Linda Manor Extended Care Facility
349 Haydenville Road, Leeds, MA 01053 · Non profit - Corporation · 123 certified beds · (413) 586-7700 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- a high payroll-based staffing rating (4/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- inspectors recorded 2 serious findings as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $8,788 in federal fines (most recent 2025-06-06)
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) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 3 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 | 3 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 3 to 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 36.0% | 16.4% | 15.4% | worse |
| Long-stay residents who lose too much weight | 3.6% | 5.1% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.5% | 0.8% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 1.5% | 1.8% | 2.0% | better |
| Long-stay residents with depressive symptoms | 25.5% | 15.5% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 4.0% | 3.4% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 34.5% | 15.4% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 13.9% | 19.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 99.0% | 94.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.0% | 4.2% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 37.7% | 21.2% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 20.3% | 21.4% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.8% | 1.4% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 83.9% | 77.7% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 22.8% | 25.7% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 10.1% | 11.9% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.95 | 1.88 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 0.82 | 1.50 | 1.80 | better |
‡ 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.
50.6% 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 319 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 53.0% 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 166 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 0.35 therapist hours per resident per day in 2026Q1 — more than 59% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 21% 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 | 50.6%CMS range 44.5–55.3 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.9%CMS range 9.5–14.7 | 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 | 53.0% | 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 | 50.0% | 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 | 42.2% | 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 | 98.1% | 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 | 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 | 1.9% | 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 | 6.7%CMS range 4.6–10.4 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.79 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 123 beds and averages 114.5 residents a day — about 93% occupied, or roughly 8 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.94 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.70 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.28 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 3.41 hrs/resident/day on weekends vs 4.15 on weekdays — 18% thinner on weekends. RN hours go from 0.81 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 52% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are 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.
28 citations, most serious first. The 12 most serious are shown; the remaining 16 are one tap away and print in full.
- Actual harm · Gcited before2025-06-06 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on records reviewed and interviews, for one of three sampled residents (Resident #3), whose care plan interventions included the need for two staff members to provide assistance during care, which included incontinence care, bed mobility and repositioning, the Facility failed to ensure staff consistently implemented and followed his/her care plan interventions. On 05/04/25, Certified Nurse Aide (CNA #1) provided incontinence care to Resident #3 without another staff member present for assistance, CNA #1 positioned Resident #3 on his/her side, then turned away from the resident, he/she rolled off the bed and fell onto the floor. Resident #3 was transferred to the Hospital Emergency Department (ED) and diagnosed with a closed displaced fracture (broken pieces of bone that moved away from each other) of the right femoral neck (part of the thigh bone just below the hip joint). Findings include: Review of the Facility's policy titled, Care Planning, last revised 10/18/22, indicated the Facility will develop and implement a comprehensive person-centered care plan for each 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.
- Actual harm · Gcited before2025-06-06 · 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 #3), who required the assistance of two staff members for dressing, toileting care needs, bed mobility, and positioning, the Facility failed to ensure he/she was provided with the necessary level of staff assistance to maintain his/her safety to prevent an incident/accident resulting in a serious injury. On 05/04/25, Certified Nurse Aide (CNA) #1 provided care to Resident #3 without having another staff member present for assistance, CNA #1 repositioned Resident #3 onto his/her side in bed, then turned away from Resident #3 to grab something, leaving him/her unattended and he/she rolled off the bed onto the floor. Resident #3 was transferred to the Hospital Emergency Department (ED) and diagnosed with a closed displaced fracture (broken pieces of bone that moved away from each other) of the right femoral neck (part of the thigh bone just below the hip joint). Findings include: Review of the Facility's Policy titled, Fall Risk Reduction, dated as revised 11/2/23, indicated but was not limited 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 · Fcited before2025-09-29 · 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 adhere to safe food practices to prevent contamination of food and beverage items intended for resident consumption in three out of three applicable facility unit kitchenettes. Specifically, the facility failed to implement safe food practices in three out of three facility unit kitchenettes relative to labeling, dating and guidelines for food storage. Findings include: Review of the facility policy titled Dietary Department Guidelines, last updated 5/2018, indicated: >Food Preparation and Handling-Food items should be labeled and use by dated to allow for rotation of supplies.-All items stored in the refrigerator will be covered and use by date labeled.-Refrigerated foods and cold foods will be stored and held at refrigerator temperatures 40 degrees Fahrenheit or below. -Refrigeration temperatures and will be monitored and documented on approved temperature monitoring logs, twice daily.-Frozen foods will be stored between zero and negative ten degrees Fahrenheit. >Foods not prepared in the facility-Personal foods brought…
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 · D2025-09-29 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure its staff provided care and services according to Physician orders for an indwelling urinary catheter (a thin, soft flexible tube that drains urine from the bladder) for one Resident (#88) out of four applicable residents, in a total sample size of 24 residents. Specifically, the facility staff failed to insert the correct indwelling urinary catheter size in accordance with Resident #88's Physician order, placing the Resident at risk for obstruction and pain. Findings include: Review of the facility policy titled Indwelling Urinary Catheters, dated 6/24/25, included but was not limited to:-Urinary catheters should only be placed under the direction of a Physician's order, including catheter size and care. Resident #88 was admitted to the facility in January 2024 with diagnoses including Obstructive (blockage in the urinary tract preventing normal urination) and Reflux (a backward flow of urine from the bladder into the ureters 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 · D2025-06-06 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on records reviewed and interviews for one of three sampled residents (Resident #1), who had multiple wounds and required an appointment with an outside wound specialist, the Facility failed to ensure nursing staff clarified and/or followed up on his/her wound consult recommendations related to the need for an X-ray, in a timely manner, which resulted in a delay in treatment. Findings include: Pursuant to Massachusetts General Law (M.G.L.), chapter 112, individuals are given the designation of Registered Nurse and Practical Nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a Registered Nurse and Practical Nurse respectively. The regulations stipulate that both the Registered Nurse and Practical Nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the Registered Nurse and Practical Nurse incorporate into the plan of care and implement…
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 before2024-08-29 · 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 one of three sampled residents (Resident #1) who sustained two unwitnessed falls and whose Comprehensive Care Plan indicated he/she was at risk for dehydration with the potential for slow wound healing due to low albumin (may indicate malnutrition, kidney/liver disease) the Facility failed to ensure they maintained a complete and accurate medical record when 1) nursing did not complete the 72 hour neurological checks following each of his/her unwitnessed falls, and 2) Certified Nurse Aides (CNAs) daily documentation related to Resident #1's fluid and food intake were not consistently recorded on his/her flow sheets. Findings include: Review of the Facility's policy titled Falls Management: Post Fall, with a revision date of 11/02/23, indicated an Incident and Accident Report would be completed after each resident fall. Review of the Facility's Incident and Accident Report Form indicated to initiate neurological checks (assessment used to determine head injury) when a resident sustained an unwitnessed fall or head strike. 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 · Dcited before2024-08-29 · 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
Based on records reviewed and interviews for one of three sampled residents (Resident #1) who was assessed by nursing to be at risk for skin breakdown with actual pressure injuries (localized damage to the skin and underlying soft tissue usually over a bony prominence which can present as intact skin or an open ulcer and may be painful) the Facility failed to ensure nursing adequately assessed, measured and obtained Physician's orders related to wound care to his/her bilateral heels that included specifics related to treatments for offloading, in accordance with professional standards of practice in an effort to promote wound healing. Findings include: Review of the Facility's Policy titled Skin Integrity Management, dated 12/03/23, indicated the following: -Stage 1 Pressure Injury: A persistent area of redness that does not disappear when pressure is removed. Skin is not broken, the site may be tender, painful, firm, or soft, warm, or cool compared to surrounding skin. -Stage 2 Pressure Injury: Partial-thickness skin loss involving the outer layer of the skin and the inner layer,…
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 before2024-08-29 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records reviewed and interviews for one of three sampled residents (Resident #1), who was assessed to be at risk for nutritional decline, dehydration, and with the potential slow wound healing due to low albumin (may indicate malnutrition, kidney/liver disease), the Facility failed to ensure Resident #1's nutritional status including body weight, meal percentage and fluid intakes, were accurately assessed and monitored appropriately by nursing and per facility policy. Findings include: Review of the Facility Policy titled Weighing and Measuring Resident, with a revision date of 05/03/11, indicated the following: -Residents will be weighed using consistent scale on admission and at least monthly thereafter. -Reweigh will be obtained if weight is +/- three pounds (lbs.) from previous weight. Review of the Facility Policy titled Nutrition Management, with a revision date of 06/06/22, indicated the following: -Identify residents who have functional limitations which may affect ability to eat or drink…
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 before2024-07-09 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interview, the facility failed to notify the Physician of the unavailability of an ordered medication for one Resident (#1) out of a total sample of 24 residents. Specifically, the facility staff failed to notify the Physician when Resident #1's Fluoxetine (a psychotropic medication used to treat Depression) medication was unavailable to be administered in accordance with his/her Physician orders, resulting in the Resident not receiving five scheduled doses of Fluoxetine medication. Findings include: Resident #1 was admitted to the facility in June 2024, with a diagnosis of Depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #1 was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of nine out of a total score of 15. Review of the current…
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 · D2024-07-09 · 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 that the Minimum Data Set (MDS) assessments were accurately coded for four Residents (#88, #12, #89, and #110) out of a total sample of 24 residents. Specifically, the facility failed to: 1. Accurately code that Resident #88 was receiving Hemodialysis (also known as dialysis: a procedure where a machine with a special filter called a dialyzer is used to remove waste products and fluids from the blood). 2. Accurately code an indwelling urinary catheter (a tube inserted into the bladder used to drain urine outside the body) usage for Resident #12 and Resident #89. 3. Accurately code the discharge disposition for Resident #110. Findings include: 1. Resident #88 was admitted to the facility in May 2023, with a diagnosis of End Stage Renal Disease (ESRD - a medical condition where the kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life) and was dependent…
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 before2024-07-09 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record and policy review, the facility failed to provide nutrition care and services for one Resident (#264) out of a total sample of 24 residents, when the Resident was determined to be at risk for malnutrition. Specifically, the facility staff failed to perform monthly weight measurements for Resident #264 as ordered for June 2024, resulting in a significant weight loss being missed and a delay of nutritional interventions. Findings include: Review of the facility policy titled Nutrition Management last revised June 2022 indicated the following: -staff will consistently observe and monitor residents for changes and implement revisions to care plan as needed. -to recognize, evaluate and address the nutritional needs of every resident, including but not limited to, the resident at risk or currently experiencing impaired nutrition. -address any immediate concern with the dietician and physician. -use the Dietician Consult Request to initiate a consult with Dietician when 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 · D2024-07-09 · tag F0791 — failed to provide routine dental services — isolatedProvide or obtain dental services for each 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 observation, interview and record review, the facility failed to provide dental care and services as required for one Resident (#16) out of a total sample of 24 residents. Specifically, the facility staff failed to provide assistance with scheduling and maintaining dental services for Resident #16, when the Resident had consents for dental care and services. Findings include: Review of the facility policy titled, Consulting Services, Podiatry/Dental/Optometry/Audiology, dated 11/22/16, indicated the following: -The facility has a contract with credentialed providers for in house services of dental. -Services are offered to all residents as a means of providing the highest practicable level of functioning and care. -Residents/representatives are provided information about consulting services on admission and at any time the need arrives. -Residents/representatives provide written consent to treatment prior to initiation of services. -Appointments are arranged by facility staff. -Transportation is…
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 16 citations
- Potential for harm · Dcited before2024-07-09 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure 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 policy review, observation and interview, the facility failed to maintain sanitary conditions for two (Meadowview and Forestview) applicable unit kitchenettes out of a total of three unit kitchenettes. Specifically, the facility failed to maintain sanitary conditions for two of the two applicable unit kitchenette microwaves located on Meadowview and Forestview to prevent contamination and the spread of food-borne infections. Findings include: Review of the facility policy titled Dietary: Sanitary Conditions, revised on 9/21/22, indicated that when cleaning fixed equipment ( .equipment that cannot readily be immersed in water), the removable parts are washed and sanitized and non-removable parts are cleaned with detergent and hot water, rinsed, air-dried and sprayed with a sanitizing solution. Review of the Housekeeping responsibilities for Forestview and Meadowview units, indicated that housekeeping staff are to ensure that all areas on the units are clean and kept up: this includes .kitchenettes. On 7/9/24 at 9:45 A.M., the surveyor observed splattered food and built up…
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 before2024-02-29 · 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
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 an activated Health Care Proxy, was transferred to the Hospital Emergency Department (ED) for an evaluation when he/she became unresponsive, the Facility failed to ensure that nursing notified his/her Health Care Agent (HCA) of the transfer. Findings include: Review of the Facility's policy, titled Health and Medical Condition, Informing Residents of, with an approval date of 01/10/17, indicated the following: -Each resident or resident representative admitted to our facility will be informed of his/her health status and medical condition on an ongoing basis. -The resident's family/resident representative will be notified when there is a medical change in the resident's condition. Review of the Facility's policy, titled Physician Notification, with a revision date of 09/2011, indicated the following: -If clinical findings are life threatening or an emergency, a nurse should notify the physician and family.…
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 before2024-02-29 · 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), whose physician's orders included the administration of Xarelto (anticoagulant medication) for treatment of atrial fibrillation (irregular heart rate) and history of bilateral pulmonary embolisms (blood clots in both lungs), the Facility failed to ensure they maintained a complete and accurate medical record when the Physician and Nurse Practitioner progress notes reference to Resident #1's anticoagulant dosage conflicted with the daily dosage being administered by nursing. Findings include: Review of the Facility's policy, titled Medical Records Policy, dated 05/19/23, indicated the following: Purpose: To ensure a system that abides by regulatory, state and federal requirements for medical records. -Each resident will have an active medical record. This record shall be kept current, complete and available at all times to authorized personnel. Resident #1 was admitted to the Facility in December 2022 with diagnoses including atrial fibrillation and bilateral pulmonary embolism. Review of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-01 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to implement a COVID-19 monitoring plan to prevent the spread of infection for two Residents (#1 and #2) out of a total sample of three residents. Specifically, the facility's staff failed to screen for signs and symptoms of COVID-19 every shift (Q-shift) while outbreak testing was being conducted within the facility. Findings include: Review of the facility policy titled Infection Prevention and Control Program, revised 12/22/16, indicated the following: -Ensure compliance with local, state, and federal regulations related to infection control and prevention . Review of the Massachusetts DPH Memorandum titled, Update to Infection Prevention and Control Considerations When Caring for Long-Term Care Residents, Including Visitation Conditions, Communal Dining, and Congregate Activities, dated May 10, 2023 included, but was not limited to: -Residents included in outbreak testing or who are being tested following an exposure, should be assessed for symptoms of Covid-19 during each shift. Review of the facility policy titled…
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 · D2023-11-01 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to provide education, assess for eligibility, and offer Pneumococcal Immunizations per the Centers for Disease Control and Prevention (CDC) recommendations for one Resident (#4) out of a total sample of five residents. Findings include: Review of the facility policy titled Resident Pneumococcal Immunization, revised 9/1/23, indicated the following: -Residents will be offered immunization to protect them from pneumococcal disease . Pneumococcal immunizations will be provided as recommended by the Centers for Disease Control and Prevention (CDC) Advisory Committee for Immunization Practices (ACIP) recommendations. Review of the CDC website Pneumococcal Vaccine Timing for Adults greater than or equal to 65 years (cdc.gov), dated 3/15/23 indicated the following: For adults 65 and over who have had Pneumococcal Conjugate Vaccine 13 (PCV13) and Pneumococcal Polysaccharide Vaccine 23 (PPSV23) and it has been 5 years or greater since the last pneumococcal vaccination then the patient and the vaccine provider may choose to administer…
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 · E2023-03-24 · 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 reviews and interview, the facility failed to ensure its staff provided a copy of the transfer and/or discharge notices to a Representative of the Office of the State Long-Term Care Ombudsman for four Residents (#113, #35, #55 and #61), out of a sample of 22 residents. Findings include: 1. Resident #113 was admitted to the facility in August 2019. A clinical record review indicated Resident #113 was sent to the hospital on 2/26/23. Further review of the clinical record indicated no documented evidence that the Ombudsman was notified of the hospital transfer on 2/26/23, as required. During an interview on 3/23/23 at 3:10 P.M., the Administrator said that the staff were unable to locate evidence that the Ombudsman was notified of Resident #113's transfer to the hospital on 2/26/23. 2. Resident #35 was admitted to the facility in June 2022. A clinical record review indicated that Resident #35 was sent to the hospital on 2/22/23. Further review of the clinical record indicated no documented evidence that the Ombudsman had been notified of the hospital transfer on 2/22/23…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-03-24 · tag F0656 — failed to write and follow a full care plan — patternDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interview, record and policy reviews, the facility failed to ensure its staff developed and implemented the plan of care for seven Residents (#40, #55, #61, #22, #16, #35 and #104), out of total sample of 22 residents. Specifically, the facility staff failed to: 1. ensure the plan of care relative to falls/activities of daily living (ADLs) was implemented for two Residents (#40 and #55), 2. implement the Physician's Orders for three Residents (#61, #22 and #16) relative to utilization of bed rails, and 3. obtain weights as ordered by the Physician for two Residents (#35 and #104). Findings include: Review of the facility policy titled Side Rails- Assessment and Use of, revised 10/17/17, included the following: -use of side rails will be addressed in the resident's plan of care and will also be documented in the resident's profile. Review of the facility policy titled Falls Risk Reduction, revised 11/28/18, included the following: -Residents determined to have risk factors will receive individualized interventions based on the risk factors in order to reduce…
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 · D2023-03-24 · 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 — the official record, unedited, may be distressing
Based on observation and interview, the facility failed to ensure its staff treated each resident with respect and dignity, impacting one Resident (#35), out of a sample of 22 residents. Specifically, staff repeatedly did not address Resident #35 by his/her preferred name. Findings include: On 3/21/23 at 9:22 A.M., while standing in the hallway outside of Resident #35's room, the surveyor overheard Certified Nurse's Aide (CNA) #2 calling the Resident names such as dear, sweetie, honey, love, and sweetheart repeatedly while she provided care for the Resident. During an interview on 3/21/23 at 10:28 A.M., CNA #2 said that she was aware that she often refers to residents by names such as honey, dear, and sweetie. She further said that she was aware of the rules and had been educated to call residents by their preferred names, not pet names, and that it was a habit that was hard to break.
- Potential for harm · Dcited before2023-03-24 · 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 observations, interviews, and record review, the facility failed to ensure its staff consulted the attending provider relative to an alteration in treatment for one Resident (#76), out of a sample of 22 residents. Specifically, facility staff failed to inform the Resident's attending Physician and/or the Physician designee that the Resident did not wear his/her right hand splint, as ordered. Findings include: Resident #76 was admitted to the facility in December 2021 with diagnoses including: Hemiparesis following Cerebral Infarction affecting the right dominant side (paralysis of the right side of the body following an area of tissue death in the brain, also known as a stroke), and a contracture to his/her right hand (a permanent tightening of the muscles, tendons, skin and nearby tissues that causes joints to shorten and become very stiff preventing normal movement of a joint). Review of the Resident's Activities of Daily Living (ADL) Care Plan, dated 4/8/22, included the following: - Provide adaptive equipment: right hand splint. Review of the March 2023 Physician'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.
- Potential for harm · D2023-03-24 · 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
Based on observation and interview, the facility failed to ensure a clean environment was maintained on one Unit (Sunrise), out of three units observed. Specifically, the facility's staff failed to ensure the privacy curtains for Resident #41's room were clean. Findings Include: Review of the facility policy titled Environmental Services Guidelines, dated September 2011, indicated the following: -Cleaning of walls, curtains, blinds, etc. will be completed when dust/soil is visible. Resident #41 was admitted to the facility in November 2021 and resided on the Sunrise Unit. On 3/21/23 at 10:15 A.M., the surveyor observed in Resident #41's room a large brown stain and multiple small brown stains on the privacy curtain. During a subsequent interview following the observation Resident #41 said he/she would like a clean curtain in his/her room. On 3/22/23 at 2:34 P.M., the surveyor observed the same large brown stain and smaller brown stains visible on Resident #41's privacy curtain. During an interview on 3/23/23 at 11:23 A.M., the Housekeeping Director said privacy curtains were cleaned…
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 · D2023-03-24 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to ensure its staff provided assistance for one Resident (#89), out of a total sample of 22 residents. Specifically, facility staff failed to provide grooming/ maintaining facial hair for the resident who was unable to carry out activities of daily living (ADLs). Findings include: Review of the facility policy titled Activities of Daily Living (ADLs), dated 11/14/16, indicated the following: -Each resident will receive the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care. -Resident's abilities, personal choices and self-image are accounted for during ADLs Resident #89 was admitted to the facility in February of 2023. Review of the Minimum Data Set (MDS) Assessment, dated 3/1/23, indicated that the Resident required an extensive assist of one person for personal hygiene. During an interview on 3/21/23 at 9:52 A.M., the surveyor asked Resident #89 about the hair on his/her face. He/she…
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 before2023-03-24 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to ensure that its staff provided care and services consistent with professional standards relative to the identification, monitoring, and documentation of a facility acquired pressure injury (also called pressure ulcer or bed sore: are injuries to the skin and underlying tissue resulting from prolonged pressure on the skin) for one sampled Resident (#105), out of five applicable residents with facility acquired pressure injuries, out of a total sample of 22 residents. Specifically, the facility failed to: 1) implement their policy relative to performing an initial and weekly assessment of a newly identified wound, 2) accurately document the location of the wound(s) throughout the clinical record, and 3)document whether turning and repositioning of the Resident occurred per the care plan. Findings include: 1) Review of the facility policy titled, Skin Integrity Management, revised 5/21/21 indicated the following: -Perform wound assessment…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-03-24 · 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, interviews, record and policy reviews, the facility failed to ensure its staff reduced the risk of falls for two Residents (#40 and #55), out of a total sample of 22 residents. Specifically, facility staff failed to implement the plan of care and provide effective interventions for Residents #40 and #55 who had numerous falls while at the facility. Findings include: Review of the facility policy titled Fall Risk Reduction, revised 11/28/18, indicated all residents will be assessed for falls risk factors. Those determined to have factors will receive individualized interventions based on the risk factors to reduce risk of falls and minimize the actual occurrence of falls. The policy also included the following: -the facility will ensure that the resident environment remains as free of accident hazards as is possible and that each resident receives adequate supervision and assistance devices to prevent accidents -the facility staff will develop an individualized plan of care -the facility staff will include fall interventions on the Resident Profile…
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 · D2023-03-24 · 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 ensure staff completed a Trauma-Informed Care Assessment at the time of admission or after it was identified for one Resident (#102), out of a sample of 22 residents. Specifically, the facility failed to complete a Trauma-Informed Care Assessment for a diagnosis of Post-Traumatic Stress Disorder (PTSD-a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event) per facility policy. Findings Include: Review of the facility policy titled Trauma-Informed Care, revised 11/18/22 indicated the following: -A Trauma-Informed Care Assessment will be completed by Social Services upon admission, as well as for all resident's residing in the facility with a diagnosis of PTSD. Resident #102 was admitted to the facility in November 2022 with a diagnosis of PTSD. Review of the Resident's Hospital Discharge/Transfer Note, dated 11/21/22, indicated the Resident had a diagnosis of PTSD. Review of the Physician Assistant (PA) Initial Assessment, dated 11/22/22, indicated the Resident had 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 · Dcited before2023-03-24 · 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 its staff maintained accurate medical records for two Residents (#105 and #102), out of a sample of 22 residents. Specifically, 1. for Resident #105, failure to accurately document: a) the location of a pressure injury (injuries to skin and underlying tissue resulting from prolonged pressure), and b) turning and positioning information on a Certified Nursing Assistant (CNA) flowsheet. 2. for Resident #102, failure to accurately complete the Preadmission Screening and Resident Review (PASRR- a federal and state required process that is designed to identify evidence of severe mental illness and/or intellectual or developmental disabilities for those seeking admission to a Medicaid and/or Medicare certified nursing facility). Findings include: 1. Resident #105 was admitted to the facility in January 2023. a) Review of a Nursing Progress Notes indicated Resident #105 had a pressure injury to his/her left buttock on the following dates: -2/22/23 -3/2/23 -3/6/23 Review of an Incident Report and Initial Skin Condition…
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 · D2023-03-24 · tag F0908 — failed to keep essential equipment working — isolatedKeep all essential equipment working safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interviews, the facility failed to ensure its staff maintained electrical equipment in safe operating condition for one Resident (#76), out of a sample of 22 residents. Specifically, the resident's electronic bed control contained exposed wires creating potential for electrocution and/or burns. Findings include: Resident #76 was admitted to the facility in December 2021. During an observation and interview on 3/21/23 at 10:40 A.M., the surveyor observed Nurse # 6 take the Resident's bed control and place it out of the Resident's reach on a metal bar underneath the Resident's bed. She said there were exposed wires on the device, that it was a hazard, and she needed to notify maintenance. The surveyor observed the base of the bed control to have a broken plastic tube containing multiple colored wires extending down to the other end of the the broken plastic tube attached to a long, coiled cord which connected underneath the bed. During an observation and interview on 3/23/23 at 11:30 A.M., the Resident said he/she was not able to put his/her head up and down,…
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
$8,788 in federal fines across 1 penalty.
- $8,788 — penalty dated 2025-06-06
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to INTEGRITUS 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 | 3 of 5 | 2.8 | +0.2 vs chain |
| Health inspection | 3 of 5 | 2.9 | +0.1 vs chain |
| Staffing | 4 of 5 | 3.4 | +0.6 vs chain |
| Quality measures | 3 of 5 | 2.7 | +0.3 vs chain |
The other 13 homes this chain runs (chain average 2.8★, 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 |
|---|---|---|---|---|
| CEC MANAGEMENT SYSTEMS INC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 100% | since 02/01/2022 |
| INTEGRITUS HEALTHCARE INC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 12/30/2022 |
| INTEGRITUS HEALTHCARE MANAGEMENT SERVICES INC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 02/01/2022 |
| JONES, WILLIAM | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; ADP OF THE SNF | — | since 02/01/2022 |
| GINGRAS, MARCIE JO | Individual | CORPORATE OFFICER; ADP OF THE SNF | — | since 02/01/2022 |
| HEINZE, JEFFREY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/01/2022 |
| WHITCOMB, WINTHROP | Individual | ADP OF THE SNF | — | since 02/01/2022 |
CMS files one row per role, so the 15 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted.
3 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $1.5M 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 225363. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-29, 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.