Nevins Nursing & Rehabilitation Center
Ten Ingalls Court, Methuen, MA 01844 · Non profit - Corporation · 153 certified beds · (978) 682-7611 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a high payroll-based staffing rating (4/5)
- lower-than-typical staff turnover (31% 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 (F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 2 actual-harm citations
- a high number of inspection citations overall (31) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $9,318 in federal fines (most recent 2024-06-18)
- its payroll-based staffing score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its facility-reported quality-measure rating is low (2/5)
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 | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own 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 | 2 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 1 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 22.9% | 16.4% | 15.4% | worse |
| Long-stay residents who lose too much weight | 3.4% | 5.1% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 1.1% | 0.8% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 2.8% | 1.8% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 0.0% | 15.5% | 6.5% | check this* — see note marked star 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 | 3.0% | 3.4% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 16.8% | 15.4% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 17.9% | 19.5% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 97.0% | 94.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.5% | 4.2% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 29.4% | 21.2% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 16.3% | 21.4% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 2.1% | 1.4% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 91.0% | 77.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 29.0% | 25.7% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 13.2% | 11.9% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 2.17 | 1.88 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.73 | 1.50 | 1.80 | typical |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
§ 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.
54.0% 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 247 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 33.3% 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 138 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 0.18 therapist hours per resident per day in 2026Q1 — more than 17% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 15% 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 | 54.0%CMS range 48.6–59.6 | 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 7.8–13.4 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 33.3% | 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 | 26.1% | 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 | 37.0% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 99.4% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.6% | 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 | 2.4% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.7%CMS range 4.9–12.4 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.73 | 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 153 beds and averages 137.8 residents a day — about 90% occupied, or roughly 15 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 3.62 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.49 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.12 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 3.25 hrs/resident/day on weekends vs 3.77 on weekdays — 14% thinner on weekends. RN hours go from 0.49 to 0.49 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 31% is below the national median of 45%. 1 administrator has left in the past year.
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.
31 citations, most serious first. The 12 most serious are shown; the remaining 19 are one tap away and print in full.
- Actual harm · Gcited before2024-06-18 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, records reviewed and interviews, for one of three sampled residents (Resident #1), who was assessed by nursing as being at high risk for falls, and whose comprehensive plan of care indicated he/she required the use of monitoring devices (bed and chair alarms) to alert staff when he/she attempted to stand or transfer alone, the Facility failed to ensure staff consistently implemented and followed interventions identified in his/her plan of care, when on 05/22/24, Nurse #1 left Resident #1 alone, without an alarm in place, seated on the commode in his/her room, Resident #1 fell, later complained of pain, was transferred to the Hospital Emergency Department and was diagnosed with a fractured right hip which required surgical intervention to repair. Findings include: The Facility's Policy, titled Comprehensive Person-Centered Care Plans, dated as revised 03/2022, indicated that a comprehensive, person-centered care plan to meet the resident's needs would be developed and implemented. 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.
- Actual harm · Gcited before2024-06-18 · 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 records reviewed and interviews, for one of three sampled residents (Resident #1), who was assessed by nursing as being at high risk for falls, was known to be impulsive and whose fall risk interventions included the use of monitoring devices (bed and chair alarms) to alert staff when he/she rose from a sitting or lying position, the Facility failed to ensure he/she was provided with the necessary level of staff supervision to maintain his/her safety, when on 05/22/24, after disabling his/her alarm, Nurse #1 left Resident #1 unattended on the commode, Resident #1 fell to the floor, complained of pain, and was transferred to the Hospital Emergency Department where he/she was diagnosed with a fractured right hip, which required surgical intervention to repair Findings include: The Facility's Policy, titled Falls Prevention and Management Program, dated 09/2018, indicated residents would be assessed for risk for falls and interventions would be implemented as appropriate. The Facility's Policy, titled…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-01-07 · tag F0695 — failed to provide proper breathing / tracheostomy care — patternProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure that respiratory care and services, consistent with professional standards of practice, were provided for three Residents, (#2, #136 and #66) out of a sample of 34 Residents. Specifically,1.For Resident #2, the facility failed to provide oxygen to the Resident as indicated in the physician's orders.2.For Resident #136, the facility failed to ensure oxygen equipment and tubing was labeled, when changed/dated and that respiratory assessments were documented as indicated in the physician's orders. 3. For Resident #66, the facility failed to ensure nebulizer equipment and tubing was labeled, when changed/dated. Findings include: Review of the facility policy titled 'Policy and Procedure: Oxygen (O2) Management' with no revision date, indicated the following: -To ensure the safe and effective administration of oxygen therapy to residents, in compliance with Massachusetts Department of Public Health and CMS guidelines. -It is the policy…
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 before2026-01-07 · tag F0761 — failed to label and store drugs safely — patternEnsure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to store all drugs and biologicals in locked compartments for three Residents (#16, #66, and #54) out of 34 total sampled residents. Specifically, the facility failed to:1.Ensure Resident #16's scheduled Tylenol was not left at the bedside while unsupervised by staff. 2. Ensure Resident #66's Augmentin Oral Tablet (antibiotic medication) was not left at the bedside while unsupervised by staff.3. Ensure Resident #54's Nasal Saline Solution was not left at the bedside while unsupervised by staff.Findings include: Review of the facility policy titled Storage of Medications, dated as revised in 2024, indicated but was not limited to the following:Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.Only…
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 · E2026-01-07 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to ensure resident meals were at an appropriate temperature and were palatable on 4 of 4 resident units. Findings include: During the initial screening process, multiple residents reported that meals are served cold and not palatable. During the Resident Group Interview held on 1/7/26 at 10:30 A.M., multiple participants reported that meals served to residents on the unit were cold, uncooked and not palatable. During an interview on 1/7/26 at 12:26 P.M., the Food Service Director (FSD) said that the food is brought up to the units on carts with closed cabinet doors and then plated on the units. On 1/7/26 at 12:47 P.M., the surveyor conducted a test tray on the B unit:Mashed Potato: 130 degrees Fahrenheit (F)Steamed Cauliflower: 119 degrees FPuree Meatloaf: 95 degrees F. The food items tasted cold and were not palatable. On 1/7/26 at 12:50 P.M., the surveyor conducted a test tray on the C unit:Meatloaf: 90 degrees F. Mashed Potato: 100 degrees F. Steamed Cauliflower: 90 degrees F. The food items tasted cold and were not…
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 before2026-01-07 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to store and prepare food in accordance with professional food safety standards. Specifically, the facility failed to1. Ensure food items were stored appropriately in the main kitchen reach in and walk in refrigerator and2. Failed to ensure staff maintained proper hand hygiene while serving food on two of four units.Findings include:Review of the facility's policy titled Food Labeling Policy and Procedures for [The Facility], undated, indicated: Policy: All food items must be labeled accurately and clearly to ensure proper identification, traceability, and safe consumptions. Procedures: 1. Labeling Requirements: All food items must be labeled with the following information: Name of the item, date item was brought into facility, use-by or expiration date. Labels must be legible and securely attached to the container or packaging. 1. On 1/6/26 at 7:11 A.M., the surveyor observed the following in the reach-in refrigerator and walk-in refrigerators: -A shopping bag with containers of food. A staff person said that the bag contained…
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 · D2026-01-07 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure Advance Directives (written documents that instructs health care providers of the decisions for specific medical treatment if a person was unable to speak or lacked the capacity to make decisions for themselves) were consistently documented in the medical record for one Resident (#66), out of a total sample of 34 residents.Findings include: Review of the facility policy titled Advanced Directives, dated as revised September 2022, indicated but was not limited to the following:The resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance directives are honored in accordance with state law and facility policy.-Information about whether or not the resident has executed an advance directive is displayed prominently in the medical record in a section that is retrievable by any staff.-If the Resident or the resident's representative has executed one or more advance…
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 before2026-01-07 · 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 record review and interview the facility failed to implement the plan of care for one Resident (#4) out of a total sample of 34 residents. Specifically, for Resident #4 the facility failed to obtain and document vital signs as indicated in the plan of care. Findings include:Review of the facility policy titled Care Plans, Comprehensive Person-Centered, dated as revised March 2022, indicated that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.Resident #4 was admitted to the facility in February 2025 with diagnoses including presence of a pacemaker, congestive heart failure and atrial fibrillation.Review of the Minimum Data Set (MDS) assessment, dated 11/14/25, indicated that Resident #4 had moderate cognitive impairment as evidenced by a score of 9 out of 15 on the Brief Interview for Mental Status exam. Further review indicated Resident #4 was dependent on staff for activities of daily living.Review of the 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.
- Potential for harm · Dcited before2026-01-07 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record review and interview the facility failed to ensure assistance with Activities of Daily Living were provided for two Residents (#62 and #129) out of a total sample of 34 Residents. Specifically,For Resident #62 the facility failed to provide supervision or touching assistance with meals as indicated in the Resident's plan of care.For Resident #129 the facility failed to provide continuous supervision with meals as indicated in the Resident's plan of care.Findings include:Review of the untitled policy provided to the surveyor when the Activities of Daily Living (ADL) policy was requested, undated, indicated the following: -Based on the comprehensive assessment of a patient and consistent with the patient's needs and choices, the Center must provide the necessary care and services to ensure that a patient's abilities in activities of daily living do not diminish unless circumstances of the individuals clinical condition demonstrate that such diminution was unavoidable. -The center must ensure that: a patient who is unable to carry out ADLs receives 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 · D2026-01-07 · 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 observations, interviews and records reviewed, the facility failed to ensure standards of quality of care for one Resident (#36) out of a total sample of 34 residents. Specifically, the facility failed to follow up on a biopsy to Resident #36's nose, failed to identify a change in a skin condition on his/her nose, and failed to document the skin area on a skin assessment. Findings include:Review of the facility policy titled Skin Management Program Assessment and Prevention of Skin Breakdown, undated, indicated but was not limited to the following:The following measures will be employed as warranted for all residents noted to be at a moderate to high risk for the development of a skin breakdown via the Norton Plus Scale.7.Check the residents skin condition daily and whenever giving care for any signs or symptoms of skin irritation or breakdown.9. Perform and document weekly in the electronic health record the weekly skin check. 10. If a wound is identified the area will be assessed, measured, 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 · D2026-01-07 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
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 consistently provide range of motion (ROM) care and treatment in accordance with professional standards of practice for one Resident (#36) out of a total sample of 34 residents. Specifically, the facility failed to ensure staff implemented physician's orders for his/her left-hand splint (a device to properly position and protect hand joints) use based on the Occupational Therapist's recommendation and failed to develop a comprehensive resident-centered care plan with individualized interventions for Resident #36 assessed left-hand contracture.Findings include:Resident #36 was admitted to the facility in March 2025 with diagnoses including dysarthria following cerebral infarction, hemiplegia, and hemiparesis affecting left non-dominant side, hypertension and vascular dementia.Review of Resident #36's most recent Minimum Data Set (MDS), dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score 14 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 · Ecited before2024-12-12 · tag F0550 — failed to protect resident dignity and rights — patternHonor 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 record review the facility failed to provide a dignified dining experience for one Resident (#140) out of a total sample of 29 residents and on 2 of 4 nursing units. Specifically: 1. For Resident #140 the facility failed to ensure a dignified dining experience in both his/her room and in the unit dining room; and 2. on Units A and C the facility failed to ensure a dignified dining experience when Certified Nursing Assistants (CNAs) used their phones while feeding residents. Findings include: The facility policy titled Dignity, undated, indicated the following: -Treating residents with dignity and respect maintains and enhances each resident's self worth and improves his or her psychosocial well-being and quality of life. -Through example, education, and monitoring, the social service staff will promote the following types of staff interactions with residents, which maintain their dignity: -Promoting independence and dignity in dining. 1. Resident #140 was admitted to the facility in August 2024 and has diagnoses that include dementia and muscle…
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 19 citations
- Potential for harm · Ecited before2024-12-12 · tag F0761 — failed to label and store drugs safely — patternEnsure 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 observations and interviews the facility failed to ensure drugs and biologicals were stored in accordance with accepted professional standards of practice. Specifically, nursing staff failed to secure their medication and treatment carts on three of four units. Findings include: Review of the facility policy titled Storage of Medications, dated November 2020, indicated the facility stores all drugs and biologicals in a safe, secure, and orderly manner. Compartments (including, not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended. On 12/10/24 at 8:03 A.M., the surveyor observed a treatment cart was unlocked and unsupervised on the B Unit. The surveyor was able to access the treatment cart. On 12/10/24 at 8:05 A.M., Nurse #3 came out of a patient room and observed the unlocked cart. Nurse #3 said the cart is supposed to be locked, my unit manager was just in it and must have left it unlocked. On 12/10/24 at 12:35 P.M. to 1:01 P.M., the surveyor…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-12-12 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, policy review, and interview, the facility failed to store food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure that staff labeled food and that staff did not store drinks with resident food and ingredients. Findings include: Review of the facility's undated policy titled Food Storage Policy and Procedures for [NAME] Nursing & Rehabilitation Center, indicated, but was not limited to, the following: -All food items must be stored in a manner that prevents contamination, maintains nutritional value, and complies with all relevant health and safety regulations. -Label all items with the delivery date. -Personal food items brought in by residents or their families must be labeled with the resident's name and the date it was brought in. -Ensure staff are aware of and comply with all relevant health and safety regulations. -Conduct regular audits to ensure compliance with this policy. Review of the facility's undated policy titled…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-12 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure the physician/nurse practitioner were notified of lab results for one Resident (#103) out of a total of 29 residents. Specifically the facility failed to : 1. notify the physician/nurse Practitioner of the recommendations, made by the covering nurse practitioner, to review labs on Monday; and 2. notify the physician/nurse practitioner of lab results reported to the facility on [DATE]. Findings include: Review of the facility policy titled Test Results, dated as revised April 2007, indicated that should test results be provided to the facility, the attending physician shall be promptly notified of the results. Resident #103 was admitted to the facility in November 2023 with diagnoses including stage four kidney disease, heart failure and diabetes. 1. Review of Resident #103's physician's order, dated 11/8/24, indicated the following orders: -A TSH (thyroid stimulating hormone) lab to be drawn in four weeks. Review of the hard copy of the 12/6/24…
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 before2024-12-12 · 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, record review and interview the facility failed to ensure comprehensive plans of care were developed for three Residents (#98, #52 and #22) out of a total sample of 29 residents. Specifically: 1. for Resident #98 the facility failed to develop a care plan regarding the Resident's history of Suicidal Ideation (SI); 2. for Resident #52 the facility failed to implement the physician's order for an air mattress; and 3. for Resident #22 the facility failed to develop a plan of care regarding the level of assistance the Resident requires with feeding. Findings include: Review of the facility policy, titled Care plans, Comprehensive Person-Centered, revised March 2022, indicated, but was not limited to, the following: - A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. - The comprehensive, person-centered care plan: Reflects currently recognized standards of practice for problem areas and conditions. -…
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 · D2024-12-12 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure for one Resident (#140) out of a total sample of 29 residents, that the interdisciplinary team reviewed and revised the plan of care after the quarterly review assessment. Specifically, for Resident #140, the facility failed to review and update a plan of care when the level of assistance with feeding increased. Findings include: Resident #140 was admitted to the facility in August 2024 and has diagnoses that include dementia and muscle weakness. Review of the most recent Minimum Data Set (MDS) assessment, dated 11/22/24, indicated that on the Brief Interview for Mental Status exam Resident #140 scored a 2 out of a possible 15, indicating severely impaired cognition. The MDS further indicated Resident #140 requires substantial/maximal assistance with eating Review of the most recent Licensed Nursing Summary, dated 11/29/24, indicates that Resident #140 requires: -Is dependent for eating. Review of the Nutrition note, dated 11/22/24, indicated:…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-12 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to meet professional standards of practice for two Residents (#32 and #74) out of a total of 29 sampled residents. Specifically, 1. For Resident #32, the facility failed to implement a physician's order to apply air boots when in bed. 2. For Resident #74, the facility failed to obtain a physician's order for a wound treatment. Findings include: Review of [NAME], Manual of Nursing Practice 11th edition, dated 2018, indicated the following: - The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated the following: - Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber that are received by a variety of methods (i.e., written, verbal/telephone, standing…
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 before2024-12-12 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to ensure assistance was provided with Activities of Daily Living (ADLs) for one Resident (#140) out of a total sample of 29 residents. Specifically, for Resident #140, the facility failed to provide assistance with bed mobility and feeding. Findings include: The facility policy titled Activity of Daily Living (ADLs), undated, indicated the following: - Based on the comprehensive assessment of a patient and consistent with the patient's needs and choices, the center must provide the necessary care and services to ensure that a patient's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. Activities of daily living (ADLs) include: - Dining-eating, including meals. (sic) Resident #140 was admitted to the facility in August 2024 and has diagnoses that include dementia and muscle weakness. Review of the most recent Minimum Data Set (MDS) assessment, dated 11/22/24, indicated that 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 · D2024-12-12 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, interview and observation, the facility failed to ensure physicians orders for the prevention and care of pressure ulcers were followed for two Residents (#94 and 26) out of a total sample of 29 residents. Specifically: 1. for Resident #94, the facility failed to elevate his/her heels while lying in bed; and 2. for Resident #26, the facility failed to review or implement wound physician recommendations for a wound treatment. Findings include: 1. Resident #94 was admitted to the facility in March 2019 and has diagnoses which include cerebral vascular accident and hemiplegia. Review of Resident #94's most recent Minimum Data Set (MDS) assessment, dated 10/4/24, indicated that on the Brief Interview for Mental Status exam Resident #94 scored a 9 out of a possible 15, indicating moderately impaired cognition. The MDS further indicated that Resident #94 was dependent on staff for all activities of daily living and bed mobility, and was at risk for the development of pressure ulcers. Review of Resident #94's skin assessment, dated 10/1/24, indicated he/she was 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 · Dcited before2024-12-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and interview, the facility failed to provide adequate supervision per the plan of care to prevent falls for one Resident (#92) out of a total of 29 sampled residents. Specifically, the facility failed to monitor and assist Resident #92 when he/she was displaying symptoms of agitation and walking independently resulting in Resident #92 falling. Findings include: Review of Falls Prevention and Management Program, dated September 2018, indicated: -Management plans interventions based on each resident risk factors can assist in eliminating or reducing the incidence of falls as well as avoiding serious injury to the resident. -Residents having a history of falls or residents who are assessed to be a high fall risk will have an active problem included in their interdisciplinary plan of care. Care Plan measures/interventions will be listed for risk factors identified. -Staff should assess the environment for factors that could have contributed to the fall and address concerns accordingly. Resident #92 was admitted to the facility in December 2023 with…
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 · D2024-12-12 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and interview, the facility failed to provide fortified foods for one Resident (#23) out of a total of 29 sampled residents. Findings include: Review of the facility's Internal Weighing Process, dated July 2022, indicated: -If the resident's weight is +/- 3 pounds (lbs) from one weight to the next the resident is to be re-weighed the following day. -If the resident's weight is confirmed by re-weigh the Staff Nurse is to record the weight in the Electronic Health Record and inform the Unit Manager and Dietitian. If weight loss is significant and a nutrition concern inform Medical Provider, resident and/or responsible party. -Consult the Dietitian to establish or consider appropriate interventions. Dietitian will write recommendations if needed in the Medical Record. Resident #23 was admitted to the facility in September 2024 with diagnoses including dementia and chronic pain. Review of the most recent Minimum Data Set (MDS) assessment, dated 9/23/24, indicated Resident #23 was severely cognitively impaired as evidenced by a score of 5 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 · D2024-12-12 · tag F0694 — isolatedProvide for the safe, appropriate administration of IV fluids for a resident when needed.
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 maintenance of a Peripherally Inserted Central Catheter (PICC: a flexible tube inserted through a vein in one's arm and passed through to the larger veins near the heart, used to deliver medications intravenously [IV] ), consistent with professional standards of practice for one Resident (#87), out of a total sample of 29 residents. Specifically, for Resident #87, the facility failed to obtain weekly measurements for the external length of Resident #87's PICC line to ensure the PICC line had not migrated (moved from the heart to another area, which could have a significant impact on treatment, or cause serious harm). Findings include: Review of the Lippincott Manual of Nursing Practice, 11th Edition, dated 2021, included the following for documentation relative to PICC line migration and dressing changes: Use a sterile measuring tape or incremental markings on the catheter to measure the external length of the catheter from hub to skin entry to make sure that the catheter hasn't migrated.…
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 · D2024-12-12 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure one Resident (#92) was free of unnecessary medications out of a total of 29 sampled residents. Specifically, for Resident #92, the facility failed to include a stop date for the use of a PRN (as needed) antipsychotic medication. Findings include: Review of the facility's Psychotropic Medication Policy and Procedure, undated, indicated: -The facility will make every effort to comply with state and federal regulations related to the use of psychopharmacological medications in the long term care facility to include regular review for continued need, appropriate dosage, side effects, risks and/or benefits. -Orders for PRN psychotropic medications will be time limited (i.e. times two weeks) and only for specific clearly documented circumstances. Resident #92 was admitted to the facility in December 2023 with diagnoses including dementia and cognitive communication deficient. Review of the most recent Minimum Data Set (MDS) assessment, dated 11/4/24, indicated Resident #92 was moderately cognitively impaired as evidenced…
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 · D2024-12-12 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and observation, the facility failed to accurately document the completion of physician orders in the clinical record for 3 Residents (#94, #124, and #52) out of a total sample of 29 residents. Specifically: 1. For Resident #94, the facility failed to correctly document that his/her heels were not elevated while in bed; 2. For Resident #124, the facility failed to document the administration of acetaminophen; and 3. For Resident #52 the facility failed to document accurately in the Medication Administration Record/Treatment Administration Record (MAR/TAR) when the nurse documented that an air mattress function was checked when it was not. Findings include: 1. Resident #94 was admitted to the facility in March 2019, and has diagnoses which include cerebral vascular accident and hemiplegia. Review of Resident #94's most recent Minimum Data Set (MDS) assessment, dated 10/4/24, indicated that on the Brief Interview for Mental Status exam Resident #94 scored a 9 out of a possible 15,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-12-14 · 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 and interviews, the facility failed to provide a dignified dining experience for the residents on 1 of 4 residents units, specifically the B Unit. Finding include: Review of the facility policy titled Dignity, not dated, indicated All residents will be treated in a manner and in an environment that maintains and enhances each resident's dignity and respect in full recognition of his or her individuality. Assisting residents in daily care in a dignified manner. On 12/12/23 from 8:41 A.M. to 9:10 A.M., the surveyor observed staff enter a resident room on the B unit with a breakfast tray and was observed to leave the tray on the bedside table out of reach of the resident but in view of the awake resident. The breakfast tray was not set up for the resident. On 12/12/23 from 8:38 A.M. to 8:49 A.M., the surveyor observed three residents lined in the hallway on the B unit with over the bed tables. Two of the three residents received their breakfast while the other resident had their breakfast tray left on his/her bedside table with out being set up, unable to eat…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-14 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
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 investigate a newly acquired bruise. Specifically, the facility failed to investigate a bruise identified on the left hand for one Resident (#67) out of a sample of 28 residents. Findings include: A review of the facility policy titled 'Skin Management Program' with no revision date indicated the following: *Check the resident's skin condition daily and whenever giving care for any signs and symptoms of skin irritation or breakdown. A review of the Resident bruise/Skin tear injury report V1.0 indicated the following: *The nurse is to complete this report on all residents who are found with a bruise/skin tear. The investigation must be completed immediately upon report or discovery of bruise/skin tear. Any bruise/skin tear of unknown origin must be reported within a 2-hour window of discovery. Resident #67 was admitted to the facility in July 2020 with diagnoses including diabetes mellitus. A review of the most recent Minimum Data Set…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-12-14 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to develop and implement care plans for three Residents, (#47), (#20) and (#101). Specifically, 1.For Resident #47, the facility failed to develop a cardiac pacemaker care plan 2. For Resident #20, the facility failed to maintain accurate air matteress settings as indicated in the physician's order 3.For Resident #101, the facility failed to implement a physician's order for an air mattress out of a total of 28 sampled residents. Findings include: 1. Review of the facility policy titled 'Pacemaker Policy' with no revision dated indicated the following: *All residents with a pacemaker will be assessed upon admission to determine monitoring for function and daily care of a pacemaker. *Upon admission a patient who has a pacemaker will be assessed for the type of pacemaker, including ID #, place in medical record. If available, review instruction booklet or contact the cardiologist for specifics regarding patient's pacemaker. Resident #47 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 · Dcited before2023-12-14 · 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, the facility failed to provide assistance with meals as needed for two Residents (#82 & #99) out of a total of 28 sampled residents. Findings include: Review of the facility policy titled Activities of Daily Living (ADLs), not dated, indicated The Center must ensure that: A patient who is unable to carry out ADLs receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. 1. Resident #82 was admitted to the facility in March 2023 with diagnoses including dementia, dysphagia, major depressive disorder, and anxiety. Review of Resident #82's most recent Minimum Data Set (MDS) dated [DATE], indicated he/she was assessed by staff to have severe cognitive impairments. The MDS further indicated Resident #82 needed maximum assistance from staff for eating. On 12/12/23 from 8:30 A.M. to 8:41 A.M., Resident #82 was observed in the hallway with their breakfast tray, he/she was not initiating eating. No staff were present assisting…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-14 · tag F0699 — isolatedProvide care or services that was trauma informed and/or culturally competent.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure a plan of care was developed for Trauma-Informed Care for one Resident (#24), who was admitted with the diagnosis of Post-Traumatic Stress Disorder (PTSD), out of a total sample of 28 residents. Findings include: Review of the facility policy titled 'Trauma Informed Care' revised October 2021, indicated the following: *The purpose of this policy is to promote the understanding of trauma and its impact to ensure the development of a trauma informed care to our residents to help prevent triggers that will cause re-traumatization, to optimize psychosocial well-being and to assure availability of trauma specific services. * It is the policy of the facility to develop Trauma Informed Care for residents to ensure that all their needs are addressed and met. * Trauma assessment will be completed by the social services department via Social Work Assessment which includes a specific trauma assessment tool. Assessment tool consists of series of questions 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 · D2023-12-14 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record review, policy review, and interviews, the facility failed to ensure it was free from a medication error rate of greater than 5% when one out of three nurses observed made four errors out of 33 opportunities, resulting in a medication error rate of 12.12 %. Those errors impacted one Resident (#77), out of four residents observed. Findings include: Review of the facility policy titled, Medication Administration-General Guidelines, dated December 2019, indicated Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling, and administration). The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions. On 12/14/23 at 8:38 A.M., the surveyor observed Nurse #3 during medication administration pass. 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.
“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
$9,318 in federal fines across 1 penalty.
- $9,318 — penalty dated 2024-06-18
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.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| GANGI, JEFFREY | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 03/10/2026 |
| WALSH, SHARON | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | NO PERCENTAGE PROVIDED | since 09/01/2025 |
CMS files one row per role, so the 6 rows in the source record cover these 2 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.
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 225409. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-07, 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.