Mount Carmel Care Center
320 Pittsfield Road, Lenox, MA 01240 · Non profit - Church related · 69 certified beds · (413) 637-2660 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a middle-of-the-pack inspection score (3/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has 1 actual-harm citation
- a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $46,410 in federal fines (most recent 2024-04-10)
- its facility-reported quality-measure rating is low (2/5)
- nursing-staff turnover (73%) 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 | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 3 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 | 16.4% | 16.4% | 15.4% | typical |
| Long-stay residents who lose too much weight | 6.7% | 5.1% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 1.7% | 0.8% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 2.6% | 1.8% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 6.3% | 15.5% | 6.5% | typical |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 2.0% | 3.4% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 17.5% | 15.4% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 16.2% | 19.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 94.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.8% | 4.2% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 18.4% | 21.2% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 23.1% | 21.4% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.4% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 93.2% | 77.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 29.1% | 25.7% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 19.1% | 11.9% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.57 | 1.88 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.72 | 1.50 | 1.80 | typical |
§ 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.
51.6% 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 166 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 56.4% 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 94 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 0.34 therapist hours per resident per day in 2026Q1 — more than 58% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 20% 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 | 51.6%CMS range 45.4–58.1 | 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 | 13.0%CMS range 9.7–16.4 | 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 | 56.4% | 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 | 54.3% | 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 | 55.3% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 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 | 2.4% | 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 | 7.3% | 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 | 7.6%CMS range 4.4–12.2 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.05 | 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 69 beds and averages 63.1 residents a day — about 91% occupied, or roughly 6 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 4.10 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.68 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.10 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 3.85 hrs/resident/day on weekends vs 4.20 on weekdays — 9% thinner on weekends. RN hours go from 0.74 to 0.52 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 73% 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 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.
22 citations, most serious first. The 11 most serious are shown; the remaining 11 are one tap away and print in full.
- Actual harm · G2024-04-10 · 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, interview, record and policy review, the facility failed to ensure that care and services to prevent and/or treat pressure ulcers were provided for two Residents (#57 and #15), out of three applicable residents reviewed, out of a total sample of 17 residents. Specifically, the facility failed to: 1. For Resident #57, ensure timely assistance with bedpan use to prevent the development of a pressure ulcer to his/her sacrum (triangular bone in the lower back) for the Resident who was at increased risk for pressure ulcers. 2. For Resident #15, ensure weekly skin assessments were completed as ordered by the Physician so that a resulting Stage 2 Pressure Ulcer (partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer) could have been identified earlier and prevented from progressing. Findings include: Review of the facility policy titled Wound and Skin Care-Pressure Injury Prevention and Management, dated 6/27/23, indicated the facility was committed 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.
- Potential for harm · D2025-04-23 · tag F0553 — failed to let residents help plan their care — isolatedAllow resident to participate in the development and implementation of his or her person-centered plan of care.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews, and record reviews, the facility failed to ensure that two Residents (#36 and #51) out of a total sample of 15 residents, and/or their Resident Representatives were afforded the right to participate in the scheduled interdisciplinary (IDT) care plan meetings. Specifically, for Resident's #36 and #51, the facility failed to ensure that a care plan meeting was rescheduled as requested by the Resident and/or Resident Representative. Findings include: Review of the facility policy titled Comprehensive Care Plans, dated 2/27/24, indicated the following: -the comprehensive care plan will be prepared by an interdisciplinary team, that includes, but is not limited to: >the resident and the resident's representative, to the extent practicable -the home will provide the resident and resident representative, when applicable, with advanced notice of care planning conferences to enable the resident/resident representative participation. Resident and resident representative participation may be accomplished in many forms, such as holding care conferences at a time when 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 before2025-04-23 · 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 record review, and interview, the facility failed to notify the Physician/Nurse Practitioner (NP) timely of a change in condition for one Resident (#28) out of a total sample of 15 residents. Specifically, for Resident #28, the facility staff failed to notify the Physician/NP of a significant weight loss (greater than 5% in one month) that occurred on 4/2/25, resulting in a delay in the assessment and treatment of the weight loss, and the Resident continued to lose weight. Findings include: Review of the facility policy titled Weight Monitoring, dated 11/13/24, indicated the following in part: -Based on the resident's comprehensive assessment, the home will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight and desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise. -Weight analysis: A significant change in weight is defined as: ---5 percent (%) change in weight with one month (30 days) ---7.5% change…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-23 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interviews, the facility failed to ensure one Resident (#56) out of a total sample of 15 residents, remained free from accidental hazards. Specifically, for Resident #56, the facility failed to evaluate and analyze hazards and risks, implement interventions to reduce hazards and risks, monitor the effectiveness and modify interventions relative to falls. Findsings include: Review of the facility policy titled Fall Prevention Program, dated 2/13/25, indicated the following: -Complete a fall risk assessment on admission, quarterly, and as indicated for significant condition changes and after each fall. -Provide additional interventions as directed by the resident's assessment, including but not limited to: i. Assistive devices ii. Increased frequency of rounds iii. Sitter if indicated iv. Medication regimen review v. Low bed vi. Alternate call system access vii. Scheduled ambulation or toileting assistance viii. Family/family caregiver or resident education. ix. Therapy services…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-23 · 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
Based on observation, interviews, and record review, the facility failed to ensure that acceptable parameters of nutritional status were maintained for one Resident (#28), out of a total sample of 15 residents. Specifically, the facility failed to: -implement the Dietitian's recommendation for a nutritional supplement for Resident #28, who was identified as being at risk for inadequate intake of nutrition and hydration, and had experienced weight loss. -assess Resident #28 when he/she continued to experience unplanned, undesired weight loss. Findings include: Review of the facility policy titled Weight Monitoring, dated 11/13/24, indicated the following in part: -Based on the resident's comprehensive assessment, the home will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight and desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise. -The home will utilize a systematic approach to optimize a resident'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 · D2025-04-23 · tag F0712 — isolatedEnsure that the resident and his/her doctor meet face-to-face at all required visits.
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 timely Physician visits for one Resident (#28) out of total sample of 15 residents. Specifically, the facility failed to ensure that Resident #28 was seen by a Physician as required after his/her admission to the facility in February 2025. Findings include: Review of the facility policy titled, Physician Services: Supervision, Visits and Frequency of Visits, dated 3/31/23, indicated the following: -Ensure that all residents remain under the care of a physician. -The Medicare A skilled resident is seen by a physician at least once every 30 days. For a resident in a Part A Medicare stay the, NPP (non-physician practitioner) must follow the requirements for physician services in a skilled nursing facility. This includes, at the option of a physician, required physician visits alternated between personal visits by the physician and visits by the NPP after the physician makes the initial comprehensive visit. -A physician visit is considered timely if it occurs not later than 10 days after the date the visit was 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 · Dcited before2025-04-23 · 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 record review, observation, and interview, the facility failed to adhere to infection control standards of practice for one Resident (#29) out of a total sample of 15 residents, and on one unit (St. Luke's) out of a total of two units. Specifically, 1) For Resident #29, the facility failed to ensure that staff wore the required Personal Protective Equipment (PPE: items such as gown and gloves worn by the staff member to decrease the spread of infection) while in the Resident's room when he/she was on Contact Precautions (interventions including use of PPE to prevent the spread of a communicable diseases). 2) For St. Luke's Unit, the facility failed to ensure that staff performed hand hygiene after removing gloves creating a risk for cross contamination. Findings include: 1) Review of the facility policy titled Determining Precaution Type Policy, dated 3/3/23, indicated the following: -Contact Precautions: In addition to Standard Precautions, implement Contact Precautions for residents known or suspected to be infected with microorganisms that can be transmitted by direct…
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 · F2024-04-10 · tag F0725 — failed to have enough nursing staff — widespreadProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
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 ensure that there was sufficient nursing staff to assist residents in attaining and maintaining the highest practicable physical, mental, and psycho-social well-being on two out of two units observed (St. Louise and St. [NAME] Units) and six Residents (#16, #57, #62, #28, #2, and #32). Specifically, the facility staff failed to: -For Resident #16, answer the call light timely for assistance with toileting. -For Resident #57, respond to the call light timely to assist with bedpan use by the Resident, who was unable to independently use the bedpan due to a fractured hip. -For Resident #62, provide bathroom assistance to the Resident during meal times. -For Resident #28, provide liquids and assistance in the early morning hours. -For Resident #2, respond timely when the call light was activated. -For Resident #32, answer call lights and provide assistance timely on evening and night shifts. Findings include: Review of the facility…
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 · F2024-04-10 · tag F0726 — failed to have competent, trained nursing staff — widespreadEnsure 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 observation, interview, record and policy review, the facility failed to provide sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and to attain and maintain the highest practicable physical, mental, and psychosocial well-being of each resident for one Resident (#60) who was receiving intravenous (IV) antibiotics, out of a total sample of 17 residents. Specifically, the facility failed to ensure that six Nurses ( #3, #8, #10, #11, #13 and #14) had the specific competencies and certification necessary to provide appropriate Central Venous Access Device (CVAD: long flexible tube that is inserted through one of the central veins found in the neck, chest or groin to allow access to the bloodstream to deliver medication) care and services for Resident #60, who was receiving IV antibiotics for a left hip infection. Findings include: According to the Board of Registration in Nursing, 244 CMR 9.00 &10.00: Standards of Conduct, Definitions and Severability; a competency is defined as 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 · D2024-04-10 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and policy review, the facility failed to ensure that one Resident (#25) out of a total sample of 17 residents, was provided privacy and dignity when assisting with personal care. Specifically, the facility staff failed to: -provide appropriate clothing or covering for the Resident's private areas while he/she was being transported to and from the shower. Findings include: Review of the facility policy titled Resident Rights - Promoting and Maintaining Resident Dignity, effective 3/16/23, indicated it was the practice of the home to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. The policy also included the following: -All staff members are involved in providing care to residents to promote and maintain resident dignity respect resident rights. -Maintain resident privacy. Resident #25 was admitted to the facility in May 2018 with diagnoses…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-04-10 · 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, record and policy review, the facility failed to ensure the Physician and the Resident Representative were notified of a change in skin condition for one Resident's (#60) out of a total sample of 17 residents. Specifically, the facility failed to notify the Physician and Resident Representative when Resident #60 was found bleeding from his/her left index finger and the Resident was on anticoagulant (medication that prevent blood from clotting) therapy. Findings include: Review of the facility policy titled Notification of Changes, dated 4/25/23, indicated the facility shall consult with the resident's physician when there are changes in the resident's condition or status, in order to obtain orders for appropriate treatment and monitoring. The policy also included the following: -The nurse will immediately attempt to notify the resident, resident representative and resident physician for the following: an accident involving the resident, which results in injury and may require medical physician intervention . -The nurse will notify the 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.
Show the remaining 11 citations
- Potential for harm · D2024-04-10 · 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 interview and record review, the facility failed to ensure the Minimum Data Set (MDS) Assessment was accurate for one Resident (#15) out of a total sample of 17 residents. Specifically, the facility failed to accurately code that Resident #15 had a pressure injury (localized damage to skin and/or underlying soft tissue, usually over a bony prominence or related to a medical or other device). Findings include: Resident #15 was admitted to the facility in October 2020 with diagnoses including Dementia and Diabetes. Review of Resident #15's medical record indicated the Resident developed a Stage 2 injury (partial thickness loss of skin with exposed dermis, presenting as a shallow open ulcer) in November 2022 that was not deemed resolved until March 2024. Review of Section M0100: Determination of Pressure Ulcer Risk, of the MDS assessment dated [DATE] did not indicate that the Resident had a pressure injury. During an interview on 4/10/24 at 10:44 A.M., the MDS Nurse said Section M0100 of the MDS 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 · D2024-04-10 · 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, record and policy review, the facility failed to provide treatment and care in accordance with professional standards relative to monitoring and assessing the skin condition for two Residents (#60 and #15). The facility also failed to ensure care and services were provided that meet professional standards relative to a Central Venous Access Device (CVAD-long flexible tube that is inserted through one of the central veins found in the neck, chest or groin to allow access to the bloodstream to deliver medication) catheter used to administer Intravenous (IV) antibiotics for Resident #60. Specifically, the facility failed to: 1. For Resident #60, a. perform weekly skin assessments, notify and obtain orders from the Physician when a new skin area of concern was identified, and b. monitor a CVC access site relative to measuring and documenting the external catheter length (measured from the catheter exit site to the 0 mark or, if no 0 mark is present, to the suture flange. Each line 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.
- Potential for harm · Dcited before2024-04-10 · 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 observation, interview, record and policy review, the facility failed to investigate accident/hazards incidents and implement interventions to the plan of care for two Residents (#60 and #57), out of a total sample of 17 residents. Specifically, the facility failed to: 1. For Resident #60, thoroughly investigate and add interventions when a new skin area was identified on his/her left index finger. 2. For Resident #57, thoroughly investigate and add interventions when a new pressure injury was identified. Findings include: Review of the facility policy titled Wound and Skin Care- Skin Assessment, effective 6/25/23, indicated it was the policy of the facility to perform a full body skin assessment as part of their systemic approach to pressure injury prevention and management. The policy also included the following: -A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/readmission, and after any newly identified pressure injury is noted. -Documentation of skin assessment: >include date and time of the 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 · D2024-04-10 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record and policy review, the facility failed to perform a trauma assessment on admission to the facility and develop a trauma care plan for one Resident (#10) out of a total sample of 17 residents. Specifically, the facility failed to assess whether Resident #10, who was admitted with a diagnosis of Post Traumatic Stress Disorder (PTSD-a disorder in which a person has difficulty recovering after a traumatic experience), had a history of trauma and failed to identify any triggers which may cause re-traumatization. Findings include: Review of the facility policy titled; Trauma Informed Care dated 10/24/23 indicated but was not limited to: -It is the policy of this facility to address trauma in the lives of the residents served by this company. -The interdisciplinary care team will be responsible for developing a care plan that addresses assessed emotional and psychosocial needs of the resident, monitoring effectiveness of approaches and updating the care plan as needed. The care plan should…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-04-10 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
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 ensure an accurate accounting of a controlled medication. Specifically the facility failed to account for the controlled medication (Ativan, generic name Lorazepam) in the controlled substance accountability record book, as required. Findings include: Review of the facility policy titled, Disposal of Medications and Medication-Related Supplies, dated 2017 indicated but was not limited to: -Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and record keeping in the facility in accordance with federal and state laws and regulations. -Disposition is documented on the individual controlled substance accountability record/book. -Unused, unwanted, and non-returnable medications should be removed from the storage area and secured until destroyed. -Accountability records for controlled substances that are disposed of or destroyed are…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-04-10 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to monitor for side effects and adverse reactions to medications for one Resident (#45) out of a total sample of 17 residents. Specifically, for Resident #45, the facility staff failed to monitor for side effects and adverse reactions related to the use of an anticoagulant (medication used to thin the blood) medication. Findings include: Resident #45 was admitted to the facility in March 2024, with the following diagnoses: Pulmonary Embolism (a blockage of an artery in the lungs by a substance that has moved from elsewhere in the body through the bloodstream) and Atrial Fibrillation (Afib - irregular, rapid heartbeat that can lead to blood clots and other heart related complications). Review of the current Order Summary Report, printed on 4/9/24, indicated the following order: -Anticoagulant medication: monitor for discolored urine, black tarry stools, sudden severe headache, numbness and tingling, diarrhea, muscle joint pain, lethargy, bruising, sudden changes in mental status and/or vital signs, shortness of breath, nose…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-04-10 · 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
Based on interview, record and policy review, the facility failed to ensure that an as needed (PRN) psychotropic medication (medication that affect the mind, emotions and behavior) was limited to 14 days for one Resident (#60), of five applicable residents reviewed, out of a total sample of 17 residents. Specifically, the facility failed to ensure that PRN Valium (an anti-anxiety medication) was limited to 14 days and was reviewed by the Physician for continued use. Findings include: Review of the facility policy titled Use of Psychotropic Medications, dated 1/11/24, indicated the following: -Psychotropic drugs are any medication that affects brain activities associated with mental processes and behavior. -Psychotropic drugs include, but are not limited to the following categories: antipsychotics, antidepressantss, anti-anxiety and hypnotics -PRN orders for all psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration (i.e. 14 days) -If the attending physician…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-04-10 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record and policy review, the facility failed to ensure that Transmission Based Precautions (TBP: for patients who are known or suspected to be infected or colonized with infectious agents which require additional control measures to effectively prevent transmission) were in place and adhered to by staff in order to minimize the potential spread of infection for two Residents (#118 and #60), of three applicable residents reviewed, out of a total sample of 17 residents. Specifically, the facility failed to ensure that Enhanced Barrier Precautions (EBP: infection control intervention designed to reduce the transmission of multi-drug resistant organisms or MDROs) were implemented for Residents #118 and #60. Findings include: Review of the facility policy titled Enhanced Barrier Precautions Policy, dated 3/27/24, indicated the following: -It is the policy of the facility to implement EBP for the prevention of transmission of MDROs -Residents will be reviewed upon admission and/or change of condition for the need for EBP by the Director of Nursing…
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 · E2023-01-23 · tag F0883 — failed to offer flu and pneumonia vaccines — patternDevelop and implement policies and procedures for flu and pneumonia vaccinations.
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 its staff maintained a clinical record that included documentation that residents were offered, received or declined the Pneumococcal immunization (a vaccine used to prevent possible life-threatening Pneumonia) for four Residents (#18, #24, #31, and #58), out of a total sample of five residents. Findings include: Review of the facility policy titled Infection Control: Influenza and Pneumococcal Immunizations, dated 10/2/2020, indicated the following: -the facility follows the recommendations from the Centers for Disease Control & Prevention (CDC) -Each resident is offered a Pneumococcal immunization unless the immunization is medically contraindicated, or the resident has already been immunized. -The resident or the resident's representative could refuse immunization. -The resident's medical record includes documentation that indicates, at a minimum, the following: >the resident or resident's representative was provided education regarding…
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 · D2023-01-23 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure that its staff implemented the plan of care for one sampled Resident (#17), relative to interventions to address accidents such as falls, and for two sampled Residents (#17 and #58), relative to the administration of the prescribed flow rate of Oxygen therapy, out of a total sample of 17 residents. Finding include: 1. For Resident #17, the facility failed to ensure the staff implemented the care plan for: A) falls prevention, and B) the administration of Oxygen therapy. Resident #17 was admitted to the facility in September 2022 with diagnoses including Congestive Heart Failure (CHF- condition where the heart is unable to pump blood efficiently), Respiratory Failure (serious condition which causes difficulty breathing) and weakness. A) Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #17 required extensive assistance of staff with transfers, ambulation, toileting and personal hygiene. 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 before2023-01-23 · 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 observations, interviews and record review, the facility failed to ensure that its staff adhered to Isolation Precautions (measures put into place to reduce transmission of microorganisms) to minimize the risk of spread of infections for two sampled Residents (#6 and #51), out of 4 applicable residents, who were identified as having Coronavirus (COVID-19) infection. Specifically, facility staff failed to ensure: A) the required personal protective equipment (PPE) was utilized prior to entering and while within the Residents' room, and B) PPE was discarded/disinfected appropriately upon exiting the Isolation Precaution room. Findings include: Review of the facility policy titled COVID-19 Prevention and Management, dated 8/12/22, indicated the facility will provide employees with all PPE in accordance with Centers for Disease Control and Prevention (CDC), Centers for Medicare and Medicaid Services (CMS), and Department of Public Health (DPH) recommendations. The policy also included the following: -N95 respirators for COVID-19 Positive or suspect . -all employees providing…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“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
$46,410 in federal fines across 1 penalty.
- $46,410 — penalty dated 2024-04-10
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 CARMELITE SISTERS FOR THE AGED AND INFIRMED — 3 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 3.7 | -0.7 vs chain |
| Health inspection | 3 of 5 | 3.7 | -0.7 vs chain |
| Staffing | 3 of 5 | 3.7 | -0.7 vs chain |
| Quality measures | 2 of 5 | 3.3 | -1.3 vs chain |
The other 2 homes this chain runs (chain average 3.7★, 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 |
|---|---|---|---|---|
| THE CARMELITE SYSTEM INC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | 100% | since 03/29/2013 |
| CARMELITE SISTERS FOR THE AGED AND INFIRM, INC. | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 100% | since 03/29/2013 |
| KIRBY, CRAIG | Individual | CONTRACTED MANAGING EMPLOYEE | — | since 06/01/2024 |
| OUIMETTE, JODI | Individual | W-2 MANAGING EMPLOYEE | — | since 05/01/2023 |
| HALEY, MARGARET | Individual | CORPORATE DIRECTOR | — | since 02/06/2014 |
| HEERY, MARY | Individual | CORPORATE DIRECTOR | — | since 02/06/2014 |
| KASPER, ROSE | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | — | since 09/16/2014 |
| KEARNS, JOHN | Individual | CORPORATE DIRECTOR | — | since 08/07/2014 |
| RANDALL, DIANE | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | — | since 03/29/2013 |
| RAWDON, PATRICIA | Individual | CORPORATE DIRECTOR | — | since 03/29/2013 |
CMS files one row per role, so the 13 rows in the source record cover these 10 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 $263K 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 225581. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-23, 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.