Regalcare At Lowell
30 Princeton Boulevard, Lowell, MA 01851 · For profit - Corporation · 90 certified beds · (978) 454-8086 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a high payroll-based staffing rating (4/5)
- lower-than-typical staff turnover (30% vs 45% nationally) — better care continuity
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 2 immediate-jeopardy problems — the most serious level
- a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $91,558 in federal fines (most recent 2026-03-10)
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection rating is low (1/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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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 | 1 of 5 |
| Short-stay residentsrehab / post-hospital | 5 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 1 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 26.0% | 16.4% | 15.4% | worse |
| 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 | 2.5% | 0.8% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 0.0% | 1.8% | 2.0% | better |
| Long-stay residents with depressive symptoms | 24.0% | 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 | 5.0% | 3.4% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 25.7% | 15.4% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 19.2% | 19.5% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 98.0% | 94.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 7.2% | 4.2% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 23.5% | 21.2% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 19.6% | 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 | 86.2% | 77.7% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 25.5% | 25.7% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 5.3% | 11.9% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.66 | 1.88 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 1.67 | 1.50 | 1.80 | typical |
‡ 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.
52.3% 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 44 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 50.0% 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 24 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 0.19 therapist hours per resident per day in 2026Q1 — more than 21% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 16% 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 | 52.3%CMS range 37.2–70.5 | 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 | 10.3%CMS range 6.1–14.6 | 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 | 50.0% | 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 | 58.3% | 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 | 45.8% | 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 | 94.3% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 2.9% | 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 | 0.0% | 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 | 7.5%CMS range 4.1–12.9 | 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 90 beds and averages 62.4 residents a day — about 69% occupied, or roughly 28 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.60 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.56 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.84 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.23 hrs/resident/day on weekends vs 3.76 on weekdays — 14% thinner on weekends. RN hours go from 0.62 to 0.40 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 30% is below 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.
29 citations, most serious first. The 12 most serious are shown; the remaining 17 are one tap away and print in full.
- Immediate jeopardy · J2026-03-10 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to provide an environment free from accidents and hazards for two Residents (#9 and #39) out of a total sample of 25 residents. Specifically,1. For Resident #9, the facility failed to identify Resident #9's needs to receive 1:1 supervision with meals upon admission, and while eating unsupervised in his/her room, the Resident choked and required the Heimlich maneuver to be administered by facility staff. The Resident was subsequently transferred to the hospital, admitted to the intensive care unit, intubated and required a bronchial scope to remove a piece of chicken from his/her bronchial tube (the main airway leading to the lung), placing the resident at the likelihood of serious harm or death.2. For Resident #38, the facility failed to provide supervision with meals as indicated in his/her care plan. Findings include: Review of the facility policy titled, Activities of Daily Living, dated 3/2002, indicated the following:-Appropriate care…
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.
- Immediate jeopardy · J2025-03-31 · tag F0742 — isolatedProvide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide the appropriate treatment and services for one Resident (#7), with a known history of depression and suicidal ideation out of a total sample of 28 residents. Specifically, for Resident #7, the facility failed to implement and update the plan of care, resulting in an attempted suicide after the vocalization of suicidal ideation (SI). Findings include: Review of the facility policy titled Behavior Management, dated 04/2022, indicated the following: -The facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. - The IDT staff will identify, document, and inform the physician about specific details regarding changes in an individuals mental status, behavior, and cognition including: * Onset, duration, intensity and frequency of behavioral symptoms * Any…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-03-10 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to maintain a homelike environment on 1 of 2 units. Findings include:Review of the facility policy titled Accommodation of Needs and Preferences and Homelike Environment Policy, dated as revised 4/2022, indicated the following:A homelike environment is one that de-emphasizes the institutional character of the setting, to the extent possible, and allows the resident to use those personal belongings that support a homelike environment. A determination of homelike should include the resident's opinion of the living environment. Orderly is defined as an uncluttered physical environment that is neat and well-kept.7. The resident's environment will be maintained in a homelike manner to ensure:-Appropriate housekeeping-Clean linens in good repair-Private closet space for each resident-Adequate and comfortable lighting-Comfortable and safe temperatures-Comfortable sound levels During a tour of the first floor unit on 3/3/26 at 8:27 A.M., the following was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-10 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interviews, the facility failed to ensure they reviewed and revised the Comprehensive Care Plan following the completion of his/her scheduled Quarterly Minimum Data Set (MDS) assessment for 1 Resident (#6) out of a total sample of 25 residents Specifically, for Resident #6 the facility failed to ensure a dementia care plan was developed following a Psychiatric assessment adding the diagnosis to the resident record. Review of the facility policy titled Comprehensive Assessments and the Care Delivery Process, dated as revised 2/2025, indicated:-Comprehensive assessments will be conducted to assist in developing person-centered care plans.-Comprehensive assessments are conducted and coordinated by a registered nurse with appropriate participation of other health professionals. 7. Completed assessments (baseline, comprehensive, MDS, etc.) are maintained in the resident's active record for a minimum of 15 months. These assessments are used to develop, review and revise the resident's comprehensive care plan. Resident #6 was admitted to the facility in October…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-10 · tag F0685 — isolatedAssist a resident in gaining access to vision and hearing services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to provide one Resident (#38) with his/her hearing aids to maintain adequate hearing for communication, out of a total sample of 25 residents. Findings include: Review of the policy titled, Ancillary Physician, dated 4/2022, indicated the following:-Direct care staff will assist residents with eyewear and hearing aid care, including removing, cleaning and storage. Resident #38 was admitted to the facility in March 2022 with diagnoses including stroke and right sided hemiplegia. Review of Resident #38's most recent Minimum Data Set (MDS), dated [DATE], indicated the Resident scored a 00 out of a possible 15 on the Brief Interview for Mental Status (BIMS) which indicated he/she had severe cognitive impairment. The MDS also indicated Resident #38 uses bilateral hearing aids. On 3/3/26 at 7:55 A.M., Resident #38 was observed lying in bed. The Resident had a difficult time hearing the surveyor's questions and he/she was not wearing hearing aids.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-10 · 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 record review and interview, the facility failed to identify a significant weight loss in a timely manner for one Resident (#46) out of a total sample of 25 residents. Findings include: Review of the facility policy titled 'Weight Management', dated 4/2022, indicated the following but not limited to:-To monitor the resident's weight from time of admission and to provide interdisciplinary support and/or intervention to avert adverse trends.-Weight change is defined as any unplanned weight gain or loss as follows:+/- 5% weight change in 1 month+/- 7.5% weight change 3 months+/- 10% weight change in 6 months-Reweights must be done within 24 hours.-The dietician will assess the resident and will communicate any recommended changes to the DNS and supervisor. Resident #46 was admitted to the facility in October 2025 with diagnoses including cognitive communication deficit and type 2 diabetes mellitus. Review of Resident #46's Minimum Data Set (MDS), dated [DATE], indicated the Resident scored a 7 out of 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 · D2026-03-10 · tag F0744 — failed to care for residents with dementia — isolatedProvide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record review and interviews, the facility failed to ensure that for 1 Resident (#6), who was diagnosed with dementia, appropriate treatment and services were provided to attain his/her highest practical physical, mental and psychosocial well-being, and that person centered interventions were implemented, out of a total sample of 25 residents. Findings include:Review of the facility policy titled Dementia CP, dated as revised 3/33, indicated:Treatment and ManagementFor the individual with confirmed dementia, the IDT will identify a resident-centered care plan to maximize remaining function and quality of life. The IDT (interdisciplinary team) will identify and document the resident's condition and level of support needed during care planning and review changing needs as they arise. Resident needs will be communicated to direct care staff through care plan conferences, during change of shift communications and through written documentation (nurses' notes and documentation tools). Progressive or persistent worsening of symptoms and increased need of staff…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-10 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
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 interviews, the facility failed to ensure that one Resident (#39) was free of significant medication errors out of a total sample of 24 residents. Specifically, the nurse substituted and attempted to administer furosemide (a diuretic- used for removing excess fluids from the body) medication without a physician order.Findings include: Review of the facility policy titled Oral Medication Administration, dated 4/22, indicated the following but not limited to:-Verify that there is a physician's medication order for this procedure.-Check the label on the medication and confirm the medication name and does with the MAR (medication administration record).-Check the medication dose. Re-check to confirm proper does. Resident #39 was admitted to the facility in January 2026 with diagnoses including acute heart failure and coronary artery disease. Review of Resident #39's Minimum Data Set (MDS), dated [DATE] indicated the Resident scored a 15 out of 15 on the Brief Interview for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-10 · tag F0790 — failed to provide dental care — isolatedProvide routine and 24-hour emergency dental care 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 observations, record review and interview, the facility failed to provide dental services to one Resident (#9) out of a total sample of 25 residents. Specifically, the facility failed to refer Resident #9 to the dentist to repair or replace his/her broken dentures. Findings include:Resident #9 was admitted to the facility in November 2025 with diagnoses including Wernicke's encephalopathy. Review of Resident #9's most recent Minimum Data Set (MDS), dated [DATE], indicated the Resident scored a 00 out of a possible 15 on the Brief Interview for Mental Status exam which indicated he/she had severe cognitive impairment. The MDS also indicated Resident #9 required assistance from staff for all functional tasks. On 3/3/26 at 7:58 A.M., Resident #9 was observed lying in bed. The Resident was observed to have a missing front tooth from his/her upper dentures and did not have lower dentures. Resident #9 could not be interviewed due to cognition. On 3/4/26 at 9:43 A.M., Nurse #2 and the surveyor observed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-10 · tag F0849 — isolatedArrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record review, the facility failed to ensure a hospice care plan was present in the medical record and coordinated between facility staff and the hospice agency for one Resident (#48) out of a total sample of 24 residents. Findings include: Review of the facility policy titled Hospice Care, revised April 2022, indicated but was not limited to the following: -In general, it is the responsibility of the hospice to manage the resident's care as it relates to the terminal illness and related conditions, including: -Determining the appropriate hospice plan of care. -Our facility staff will coordinate care provided to the resident with the hospice staff. He or she is responsible for the following: -Obtaining the following information from the hospice: -The most recent hospice plan of care specific to each resident. -Coordinated care plans for residents receiving hospice services will include the most recent hospice plan of care as well as the care and services provided by our facility (including the responsible provider and discipline assigned to specific tasks) in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-29 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interviews, for one of three sampled Personnel Files (Occupational Therapist #1), the Facility failed to ensure they implemented and followed their abuse prohibition procedures as defined in their policy when a Massachusetts Nurse Aide Registry background check was not conducted prior to hire.Findings include: Review of the Facility's Policy titled Abuse Screening, dated March 2022, indicated all potential employees will be screened to rule out a history of abuse, neglect or mistreating residents which includes attempting to obtain information by checking with appropriate licensing registries. The Policy indicated the Nurse Aide Registry is checked prior to employment for all facility employees. Review of Occupational Therapist (OT) #1's Personnel File indicated she was hired on 05/20/24. There was no documentation to support that the facility had conducted a Massachusetts Nurse Aide Registry background check on OT #1 before hire.During a telephone interview on 02/09/26 at 2:45 P.M., the Director of Nurses (DON) said OT #1 was a contracted employee. 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 · Fcited before2025-03-31 · tag F0584 — failed to keep a safe, clean, comfortable home — widespreadHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and policy review, the facility failed to maintain a homelike environment on 2 out of 2 resident units in the facility. Specifically on 2 of 2 units there were stained ceiling tiles, missing thresholds, broken blinds, holes in walls, gouged walls, peeling baseboards, missing baseboards, peeling wallpaper, dark and brown substance on ceiling tiles, stained floor tiles and missing closet doors. Findings include: A review of the facility policy titled, Resident Rights: Accommodation of Needs and Preferences and Homelike Environment, not dated, indicated that the facility will provide a safe, clean, comfortable and homelike environment. On 3/27/25 between 7:22 A.M. and 8:45 A.M., the surveyor observed the following in the bedrooms on the first floor unit: 100: A hole in the bathroom ceiling next to the vent. 101: The door bed had a brown substance was on the wall and the toilet was continuously running. 102: A wall was patched white and not painted. 103: A wall was patched white 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.
Show the remaining 17 citations
- Potential for harm · E2025-03-31 · tag F0679 — failed to provide activities — patternProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
2. Resident #2 was admitted to the facility in January 2023 with diagnoses including hemiplegia and hemiparesis following cerebral infarction effecting right dominant side and weakness. Review of the most recent Minimum Data Set (MDS) assessment, dated 2/27/25, indicated Resident #2 did not have a Brief Interview for Mental Status assessment completed and was assessed by staff to have moderately impaired cognition. The MDS further indicated Resident #2 speaks Cantonese, has clear speech but is rarely/never understood, and is dependent on staff for care.Review of Section F. on the MDS indicated an interview for daily and activity preferences should not be conducted and indicated the Resident is rarely/never understood and family/significant other not available. On 3/25/25 the following was observed:-At 9:30 A.M., Resident #2 was observed sitting in the main dining room in a wheelchair. The television was on.-At 9:45 A.M., the activity calendar had Coffee Social, as the activity. The activity was not observed on the unit and Resident #2 remained in the dining room sitting alone at 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 · E2025-03-31 · tag F0770 — failed to provide lab services — patternProvide timely, quality laboratory services/tests to meet the needs of residents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to ensure they provided laboratory services to meet the needs of its residents. Specifically, the facility failed to maintain a current Clinical Laboratory Improvement Amendment (CLIA) certificate appropriate for the level of testing performed within the facility. Findings include: On [DATE] at 7:15 A.M., the surveyor observed a CLIA certificate posted on the bulletin board adjacent to the lobby near the Administrator's office with an expiration date of [DATE]. On [DATE] the surveyor requested the facility's CLIA certificate. On [DATE], the Administrator provided the surveyor with a CLIA certificate dated as expired [DATE] and the following document indicating Application Name: CLIA Laboratory Program dated [DATE], which indicated the payment was made on [DATE], for a CLIA renewal application. Further review of the documents provided by the facility indicated that an incomplete application was submitted but not followed up on until the day of survey on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-03-31 · tag F0808 — failed to follow doctor-ordered diets — patternEnsure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, diet manual review, and interviews, the facility failed to ensure that the [NAME] consistently prepared meals according to the therapeutic diet manual as ordered by the physician. Specifically, the facility failed to ensure the [NAME] consistently served the IDDSI 6 (soft and bite sized) therapeutic diet in accordance with 13 applicable resident's physician's order. Findings include: Review of the facility policy titled Therapeutic Diet, dated as revised 4/22, indicated that therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences. 1. Diet will be determined in accordance with the resident's informed choices, preferences, treatment goals and wishes. Diagnosis alone will not determine whether the resident is prescribed a therapeutic diet. 2. A therapeutic diet must be prescribed by the resident's attending physician (or non-physician provider). The attending physician may delegate this task to a registered or licensed dietitian as permitted by state…
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 · D2025-03-31 · 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, interviews, and reviewed records, the facility failed to ensure staff treated residents in a dignified manner to effectively communicate in a language they understand for one Resident (#2) out of a total sample of 28 Residents. Findings include: The facility failed to indicate a language/communication policy was available as requested during the survey. Resident #2 was admitted to the facility in January 2023 with diagnoses including weakness, hemiplegia and hemiparesis following cerebral infarction effecting right dominant side, and weakness. Review of the most recent Minimum Data Set (MDS) assessment, dated 2/27/25, indicated Resident #2 did not have a Brief Interview for Mental Status assessment completed and was assessed by staff to have moderately impaired cognition. The MDS further indicated Resident #2 speaks Cantonese. Review of Resident #2's communication care plan dated, 2/19/25, indicated the following interventions: -Resident has impaired communication related to primary language is Cantonese. -Enlist use of communication devices as needed (i.e.)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-31 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record review, and interviews, the facility failed to ensure a call light was within reach for one Resident (#2) out of a total sample of 28 residents. Findings include: Resident #2 was admitted to the facility in January 2023 with diagnoses including weakness, hemiplegia and hemiparesis following cerebral infarction effecting right dominant side, and weakness. Review of the most recent Minimum Data Set (MDS) assessment, dated 2/27/25, indicated Resident #2 did not have a Brief Interview for Mental Status assessment completed and was assessed by staff to have moderately impaired cognition. The MDS further indicated Resident #2 speaks Cantonese. During an observation on 3/25/25 at 7:27 A.M., Resident #2 was in bed, the call light was located behind the bed on the floor. The call light was out of reach. During an observation on 3/26/25 at 7:12 A.M., Resident #2 was in bed, the call light was located behind the bed on the floor. The call light was out of reach. During an interview on 3/26/25 at 10:05 A.M., CNA #2 said Resident #2 uses the call light and staff…
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 · D2025-03-31 · 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 observation, interviews, and reviewed records, the facility failed to implement a communication care plan for one Resident (#2) out of a total sample of 28 Residents. Findings include: Resident #2 was admitted to the facility in January 2023 with diagnoses including weakness, hemiplegia and hemiparesis following cerebral infarction effecting right dominant side, and weakness. Review of the most recent Minimum Data Set (MDS) assessment, dated 2/27/25, indicated Resident #2 did not have a Brief Interview for Mental Status assessment completed and was assessed by staff to have moderately impaired cognition. The MDS further indicated Resident #2 speaks Cantonese. Review of Resident #2's communication care plan dated, 2/19/25, indicated the following interventions: -Resident has impaired communication related to primary language is Cantonese. -Enlist use of communication devices as needed (i.e.) communication board, sign language specify. -Allow time to process information -Anticipate resident needs if resident is unable to express needs. -Assess body and facial expressions.…
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 · D2025-03-31 · 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, record review and interview, the facility failed to provide treatment and care in accordance with professional standards of practice for one Resident (#51), out of a total sample of 28 residents. Specifically, the facility failed to identify a skin wound to the right elbow and document it on a skin assessment. Findings include: Resident #51 was admitted to the facility in January 2025 with diagnoses including sepsis, non-pressure chronic ulcer of lower leg, generalized edema, peripheral vascular disease, and kidney failure. Review of Resident #51's most recent Minimum Data Set (MDS) assessment, dated 2/25/25, indicated the Resident scored a 15 out of total 15 on the Brief Interview for Mental Status indicating intact cognition. The MDS further indicated Resident #51 requires substantial/maximal assistance with activities of daily living tasks. During an observation on 3/25/25 at 12:07 P.M., the surveyor observed Resident #51 in bed with both arms exposed. The Resident was observed to have 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 · D2025-03-31 · 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
Based on observation, record review, and interview, the facility failed to ensure professional standards of practice for the care of a suprapubic urinary catheter (a tube placed through the suprapubic region into the bladder to drain urine) for one Resident (#47) out of a total sample of 28 residents. Specifically, the facility failed to ensure nursing changed Resident #47's urinary catheter in accordance with physician's orders. Findings include: Review of the facility policy titled Catheter Insertion- Male, dated as revised 4/2022, indicated verify that there is a physician's order. 4. Use the smallest catheter possible, consistent with good drainage, to minimize urethral trauma. Resident #47 was admitted to the facility in March 2022 with diagnoses including urethral fistula, urinary retention, and neuromuscular dysfunction of the bladder. Review of the most recent Minimum Data Set (MDS) assessment, dated 2/20/25, indicated that Resident #47 was rarely understood. This MDS indicated Resident #47 had an indwelling catheter. Review of Resident #47's plan of care related 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 · D2025-03-31 · tag F0740 — failed to provide behavioral / mental-health care — isolatedEnsure each resident must receive and the facility must provide necessary behavioral health care and services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to maintain the highest practicable physical, mental, and psychosocial well-being for one Resident (#7) with a history of suicidal ideation (SI) and depression, out of a total sample of 28 residents. Specifically, Resident #7 was not provided with appropriate behavioral health services following verbalization of SI and attempted to kill him/herself at the facility by ingesting nail polish remover. Findings include: Review of the facility policy titled Behavior Management, dated 04/2022, indicated the following: - The facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. - The IDT staff will identify, document, and inform the physician about specific details regarding changes in an individuals mental status, behavior, and cognition including: * Onset, duration,…
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 · D2025-03-31 · tag F0745 — failed to provide medically-related social services — isolatedProvide medically-related social services to help each resident achieve the highest possible quality of life.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide medically related social services to one Resident (#7) out of a total sample of 28 residents, after their verbalization of suicidal ideation (SI). Findings include: Review of the facility policy titled Suicide Threats, dated [DATE], indicates the following: - All nursing personnel and other staff involved in caring for the resident shall be informed of the suicide threat and instructed to report changes in the resident's behavior immediately. - As indicated, a psychiatric consultation or transfer for emergency psychiatric evaluation may be indicated. - If the resident remains in the facility, staff will monitor the resident's mood and behavior and update care plans accordingly, until a physician has determined that a risk of suicide does not appear to be present. Review of the facility policy titled Behavior Management, dated 04/2022, indicated the following: - The facility will provide and residents will receive behavioral health services as…
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 · D2025-03-31 · tag F0806 — failed to honor food preferences — isolatedEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to provide foods that accommodates resident preferences to one Resident (#6) out of a total sample of 28 residents. Specifically, the facility failed to consistently honor Resident #6's food preferences. Findings include: Review of the facility policy titled Food and Nutrition Services, dated as revised 1/2025, indicated that each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. 4. Reasonable efforts will be made to accommodate resident choices and preferences. 7. Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident. a. If an incorrect meal is provided to a resident, nursing staff will report it to the food service manager. During the initial screening process on 3/25/25 and through the Recertification survey, the team of surveyors received several complaints of resident's food preferences not being…
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 · D2025-03-31 · tag F0865 — failed to run a quality-improvement (QAPI) program — isolatedHave a plan that describes the process for conducting QAPI and QAA activities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to develop, implement and maintain a Quality Assurance and Performance Improvement (QAPI) program, which focuses on indicators of outcomes of quality of life, quality of care, and services to residents in the facility. Specifically, the facility failed to ensure a QAPI plan was implemented and addressed concerns regarding the behavioral health services and medically related social services provided when a Resident (#7) with a known history of suicidal ideations (SI) attempted suicide at the facility. Findings include: The facility policy titled Quality Assurance Performance Improvement, dated 4/17, indicated the following: -The facility has a Quality Assurance / Performance Improvement Program which systematically monitors, analyzes and improves its performance to improve resident outcomes. II. Feedback, Data systems and Monitoring. a.a. QAPI is integrated into the responsibilities and accountabilities of all senior management. b.b. The following data is monitored through QAPI: i. Input from caregivers, residents, families,…
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 · D2025-03-31 · tag F0921 — failed to keep a safe, functional, sanitary building — isolatedMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
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 provide a safe environment on one of two nursing units. Specifically, in an resident room on the unit, that was not secured and was accessible to residents and staff, a radiator cover was removed and the electric radiator parts/motors were spread out on the floor, exposing electric wires within the radiator. Findings include: A review of the facility policy titled Resident Rights: Accommodation of Needs and Preferences and Homelike Environment, not dated, indicated that the facility will provide a safe, clean, comfortable and homelike environment. On 3/27/25, at 8:25 A.M., the surveyor observed room [ROOM NUMBER] to be an unoccupied room on a resident unit, that was not secured and was accessible to residents and staff. In the room a radiator cover was removed and the electric radiator parts/motors were spread out on the floor, exposing electric wires within the radiator During an interview on 3/27/25 at 8:39 A.M., Nurse #2 said that there…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-04-03 · tag F0693 — failed to provide proper feeding-tube care — patternEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to provide water flushes via an enteral feeding tube in accordance with physician's orders for one of two applicable Residents (#37), out of a total of 16 sampled Residents. Findings include: Review of the facility's policy, entitled, Enteral Nutrition, dated as revised April 2022 indicated the following: The principle indication for enteral nutrition is a functional tract with sufficient length and absorptive capacity and the inability to take nutrients through the oral route either totally or in part such as the inability to swallow without choking or aspiration or lack of sufficient alertness for oral nutrition. 2. The interdisciplinary team (IDT) collaborates with the physician, and the resident or his/her DPOA for health care, family, or surrogate to determine the clinical rationale for tube feeding placement. This may include but is not limited to: a. An assessment of the resident's clinical status, which may include usual food and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-04-03 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview for two Residents (#37 and #47), out of a total sample of 16 residents, the facility failed to provide activities of daily living (ADLs) in accordance with the plan of care. Specifically, 1. The facility failed to provide Resident #37, mouth care and 2. The facility failed to provide supervision during meals that included soft bread for Resident #47. Findings include: Review of the facility's policy entitled, Activities of Daily Living, policy dated as revised 3/2022 indicates, Residents who are unable to carry out activities of daily living independently will receive the services necessary for activities of daily living. 1. Resident #37 was admitted to the facility in June 2017 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, contracture of muscle right hand, obstructive and reflux uropathy, cognitive communication deficit, dysphagia, and neuromuscular dysfunction of the bladder. Review of Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-04-03 · tag F0685 — isolatedAssist a resident in gaining access to vision and hearing services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review for one Resident (#48), the facility failed to implement the use of one available hearing aid, out of a total sample of 16 residents. Findings include: Review of the facility's policy entitled, Care of Hearing Device, dated as revised 4/2022 indicated the purpose of caring for a hearing aid is to maintain the resident's hearing as the highest attainable level. Preparation, Review of the resident's care plan to assess or any special needs of the resident. Resident #48 was admitted to the facility in November 2019 and has diagnoses that include but not limited to adult failure to thrive and unspecified dementia. Review of Resident #48's Minimum Data Set assessment, dated 2/29/24 indicated Resident #48 scored a 3 out of 15 on the Brief Interview for Mental Status exam indicating Resident #48 as having a severe cognitive impairment and has highly impaired hearing and uses a hearing appliance. On 4/01/24 at 7:57 A.M., Resident #48 was observed in bed, with his/her…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-04-03 · tag F0805 — failed to prepare food in a form residents can eat — isolatedEnsure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to provide food in form to meet the needs of one Resident (#47) out of a sample of 16 Residents. Specifically, the facility failed to provide an International Dysphagia Diet Standardization Initiative (IDDSI) level 5 diet as indicated in the physician's orders. Findings include: A review of the facility policy titled Therapeutic Diet with a revision date of April 2022 indicated the following: *A therapeutic diet is considered a diet ordered by a physician, practitioner or dietitian as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet or to alter the texture of a diet. A review of the Dysphagia Diet (Level 5) handout indicated the following: *Level 5 foods are soft and moist but will not leak, drip or crumble *Can be scooped with a fork *Need only minimal chewing but no biting *Lumps should be minced into pieces no larger than 4 millimeters in size (the size of a short grain of rice or smaller)…
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
$91,558 in federal fines across 2 penalties.
- $61,050 — penalty dated 2026-03-10
- $30,508 — penalty dated 2025-03-31
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 REGALCARE — 9 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 1 of 5 | 1.7 | -0.7 vs chain |
| Health inspection | 1 of 5 | 1.9 | -0.9 vs chain |
| Staffing | 4 of 5 | 3.0 | +1.0 vs chain |
| Quality measures | 3 of 5 | 2.2 | +0.8 vs chain |
The other 8 homes this chain runs (chain average 1.7★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| MIRLIS, ELIYAHU | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; W-2 MANAGING EMPLOYEE | 100% | since 11/01/2022 |
CMS files one row per role, so the 2 rows in the source record cover these 1 parties — each is shown once here with every role it holds. Nothing is omitted.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 90% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.1M paid to related parties — landlords or management companies under common ownership — equal to about 13% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. 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 225511. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-10, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.