Lee Healthcare
620 Laurel Street, Lee, MA 01238 · For profit - Limited Liability company · 88 certified beds · (413) 243-2010 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- no federal fines or payment denials on record
- it has 1 actual-harm citation
- a high number of inspection citations overall (34) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (2/5)
- its facility-reported quality-measure rating is low (1/5)
- nursing-staff turnover (62%) runs well above the national median (45%)
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 | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 1 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 1 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 1 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 3 to 1 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 7.3% | 16.4% | 15.4% | better |
| Long-stay residents who lose too much weight | 10.8% | 5.1% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 2.1% | 0.8% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 2.9% | 1.8% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 9.0% | 15.5% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 4.5% | 3.4% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 5.9% | 15.4% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 17.1% | 19.5% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 96.5% | 94.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 9.8% | 4.2% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 25.6% | 21.2% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 24.0% | 21.4% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 2.5% | 1.4% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 68.1% | 77.7% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 33.9% | 25.7% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 20.8% | 11.9% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.99 | 1.88 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.84 | 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.
44.1% 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 138 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 40.0% 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 90 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 0.27 therapist hours per resident per day in 2026Q1 — more than 39% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 11% 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 | 44.1%CMS range 36.9–53.2 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 13.1%CMS range 9.6–17.3 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 40.0% | 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 | 40.0% | 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 | 40.0% | 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 | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.8% | 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 | 4.4% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.4%CMS range 4.1–12.7 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.30 | 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 88 beds and averages 69.3 residents a day — about 79% occupied, or roughly 19 beds typically open. It usually has some room. 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 3.18 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.60 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.93 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.90 hrs/resident/day on weekends vs 3.30 on weekdays — 12% thinner on weekends. RN hours go from 0.60 to 0.60 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 62% is well above the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
34 citations, most serious first. The 11 most serious are shown; the remaining 23 are one tap away and print in full.
- Actual harm · G2025-09-10 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that professional standards of practice were implemented relative to skin and wound care for one Resident (#19) of four applicable residents reviewed for wound care, out of a total sample of 26 residents. Specifically, for Resident #19, the facility failed to: -appropriately assess and implement skin care and diabetic foot care for the Resident with a history of Diabetes, Peripheral Vascular Disease and a right below knee amputation (BKA), resulting in left toe wounds not being identified and treated timely. -submit a referral to the Wound Care Provider timely for on-going wound care when diabetic wounds were identified on the toes of the Resident's left foot. -implement treatment orders for the Resident's left toe wounds timely, resulting in delayed treatment interventions when the Resident had suspected osteomyelitis, bone exposure of the left great toe, was subsequently hospitalized and administered intravenous (IV) antibiotics…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-13 · tag F0557 — isolatedHonor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
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 moderately cognitively impaired and prone to agitation, the Facility failed to ensure he/she was treated in a dignified and respectful manner, when on 12/20/25, despite Resident #1 verbally objecting and telling staff not to touch his/her hat, Certified Nurse Aide (CNA) #1 taunted Resident #1 by touching his/her hat twice, provoking him/her, instead of respecting his/her request.Findings include:Review of the Facility Policy titled Resident Rights and Responsibilities, dated as revised January 2024, indicated employees shall treat all residents with kindness, respect, and dignity.Resident #1 was admitted to the Facility in August 2023, diagnoses included moderate vascular dementia with mood disturbance and anxiety disorder.Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 09/30/25, indicated Resident #1 was moderately cognitively impaired with a score of 9 out of 15 on the Brief Interview for Mental Status (BIMS, scores indicate: 0-7 severe cognitive impairment, 8-12…
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 before2025-11-19 · 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
Based on records reviewed and interviews for one of three sampled residents (Resident #1), the facility failed to ensure they maintained a complete and accurate medical record when on 10/18/25 after Resident #1 was seen by the Physician who made recommendations for interventions related to prevention of pressure injuries, there was no nursing documentation to support they were addressed or followed up on.Findings include:Review of the Facility Policy titled Charting and Documentation, revised 11/2024, indicated that services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical physical, functional or psychosocial condition, should be documented in the resident's medical record. Resident #1 was admitted to the Facility in October 2024, diagnoses included non-displaced comminuted fracture shaft of the left femur (injury where the thigh bone breaks into three or more pieces due to high-energy trauma), and left sided and right sided foot drop (inability to lift the front part of the foot). Review of Resident #1's Physician History and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-09-10 · tag F0726 — failed to have competent, trained nursing staff — patternEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure three Nurses (Nurse #2, #3 and #4), of five Nurses reviewed, had been evaluated upon hire and/or annually to ensure skills and competencies were met relative to wound care.Specifically, for one Resident (#19) who had diabetic wounds, the facility failed to ensure Nurses #2, #3, and #4, who provided care to Resident #19, were evaluated upon hire and/or annually to ensure they had the skill sets and competencies when providing wound care. Finding include: Review of the Facility Assessment, last reviewed on 8/29/25, indicated the facility had the capability to care for the residents who had:-skin ulcers and injuries-skin and soft tissue infections-advanced wound care needs In addition, the Facility Assessment indicated the following relative to Staff Training/Education and Competencies:-facility utilizes a computer-based program for various training modules which are assigned and completed throughout the year. -an annual competency fair is conducted, allowing staff to practice and demonstrate required…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-09-10 · tag F0730 — patternObserve each nurse aide's job performance and give regular training.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to complete a performance review of every nurse aide at least once every 12 months, for five Certified Nurse Aide (CNA #1, #2, #4, #5, and #6), out of five total records sampled. Specifically, the facility failed to ensure annual performance reviews were completed every 12 months for CNAs #1, #2, #4, #5, and #6. Findings include: Review of the facility provided CNA Active Employee Listing, undated, indicated the following: -CNA #1 was hired 7/28/15-CNA #2 was hired 7/1/24-CNA #4 was hired 12/4/23. -CNA #5 was hired 7/1/24. -CNA #6 was hired 2/5/24. During an interview on 9/9/25 at 2:51 P.M., the Director of Nursing (DON) said CNA performance reviews should be completed annually with all CNA's who worked in the facility. The DON said she was unable to locate annual performance reviews for CNA #1 and CNA #2.During a follow-up interview on 9/9/25 at 3:41 P.M., the DON said she was unable to provide annual performance reviews for CNAs #4, #5, and #6. During an interview on 9/10/25 at 11:32 A.M., the Administrator said annual…
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 · D2025-09-10 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that Advance Directives were honored for one Resident (#11), out of a total sample of 26 residents. Specifically, for Resident #11, the facility failed to ensure that the Physician's orders accurately reflected the Resident/Resident Representative's wishes as indicated on the Medical Orders for Life-Sustaining Treatment (MOLST: legal document that allows individuals to communicate their preferences for life-sustaining treatment to healthcare providers) form, putting the Resident at risk for being resuscitated (perform full measures including cardiopulmonary resuscitation and intubation) when the advanced directive wishes were for no resuscitation (do not resuscitate [DNR]). Findings include: Review of the facility policy Advance Directives, revised January 2024, indicated the following: -Advance directives will be respected in accordance with state law and facility policy -The plan of care for each resident will be consistent with his or 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.
- Potential for harm · D2025-09-10 · tag F0585 — failed to handle grievances — isolatedHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interviews, the facility failed to respond to or resolve grievances for one Resident (#54) out of a total sample of 26 residents. Specially the facility failed to respond to three grievances filed by Resident #54's family on 4/25/25. Findings include:Review of the facility policy titled Grievances, last updated on 2/2024, indicated the following in part:-The administrator is identified as the grievance official responsible for oversight of the grievance process in the facility. This includes responsibility for reviewing and tracking grievances, necessary investigating, ensuring that grievances are addressed and a response provided.-Any resident, and or health care representative, family member, employee or appointed advocate may file a grievance without fear or discrimination or reprisal in any form-Grievances may be submitted orally or in writing.The administrator will review the findings with the person investigating the grievance to determine what corrective actions need to be made-The resident, and/or health care representative, or person filing 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 · D2025-09-10 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview the facility failed to ensure a Notice of Transfer or Discharge and a Bed Hold were provided to residents or their resident representatives at the time of transfer or shortly there after and that the Office of the State Long-term Care Ombudsman was notified at the time of transfer or shortly there after for one Resident (#74) out of a total sample of three residents reviewed for closed records and for one Resident (#70) out of a total of 26 active records reviewed.Specifically, 1. For Resident #74 and #70 the facility failed to ensure the Office of the State Long-term Care Ombudsman was notified when Resident #74 and #70 were transferred from the facility to the hospital, and 2. Additionally, for Resident #70 the facility failed to ensure the -Resident/Representative had been provided with a copy of the bed hold policy, a notice of intent to transfer and that the appropriate information had been provided to the receiving facility, that included a discharge summary with vital information relative to the Resident and his/her level of care. Findings…
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 · D2025-09-10 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
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 Minimum Data Set (MDS) Assessments were completed accurately to reflect the resident's status for eight Residents (#1, #3, #4, #6, #23, #31, #48, and #67), out of a total of 26 residents sampled.Specifically, for Residents #1, #3, #4, #23, #31, #48, and #67, the facility failed to ensure the Section F-Preferences for Customary Routine and Activities Assessment was completed with the Resident or a Staff Interview was completed if the Resident was unable to participate in a Resident Interview for the most recent comprehensive MDS Assessment. Findings include:1. Resident #1 was admitted to the facility in August 2025 with diagnoses including but not limited to Paraplegia, Osteomyelitis, Adult Failure to Thrive, and Type 2 Diabetes. Review of Resident #1's most recent comprehensive MDS assessment dated [DATE] indicated he/she scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) indicating he/she was cognitively intact, he/she had…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-09-10 · 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 record review and interviews, the facility failed to ensure its staff followed professional standards for care and services relative to a suprapubic catheter (an indwelling urinary catheter placed directly into the bladder through the abdomen) and a colostomy (a surgical procedure where a portion of the large intestine is brought through the abdominal wall to carry stool out of the body) for one Resident (#70), out of a total sample of 26 residents. Specifically, the facility failed to obtain Physician orders on how to provide care and services for both the suprapubic catheter and the colostomy. Additionally, the facility failed to develop policies and procedures on how to provide care and services for both the suprapubic catheter and the colostomy, putting the Resident at an increased risk of infection, complications and/or improper care techniques.Findings include:Resident #70 was admitted to the facility July 2025 with diagnoses that included Type 2 Diabetes, below the left knee leg amputation, above…
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 · D2025-09-10 · 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 observations, record review and interviews, the facility failed to provide an environment that was free of potential accidents and hazards and implement the facility policy to ensure smoking safety for two residents (#70 and #1) of three applicable residents reviewed for smoking, out of a total sample of 26 residents. 1. For Resident #70 the facility failed to ensure adequate supervision was provided and an individualized care plan was developed.2. For Resident #1, the facility failed to ensure that the Resident was assessed for safety prior to the Resident resuming smoking at the facility placing the Resident at risk for injury. Findings include: Review of the facility policy titled Smoking Policy- Residents, last revised on 3/2024, indicated the following: -The resident will be evaluated upon admission or when a resident chooses to smoke to determine of the resident's ability to smoke safely -Any smoking related concerns will be noted in the resident care plan -Residents who are supervised for smoking will be monitored by a staff member or designee during the allowed…
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 23 citations
- Potential for harm · D2025-09-10 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, and interview, the facility failed to ensure that the Consulting Pharmacist Medication Regimen Reviews (MRRs) were reviewed by the attending Physician timely and implemented as recommended for three Residents (#9, #31, and #8) out of a total sample of 26 residents. Specifically, for Resident's #9, #31, and #8, the facility failed to ensure that the Resident's Attending Physician reviewed and implemented or declined the Pharmacist MRRs timely. Findings include: 1. Resident #9 was admitted to the facility in February 2025 with diagnoses including but not limited to Congestive Heart Failure, Chronic Kidney Disease, and Unspecified Mood Disorder. Review of Resident #9's Pharmacy MRRs dated 2/26/25, 3/19/25, and 5/15/25, indicated the following Pharmacist Recommendations: -Acetaminophen 650 milligrams (mg) by mouth every six hours as needed (PRN) for pain or temperature. Give (2) 325 mg tabs to equal 650 mg. Not to exceed 3000 mg in 24 hours. -Oxycodone 5 mg by mouth every six hours as needed (PRN) for pain. -Please clarify what type of pain (using pain assessment…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-09-10 · 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 observation, interview, and record reviews, the facility failed to ensure that complete and accurate medical records were maintained for two Residents (#8, and #11), out of a total sample of 26 residents. Specifically, for Residents #8 and #11, the facility failed to ensure that the Physician Order for nutritional supplements included the amount to be administered, placing the Residents at risk of not receiving adequate nutritional supplementation. Findings include: Review of the facility policy Nutrition, dated June 2018, indicated the following: -Residents maintain acceptable parameters of nutritional status, such as usual or desirable body weight range, and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise. -Nutritional Supplements refers to products that are used to complement a resident's dietary needs (e.g., calorie or nutrient dense drinks, total parenteral products [given through intravenous methods],…
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 · D2025-09-10 · tag F0849 — isolatedArrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, and record review, the facility failed to maintain a communication process that included maintaining documentation relative to Hospice services for one Resident (#3) out of a total sample of 26 residents. Specifically, for Resident #3, the facility failed to ensure Hospice Services documentation was readily accessible to all staff and providers for communicating necessary information regarding the resident's care between the nursing home and the Hospice.Findings include:Review of the Inpatient Hospice Services Agreement between the facility and Hospice, dated 10/15/18, indicated the following:>Records:-Creation and Maintenance of Records: Facility shall prepare and maintain complete and detailed records concerning each Hospice Patient receiving Inpatient Services under this Agreement.Each clinical record shall completely, promptly and accurately document all services provided to, and events concerning, each Hospice Patient, including evaluations, treatments, progress notes. Resident #3 was admitted to the facility in July 2017 with diagnoses including End Stage…
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 · D2025-09-10 · tag F0868 — isolatedHave the Quality Assessment and Assurance group have the required members and meet at least quarterly
What the surveyor found here — the official record, unedited, may be distressing
Based on interview, and record review, the facility failed to ensure at minimum quarterly Quality Assurance Performance Improvement (QAPI) meetings were held during one quarter, out of four quarters reviewed.Specifically, the facility failed to ensure that a QAPI meeting for October 2024, was completed as scheduled quarterly to identify issues with respect to which quality assessment and assurance activities, including performance improvement projects required under the QAPI program, are necessary. Findings include:Review of the facility's last four quarter QAPI meeting attendance sheets indicated a quarterly meeting was scheduled for October 2024, however, the QAPI meeting for October 2024 was not held. During an interview on 9/10/25 at 10:46 A.M., the Administrator said QAPI meetings are required to be held at least quarterly, and the facility did not hold a quarterly QAPI meeting in October 2024 as required.
- Potential for harm · D2025-09-10 · tag F0881 — failed to use antibiotics responsibly — isolatedImplement a program that monitors antibiotic use.
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, and record review, the facility failed to ensure that antibiotic use was monitored for one Resident (#5), of five applicable residents reviewed for unnecessary medication review, out of a total sample of 26 residents. Specifically, for Resident #5, the facility failed to ensure a prophylactic antibiotic was monitored and re-evaluated for continued use of the antibiotic. Findings include: Review of the facility policy titled Antibiotic Stewardship Program, revised 1/24, indicated the following: -The Antibiotic Stewardship Program purpose is to monitor the use of antibiotics in residents. -As part of the facility Antibiotic Stewardship Program, clinical infections treated with antibiotics will undergo review by the Infection Preventionist (IP), or designee. -The IP, or designee, will review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that are not consistent with the appropriate use of antibiotics. -Residents antibiotic regimens will 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 · D2025-09-10 · tag F0887 — isolatedEducate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interview, the facility failed to ensure one Resident (#5), of five applicable residents reviewed for immunizations, out of a total sample of 26 residents, was offered to receive or decline the COVID-19 vaccine. Specifically, for Resident #5, the facility failed to offer and provide the COVID-19 vaccine when he/she was not up to date with the COVID-19 vaccination. Findings include: Review of the CDC website (Adult Immunization Schedule Notes | Vaccines & Immunizations | CDC), titled Adult Immunization Schedule, dated 7/2/25, indicated the following relative to COVID-19 vaccination for persons greater than [AGE] years of age: -2 or more doses of 2024-2025 vaccine. -those previously vaccinated before the 2024-2025 vaccine: follow recommendations above for previously vaccinated persons ages 19-64 years and administer dose 2 of 2024-2025 Moderna or Novavax or Pfizer-BioNTech 6 months later (minimum interval 2 months) Resident #5 was admitted to the facility in January 2025 and was over…
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 · F2024-07-25 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to maintain sanitary and safe conditions for two unit kitchenettes (Unit One and Unit Two) out of two unit kitchenettes. Specifically, the facility failed to maintain clean and sanitary conditions for the toasters in both Unit One and Unit Two kitchenettes that presented a fire risk. Findings include: On 7/24/24 at 2:38 P.M., the survey observed the following on the Unit Two Kitchenette: -A crumb laden toaster. On 7/24/24 at 3:00 P.M., the surveyor observed the following in the Unit One kitchenette: -Crumbs lining the top of each toaster slot. -Larger crumbs inside of the toaster slot. During an observation and interview on 7/25/24 at 9:18 A.M., the surveyor and the Director of Housekeeping observed both kitchenettes on Unit One and Unit Two. The Director of Housekeeping said that the housekeeping staff are responsible to clean the floors, walls, counters, and microwave. The Director of Housekeeping said she was unsure who was responsible for the toasters, she thought maybe the kitchen staff were to ensure they were cleaned but…
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 · D2024-07-25 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
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 policy review, the facility failed to maintain a clean and homelike environment on one (Unit One) out of two Units observed. Specifically, the facility staff failed to clean a resident's room with visible marking/drippings on the wall. Findings include: Review of the Complete Room Cleaning list, located on the cleaning closet door, undated, indicated the following: -Wipe walls as needed. -Windows and window sill [sic] Review of the Daily Patient Room Cleaning, revised on 9/5/2017, indicated the following: 3) Spot clean. With a cloth and disinfectant spot clean all vertical surfaces. On 7/23/24 at 8:50 A.M., the surveyor observed the following on Unit One, in room [ROOM NUMBER]: -The windowsill and wall, directly under the window/windowsill, located directly to the right of the Resident's bed to have multiple brown, dried drip marks down the wall. -During the observation the Resident was lying in his/her bed and facing the wall with the visible marks. On 7/24/24 at 2:42 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.
- Potential for harm · D2024-07-25 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record the facility failed to ensure that a Preadmission Screening and Resident Review (PASRR - a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care. PASRR requires that 1) all applicants to a Medicaid-certified nursing facility be evaluated for serious mental disorder and/or intellectual disability; 2) be offered the most appropriate setting for their needs (in the community, a nursing facility, or acute care setting); and 3) receive the services they need in those settings) Level I Screening (A preliminary screening of all nursing facility applicants, conducted prior to their admission to a nursing facility that identifies whether an applicant for admission to a nursing facility has, or may have, Intellectual Disabilities [ID], Developmental Disabilities [DD], and/or Serious Mental Illness [SMI]) was completed prior to one Resident's (#35) admission to the facility out of a total sample of 14 residents. Specifically, for Resident #35 the facility failed to ensure that a Preadmission Level I…
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 before2024-07-25 · 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
Based on observation, interview, record and policy review, the facility failed to provide care in accordance with professional standards of practice relative to the application and monitoring of a wound dressing for one Resident (#201) out of a total sample of 14 residents. Specifically, the facility staff failed to: -accurately assess Resident's #201 skin. -obtain a Physician's order for a dressing that was applied to the Resident's left elbow. -provide on-going assessment of the left elbow area resulting in the applied dressing not being changed timely and putting the Resident at risk for worsening wound status and infection. Findings include: Review of the facility policy titled, Medication and Treatment Orders, dated 4/2018, indicated the following: -Orders for medications and treatments will be consistent with regulatory standards. Review of the Lippincott Nursing Procedures Manual - 9th edition (2023) indicated the following: -Comprehensive skin assessment shouldn't be a one-time event limited to admission. Repeat it regularly to determine any changes in skin condition. -If…
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 · D2024-07-25 · tag F0661 — isolatedEnsure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
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 and record review, the facility failed to ensure that a discharge summary was completed for one Resident (#35) out of a total sample of 14 residents. Specifically, for Resident #35, the facility failed to ensure that: -a post discharge plan of care was developed with the participation of the Resident. -a discharge summary was completed at the time of discharge that included any arrangements that had been made for the Resident's follow-up care. -communication was provided to continuing care providers. Findings include: Resident #35 was admitted to the facility in May 2024, with diagnoses of Parkinson's Disease (a chronic degenerative disorder of the central nervous system characterized by tremor and impaired muscular coordination) and status post fall with a right femur (thigh bone) fracture. Review of the most recent comprehensive Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #35 scored 11 out of 15 on the Brief Interview of Mental Status (BIMS) Assessment 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.
- Potential for harm · D2024-07-25 · tag F0699 — isolatedProvide care or services that was trauma informed and/or culturally competent.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to develop a comprehensive Trauma Informed Care Plan for one Resident (#35)out of a total sample of 14 residents. Specifically, for Resident #35, the facility failed to complete an assessment and ensure that a comprehensive Trauma Informed Care Plan was developed relative to the Resident's history of PTSD (Post -Traumatic Stress Disorder- a mental and behavioral disorder that develops from having experienced a traumatic event, causing flashbacks, nightmares and severe anxiety). Findings include: Resident #35 was admitted to the facility in May 2024, with a diagnosis of PTSD. Review of the Social Services Evaluation, dated 5/15/24, indicated the following: -The Resident had past experiences that were so upsetting they changed him/her emotionally, spiritually, physically, or behaviorally. Further review of the Social Services Evaluation indicated a Care Plan should be created related to Trauma Informed Care. Review of the Resident's Comprehensive Care Plan indicated no documentation that a Trauma Informed Care Plan had been…
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 before2024-07-25 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure that a Certified Nurses Aide (CNA) documentation was complete and accurate for one Resident (#1) out of a total sample of 14 residents. Specifically, for Resident #1, the facility failed to ensure CNA documentation related to meal intake was documented every shift for the Resident who had a history of significant weight loss and was at increased risk for nutritional decline. Findings include: Resident #1 was admitted to the facility in May 2022, and had a diagnosis of muscle wasting and atrophy (the loss of muscle tissue or muscle mass that cause muscles to weaken, shrink or shorten and can lead to a decrease in strength and mobility) and chronic pain. Review of the Dietician's Progress Note dated 6/4/24, indicated that Resident #1 had been identified as having a weight loss. Review of the Weights and Vitals Summary indicated: -3/5/24: Resident #1 weighed 135.2 pounds (lbs.) -6/4/24: Resident #1 weighed 124.6 lbs. (indicating a significant weight loss of 7.8% in three months). Review of Care Plan titled Increased…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-05-09 · tag F0695 — failed to provide proper breathing / tracheostomy care — patternProvide 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 provide respiratory care consistent with professional standards of practice and the comprehensive care plan for five Residents (#3, #39, #42, #28, #103) out of six applicable residents with respiratory care needs, out of a total sample of 15 residents and one closed record for Resident (#51) out of a total sample of two closed records. Specifically, the facility failed to ensure its staff: -posted signage relative to Oxygen (O2) use, -delivered O2 at the prescribed flow rate, -labeled, dated, and stored oxygen tubing and respiratory equipment properly between use, -and had comprehensive orders in place for the use and care of Continuous Positive Airway Pressure machines (CPAP- machine used to treat sleep apnea that involves the administration of a pre-determined level of pressure through a facial mask). Findings include: Review of a facility policy titled Oxygen Administration, revised 2/23 indicated the following: -verify there is a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-05-09 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure its staff notified the attending Physician of a recommendation from the Wound Care Specialist for one Resident (#22) out of 15 sampled residents. Findings include: Resident #22 was admitted to the facility in November 2016. On 5/7/23 at 8:32 A.M., Resident #22 was observed in bed with a large dark scab on his/her forehead and another smaller dark scab on his/her nose. He/she said he/she was unsure what was occurring for the treatments of the two areas as the doctor had not said much about the treatment for them. Review of the Wound Care Specialist's note dated 3/7/23 indicated the Resident's forehead had a raised lesion/bloody scab. Review of the Wound Care Specialist's note dated 4/11/23 indicated the Resident had a bloody scab removed from his/her forehead, which was suspicious for a skin cancer lesion and the recommendation was made for the Resident to have a consult with Dermatology, for a biopsy of the lesion. Review of the Wound Care Specialist's note dated 4/25/22 indicated a recommendation to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-05-09 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure its staff provided a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN- a notice to inform a resident or resident representative that skilled Medicare services will no longer be covered and to inform them of the cost they may be responsible to pay), for two Resident's (#9 and #11) out of a total of three sampled residents. Findings include: 1. Resident #9 was admitted to the facility in February 2023. Review of the record indicated skilled services for Resident #9 ended on 4/21/23 and he/she remained in the facility. Review of the SNF Beneficiary Protection Notification Review form indicated the following: -The facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted. -SNF ABN form was not provided to the resident because it was not applicable and not required. 2. Resident #11 was admitted to the facility in November 2022. Review of the record indicated skilled services for Resident #11 ended on 1/11/23 and he/she remained in the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-05-09 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure its staff reviewed and revised the care plan after each assessment, for two Residents (#2 and #39) out of a total sample of 15 Residents. Findings include: Review of the facility policy titled Comprehensive Person-Centered Care Plans, dated 11/2017, indicated: -the Interdisciplinary Team (IDT) in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive care plan for each resident -the IDT consists of the Physician, a Nurse who has responsibility for the resident, a member of the food and nutrition services staff, the resident and resident's legal representative, as practicable, and other appropriate staff as determined by the resident's needs or at resident request -the resident will be informed of his/her right to participate in his/her treatment and an explanation will be included in the medical record if the participation of the resident/resident representative is determined not to be practicable -the IDT must review and update the care plan at least…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-05-09 · tag F0740 — failed to provide behavioral / mental-health care — isolatedEnsure each resident must receive and the facility must provide necessary behavioral health care and services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure its staff obtained recommended Behavioral Health Services for one Resident (#35) out of a sample of 15 residents. Findings include: Review of the facility policy titled Behavioral Health Services, revised 9/2019, indicated the following: -The facility will provide, and residents will receive behavioral health services as needed . Resident #35 was admitted to the facility in March 2023. Review of the Social Work progress note dated 4/4/23 indicated the Social Worker (SW) visited with the Resident on that day as there was a question of the Resident's safety related to possible suicidal ideation. The SW indicated the Resident had no plan or intent to harm him/herself but that he/she was depressed and would be open to see the facility Psychologist. The note further indicated the SW would make a referral to the facility Psychologist. Review of the Health Drive (company the facility contracts with to provide Behavioral Health Services) consent form indicated the Resident had requested behavioral health services and signed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-05-09 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure its staff indicated a duration for an as needed (PRN) Psychotropic medication (a medication that affects brain activities associated with mental processes and behavior) for one Resident (#39) out of a total sample of 15 residents. Findings include: Resident #39 was admitted to the facility in April 2022 with a diagnosis of Anxiety. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #39 had mild cognitive impairment as evidenced by a score of 11 out of a possible 15 on the Brief Interview of Mental Status (BIMS) assessment. Review of the clinical record indicated the Resident was followed by Behavioral Health Services for counseling related to Anxiety and Depression. Review of the Medication Regimen Reviews (MRR) indicated the following: -MRR dated 10/26/22: recommended review of the PRN Alprazolam (a medication used to treat anxiety) and consider discontinue or document continued need for therapy and specify stop…
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 · Bcited before2024-07-25 · tag F0582 — patternGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure a Notice of Medicare Non-Coverage (NOMNC - - notice issued to a resident who is receiving benefits under Medicare Part A when all covered services end) and a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN - notice issued to a resident when a facility determines the beneficiary no longer qualifies for Medicare Part A skilled services and the resident has not used all his/her Medicare benefit days) were issued for one Resident (#36) out of a total applicable sample of three residents. Specifically, the facility failed to issue advance NOMNC and SNF ABN notice to Resident #36's Guardian (a court appointed person who makes important personal and healthcare decisions for an adult who lacks sufficient capacity to make their own decisions) so the Resident/ Guardian could decide if they wish to continue receiving skilled services that may not be paid for by Medicare, and were aware of the financial responsibility they may have to assume. Findings include: Resident #36 was admitted to the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · B2024-07-25 · tag F0623 — patternProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to provide a written Notice of Transfer and Discharge to the Resident and Resident's Representative at the time of discharge for one Resident (#40) out of a total sample of 14 residents. Specifically, the facility staff failed to provide Resident #40/ Resident Representative a written Notice of Intent to Transfer and Discharge when the Resident was transferred from the facility to the hospital. Findings include: Resident #40 was admitted to the facility in July 2023. Review of the Discharge Transfer Evaluation, effective date 5/12/24, indicated Resident #40 was transferred from the facility to the hospital on 5/12/24. Further review of the Resident's medical record indicated no documentation that a written Notice of Intent to Transfer and Discharge was provided to the Resident and Resident Representative at the time of discharge or shortly thereafter. During an interview on 7/24/24 at 10:09 A.M., the Social Worker (SW) said she does not provide the Resident or Resident Representative with a Notice of Intent to Transfer 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.
- No harm found · C2023-05-09 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and interview, the facility failed to ensure its staff maintained the daily posting of the nursing staffing data with current information. During an observation on 5/7/23 at 10:07 A.M., the daily Nursing Staffing Form was posted in the entrance area. The form was dated 4/21/23. During an interview on 5/9/23 at 10:42 A.M., with the Scheduler and Administrator, the Scheduler said that she posted the required staffing form daily in the lobby but had been out of the building on vacation and that it had not been done as required. The Administrator said that the purpose of the daily posting was to inform the residents and visitors of the amount of nursing staff working daily.
- No harm found · C2023-05-09 · tag F0847 — widespreadInform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure the arbitration agreement, signed by residents or their representative, explicitly stated: 1. The resident or his/her representative had the right to rescind the agreement within 30 calendar days of signing it, and 2. that neither the resident nor his/her representative was required to sign an agreement as a condition of admission to, or as a requirement to continue to receive care at the facility, for three Residents (#20, #29 and #41) out of a total sample of three residents. Findings include: Review of Attachment M Arbitration Agreement dated 9/2017 did not indicate that the resident or his/her representative had the right to rescind the agreement within 30 calendar days of signing it. The agreement also did not indicate that the resident or his/her representative was not required to sign the binding arbitration agreement as a condition of admission to, or as a requirement to continue to receive care at the facility. Review of the signed arbitration agreements indicated the following: Resident #20's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“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 NEXT STEP HEALTHCARE — 14 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 | 1 of 5 | 1.7 | -0.7 vs chain |
| Health inspection | 2 of 5 | 1.9 | +0.1 vs chain |
| Staffing | 2 of 5 | 2.6 | -0.6 vs chain |
| Quality measures | 1 of 5 | 2.2 | -1.2 vs chain |
The other 13 homes this chain runs (chain average 1.7★, 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 |
|---|---|---|---|---|
| NEXT STEP MA MASTER SUBTENANT, LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 12/01/2017 |
| DELL'ANNO, DAMIAN | Individual | INDIRECT OWNERSHIP INTEREST; INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 07/31/2025 |
| STEPHAN, WILLIAM | Individual | INDIRECT OWNERSHIP INTEREST | — | since 12/01/2017 |
| NEXT STEP HEALTHCARE LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/10/2025 |
| MINTZ, JOSHUA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 09/02/2021 |
| THIMOT, FRANTZ | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 12/03/2019 |
CMS files one row per role, so the 10 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted.
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $362K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in MA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Massachusetts Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 225749. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-10, 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.