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Reservoir Center For Health & Rehabilitation, The

400 Bolton Street, Marlborough, MA 01752 · For profit - Limited Liability company · 144 certified beds · (339) 224-1189 Medicare & Medicaid certified

Call the home — (339) 224-1189 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Behavioral-health or dementia-care citation — no harm found (F0744)
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
  • lower-than-typical staff turnover (34% vs 45% nationally) — better care continuity
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • about 33% of its spending goes to commonly-owned related companies

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.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 4 of 5

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
320 Bolton St · (508) 481-4288 · Call to confirm hours
Pharmacy
Walgreens1.0 mi
99 Granger Blvd · (508) 229-0540 · Call to confirm hours
Grocery
121 Bolton St · (508) 481-3400 · Call to confirm hours
Park
Main St · Typically dawn to dusk
Place of worship

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 4 of 5
Long-stay residentspeople who live here 4 of 5
Short-stay residentsrehab / post-hospital 3 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating 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.

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased10.0%16.4%15.4%better
Long-stay residents who lose too much weight4.6%5.1%5.4%better
Long-stay residents with a catheter left in their bladder0.9%0.8%0.9%typical
Long-stay residents with a urinary tract infection1.8%1.8%2.0%typical
Long-stay residents with depressive symptoms12.1%15.5%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury2.4%3.4%3.3%better
Long-stay residents whose ability to walk worsened4.3%15.4%16.1%better
Long-stay residents on antianxiety or hypnotic medication23.3%19.5%18.9%worse
Long-stay residents given the seasonal flu vaccine99.2%94.8%95.3%typical
Long-stay residents with pressure ulcers5.5%4.2%4.7%worse
Long-stay residents with worsening bladder/bowel control32.0%21.2%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table22.0%21.4%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.0%1.4%1.4%better
Short-stay residents given the seasonal flu vaccine90.3%77.7%79.4%better
Short-stay residents rehospitalized after admission24.1%25.7%22.6%typical
Short-stay residents with an outpatient ER visit9.3%11.9%12.0%better
Long-stay hospitalizations per 1,000 resident days1.241.881.67better
Long-stay outpatient ER visits per 1,000 resident days1.621.501.80better

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.

49.5% 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 190 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

49.5%U.S. median 51.5%
Got home and stayed home
11.0%U.S. median 10.7%
Went back to hospital
56.1%U.S. median 56.6%
Met the expected recovery
0.25U.S. median 0.31
Therapy hours / resident / day
0.09hours / resident / day
Physical therapy
0.10hours / resident / day
Occupational therapy
0.07hours / resident / day
Speech therapy

Met the expected recovery: 56.1% 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 98 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 0.25 therapist hours per resident per day in 2026Q1 — more than 35% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 33% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF49.5%CMS range 39.3–56.651.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.0%CMS range 8.5–14.110.7%Oct 2022–Sep 2024no 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 discharge56.1%56.6%Oct 2024–Sep 2025CMS 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 discharge42.9%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge45.9%50.0%Oct 2024–Sep 2025CMS 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 identified99.4%98.7%Oct 2024–Sep 2025CMS 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 setting98.2%100.0%Oct 2024–Sep 2025CMS 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 dischargenot 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 stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened3.5%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization9.3%CMS range 6.5–13.07.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.071.02Oct 2022–Sep 2024CMS 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

0.63
RN hours/ resident / day
1.10
LPN hours/ resident / day
2.21
Aide hours/ resident / day
3.95
Total nurse hours/ resident / day
0.36
RN hoursweekends
33.6%
Total nursing turnover
21.1%
RN turnover

How full it usually is: this home is certified for 144 beds and averages 133.1 residents a day — about 92% occupied, or roughly 11 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.95 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.63 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.21 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 3.54 hrs/resident/day on weekends vs 4.11 on weekdays — 14% thinner on weekends. RN hours go from 0.74 to 0.36 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 34% 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

8
deficiencies at the latest standard inspection (2026-01-13)
13
at the previous standard inspection (2024-10-02)

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.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

28 citations, most serious first. The 10 most serious are shown; the remaining 18 are one tap away and print in full.

  • Potential for harm · E2026-01-13 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor 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, record review, and interviews, the facility failed to provide residents with a homelike environment on three out of four Resident Units (East Two, [NAME] One, and [NAME] Two) and for one Resident (#71) out of total sample of 28 Residents. Specifically, 1. the facility failed to provide Residents #41 and #69 and other residents with appropriate and comfortable air temperature levels during Resident meals in the Sitting Rooms on the East Two, [NAME] One, and [NAME] Two resident Units. 2. the facility failed to ensure safe and sanitary side rail pads for Resident #71's bed, placing the Resident at the risk of injury and contamination. Findings include: Review of the facility policy titled Environmental Rounds, dated 6/2023, included but was not limited to: Each center will have an effective process for identification of .risks in the resident environment. >Rounds will be conducted monthly by the Infection Prevention Committee and appropriate department heads. >Areas identified 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-01-13 · tag F0865 — failed to run a quality-improvement (QAPI) program — pattern
    Have 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 records reviewed, interviews, and observations, the facility failed to ensure they developed, implemented and maintained a Quality Assurance and Performance Improvement (QAPI) program that was comprehensive, ensured the residents' environment was maintained to promote a clean, safe, homelike environment, and was focused on indicators of quality of life for residents in the facility.Specifically, the facility failed to develop and implement an effective performance improvement plan to address the non-operational heating units on three out of four Resident Sitting Rooms, utilized for Resident meals. Findings include:Review of the Facility's policy for QAPI Program, last revised October 2024 indicated:-Our facility provides services across the continuum of care. These services have an impact on the clinical care and quality of life for residents living in our community.-All departments and services will be involved in QAPI activities and the organization's efforts to continuously improve services.>Our QAPI plan includes the policies and procedures used to:-Identify and use…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-13 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of 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, interviews, and record review, the facility failed to ensure that appropriate access to the call light system was provided for one Resident (#20) out of a total sample size of 28 residents. Specifically for Resident #20, the facility staff failed to ensure that the call light was positioned within his/her reach for use when the Resident required staff assistance with Activities of Daily Living (ADL) care and was a falls risk due to generalized weakness. Findings include: Review of the facility policy titled Administration: Residents' [NAME] of Rights Policy, last revised February 2024, indicated the following: -It is the policy of the facility to adhere, inform and educate residents and staff of the Residents' [NAME] of Rights. -You have the right to be treated with consideration, respect and full recognition of your dignity and individuality. -You have the right to receive quality care and services with reasonable accommodation of your individual needs and preferences except when your…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-13 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interviews, and records review, the facility failed to provide services that met professional standards of quality relative to neurological evaluation, for one Resident (#54) out of a total sample of 28 residents. Specifically, the facility failed to evaluate Resident #54's neurological status according to the Nurse Practitioner's (NP) order after: -The Resident sustained a fall and struck his/her head. -The Resident was prescribed for anticoagulant (blood thinning) medication. -The NP ordered neurological checks to be completed according to the facility's policy, placing the Resident at risk for unidentified neurological complications. Findings include: Review of the facility's policy titled Neurological Evaluation Policy, dated August 2011 and last revised 4/30/25, indicated the following: -Licensed Nurses perform neurological evaluations when a resident experiences any of the following: *potential or confirmed head injury *unwitnessed fall *a witnessed fall for those receiving anticoagulants/antiplatelets *other events suggesting potential neurological…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-13 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure 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, interview, and record review, the facility failed to provide necessary care and services relative to enteral feeding (nutrients provided directly into the stomach), for one Resident (#2) out of a total sample of 28 residents.Specifically, for Resident #2, the facility failed to ensure that enteral feeds and fluids being administered through the Percutaneous Endoscopic Gastrostomy Tube (PEG Tube) and /or Feeding Tube (medical device that provides a direct route for delivering nutrition, fluids, and medications directly into the stomach, bypassing the mouth and esophagus), were labeled and dated appropriately. Findings include:Review of the facility policy titled Enteral Nutrition, revised 6/2023, included but was not limited to: *Continuous feeding/Ready to hang feeding:-Date-Time-Initial the feeding -Initial the tubing Resident #2 was admitted to the facility in December 2025, with diagnoses including Dysphagia oropharyngeal phase following Cerebral Infarction, and Gastrostomy Status.…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-01-13 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    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 care and services consistent with professional standards of practice for one Resident (#43), out of one applicable resident receiving dialysis (process that filters waste, salt, and fluid from your blood when the kidneys are unable to work adequately) services, out of a total sample of 28 residents. Specifically, for Resident #43, the facility failed to:-ensure that dialysis communication forms included updated and active Physician orders on the Resident's dialysis care and services.-communicate and maintain ongoing documentation with the dialysis center to ensure that the dialysis center and the facility received the most current information pertaining to the Resident. Findings Include:Review of the facility policy titled Hemodialysis, revised 1/26, include but was not limited to:*The Licensed Nurse will obtain the healthcare provider orders for hemodialysis which should include the following:-Dialysis Days (Example (Ex: Monday-Wednesday-Friday) and location of the dialysis clinic-Schedule Dialysis…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-13 · tag F0744 — failed to care for residents with dementia — isolated
    Provide 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, interviews, and records reviewed, the facility failed to provide appropriate treatment to maintain the highest practicable physical, mental, and psychosocial well-being for one Resident (#112), who was diagnosed with dementia, out of a total sample of 28 residents. Specifically, the facility failed to provide timely assistance for Resident #112 when the Resident: -had a diagnosis of dementia. -received medication to improve urine flow. -received medication to treat constipation. -was dependent on staff for toileting and toilet transfers. -verbally expressed the need to use the bathroom repeatedly. Findings include: Review of the facility's policy titled Activities of Daily Living (ADL), dated June 2023, indicated the following: -The purpose was to provide the level of care required by each individual resident. -Staff provided assistance to complete ADLs per the person-centered evaluation and care plan. -ADLs included toileting and toilet hygiene. Resident #112 was admitted to the facility in January 2024 with diagnoses including Dementia with Behavioral…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-10-15 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately 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 records reviewed and interviews, for one of three sampled residents (Resident #1), who required hemodialysis (a life-saving treatment that filters waste products and excess fluid when the kidneys stop working) three times a week, the Facility failed to ensure Resident #1's physician had been notified of a missed dialysis session, when on 09/13/24, due to a transport issue, Resident #1 missed his/her scheduled appointment, and required transfer to the Hospital Emergency Department for evaluation and dialysis treatment. Findings include: Review of the Facility Policy titled Change of Condition Notification, dated as lest revised 04/2023, indicated that the facility will inform the resident, resident 's healthcare provider, and the resident's family/legal representative when there is a change of condition. The Policy further indicated that the facility must consult with the resident's healthcare provider when there is an incident involving the resident which may result in injury or require medical treatment and must be documented in the electronic medical record. Resident #1…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-15 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records reviewed and interviews, for two of three sampled residents, (Resident #1 and #2), the facility failed to ensure that upon admission, nursing developed and implemented baseline care plans with interventions, treatments, goals, and outcomes that addressed the residents overall immediate care needs within 48 hours of admission, or in the absence of a baseline care plans that comprehensive care plans had been developed with in 48 hours. Findings include: Review of the Facility Policy titled, Baseline/Comprehensive Person-Centered Care Plan, dated as last revised 3/2023, indicated that a baseline care plan must be developed within 48 hours of admission. The baseline care plan includes at least a minimum of healthcare information necessary to provide proper care for the residents. 1) Resident #1 was admitted to the Facility in September 2024, diagnoses included End Stage Renal Disease (ESRD) and dependent on hemodialysis three days a week, history of a heart transplant 29 years ago, chronic anemia,…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-10-15 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such 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 records reviewed and interviews, for one of three sampled residents (Resident #1), who required hemodialysis (a life-saving treatment that filters waste products and excess fluid when the kidneys stop working) three times a week for end stage renal disease, the facility failed to ensure Resident #1 received the care and services consistent with his/her care plan, when Resident #1 missed a dialysis session because of a transportation issue, and days later required transfer to the Hospital Emergency Department (ED) for evaluation of changes in his/her mental status, and required dialysis treatment. Findings include: Review of the Facility Policy titled Hemodialysis, dated as last revised 6/2023, indicated that a resident who is admitted to the facility requiring hemodialysis, with their consent, will have their dialysis needs met. The Policy further indicated that the resident would leave the facility to obtain hemodialysis to a dialysis center agreed upon by the resident and the physician and 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 18 citations
  • Potential for harm · Dcited before2024-10-15 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure 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 record reviews and interviews for one of three sampled residents (Resident #1), who upon admission and then re-admission, the Facility failed to ensure he/she was free from a significant medication errors, when medications from his/her Hospital Discharge Summary (s) were not accurately reconciled by Nursing and he/she was administered the incorrect dosage of medications for multiple days. Findings include: Review of the facility Policy titled, Medication Reconciliation, dated as last revised 04/2023, indicated that the medication reconciliation process is to be completed at admission, re-admission, and discharge by the nursing staff. The Policy further indicated that the purpose is to identify clarifications and discrepancies that needed to be resolved with the primary care physician to ensure the resident's safety and prevent negative outcomes as related to medication management. Review of the Facility Policy titled Medication Error, dated as last revised 5/2023, indicated that a medication error is a…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-10-02 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record and policy review, the facility failed to implement infection control measures according to professional standards of practice on one Unit (East One Unit) out of four resident units, and for two Residents (#65 and #84) out of a total sample of 27 residents. Specifically, the facility failed to: 1. Ensure that staff who worked on the East One Unit and considered as exposed to COVID-19, completed initial and requisite outbreak testing when the facility was experiencing an outbreak of COVID-19 on the East One Unit, increasing the risk for transmission of infection to residents and staff. 2. Ensure timely and effective implementation of interventions to prevent the transmission of Clostridium Difficile (C. Diff: bacterium that causes diarrhea and colitis [an inflammation of the colon] and can be life-threatening) when Resident #65 was actively being treated for C.diff and required the use of Contact Precautions (use of proper hand hygiene, gloves, and gown upon…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-02 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor 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 provide a dignified dining experience for one Resident (#79), out of a total sample of 27 residents. Specifically, the facility staff remained standing and stood over Resident #79 while assisting the Resident during a breakfast meal. Findngs include: Resident #79 was admitted to the facility in April 2024, with diagnoses including Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory and loss of judgment) and Malnutrition (condition caused by not getting enough calories or the right amount of key nutrients, such as vitamins and minerals, that are needed for health). Review of Resident #79's MDS Assessment, dated 7/30/24, indicated that the Resident was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 9 out of a total 15. On 9/26/24 at 9:13 A.M., the surveyor observed Resident #79 lying in bed with the head of the bed elevated. The surveyor also observed Certified Nurses Aide (CNA) #6 standing over 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-10-02 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately 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 reviewed, the facility failed to notify the Physician/Nurse Practitioner (NP) of the need to alter treatments, based on specialist medical practitioners' recommendations for two Residents (#84 and #79), out of a total sample of 27 residents. Specifically, the facility failed to notify the Physician/NP of: 1. a recommended change in treatment from Resident #84's Wound Care Consultant to cleanse two Stage Four pressure ulcers (PUs: full-thickness skin and tissue loss, usually over a bony prominence, with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer), which increased the Resident's risk for infection and delayed healing. 2. a recommended change in treatment from Resident #79's Urologist (Physician who specializes in treatment of the urinary tract) relative to the size change of the Resident's indwelling urinary catheter, increasing the Resident's risk for indwelling urinary catheter associated complications. Findings include: 1. Resident #84 was admitted to the facility in March 2021,…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-02 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop 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 interview, record and policy review, the facility failed to ensure its staff implement the plan of care for one Resident (#75) relative to weight measurements, out of a total sample of 27 residents. Specifically, the facility staff failed to perform weight measurements for Resident #75 when the Resident had been re-admitted to the facility with a gastrostomy tube (G-tube: a small flexible tube surgically inserted into the stomach through the abdomen to provide nutrition, fluids, and medicine), a diagnosis of Malnutrition and a significant change in condition. Findings include: Resident #75 was admitted to the facility in August 2024, with diagnoses of G-tube placement and Malnutrition (condition caused by not getting enough calories or the right amount of key nutrients, such as vitamins and minerals, that are needed for health). Review of the facility policy titled Weight Policy and Procedure last revised January 2023, indicated the following: -Each resident's weight will be obtained and documented upon admission, re-admission, monthly, or significant change in condition,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-02 · tag F0657 — failed to keep the care plan current — isolated
    Develop 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interview, the facility failed to ensure that comprehensive care plans were reviewed and revised by the interdisciplinary team (IDT) for two Residents (#40 and #9), out of a total sample of 27 residents. Specifically, facility staff failed to review and revise comprehensive care plans following: 1. one comprehensive and one quarterly review assessment for Resident #40. 2. one comprehensive review assessment for Resident #9. Findings include: 1. Resident #40 was admitted to the facility in June 2023, with diagnoses including Chronic Obstructive Pulmonary Disease (COPD: group of lung diseases that worsen over time and prevent air flow to the lungs causing difficulty breathing). Review of Resident #40's clinical record indicated the following: -A comprehensive review assessment, dated 5/24/24, had been completed. -A quarterly review assessment, dated 8/17/24, had been completed. Further review of Resident #40's clinical record included no evidence the Resident's comprehensive care plan…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-02 · tag F0660 — isolated
    Plan the resident's discharge to meet the resident's goals and 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 interview, policy and record review, the facility failed to develop and implement an effective discharge planning process for one Resident (#9), out of a total sample of 27 residents. Specifically, for Resident #9, the facility failed to identify the discharge needs and involve the Resident in the development of a discharge plan. Findings include: Review of the facility policy titled Team Based Assessment (TBA), revised February 2023, indicated: -Within two to three business days of admission, an Interdisciplinary Team (IDT) meeting will be scheduled . -Together with the residents, their family or responsible party, the following members of the IDT will be present: Licensed Rehab Therapist, Licensed Nursing Manager Designee, MDS (Minimum Data Set) Coordinator, Social Worker, Business Office Manager . -The meeting will address the following: >Resident input: Expectation of their stay, anticipation of discharge, and Resident's goals for discharge >Social Service needs: anticipation of need for community…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-02 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide care and services according to professional standards of practice for two Residents (#124 and #84), out of a total sample of 27 residents, with an indwelling urinary catheter (Foley Catheter/Foley - a tube placed through the urethra into the bladder to drain urine) increasing the Residents' risk for indwelling urinary catheter complications. Specifically, the facility staff failed to: 1. For Resident #124, follow Physician orders to insert the Foley catheter with the correct balloon size and switch the Foley catheter bag from straight drainage to leg bag upon the Resident getting out of bed in the morning. 2. For Resident #84, obtain a Physician order to include indications, the type and amount of solution required to flush (manual injection with normal saline to clean or clear the catheter) and irrigate the Resident's indwelling urinary catheter. Findings include: Review of the facility's policy titled Urinary Catheterization,…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-02 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such 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, the facility failed to provide appropriate pain management for one Resident (#84), out of a total sample of 27 residents, when Physician ordered pain medications were not administered in a timely manner. Specifically, for Resident #84, the facility staff failed to administer three pain medications as scheduled during the morning medication pass, resulting in the Resident experiencing unrelieved pain. Findings include: Review of the facility's policy titled Pain Management, revised April 2023, indicated: -Qualified staff will monitor the resident's response to pain management according to CMS, State, specific rules and regulations and facility practice guidelines. -To improve the resident's wellbeing by increasing comfort and reducing depression and anxiety. -To monitor treatment efficacy and side effects. -Administer pain relief medications when needed and monitor for effect. -To evaluate pain status and treatment effects on a regular basis, example during…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-10-02 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    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 provide services consistent with professional standards of practice relative to hemodialysis (a procedure where a machine with a special filter called a dialyzer is used to remove waste from the blood) treatment schedule coordination, for one Resident (#34) out of two residents receiving dialysis services, out of a total sample of 27 residents. Specifically, for Resident #34, the facility staff failed to: -coordinate meal and medication times with the dialysis treatment schedule when the Resident was not offered breakfast or food to take with him/her on dialysis days, increasing the Resident's risk for malnutrition and weight loss. -administer a dialysis support medication as scheduled and with food as required. Findings include: Review of the facility's policy titled Hemodialysis, dated February 2002 and revised May 2014, indicated the following: -A resident admitted to the facility requiring hemodialysis will have their dialysis needs met. -After initial assessment, the Care Planning Team develops a 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-02 · tag F0742 — isolated
    Provide 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

    Based on interview, policy and record review, the facility failed to provide appropriate treatment and services to attain the highest practicable mental and psychosocial well-being for one Resident (#9) with a known history of Suicidal Ideation (SI- verbal expressions of thoughts of harming oneself that may or may not lack specific intent) and Post-Traumatic Stress Disorder (PTSD- a mental health condition triggered by a terrifying event, causing flashbacks, nightmares and severe anxiety), out of a total sample of 27 residents. Specifically, for Resident #9, the facility failed to provide behavioral health services timely putting the Resident at risk for further psychosocial decline when he/she continued to express SI. Finding include: Review of the facility policy titled Suicide Ideation, revised May 2023, indicated: -Should there be a determination that there is a potential threat of harm to the resident's well being or others, the following will occur: >Licensed Nurse will notify Psychiatry Services and request an evaluation be done on the resident as soon as possible. If…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-10-02 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure 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 interview, policy and record review, the facility failed to ensure that one Resident (#84), out of a total sample of 27 residents, was from significant medication error. Specifically, the facility staff failed to adhere to the time and the administration of ordered pain medications for Resident #84 when he/she was having pain. Findings include: Review of the facility's policy titled Medication Pass, revised May 2023, indicated: -All medications are administered safely and timely per the Physician's orders. -Acceptable medication pass time is one hour before and one hour after the scheduled time. -Remember the ten rights of the medication pass: *Right Resident, *Right Drug, *Right Dose, *Right Route, *Right Time, *Right Education, *Right to Refuse, *Right Documentation, *Right Drug-Drug interaction, *Right Evaluation. Review of the facility's policy titled Pain Management, revised April 2023, indicated: -Qualified staff will monitor the resident's response to pain management according to CMS, 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-10-02 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and policy review, the facility failed to remove expired medications from one medication cart, out of a sample of four medication carts. Specifically, the facility failed to remove and dispose expired Famotidine (acid reducer) medication, increasing the risk of non-therapeutic benefit when the medication is administered. Findings include: Review of the facility policy titled Medication Storage in the Facility, undated, indicated the following: -Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists. On 9/30/2024 at 10:20 A.M., the surveyor and Nurse #6 observed the [NAME] 2A medication cart on the second floor nursing unit. The surveyor and Nurse #6 found 13 individually packaged Famotidine tablets (a medication used to treat gastrointestinal [stomach and intestine] conditions by reducing acid production in the stomach)…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-07-11 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on inspection and interview, the facility failed to label, date and maintain food products that were not expired, in four out of four Unit Nourishment kitchenettes. Findings include: Review of the Use and Storage of Food Brought to Residents by Family and Visitors Policy, revised 3/2022, included, but not limited to: -Perishable foods must be stored in the nursing unit kitchen nourishment refrigerator and identified with the resident's name, food item and use by date. Facility staff is responsible to discard perishable foods within 72 hours of being brought in from outside. 1. During an observation on 7/7/23 at 3:34 P.M., of the [NAME] One Nourishment Kitchenette with Nurse #2, the following undated and unlabeled items were found: -In the refrigerator freezer: *One bottle of frozen Diet Root Beer. *One frozen container of yogurt. *One frozen eight ounce piece of cheddar cheese. *One container of frozen cream cheese. *One white plastic bag containing a frozen piece of unidentifiable food product along with an opened half bag of frozen french fries. -In the refrigerator: *One…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-07-11 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, policy review and interview, the facility failed to ensure that all medications were properly stored and labeled in accordance with currently accepted professional principles and that expired medications were removed from active supply. Specifically, the facility failed to ensure: 1a) That staff had labels on medications in one out of four medication carts and 1b) That staff removed expired medications on four of four units reviewed with three out of eight medication carts reviewed. 2) That staff safely stored medications for one Resident (#108) in a sample of 25 residents. Findings include: Review of the facility's policy titled Medication Storage in the Facility, dated 2017, indicated but was not limited to the following: -Only Licensed Nurses, pharmacy personnel, and those lawfully authorized to administer medications permitted to access medications . -All medications dispensed by the pharmacy are stored in the container with the pharmacy label. -Outdated, contaminated, or deteriorated medications and those in cracked, soiled, or without secure closures 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-07-11 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, policy review and interview, the facility failed to provide care and services consistent with professional standards for one Resident (#51) who required renal dialysis (a life sustaining treatment that helps your body remove extra fluid and waste products from your blood when the kidneys are not able to) out of a total sample of 25 residents. Specifically, the facility failed ensure that clamps and pressure dressings were kept with the Resident (#51) for emergency related to a tunneled hemodialysis catheter (a plastic tube used for exchanging blood between a patient and a hemodialysis machine). Findings include: Review of the facility policy for Clinical Services Hemodialysis, last revised March 2023, indicated hemostat clamps should be kept with the patient/resident. Resident #51 admitted to facility in June 2023 with diagnoses including Chronic Kidney Disease, Stage 4 (advanced kidney damage) and dependence of renal dialysis. Review of Resident #51's Minimum Data Set (MDS) Assessment, dated 6/18/23, indicated a Brief Interview of Mental Status (BIMS) score…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2026-01-13 · tag F0636 — pattern
    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
    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 complete an accurate comprehensive assessment, according to the required Resident Assessment Instrument (RAI) process, for one Resident (#3) out of a total sample of 28 residents.Specifically, the facility staff failed to assess Resident #3's cognitive status and mood through the required resident interview process when the Resident had difficulty with communication and a fluctuating ability to communicate. Findings include:Resident #3 was admitted to the facility in August 2024 with diagnoses including Multiple Sclerosis, Hemiplegia and Hemiparesis and locked-in state. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #3:-had minimal difficulty with hearing.-could sometimes make him/herself understood.-sometimes understands others.-did not have the BIMS (Brief Interview for Mental Status) and the Staff Assessment for Mental Status conducted for the assessment. -did not have the Mood interview…

    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.

    Resident Assessment and Care Planning Deficiencies · No revisit needed
  • No harm found · B2024-10-02 · tag F0646 — pattern
    Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
    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 policy and record review, and interview, the facility failed to notify the state mental health authority for a resident review after a significant change in mental condition occurred for one Resident (#104) out of a total sample of 27 residents. Specifically, the facility failed to request a Preadmission Screening and Resident Review Level II screen (PASRR- an evaluation done to determine if a resident has an intellectual or developmental disability and/or serious mental illness and is in need of additional specialized support services at the facility) after Resident #104 received a diagnosis of Psychosis and experienced limitations in major life activities due to mental illness. Findings include: Resident #104 was admitted to the facility in June 2022, with diagnoses of Anxiety Disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with daily activities), Depression (a mood disorder that causes a persistent feeling of sadness and loss…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction

“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.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • 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.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to NATIONAL HEALTH CARE ASSOCIATES — 42 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 →

RatingThis homeChain avg
Overall 3 of 53.2-0.2 vs chain
Health inspection 3 of 52.8+0.2 vs chain
Staffing 4 of 53.0+1.0 vs chain
Quality measures 4 of 54.1≈ chain avg
The other 41 homes this chain runs (chain average 3.2★, per CMS)
1 of 5Brentwood Center For Health & Rehabilitation, LLCYarmouth, ME 1 of 5The Pines At Utica Center For Nursing And RehabUtica, NY 2 of 5Beacon Brook Center For Health & RehabilitationNaugatuck, CT 2 of 5Bloomfield Center For Nursing & RehabilitationBloomfield, CT 2 of 5Eastside Center For Health & Rehabilitation, LLCBangor, ME 2 of 5Kennebunk Center For Health & Rehabilitation, LLCKennebunk, ME 2 of 5Ludlowe Center For Health & RehabilitationFairfield, CT 2 of 5Mansfield Center For Nursing And RehabilitationStorrs Mansfield, CT 2 of 5Montowese Center For Health & RehabilitationNorth Haven, CT 2 of 5Riverside Health & Rehabilitation CenterEast Hartford, CT 2 of 5Shady Knoll Center For Health & RehabilitationSeymour, CT 2 of 5Summit At Plantsville Center For Health & RehabiliPlantsville, CT 2 of 5The Pines At Catskill Center For Nursing & RehabCatskill, NY 2 of 5The Pines At Glens Falls Ctr For Nursing & RehabGlens Falls, NY 3 of 5Augusta Center For Health & Rehabilitation, LLCAugusta, ME 3 of 5Cambridge Health And Rehabilitation CenterFairfield, CT 3 of 5Evergreen Center For Health & RehabilitationStafford Springs, CT 3 of 5Glastonbury Center For Health & RehabilitationGlastonbury, CT 3 of 5Hebrew Center For Health And RehabilitationWest Hartford, CT 3 of 5Laurel Ridge Center For Health & RehabilitationRidgefield, CT 3 of 5Maefair Center For Health & RehabilitationTrumbull, CT 3 of 5Marlborough Health & Rehabilitation CenterMarlborough, CT 3 of 5Water's Edge Center For Health & RehabilitationMiddletown, CT 3 of 5Winship Green Center for Health & Rehab, LLCBath, ME 4 of 5Bethel Health Care CenterBethel, CT 4 of 5Brewer Center For Health & Rehabilitation, LLCBrewer, ME 4 of 5Dover Center For Health & RehabilitationDover, NH 4 of 5Huntington Hills Center for Health and RehabilitatMelville, NY 4 of 5Pines At Bristol For Nursing & Rehabilitation, TheBristol, CT 4 of 5Sharon Center For Health & RehabilitationSharon, CT 4 of 5Stone Bridge Center For Health & RehabilitationNewtown, CT 4 of 5The Pines At Poughkeepsie Ctr For Nursing & RehabPoughkeepsie, NY 4 of 5The Pines at Rutland Center for Nursing & RehabiliRutland, VT 4 of 5Village Crest Center For Health & RehabilitationNew Milford, CT 5 of 5Belair Care Center IncBellmore, NY 5 of 5Maple View Health & Rehabilitation CenterRocky Hill, CT 5 of 5Milford Health And Rehabilitation CenterMilford, CT 5 of 5Norway Center For Health & Rehabilitation, LLCNorway, ME 5 of 5Pine Heights at Brattleboro Center for Nursing & RBrattleboro, VT 5 of 5Regency House Nursing And Rehabilitation CenterWallingford, CT

Showing 40 of 41; lowest-rated first.

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 / managerTypeRoleSince
MARVIN OSTREICHER FAMILY TRUST 2012OrganizationINDIRECT OWNERSHIP INTERESTsince 01/28/2013
MERIDIAN CAPITAL FOUNDATIONOrganizationINDIRECT OWNERSHIP INTERESTsince 01/28/2013
MSO ASSOCIATES LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 01/28/2013
SUSAN OSTREICHER FAMILY TRUST 2012OrganizationINDIRECT OWNERSHIP INTERESTsince 01/28/2013
VENTAS NHV FUNDOrganizationINDIRECT OWNERSHIP INTERESTsince 01/28/2013
BOKOW, BARRYIndividualINDIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; ADP OF THE SNFsince 01/28/2013
DAVID, ALBERTIndividualINDIRECT OWNERSHIP INTERESTsince 01/28/2013
GEFFNER, IRAIndividualINDIRECT OWNERSHIP INTERESTsince 01/28/2013
GLUCK, ROBERTIndividualINDIRECT OWNERSHIP INTERESTsince 01/28/2013
LOBELL, JONAHIndividualINDIRECT OWNERSHIP INTERESTsince 01/28/2013
LOWINGER, BENIndividualINDIRECT OWNERSHIP INTERESTsince 01/28/2013
LOWINGER, JOSEPHIndividualINDIRECT OWNERSHIP INTERESTsince 01/28/2013
OSTREICHER, DAVIDIndividualINDIRECT OWNERSHIP INTERESTsince 01/28/2013
OSTREICHER, MARCIndividualINDIRECT OWNERSHIP INTERESTsince 01/28/2013
OSTREICHER, MARVINIndividualINDIRECT OWNERSHIP INTEREST; CORPORATE DIRECTORsince 01/28/2013
OSTREICHER, SUSANIndividualINDIRECT OWNERSHIP INTERESTsince 01/28/2013
SCHOOR, KALMANIndividualINDIRECT OWNERSHIP INTERESTsince 01/28/2013
SHAYA-MOGRABY, MOSHEIndividualINDIRECT OWNERSHIP INTERESTsince 01/28/2013
STEG, YITZCHOKIndividualINDIRECT OWNERSHIP INTERESTsince 01/28/2013
WEINSTOCK, ABRAHAMIndividualINDIRECT OWNERSHIP INTERESTsince 01/28/2013
GILMARTIN, THOMASIndividualCORPORATE DIRECTOR; ADP OF THE SNFsince 01/28/2013
IDUMWONYI, EGHOSAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/30/2025
SHALLER, CAITLINIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/01/2023
NATIONAL HEALTH CARE ASSOCIATES INCOrganizationADP OF THE SNFsince 01/28/2013
PREFERRED THERAPY SOLUTIONS, LLCOrganizationADP OF THE SNFsince 01/28/2013
PROCARE LTC HOLDING LLCOrganizationADP OF THE SNFsince 01/01/2016

CMS files one row per role, so the 32 rows in the source record cover these 26 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

8 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.

$16.0M
Net patient revenuemost recent cost report
-10.6%
Operating marginrevenue minus expenses
$5.8M
Related-party expense33% of expenses
Who pays — share of resident-days
Medicaid 53%Medicare 8%Other / private 39%

This home reported $5.8M paid to related parties — landlords or management companies under common ownership — equal to about 33% 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

$401per resident / day
operating cost
$12,193per month
≈ monthly operating cost
$362per day
avg. revenue, all payers

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

Paying with Medicaid

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.

Typical monthly cost in Massachusetts
$14,448/mo
Nursing home (semi-private)
$15,817/mo
Nursing home (private)
$9,600/mo
Assisted living

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 225326. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-13, 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.

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