wearing her mask below her nose. There were several residents in the area. On 3/15/23 at 12:29 P.M., a Certified Nursing Assistant (CNA) was eating at the 2 South nursing station while talking with a resident. Her mask was on her chin. On 3/15/23 at 12:44 P.M. a nurse was sitting at the 2 North nursing station with her mask below her nose. There were several residents in the area. On 3/16/23 at 12:14 P.M., a nurse was standing at the 2 North nursing station not wearing a mask. There were several residents in the area. On 3/16/23 at 2:35 P.M., an activity assistant was in the 2 South activity room with residents and her mask was on her chin, below her mouth and…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-03-20 · tag F0947 — failed to train nurse aides adequately — pattern
    Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to ensure that 5 of 5 Certified Nursing Assistants reviewed, received 12 hours of mandatory in-service training in a year. During review of 5 of the facility's CNA education records on 3/17/23 at 1:30 P.M., there was no evidence that the CNA's received the 12 hours of required annual in-service education training. During an interview on 3/17/23 at 2:46 P.M., the Administrator said the facility did a poor job providing training last year and most of it had not been completed.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-20 · tag F0552 — isolated
    Ensure 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 obtain an informed consent for the use of psychotropic medication for 3 Residents (#12, #96 and #88) out of a total sample of 35 residents. Findings include: Based on the facility policy titled, Psychotropic Medications - Instruction Sheet, undated, indicated the following: *When an order to initiate a psychotropic medication is given, the provider must have a documented conversation with the resident or the HCP (if activated). These include all antipsychotics, antidepressants, and anxiolytics. *A psychotropic Med form must be filled out by the nurse. The patient or HCP has to sign the form with the nurse as a witness. The provider does not need to sign the form, but the date and time of the provider conversation must be documented on the form. *Consent forms need to be resigned and the provider has to have another documented conversation if the medication dose rates range changes from its original parameters, if a new Med is initiated, if the HCP…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-03-20 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and policy review, the facility failed to report a potential incident of abuse for 1 Resident (discharged Resident #1) out of 35 sampled residents. Findings include: Review of the facility policy titled Abuse Policy and Procedures, dated, April 1, 2017, indicated the following: *Any alleged violations and all substantiated incidents of any form of abuse or suspicious injuries of unknown origin will be reported to the state agency and to all other agencies as required by State and Federal regulations. *When an alleged or suspected case of abuse mistreatment, neglect, exploitation, misappropriation, of resident property, or injuries of unknown origin is reported, the Administrator, or designee, will immediately notify the State Agency but no later than 2 hours after the allegation are made. discharged Resident #1 was admitted to the facility in October 2022 with diagnoses that include unspecified fracture of femur, anxiety disorder and major depressive disorder. 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-03-20 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and interviews, the facility failed to provide assistance with meals for 2 Residents (#41 and #51) out of a total sample of 35 residents. Findings include: 1. Resident #41 was admitted to the facility in April 2022 with diagnoses including Alzheimer's disease. Review of Resident #41's most recent Minimum Data Set (MDS) dated [DATE] indicated the Resident has a Brief Interview for Mental Status (BIMS) score of 3 out of a possible 15 which indicates he/she has severe cognitive impairment. The MDS also indicates Resident #41 requires supervision during meals. On 3/15/23 at 8:18 A.M., Resident #41 was observed eating breakfast in bed. Resident #41 was attempting to eat scrambled eggs with his/her fingers without success. Resident #41 then began to use his/her finger to spread jelly on a piece of toast. Resident #41 was not observed eating any food from 8:18 A.M. to 8:37 A.M., and no staff entered the room to assist him/her or to provide supervision. On 3/15/23 at 12:39 P.M.,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-20 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide 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 ensure an air mattress was on the correct setting for 2 Residents (#51 and #24) who were at high risk of pressure ulcers, out of a total sample of 35 residents. Findings include: 1. Resident #51 was admitted to the facility in January 2021 with diagnoses including dementia, dysphagia and psychotic disorder. Review of Resident #51's most recent Minimum Data Set (MDS) dated [DATE] indicated the Resident has a Brief Interview for Mental Status (BIMS) score of 3 out of a possible 15 indicating he/she has severe cognitive impairment. The MDS also indicated Resident #51 requires supervision for feeding tasks. On 3/15/23 at 8:21 A.M., 3/16/23 at 8:24 A.M., and 3/17/23 at 8:18 A.M., Resident #51 was observed lying in bed with his/her air mattress set to 325 pounds. Review of Resident #51's most recent weight taken on 1/25/23, indicated Resident #51 weighs 164 pounds. Review of Resident #51's physician orders indicated an order written on…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, policy review and interviews, the facility failed to prevent a fall for 1 Resident (#68) out of a total sample of 35 residents. Findings include: Review of the facility policy titled, Fall Prevention Policy, dated November 2022 indicated the following: *All of our residents are at risk for falls. Some residents happen to be at a higher risk than others related to medications, changes in medical condition, and competitive or physical decline. The most evidence based practice states that a patient who has sustained a recent fall is at the highest risk to fall again. *All (facility) staff are responsible for keeping residents safe. *IDT (Interdisciplinary Team) will determine the most appropriate and patient specific interventions for ongoing fall prevention. *Following a fall, the care plan is to be updated with intervention as related to the fall immediately after the incident if the resident is not transferred to the hospital - the new intervention will be relayed to all staff working…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-20 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    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, policy review and interviews, the facility 1) failed to address a significant weight loss for 1 Resident (#74) and 2) failed to implement nutritional interventions for 2 Residents (#96 and #51), out of a total sample of 35 residents. Findings include: Review of the facility policy titled, Interventions for Unintended Weight Loss, dated 2021, indicated the following: *Unintended weight loss or gradual weight loss will be identified and monitored so that appropriate and individualized interventions can be implemented. 1. Resident #74 was admitted to the facility in April 2022 with diagnoses including Alzheimer's disease and dysphagia. Review of Resident #74's most recent Minimum Data Set (MDS) dated [DATE] indicated the Resident has a Brief Interview for Mental Status (BIMS) score of 4 out of a possible 15 which indicates he/she has severe cognitive impairment. Review of Resident #74's weights indicated the following: On 10/10/2022 Resident #74 weighed 138.0 Lbs. (pounds) On…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-20 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    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 follow professional standards in changing tube feeding administration sets every 24 hours for 1 Resident (#188) out of a total sample of 35 residents. Review of facility policy titled, Enteral Tube Feeding-NG tube, G-tube, J-tube or other updated date April 2018 included: -Cover, label with initials and date, and refrigerate remaining formula. Use within 24 hours. -Change administration sets and administration supplies every 24 hours. Resident #188 was admitted to the facility in February 2023 with diagnoses including Multiple sclerosis, tracheostomy status, and gastrostomy status. Review of the most recent Minimum Data Set Assessment (MDS) dated , 3/14/23, indicated a Brief Interview for Mental Status score of 14 out of a possible 15 indicating intact cognition. The MDS indicated Resident #188 required total assistance for all hygiene tasks and required tube feedings. Further review indicated Resident #188 required oxygen, tracheostomy care and suctioning. During an observation on 3/17/23 at 8:21 A.M.,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-03-20 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to 1). follow physicians' orders for oxygen use for one Resident (#188) and 2). failed to obtain a physician order for oxygen for one Resident (#24) out of a total of 35 sampled residents. Findings include: -Review of facility policy titled, Oxygen Administration, included: -Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 1. Resident #188 was admitted to the facility in February 2023 with diagnoses including acute respiratory failure, tracheostomy status, and multiple sclerosis. Review of the most recent Minimum Data Set Assessment (MDS) dated [DATE], indicated a Brief Interview for Mental Status score of 14 out of a possible 15 indicating intact cognition. Further review of the MDS indicated Resident #188 required total assistance for all hygiene tasks and required abdominal feedings. Further review indicated Resident #188 required oxygen, tracheostomy…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-20 · tag F0744 — failed to care for residents with dementia — isolated
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to develop a dementia care plan with measurable goals and interventions to address the care and treatment for a resident with dementia for 1 Resident (#88) out of a total sample of 35 residents. Resident #88 was admitted to the facility in November 2021 with diagnoses including, dementia, benign prostatic hyperplasia without lower urinary tract symptoms, and acquired absence of kidney. Review of the most recent Minimum Data Set Assessment, dated 12/29/22, indicated a Brief Interview for Mental Status score of 11 out of a possible 15 indicating moderate cognitive impairment. Review of Resident #88's medical record indicated: -A Health status note dated 3/9/23, indicated Resident #88 had exhibited increased behaviors, including yelling/screaming and using foul language. -A Health status note dated 3/7/23, indicated Resident #88 had increased behaviors, only alert to self, confused and irritable. -A health status note dated 2/5/23, indicated Resident started to get agitated around 2:00 P.M. --A health status noted dated 2/4/23…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-20 · tag F0825 — isolated
    Provide or get specialized rehabilitative services as required for a resident.
    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 provide rehab services in a timely manner for 1 Resident (#114) out of a total sample of 35 residents. Findings include: Resident #114 was admitted in 07/2022 with diagnoses including cellulitis. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #114 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. Review of the MDS indicated that Resident #114 requires limited assistance to dependence with all activities of daily living except eating. Review of the progress note, dated 7/5/23, indicated that Resident #114 was admitted for short term rehab following a hospitalization. Review of the hospital discharge note, dated 6/29/22, indicated that it was recommended that Resident #114 received continued skilled PT services 2-5 times per week. Review of the Physical Therapy Plan of Care note, dated 8/8/22, indicated the following: Patient seen for PT (physical therapy) eval to restart…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-20 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to accurately document application of oxygen in the Treatment Administration Record (TAR) for 1 Resident (#188) out of a total sample of 35 residents. Resident #188 was admitted to the facility in February 2023 with diagnoses including Multiple sclerosis, tracheostomy status, and gastrostomy status. Review of the most recent Minimum Data Set Assessment (MDS), dated [DATE], indicated a Brief Interview for Mental Status score of 14 out of a possible 15 indicating intact cognition. Further review of the MDS indicated Resident #188 required total assistance for all hygiene tasks and required abdominal feedings. Further review indicated Resident #188 required oxygen, tracheostomy care and suctioning. During an observation on 3/17/23 at 8:21 A.M., Resident #188 was observed lying in bed with tubing from an oxygen concentrator set to 5 liters per minute that was connected to a tracheostomy. Additional observations were made on 3/17/23 at 10:14 A.M.…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2023-03-20 · tag F0641 — pattern
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — the official record, unedited, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to accurately code a Minimum Data Set assessment for 1 Resident (#137) out of a total sample of 35 residents. Finding include: Resident #137 was admitted to the facility in December 2022 with diagnoses including a femur fracture. Review of Resident #137's social service discharge note dated 12/15/22, indicated the Resident was discharged back to his/her home. Review of Resident #137's discharge Minimum Data Set (MDS) dated [DATE] indicated the Resident was discharged to an acute hospital. During an interview on 3/17/23 at 10:46 A.M., the MDS nurse said the Resident was discharged home and the MDS was inaccurate.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

$10,868 in federal fines across 1 penalty.

  • $10,868 — penalty dated 2025-04-29

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 COVENANT HEALTH — 8 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 4 of 53.0+1.0 vs chain
Health inspection 4 of 52.8+1.2 vs chain
Staffing 4 of 54.4-0.4 vs chain
Quality measures 3 of 52.9+0.1 vs chain
The other 7 homes this chain runs (chain average 3.0★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleSince
CASTILLO, NICOLEIndividualW-2 MANAGING EMPLOYEEsince 05/18/2018
BELL, MICHAELIndividualCORPORATE DIRECTORsince 10/20/2020
DELANEY, JOHNIndividualCORPORATE OFFICERsince 09/01/2020
MASYS, CAITLINIndividualCORPORATE OFFICERsince 01/01/2017
MORTIMER, THOMASIndividualCORPORATE OFFICERsince 01/01/2012
RIOPELLE, JUDITHANNIndividualCORPORATE OFFICERsince 01/01/2020
SARRO, JOHNIndividualCORPORATE OFFICERsince 01/01/2017
SHAW, GREGORYIndividualCORPORATE OFFICERsince 01/01/2019

The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.

Follow the money — this home’s finances

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

$13.8M
Net patient revenuemost recent cost report
-27.8%
Operating marginrevenue minus expenses
$363K
Related-party expense2% of expenses
Who pays — share of resident-days
Medicaid 78%Medicare 5%Other / private 17%

About 78% 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 $363K 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

$356per resident / day
operating cost
$10,809per month
≈ monthly operating cost
$278per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in MA

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Massachusetts Medicaid page.

Typical monthly cost in Massachusetts
$14,448/mo
Nursing home (semi-private)
$15,817/mo
Nursing home (private)
$9,600/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 225376. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-04, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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