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Jesmond Skilled Nursing & Rehabilitation Center

271 Nahant Road, Nahant, MA 01908 · For profit - Limited Liability company · 57 certified beds · (781) 581-0420 Medicare & Medicaid certified

Call the home — (781) 581-0420 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Aug 20242 actual-harm citations$56,375 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • a high payroll-based staffing rating (4/5)
  • lower-than-typical staff turnover (26% 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
  • it has an abuse, neglect, or exploitation citation (F0600), cited Aug 2024
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604) — 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 (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $56,375 in federal fines (most recent 2024-08-15)

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 3 of 5

Location & what’s nearby

Hospital
★★★★★ 5/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
330 Lynnway · (781) 593-6005 · Call to confirm hours
Pharmacy
152 Lynnway · (781) 460-2000 · Call to confirm hours
Grocery
157 Nahant Rd · (781) 584-4147 · Call to confirm hours
Park
95 Marginal Rd · 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 3 of 5
Long-stay residentspeople who live here 2 of 5
Short-stay residentsrehab / post-hospital 3 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 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 increased17.1%16.4%15.4%worse
Long-stay residents who lose too much weight1.4%5.1%5.4%better
Long-stay residents with a catheter left in their bladder0.4%0.8%0.9%better
Long-stay residents with a urinary tract infection8.6%1.8%2.0%worse
Long-stay residents with depressive symptoms2.1%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 injury2.5%3.4%3.3%better
Long-stay residents whose ability to walk worsened12.6%15.4%16.1%better
Long-stay residents on antianxiety or hypnotic medication10.1%19.5%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%94.8%95.3%typical
Long-stay residents with pressure ulcers7.7%4.2%4.7%worse
Long-stay residents with worsening bladder/bowel control6.2%21.2%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table48.3%21.4%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.0%1.4%1.4%better
Short-stay residents rehospitalized after admission20.2%25.7%22.6%better
Short-stay residents with an outpatient ER visit8.4%11.9%12.0%better
Long-stay hospitalizations per 1,000 resident days2.301.881.67worse
Long-stay outpatient ER visits per 1,000 resident days1.021.501.80better

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.

0.22U.S. median 0.31
Therapy hours / resident / day
0.11hours / resident / day
Physical therapy
0.10hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.22 therapist hours per resident per day in 2026Q1 — more than 27% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 24% 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 SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified84.8%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 settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final 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 worsened9.1%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 hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.011.02Oct 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

0.53
RN hours/ resident / day
0.97
LPN hours/ resident / day
3.00
Aide hours/ resident / day
4.50
Total nurse hours/ resident / day
0.51
RN hoursweekends
25.6%
Total nursing turnover
37.5%
RN turnover

How full it usually is: this home is certified for 57 beds and averages 37.9 residents a day — about 66% occupied, or roughly 19 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.50 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.53 is below the 0.55-hour RN benchmark and nurse-aide staffing of 3.00 is at or above 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 4.22 hrs/resident/day on weekends vs 4.61 on weekdays — 8% thinner on weekends. RN hours go from 0.54 to 0.51 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 26% 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

3
deficiencies at the latest standard inspection (2025-08-06)
15
at the previous standard inspection (2024-08-15)

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 12 most serious are shown; the remaining 16 are one tap away and print in full.

  • Actual harm · G2024-08-15 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility failed to notify the physician of a change in nutritional status resulting in a hospitalization for dehydration and hypernatremia for one Resident (#24), out of a total sample of 20 residents. Findings include: Resident #24 was admitted to the facility in August 2022 with diagnoses including Alzheimer's Disease, mild protein-calorie malnutrition, and dysphagia. Review of Resident #24's most recent Minimum Data Set (MDS) dated [DATE], indicated he/she was unable to complete the Brief Interview for Mental Status (BIMS) and the staff assessed him/her to have severe cognitive impairment. The MDS also indicated Resident #24 was dependent on staff for all daily care tasks. Review of Resident #24's care plans indicated a hydration care plan last revised 7/9/24, with the following intervention: -Monitor/document/report to MD PRN s/sx (signs/symptoms) of dehydration: decreased or no urine output, concentrated urine, strong odor, tenting skin, cracked…

    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
  • Actual harm · G2024-08-15 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to address the nutrition and hydration status of two Residents (#24, #32) out of a total sample of 20 residents. Specifically, the facility failed to: 1) provide one Resident (#24) with nutritional intervention leading to a diagnosis of severe dehydration. 2) Ensure Resident #32's documented significant weight losses and weight gains were addressed by the Registered Dietitian and develop a resident focused care plan for nutrition care. Findings include: 1) Review of the policy titled, Resident Hydration and Prevention of Dehydration, undated, indicated the following: -If potential inadequate intake and/or signs and symptoms of dehydration are observed, intake and output monitoring will be initiated and incorporated into the care plan. ADL status, diagnosis, individual preferences, habits, and cognitive and medical status will be considered in all interventions. Physician will be informed. -Nursing will monitor and document fluid intake 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-08-06 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and records reviewed, the facility failed to provide a dignified experience for one Resident (#11) out of a total sample of 15 residents. Specifically: for Resident #11 the facility failed to ensure the Resident was provided dignity during activities of daily living (ADL) care. Findings include: Review of the facility policy titled Dignity and Respect dated revised 8/1/24, indicated that the facility will ensure that all residents are treated with dignity and respect. Further review indicated that the intent of the policy includes maintaining resident privacy of body. Resident #11 was admitted to the facility in February 2025 with diagnoses including severe dementia with psychotic disturbance, stroke and malnutrition. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #11 is severely cognitively impaired, scoring a 4 out of 15 on the Brief Interview for Mental Status exam. Further review indicated that Resident #11 requires assistance with ADL…

    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 before2025-08-06 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor 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 observation, record review and interview the facility failed to ensure for one Resident (#5), out of total of 15 residents that the Health Care Proxy (a document executed in advance which designates a Health Care Agent, to make informed medical decisions, when a person is determined by a medical provider to lack the capacity to make health care decisions) was activated in accordance to standards of practice. Findings include: Review of the document titled 'GENERAL LAWS OF MASSACHUSETTS CHAPTER 201D. HEALTH CARE PROXIES.' Included but not limited to the following: Chapter 201D: Section 6. Incapacity of patient; regained capacity Section 6. The authority of a health care agent shall begin after a determination is made, pursuant to the provisions of this section, that the principal lacks the capacity to make or to communicate health care decisions. Such determination shall be made by the attending physician according to accepted standards of medical judgment. The determination shall be in writing and shall…

    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 · D2025-08-06 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    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 ensure that respiratory care and services, consistent with professional standards of practice, were provided for one Resident (#10) out of sample of 15 residents. Specifically, for Resident #10, the facility failed to assess the Resident's respiratory status and response to therapy.Findings include: Review of facility policy, titled Oxygen Administration and Storage, undated, indicated the following:-Review Physician Order for instructions regarding flow rate (liters/minute), means of administration (mask or cannula), and whether oxygen is to be administered on a continuous or PRN (as needed) basis. If ordered, PRN, indications for use must be included in the order.Review of the facility policy, titled Respiratory Care Policy, dated as last reviewed 7/25/24, indicated the following:To provide safe, effective, and consistent respiratory care to residents requiring respiratory support in the facility.-Respiratory services shall be provided in accordance with physician orders, resident needs, 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-08-15 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    Provide 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, interview and record review, the facility failed to provide assistance with activities of daily living (ADLs) for five dependent Residents (#1, #2, #38, #19, #12) out of a total sample of 20 Residents. Specifically, the facility failed to: 1) Provide incontinence care timely and in accordance with the plan of care for Resident #1. 2) Provide supervision while eating for three Residents (#2, #38, #19). 3) Provide showers as ordered for Resident #12. Findings include: Review of the facility's policy titled Activities of Daily Living, effective date 01/01/2015 indicated the following: A program of activities of daily living (ADL) is provided to residents by the following method: The ability of each resident to meet the demands of daily living is assessed by a licensed nurse and/or member of the interdisciplinary team. A program of assistance and instruction in ADL skills is implemented. Assistive devices and adaptive equipment are provided by occupational therapy services. Educations is…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-15 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor 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 observation, record review and interview the facility failed to ensure advanced directives were followed, resulting in one Resident (#24) being transferred to the hospital, out of a total sample of 20 residents. Findings include: Review of the facility policy titled, Advanced Care Planning, dated [DATE], indicated the following: -Individuals will have the opportunity to discuss preferences for care and treatment upon admission and to establish written directives, preferences, and choices for care and treatment in the event that the individual becomes unable to continue to express his or her wishes at a later time. -Known as an Advanced Care Plan, these preferences, directives, and choices will guide care and treatment for individuals who can no longer express their goals for care or make treatment choices. -Advanced Care Planning is a process enabling a patient to express wishes about his or her future health care in consultation with health care providers, family members and other important people in…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-15 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure one Resident (#1) was free from neglect, out of a total sample of 20 residents. Specifically, the facility failed to implement an established care plan for incontinence care resulting in incontinence care not being provided in a timely manner. Findings include: Review of the facility's policy titled Resident Abuse/Mistreatment/Neglect/Exploitation Misappropriation of Property Policy, not dated indicated the following: It is the policy of the facility that each resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, exploitation, and misappropriation of property. Further, each resident at the facility will be treated with respect and dignity at all times. Definitions Neglect: failure to provide goods and services necessary to avoid physical harm mental anguish or mental illness. In determining whether or not neglect has occurred the following standards shall apply:…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-15 · tag F0604 — failed to not use physical restraints improperly — isolated
    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
    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 complete a restraint assessment for one Resident (#36) out of a total sample of 20 residents. Specifically, the facility failed to complete a bed safety assessment prior to adding a bolster pillow in the Resident's bed. Findings include: A review of the facility policy titled 'Restraints' with no revision date indicated the following: -Definitions-Physical restraint-any manual or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. -Goal-To provide a systematic method of evaluating and monitoring restraint use to assure utilization of the least restrictive method and medical necessity. -It is the facility policy that the resident has the right to be free from any physical restraint imposed for the purpose of discipline or convenience and not required to treat the resident's medical…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-15 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interview, the facility failed to follow the plan of care for three Residents (#25, #26 and #41) out of a total sample of 20 residents. Specifically, the facility 1) Failed to follow a physician's order to provide an air mattress for Resident #25. 2) Failed to offload Resident #26's heels as written in his/her care plan. 3) Failed to offload Resident #41's right heel as ordered by the physician. Findings include: 1. Resident #25 was admitted to the facility in April 2018 with diagnoses including diabetes. Review of Resident #25's most recent Minimum Data Set (MDS) dated [DATE], indicated he/she had a Brief Interview for Mental Status (BIMS) score of 6 out of a possible 15 which indicated he/she has severe cognitive impairment. The MDS also indicated Resident #25 is dependent on staff for bed mobility tasks. Review of Resident #25's physician orders indicated the following order initiated on 4/27/23: - Air Mattress - check function and settings #130 (pounds) every shift…

    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 · D2024-08-15 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record reviews and interviews, the facility failed to ensure a physician's order was implemented as ordered for one Resident (#25) out of a total sample of 20 residents. Specifically, the facility failed to obtain blood pressure parameters as ordered. Findings include: Resident #25 was admitted to the facility in April 2028 with diagnoses including cardiomyopathy. Review of Resident #25's Minimum Data Set (MDS), dated [DATE], indicated he/she scored a 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident was cognitively intact. During a medication observation pass on 8/13/24 at 9:15 A.M., the surveyor observed Nurse #1 prepare and administer medications to Resident #25 including metoprolol 12.5 mg (milligram). Review of Resident #25's physician orders for the month of August 2024 indicated the following order: -Metoprolol succinate tab 25 mg (milligram) extended release. Give 12.5 mg orally one time a day related to cardiomyopathy. Hold for systolic…

    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 before2024-08-15 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interview, the facility failed to implement the medical plan of care for two Residents (#28, #32) who are assessed as high risk for developing pressure ulcers, out of a total sample of 20 residents. Specifically, the weekly skin assessments for both residents were not completed in accordance with the physician's orders. Findings include: 1) Resident #28 was admitted to the facility in 9/2023 with diagnoses that include but are not limited to unspecified dementia, Parkinson's disease, congested heart failure, and anemia. Review of Resident #28's Minimum Data Set assessment dated [DATE] indicated Resident #28 scored a 12 out of 15 on the Brief Interview for Mental Status exam indicating he/she as having moderate cognition, is dependent on staff for bathing, toileting, dressing and is at risk for developing pressure ulcers. Review of Resident #28's medical record indicated the following: -The Norton Scale for Predicating Risk of Developing Pressure Ulcers dated 12/2/23 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 16 citations
  • Potential for harm · D2024-08-15 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide 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, record review and interview the facility failed to implement the use of a hand splint in accordance with the rehabilitation plan of care for one Resident (#38), out of a total sample of 20 residents. Findings include: Review of the facility policy titled Therapy Screen Policy, dated January 2017, indicted the following: - Therapy will screen residents for appropriateness of therapy intervention. This will include quarterly, annual or as needed screens or referrals from other clinical team members. Resident #38 was admitted to the facility in November 2023 with diagnoses including cerebral infarction, hemiplegia and hemiparesis affecting right dominant side and contracture of the right hand. Review of Resident #38's most recent Minimum Data Set assessment (MDS) dated [DATE] indicated that the Resident had a Brief Interview for Mental Score of 7 out of a possible 15 indicating he/she has moderate cognitive impairment. Further review of Resident #38's MDS indicated that he/she is dependent on…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-15 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, policy review and interviews, the facility failed to complete an investigation of a fall for one Resident (#12) out of a total sample of 20 residents. Findings include: Review of the facility policy titled, Accident and Incident Reports, undated, indicated the following: -All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator. Resident #12 was admitted to the facility in January 2017 with diagnoses including respiratory failure and heart failure. Review of resident #12's most recent Minimum Data Set (MDS) dated [DATE] indicated the Resident had a Brief Interview for Mental Status of 14 out of 15 which indicated the Resident was cognitively intact. The MDS also indicated Resident #12 required substantial assistance from staff for mobility tasks. During an interview on 8/13/24 at 7:42 A.M., Resident #12 said he/she sustained a fall within the last year and he/she has…

    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 before2024-08-15 · 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 observations, policy review and interviews, the facility failed to ensure medications with short expirations dates were dated when opened, expired medications were removed from supply, medications were securely stored and medication carts were locked when unattended. Findings include: Review of the facility policy titled 'Medication Storage In The Facility', dated 2017, indicated the following but not limited to: -Medications and biologicals are stored safely, securely, and properly, following manufacturers' 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 licensed nurses, pharmacy personnel, and those lawfully authorized to administer medication (such as medication aides) permitted to access medications. Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access. -The nurse shall place a date opened sticker on the medication and enter the date opened and the new date…

    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 · D2024-08-15 · tag F0805 — failed to prepare food in a form residents can eat — isolated
    Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that the correct diet texture was implemented for one Resident (#38) out of a total sample of 20 residents. Specifically, the facility failed to ensure that Resident #10 received a minced textured diet as ordered by the physician. Findings include: Resident #38 was admitted to the facility in November 2023 with diagnoses including cerebral infarction, hemiplegia and hemiparesis affecting right dominant side and contracture of the right hand. Review of Resident #38's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident had a Brief Interview for Mental score of 7 out of a possible 15 indicating he/she has moderate cognitive impairment. Further review of Resident #38's MDS indicated that he/she is dependent on staff for Activities of Daily Living. The surveyor made the following observations: - On 8/13/24 at 12:27 P.M., Resident #38 was observed eating lunch in the second-floor dining room. On 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-15 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard 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 observations, record review and interview, the facility failed to maintain an accurate medical record for one Resident (#25) out of a total sample of 20 residents. Findings include: Resident #25 was admitted to the facility in April 2018 with diagnoses including diabetes. Review of Resident #25's most recent Minimum Data Set (MDS) dated [DATE], indicated he/she had a Brief Interview for Mental Status (BIMS) score of 6 out of a possible 15 which indicated he/she has severe cognitive impairment. The MDS also indicated Resident #25 is dependent on staff for bed mobility tasks. Review of Resident #25's physician orders indicated the following order initiated on 4/27/23: - Air Mattress - check function and settings #130 (pounds) every shift, every shift for positioning. On 8/13/24 at 7:35 A.M., 8:41 A.M., 11:19 A.M., and 1:26 A.M., Resident #25's bed was observed with a facility pressure relieving mattress, not an air mattress. Review of the Medication Treatment Record indicated the Nursing staff had…

    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 · D2024-08-15 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review, and interviews, the facility failed to implement the infection prevention and control program. Specifically: the facility failed to ensure nursing implemented infection control standards for blood glucose meter cleaning. Review of the facility policy, infection control, undated indicated the following but not limited to: -Equipment if disinfecting is not possible, clean and disinfect equipment using the same guidelines as for environmental cleaning, after contact with the resident and prior to using the equipment on another resident. -All equipment must be cleaned with PDI sani-cloth germicidal disposable cloth. On 8/13/24 at 7:45 A.M., the surveyor observed Nurse #2 gather supplies to obtain a Resident's blood sugar. On 8/13/24 at 7:45 A.M., the surveyor observed Nurse #2 obtain Resident #2's blood sugar. Nurse #2 exited the room with the contaminated glucometer and placed it in the carrier case where there were more lancets (devices used to obtain blood for testing blood sugar levels) test strips and alcohol wipes. Nurse #2 did not disinfect…

    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 · Ecited before2023-06-21 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    Provide 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 observations, policy review, record review and interviews, the facility failed to provide assistance for meals for 4 Residents (#31, #23, #5, and #6) out of a total sample of 15 residents. Findings include: Review of the facility policy titled, Activities of Daily Living, dated 1/1/2015, indicated the following: *A program of activities of daily living (ADL) is provided to residents by the following method: The ability of each resident to meet the demands of daily living is assessed by a licensed nurse and/or member of the interdisciplinary team. A program of assistance and instruction in ADL skills is implemented. Assistive devices and adaptive equipment are provided by occupational therapy services. Education is provided to resident and family. *Feeding: Meals are planned considering needs and desires of residents. 1. Resident #31 was admitted to the facility in May 2018 with diagnoses including stroke and left sided hemiplegia (paralysis). Review of Resident #31's most recent Minimum Data Set (MDS)…

    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 before2023-06-21 · 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 observations, policy review and interviews, the facility failed to provide a dignified dining experience to the residents on the first floor. Findings include: Review of the facility policy titled, Dignity and Respect, dated 8/1/22, indicated the following: *Promoting independence & dignity and dining: facility and staff should avoid: staff standing over residents while assisting them to eat and staff interacting/conversing only with each other rather than with residents while assisting residents. The following was observed in the first floor dining room during the breakfast meal on 6/20/23 at 8:33 A.M.: * Two Certified Nursing Assistants (CNAs) were sitting at a table with 3 residents. The CNAs began to feed the residents without speaking to them. Throughout the meal, the CNAs spoke to each other in Spanish, however, never conversed with the residents. The following was observed in the first floor dining room during the lunch meal on 6/20/23 at 12:35 P.M.: * Two CNAs were sitting at a table with 3 residents. The CNAs began to feed the residents without speaking to them.…

    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 · D2023-06-21 · 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, record reviews and interviews, the facility failed to accommodate one Resident (#8)'s needs by having the bed remote within reach, out of a total sample of 15 residents. Findings include: Resident #8 was re-admitted to the facility in May 2023 with diagnoses including pneumonia and stroke. Review of Resident #8's most recent Minimum Data Set (MDS) dated [DATE], indicates the Resident has a Brief Interview for Mental Status (BIMS) exam of 6 out of a possible 15, indicating he/she has severe cognitive impairment. The MDS also indicated Resident #8 is dependent on staff for all functional daily tasks. During an interview on 6/20/23 a 9:34 A.M., Resident #8 was observed lying in bed with the head of the bed elevated to approximately 75 degrees and the bed remote behind the head of the bed, out of his/her reach. Resident #8 said he/she would like to change the position of his/her bed, however, cannot reach the remote. On 6/20/23 at 12:08 P.M., Resident #8 was observed lying in bed with the head…

    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 · D2023-06-21 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and interviews, the facility failed to ensure resident Protected Health Information (PHI) was secure and not visible to others on one of two nursing units. Findings include: During an observation on 6/21/23 at 9:30 A.M., during a medication pass, Nurse #3 had an Electronic Health Record (EHR) located on a medication cart on the 2nd floor hallway. The screen was open, unattended and the screen of residents' PHI was visible to anyone who passed by. During an observation on 6/21/23 at 9:36 A.M., during a medication pass, Nurse #3 left the EHR computer screen open, revealing PHI to anyone who passed by. During an observation on 6/21/23 at 9:43 A.M., during a medication pass, Nurse #3 left the EHR computer screen open, revealing PHI to anyone who passed by. During an interview on 6/21/23 at 9:50 A.M., Nurse #3 said the computer screen should be closed out of view anytime she is not near it. During an interview on 6/21/23 at 2:30 P.M., the Director of Nursing said anytime a nurse moves away from the computer screen they are expected to put a privacy screen up 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-06-21 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to provide a dietary supplement as ordered for one Resident (#6) out of a total sample of 15 residents. Findings Include: Resident #6 was admitted to the facility in May 2016 with diagnosis including abnormal weight loss, dementia, and dysphagia. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #6 was unable to complete a Brief Interview for Mental Status (BIMS) due to being rarely or never understood. Further review of the MDS indicated Resident #6 is totally dependent on staff to assist with eating. Review of Resident #6's diet orders indicated the following: *Magic cup (a high calorie, nutrient fortified ice-cream) all meals for meals On 6/20/23 at 8:44 A.M., the surveyor observed a card on Resident #6's breakfast tray indicating Magic Cup three times a day with meals. There was no magic cup on the Resident's meal tray. On 6/21/23 at 8:33 A.M., the surveyor observed a card on Resident #6's breakfast tray…

    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 · D2023-06-21 · tag F0676 — failed to keep up residents' daily-living abilities — isolated
    Ensure residents do not lose the ability to perform activities of daily living unless there is 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 observations, record review, policy review and interviews, the facility failed to ensure one Resident (#4) was provided with services and/or materials to maintain communication in his/her own language, out of a total sample of 15 residents. Findings include: Review of the facility policy titled, Communication Translation, indicated the following: *Should a non-English speaking or deaf resident be admitted , a resident rights and facility responsibilities will be translated into the appropriate foreign or sign language that is understood by the resident. It will be accessible for all staff to communicate with the resident and care planned as a communication tool. *The facility has developed an interpreter service policy to assure adequate and effective communication between residents and staff. Employees of the facility will be utilized whenever possible to interpret for non-English speaking or hearing-impaired persons of a staff member is not available, the facility will contract with (an interpreter…

    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 before2023-06-21 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure physician wound recommendations were addressed for a resident with a coccyx pressure ulcer for 1 Resident (#19) and failed to ensure that an air mattress was at the ordered setting and heel protective booties were applied for 1 Resident (#8) with a pressure ulcer out of a total of 15 sampled Residents. Findings include: Review of Facility policy titled, Wound Policy dated 6/16/19 included the following: -Wound rounds will be done weekly by the wound team which will consist of the ADNS, UM, and rehab. These rounds are done the same day every week. Wound measurements are done at this time in treatment response and progress of the wound is discussed After rounds are completed a descriptive note will be written on the weekly pressure/non pressure documentation tool. The MD/NP should also document in their progress notes. 1. Resident #19 was admitted to the facility in March 2022 with diagnoses including type 2 diabetes, pressure ulcer of…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-06-21 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure 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 observation, record review and interview, the facility failed to ensure it was free from a medication error rate of greater than 5%. Two out of two nurses observed made three errors in 28 opportunities resulting in a medication error rate of 10.71%. These errors impacted 2 Residents (#17 and #11) out of 4 residents observed. Findings include: Review of the facility policy titled, Medication Administration Policy and Procedures undated included the following: -Administration of the correct dosage, form and route -Dosage, route of administration and drug form (tablets, suppository's, liquid) are only ordered by the physician. On 6/21/23 at 8:20 A.M., the surveyor observed a medication pass on the 1st floor nursing unit. Nurse #2 prepared and administered the following medications for Resident #17: -Two docusate sodium 100 milligram (mg) tablets. Review of Resident #17's medical record indicated the following: - A physician order dated 10/5/21 for Docusate Sodium Cap 100 mg, give two capsules orally in the morning. During an interview on 6/21/23 at 11:29 A.M., Nurse #2 said…

    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 before2023-06-21 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure medications were appropriately stored per policy for one Resident (#25) out of a total of 15 sampled Residents. Findings include: Review of the Facility's Medication Storage policy, dated 2017, indicated 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. Review of the Facility's Medication Administration Policy, undated, indicated the following: *Observe patient to ensure that medication is swallowed. Do not leave medications with a patient even if you feel a patient is competent. Resident #25 was admitted to the facility in May 2016 with diagnoses including stroke, and hypoxic respiratory arrest requiring intubation. Review of Resident #25's Minimum Data Set assessment dated…

    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 · D2023-06-21 · tag F0812 — failed to store, cook, and serve food safely — isolated
    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 observations and interviews, the facility failed to properly handle food to prevent the spread of food borne illnesses during mealtimes on the first floor. Findings include: The following was observed in the first floor dining room during the breakfast meal on 6/20/23 at 8:33 A.M.: * 4 staff members were observed putting on gloves without washing or sanitizing their hands. The staff then proceeded to open containers and touch packaging on the food, potentially contaminating their gloves. Without changing their gloves, one staff member then touched the head of the spoon that holds the resident's food. Another staff member opened two juice cartons by sticking her finger in the carton to expand the spout. A third staff member was cutting a resident's food and while doing so, her glove on her index finger was in the resident's eggs. The following was observed in the first floor dining room during the breakfast meal on 6/21/23 at 8:10 A.M.: *3 staff members were observes putting on gloves without washing or sanitizing their hands. The staff then proceeded to open containers 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.

    Nutrition and Dietary 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

$56,375 in federal fines across 1 penalty.

  • $56,375 — penalty dated 2024-08-15

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 / managerTypeRoleSince
BARRASSO, DAVIDIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2012
BLAKE, MARKIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/21/2015
KHAN, AMIRIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/21/2015
QURESHI, TARIQIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/21/2015

CMS files one row per role, so the 8 rows in the source record cover these 4 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.

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.

$5.5M
Net patient revenuemost recent cost report
+8.7%
Operating marginrevenue minus expenses
$600K
Related-party expense12% of expenses
Who pays — share of resident-days
Medicaid 64%Medicare 7%Other / private 29%

This home reported $600K paid to related parties — landlords or management companies under common ownership — equal to about 12% 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.

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

$325per resident / day
operating cost
$9,890per month
≈ monthly operating cost
$356per 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 225471. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-06, 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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