Royal Wood Mill Center
800 Essex Street, Lawrence, MA 01841 · For profit - Limited Liability company · 94 certified beds · (978) 289-5048 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0607, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 2 actual-harm citations
- 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
- its payroll-based staffing rating is low (2/5)
- its facility-reported quality-measure rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 1 of 5 |
| Short-stay residentsrehab / post-hospital | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 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 | 29.6% | 16.4% | 15.4% | worse |
| Long-stay residents who lose too much weight | 2.4% | 5.1% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.3% | 0.8% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 4.8% | 1.8% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 78.4% | 15.5% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 0.8% | 3.4% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 27.5% | 15.4% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 25.7% | 19.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 98.6% | 94.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.6% | 4.2% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 26.7% | 21.2% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 45.5% | 21.4% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 1.9% | 1.4% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 74.3% | 77.7% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 33.1% | 25.7% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 13.2% | 11.9% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 2.11 | 1.88 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.95 | 1.50 | 1.80 | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
Met the expected recovery: 25.0% 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 20 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 0.14 therapist hours per resident per day in 2026Q1 — more than 11% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 39% 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 | 11.2%CMS range 8.0–16.9 | 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 | 25.0% | 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 | 30.0% | 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 | 30.0% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 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 | 3.6% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.92 | 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 94 beds and averages 60.3 residents a day — about 64% occupied, or roughly 34 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 0.57 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.02 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 3.23 hrs/resident/day on weekends vs 3.97 on weekdays — 19% thinner on weekends. RN hours go from 0.63 to 0.42 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 50% is about the same as the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
26 citations, most serious first. The 12 most serious are shown; the remaining 14 are one tap away and print in full.
- Actual harm · Gcited before2024-04-09 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had dementia, was known to wander and put objects in his/her mouth, the Facility failed to ensure that he/she was provided with an adequate level of staff supervision and an environment that was free from safety hazards, when on 03/29/24 nursing staff failed to secure medications delivered from the pharmacy, left them unattended at the Nurses' Station, and Resident #1 gained accessed to and was believed to have ingested multiple Seroquel (antipsychotic) and Risperidone (antipsychotic) tablets. Resident #1 was transferred to the Hospital Emergency Department for evaluation and monitoring, later that evening he/she required intubation and admission to the Hospital Intensive Care Unit. Findings include: The Facility Policy, titled Safety and Supervision of Residents, dated 11/2017, indicated the Facility would maintain an environment as free from accident hazards as possible, and resident safety, supervision, 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.
- Actual harm · Gcited before2024-04-09 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was known to wander, rummage, and eat food he/she found, the Facility failed to ensure that medications were kept locked up (secured) or under direct supervision of nursing staff, when on 03/29/24, Nurse #1 left a medication package delivered from the Pharmacy unattended on the desk at the Nurses' Station, and as a result, Resident #1 was later found with the opened package and was believed to have ingested multiple Seroquel (antipsychotic) and Risperidone (antipsychotic) tablets. Resident #1 was transferred to the Hospital Emergency Department for evaluation and monitoring, and later required intubation and admission to the Hospital Intensive Care Unit. Findings include: The Facility Policy, titled Storage of Medications, dated 05/2023, indicated the Facility would store all drugs and biologicals in a safe, secure, and orderly manner. Review of the Facility's Investigation Report, undated, indicated that on 03/29/24,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-25 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to provide services that meet professional standards of quality as evidenced by failing to implement physician's orders for one Resident (#30), out of a total sample of 23 residents. Specifically, for Resident #30, the facility failed to implement a physician's order to administer Pyridostigmine Bromide (a medication to treat orthostatic hypotension/low blood pressure).Findings include: Review of [NAME], Manual of Nursing Practice 11th edition, dated 2019 indicated the following: - The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated the following: Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber that are received by a variety of methods (i.e.,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-09 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had dementia, with known behaviors of being intrusive and rummaging, the Facility failed to ensure they provided an environment free from accident hazards, when Resident #1 was able to get a hold of and consumed an object not meant for human consumption.Findings include:The Facility Policy, titled Safety and Supervision of Residents, dated as revised 05/2025, indicated the Facility would strive to provide an environment as free from accident hazards as possible, and resident supervision was a core component of the systems approach to safety.The Facility Policy, titled Meal Supervision and Assistance, dated 01/2025, indicated residents would be provided meals in the location of his/her preference and with adequate supervision and assistance to prevent accidents.Resident #1 was admitted to the Facility in November 2012, diagnoses included stroke, schizophrenia, anxiety, and dementia.Review of Resident #1's Activities of Daily Living (ADLs) Care Plan, dated as initiated 03/27/24 and renewed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-04-09 · tag F0658 — failed to meet professional standards of care — patternEnsure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Review of the facility policy titled Administering Medications, dated August 2024, failed to indicate that the nurse is to check the medications against the physician's orders. During medication pass on 4/7/25, at 8:48 A.M., Nurse #3 told the surveyor that her medication cart computer was broken. Nurse #3 then said that she was stationing her medication cart near the nurse's station because she was using the computer at the nurse's station to pass medications. The surveyor then observed Nurse #3 read from the computer at the nurse's station. Nurse #3 then returned to the medication cart where she dispensed four medications into a medication cup from memory. The surveyor then observed Unit Manager (UM) #1 print out a list of 3 more medications and hand the list to Nurse #3. Nurse #3 dispensed the medications from the list. UM #1 then told Nurse #3 that she could not print out the remaining medications scheduled to be dispensed, wrote them out on a piece of paper and handed the hand written list to Nurse #3.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-04-09 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and policy review, the facility failed to ensure staff stored drugs and biological's in accordance with State and Federal requirements. Specifically: 1. The facility failed to ensure medication and treatment carts were locked while a nurse was not present and failed to ensure medications were not left unattended on top of the medication cart when a nurse was not present. 2. The facility failed to ensure medications were not left at the bedside for one Resident (#64) out of a total of 20 sampled Residents. Findings include: 1. Review of the facility policy titled Administering Medications, dated August 2024 indicated that during the administration of medications, the medication cart will be kept closed and locked when out of sight of the nurse. Further review indicated that no medications are to be left on top of the cart and all medications must be inaccessible to residents and other passers by. Review of the facility policy titled Storage of medications, not dated, indicated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-04-09 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard 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, record review and interview, the facility failed to ensure medical records were complete and accurate for 4 residents, (#40, #30, #2 and #268) out of total of 20 sampled Residents. Specifically: 1. For Resident #40, the facility failed to accurately document an order and implementation related to oxygen use. 2. For Resident #30 the facility inaccurately documented that they took blood pressures on the correct arm. 3. For Resident #2, the facility inaccurately documented that they applied both seizure pads in the Resident's bed. 4. For Resident #268, the facility inaccurately documented that the air mattress settings were set correctly. Findings include: Review of the Charting and Documentation policy, undated, indicated: Documentation in the medical record will be objective (not opinionated or speculative), complete and accurate. 1. Resident #40 was admitted to the facility in January 2025 with diagnoses including acute respiratory failure with hypoxia and type II diabetes. Review of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-09 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure staff implemented abuse policies and procedures for one Resident (#28) out of a total of 20 sampled Residents. Specifically, for Resident #28 staff failed notify facility administration of an accusation that a Certified Nurse's Aide (CNA) wrapped a remote cord around his/her neck. Findings include: Review of the facility policy titled Abuse, undated, indicated that any employee who suspects an alleged violation shall immediately notify the executive director or his/her designee. Resident #28 was admitted to the facility in January 2025 with diagnoses including stroke with left sided hemiplegia/hemiparesis, dementia and depression. Review of the Minimum Data Set (MDS) dated [DATE] indicated that Resident #28 is totally dependent for all activities of daily living and scored an 11 out of 15 on the Brief Interview for Mental Status exam indicating moderate cognitive impairment. Review of the progress notes dated 3/23/25 at 21:28 indicated that at…
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 · D2025-04-09 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to report an incident of resident to resident abuse to the state agency for one Resident (#11) out of a total sample of 20 residents. Findings include: Review of the facility policy titled Abuse Policy, undated, indicated the following: - The ED (executive director) shall also notify the appropriate state agency in accordance with the state law. - The results of all investigations must be reported immediately to the ED or his/her designee and the appropriate state agency, as required by state law. Resident #11 was admitted in November 2010 with diagnoses including dementia. Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #11 scored a three out of a possible 15 on the Brief Interview for Mental Status exam, indicating severe cognitive impairment. Review of the MDS indicated Resident #11 has verbal and physical behaviors. Review of the incident report, dated 9/29/24, indicated Resident #11 walked into another Resident's room and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-09 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
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 thoroughly investigate an injury of uknown origin for one Resident (#18) out of a total sample of 21 residents. Specifically, Resident #18 was found to have a dislocated shoulder and the facility interviewed the staff on the morning shift of the incident, but no other staff that had taken care of Resident #18. Findings include: Review of the policy titled Abuse Policy, undated, indicated the following: -The facility shall take the following steps to prevent, detect, and report abuse, neglect, injuries of unknown source, and misappropriation of resident property. - Where the circumstances of the alleged violation warrants, the DNS or his/her designee, shall initiate a physical and mental assessment of the resident and document the findings. Factual information only shall be documented, no assumptions. - Interview staff members implicated. - Interview other staff members. Employee should document incident in a written statement. - Interview with resident…
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 · D2025-04-09 · tag F0626 — isolatedPermit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record review, for one of two sampled discharge residents (Resident #67), the facility failed to permit Resident #67 to return following an evaluation in the emergency department (ED) when on 02/10/25, the Facility considered Resident #67 discharged at the time of the transfer. Findings include: Review of the facility policy titled Transfer and Discharge (including AMA), dated revised January 2025, indicated that an emergent section 12 discharge authorizes temporary involuntary hospitalization for up to 72 hours. Further review indicated that the resident will be permitted to return to the facility upon discharge from the acute care setting if the resident's needs can be met by the facility. Resident #67 was admitted to the facility in February 2025 with diagnoses including disorganized schizophrenia, high blood pressure and schizoaffective disorder. Review of the progress note dated 2/7/25, indicated that Resident #67 scored a 15 out of 15 on the Brief Interview for Mental Status exam, indicating intact cognition. Review of the progress notes dated 2/10/25,…
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 · D2025-04-09 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to update the plan of care after an incident of physical abuse for one Resident (#11) out of a total sample of 20 residents. Findings include: Review of the policy titled Abuse Policy, undated, indicated the following: - The facility shall take the following steps to prevent, detect, and report abuse, neglect, injuries of unknown source, and misappropriation of resident property. - ABUSE: unjustified physical contact, intentional or careless, which is likely to result in physical or psychological harm. - If the suspected perpetrator is another resident, the DNS (director of nursing services) or his/her designee, shall separate the residents so they do not have access to each other until the circumstances of the alleged incident can be determined. - Where the circumstances of the alleged violation warrants, the DNS or his/her designee, shall initiate a physical and mental assessment of the resident and document the findings. Factual information only shall…
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 14 citations
- Potential for harm · D2025-04-09 · 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 record review and interview, the facility failed to follow a physician's order for air mattress settings for three Residents (#49, #17 and #268) out of a total sample of 20 residents. Findings include: Review of the policy titled Prevention of Pressure Ulcers/Injuries, dated May 2023, indicated the following: - Select appropriate support surfaces based on the resident's mobility, continence, skin moisture and perfusion, body size, weight, and overall risk factors. Review of the facility policy titled Support Surface Guidelines, dated October 2023, indicated the following: - Any individual at risk for developing pressure ulcers may be placed on a redistribution support surface, such as foam, gel, static air, alternating air, or air-loss or gel when lying in bed. - Support surfaces alone are not effective in preventing pressure ulcers, but studies indicate that the use of appropriate support surfaces with interventions such as turning, repositioning and moisture management can assist in reducing pressure…
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 before2025-04-09 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interview, the facility failed to ensure three residents (#58, #17, and #2) were free from accidents and hazards including elopement and failed to ensure the appropriate interventions were implemented for safety. Specifically, 1. For Resident #58, the facility to a. prevent an elopement from a secured unit and b. perform a thorough investigation 2. For Resident #17, the facility failed to implement a falls intervention 3. For Resident #2, the facility failed to apply seizure pads to bilateral side rails as ordered Findings include: Review of the facility policy titled Resident Elopement and Wandering, dated June 2024, indicates the following: - Resident elopement is defined as that situation where a cognitively impaired resident or someone with impaired safety awareness actually leaves the facility premises/property without staff knowledge. - When the resident is located: - Nursing to assess the resident thoroughly and document findings in the medical record/nurses notes…
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 · D2025-04-09 · tag F0825 — isolatedProvide 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 ensure specialized rehab services were provided in a timely fashion for one Resident (#28) out of a total sample of 20 residents. Findings include: Review of the facility policy titled Specialized Rehabilitative Services, not dated, indicated that the facility provides specialized rehabilitative services by qualified professional personnel. Resident #28 was admitted to the facility in January 2025 with diagnoses including stroke with left sided hemiplegia/hemiparesis, contracture of muscle of left hand and dementia. Review of the Minimum Data Set (MDS) dated [DATE] indicated that Resident #28 is totally dependent for all activities of daily living and scored an 11 out of 15 on the Brief Interview for Mental Status exam indicating moderate cognitive impairment. Further review indicated range of motion impairment on one side of upper extremity including wrist and hand. On 4/06/25, at 7:59 A.M. the surveyor observed Resident #28 lying in bed. The surveyor…
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 · D2025-04-09 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, policy review and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and potential transmission of communicable diseases and infections. Specifically the facility failed to: 1. Ensure that nursing performed hand hygiene (HH) and changed a wound dressing in accordance of professional standards to prevent infection. 2. Ensure the nurse did not touch medications while dispensing. 3. Ensure personal protective equipment (PPE) was readily available to staff when needed. 4. For Resident #40, the facility failed to implement contact precautions after he/she developed symptoms and tested positive for Clostridioides difficile (C-Diff; a bacterium that causes an infection of the colon, the longest part of the large intestine). Findings include: 1. Review of the facility policy titled Dry, Clean Dressings, dated October 2023 indicated that hand hygiene is to be…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-04-22 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, policy review, and interview, the facility failed to ensure 1) medication rooms on two of two units were locked and secured while not in use and 2) medications were opened and dated on 2 of 3 sampled medication carts. Findings include: Review of the facility policy, Storage of Medications, dated May 2023, indicated the facility stores all drugs and biologicals in a safe, secure, and orderly manner. 5. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. 8. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. 11. Medications requiring refrigeration are stored in a refrigerator located in the drug room at the nurses' station or other secured location. Medications are stored separately from food and are labeled accordingly. 1) Medication rooms on two of two units were unlocked and not in a secured location while not in use. a. On 4/18/24 at 8:15 A.M., the surveyor observed the Arlington Unit…
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 · E2024-04-22 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and interview the facility failed to ensure food was stored and the kitchen was maintained, in accordance with professional standards for food service safety to prevent possible foodborne illness. Findings include: Review of the Food and Drug Administration document titled Storage Basics, dated as current 1/18/23 indicated the following: *Keep your appliances at the proper temperatures. Keep the refrigerator temperature at or below 40° (Fahrenheit) (4° C). The freezer temperature should be 0° (degrees) F (-18° C). Check temperatures periodically. Appliance thermometers are the best way of knowing these temperatures and are generally inexpensive. Review of the facility's policy, titled 'Preventing Foodborne Illness-Food Handling', dated May 2023, indicated the following: Food will be stored, prepared, handled and served so that the risk of foodborne illness is minimized. 4. Functioning of the refrigeration and food temperatures will be monitored at designated intervals throughout the day and documented according to state-specific requirements.…
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 · E2024-04-22 · tag F0908 — failed to keep essential equipment working — patternKeep all essential equipment working safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record review and interview the facility failed to ensure a reach in freezer containing food for preperation in the facility's main kitchen, was in a safe operable condition, ensuring that frozen food was frozen solid. Findings include: Review of the Food and Drug Administration document titled Storage Basics, dated as current 1/18/23 indicated the following: *Keep your appliances at the proper temperatures. Keep the refrigerator temperature at or below 40° (Fahrenheit) (4° C). The freezer temperature should be 0° (degrees) F (-18° C). Check temperatures periodically. Appliance thermometers are the best way of knowing these temperatures and are generally inexpensive. Review of the facility's policy, not dated, titled 'Refrigerator/Freezer Maintenance and Operation' indicated the following: *Refrigerators and freezers are closely monitored for proper operation and temperature. *Temperatures are recorded and units cleaned to ensure proper operation. *If any refrigerators/freezer is discovered to not maintain proper temperatures, the Maintenance Supervisor will…
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 · D2024-04-22 · 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 observation and interview, the facility failed to ensure staff respected resident room privacy for one Resident (#15) out of a total of 16 sampled residents. Findings include: Resident #15 was admitted to the facility in February 2021 with diagnoses including chronic obstructive pulmonary disease, toxic encephalopathy, and unspecified psychosis. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #15 scored 5 out of a possible 15 on the Brief Interview for Mental Status Exam indicating he/she is severely cognitively impaired. On 4/19/24 at 6:50 A.M., a Certified Nursing Assistant (CNA) was observed standing in Resident #15's room in front of the shared closet space while Resident #15 slept in bed. The door to the closet was open and the CNA was putting on his/her jacket. Upon seeing the surveyor, the CNA left the room and walked down the hallway. The surveyor then observed a green purse, a phone plugged into the wall and charging, a plastic shopping bag and a food container…
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 · D2024-04-22 · tag F0604 — failed to not use physical restraints improperly — isolatedEnsure that each resident is free from the use of physical restraints, unless needed for medical treatment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed for one Resident (#58), out of a total sample of 16 residents, to remain free from a potential restraint. Specifically, the facility failed to identify and assess the use of a specialized low chair used by Resident #58 as a potential restraint. Findings include: Review of the facility's policy, titled 'Use of Restraint', dated November 2023 indicated the following: Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls. When the use of restraints is indicated, the least restrictive alternative will be used for the least amount of time necessary and the ongoing reevaluation for the need for restraints will be documented. Policy Interpretation and Implementation: 1 physical restraints are defined as any…
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 · D2024-04-22 · tag F0694 — isolatedProvide for the safe, appropriate administration of IV fluids for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record review, policy review, and interview, the facility failed to provide care and maintenance of a peripherally inserted central catheter (PICC), consistent with professional standards of practice for one Resident (#41), out of a total sample of 16 residents. Specifically, for Resident #41 the facility failed ensure nursing completed a PICC line dressing change as ordered by the physician on 4/18/24 and nursing failed to ensure the PICC line dressing allowed nursing to observe the insertion site (insertion site was covered by a 2x2 gauze pad). Findings include: Review of the facility policy, Central Venous Catheter Care and Maintenance, dated September 2023, indicated to provide a general procedure regarding central venous catheters. *Site Care and Observation Observe the insertion site every shift for signs and symptoms or intravenous (IV) related complications including but not limited to pain, redness/hematoma, swelling/edema/infiltration, and DVT (Deep Vein Thrombosis). -Monitor and assess insertion site and surrounding area every shift for signs and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-04-22 · 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 interview, record and policy review and observation for one Resident (#21) of 16 sampled residents, the facility failed to clean the oxygen concentrator filters resulting in a thick layer of dust. Findings include: Review of the facility's Oxygen Administration Via Nasal Cannula, Mask, CPAP, BIPAP policy dated May 2023, indicated, but was not limited to: - Oxygen concentrators will be checked frequently, and filter cleaned no less than weekly. Resident #21 was admitted to the facility in September 2015, and had diagnoses which included chronic obstructive pulmonary disease (an inflammatory lung disease that causes obstructed airflow from the lungs), asthma and congestive heart failure (inability to maintain adequate blood circulation, symptoms include shortness of breath). Resident #21's minimum data set assessment dated [DATE] indicated he/she has shortness of breath while sitting at rest and lying down. Resident #21's care plan dated 12/9/21, indicated he/she was at risk for ineffective breathing…
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 before2024-04-22 · 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 interview, record and policy review and observation for one Resident (#21) of 16 sampled residents, the facility failed to accurately document cleaning of the oxygen concentrator filters. Findings include: Review of the facility's Oxygen Administration Via Nasal Cannula, Mask, CPAP, BIPAP policy dated May 2023, indicated, but was not limited to: - Oxygen concentrators will be checked frequently, and filter cleaned no less than weekly. Resident #21 was admitted to the facility in September 2015, and had diagnoses which included chronic obstructive pulmonary disease (an inflammatory lung disease that causes obstructed airflow from the lungs), asthma and congestive heart failure (inability to maintain adequate blood circulation, symptoms include shortness of breath). Resident #21's minimum data set assessment dated [DATE], indicated he/she has shortness of breath while sitting at rest and lying down. Resident #21's care plan dated 12/9/21, indicated he/she was at risk for ineffective breathing pattern due…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-12-12 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on records reviewed and interviews for three of three sampled residents (Resident #1, Resident #2, and Resident #3), who had diagnoses that included dysphagia (difficulty swallowing), the Facility failed to ensure they maintained accurate medical records related to the level of care and assistance they required from staff, when Certified Nurse Aide (CNA) documentation on Activity of Daily Living (ADL) Flowsheets for level of assistance provided to the residents for eating was inconsistent, inaccurate and/or incomplete (left blank). Findings Include: 1)Resident #1 was admitted to the Facility in April 2019, diagnoses included traumatic brain injury, dysphagia, aphasia, cerebral palsy, hypotension, bradycardia, bipolar disorder, and anxiety disorder. Review of Resident #1's Quarterly Minimum Data Set Assessment, dated 11/15/23, indicated he/she demonstrated signs and symptoms of possible swallowing disorder that included loss of liquids/solids from mouth when eating or drinking and coughing or choking during meals or when swallowing medications. Review of Resident #1's ADL Self…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · B2024-04-22 · tag F0582 — patternGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and interview the facility staff failed to inform two out of three residents reviewed, or their representatives with potential liability for payment for non-covered services including estimated cost of services. Findings include: The Advanced Beneficiary Notice (SNFABN) is a form which provides information to Residents and/or their beneficiaries so that they can decide if they wish to continue receiving the skilled services they are receiving at the facility that may not be paid for by Medicare and assume financial responsibility for these services. Review of the facilities' SNFABN form failed to include the cost of rehab services for two of three applicable residents. During an interview on 4/22/24 at 11:10 A.M., the Director of Nursing said the cost indicated on the form was for room and board and did not include skilled services, such as rehab.
“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.
Part of a chain
This home belongs to ROYAL HEALTH GROUP — 12 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 3.1 | -0.1 vs chain |
| Health inspection | 3 of 5 | 3.2 | -0.2 vs chain |
| Staffing | 2 of 5 | 2.4 | -0.4 vs chain |
| Quality measures | 2 of 5 | 3.1 | -1.1 vs chain |
The other 11 homes this chain runs (chain average 3.1★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| MAMARY, JAMES | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; W-2 MANAGING EMPLOYEE | 45% | since 03/12/2017 |
CMS files one row per role, so the 2 rows in the source record cover these 1 parties — each is shown once here with every role it holds. Nothing is omitted.
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 90% 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 $575K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
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 225505. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-25, 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.