Mary Ann Morse Nursing & Rehabilitation
45 Union Street, Natick, MA 01760 · Non profit - Corporation · 124 certified beds · (508) 433-4403 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- 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 (F0604) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- a high number of inspection citations overall (18) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
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 | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 5 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 | 9.2% | 16.4% | 15.4% | better |
| Long-stay residents who lose too much weight | 9.3% | 5.1% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.4% | 0.8% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 2.7% | 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 | 1.8% | 3.4% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 17.9% | 15.4% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 10.2% | 19.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 94.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.6% | 4.2% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 21.3% | 21.2% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 19.0% | 21.4% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.8% | 1.4% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 92.0% | 77.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 20.1% | 25.7% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 7.7% | 11.9% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.31 | 1.88 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.64 | 1.50 | 1.80 | better |
* 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.
55.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 364 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 68.4% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 152 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 0.31 therapist hours per resident per day in 2026Q1 — more than 50% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 28% 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 | 55.6%CMS range 50.2–60.6 | 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 | 9.3%CMS range 7.0–12.1 | 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 | 68.4% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 60.5% | 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 | 58.5% | 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 | 97.4% | 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 | 97.8% | 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 | 0.0% | 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 | 2.1% | 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 | 6.6%CMS range 4.5–9.7 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.85 | 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 124 beds and averages 108.0 residents a day — about 87% occupied, or roughly 16 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.13 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.73 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.54 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 3.87 hrs/resident/day on weekends vs 4.24 on weekdays — 9% thinner on weekends. RN hours go from 0.77 to 0.65 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.
18 citations, most serious first. The 11 most serious are shown; the remaining 7 are one tap away and print in full.
- Actual harm · G2023-06-27 · 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
Based on policy review, observation, record review and interview, the facility failed to ensure its staff provided treatments in accordance with professional standards of practice for three Residents (#203, #204 and #207) out of a total sample of 21 residents. Specifically, 1. For Resident #203, the facility failed to ensure that its staff removed a post operative dressing in a timely manner, as ordered by the Physician, which resulted in a deterioration of the surgical incision. 2. For Resident #204, the facility failed to ensure that its staff obtained Physician's orders for the application of an ace wrap bandage to the right lower extremity, and the frequency of which to change it. 3. For Resident #207, the facility failed to ensure that its staff obtained Physician's orders for the application of a foam adhesive dressing to the coccyx (tailbone), and the frequency of which to change it. Findings include: Review of the facility's Treatment Policy, dated 2/6/10, indicated the following: -Policy: It is the policy of the facility to provide treatments (e.g. changing dressing 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.
- Potential for harm · D2026-05-20 · 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, interviews and observations for one of three sampled residents (Resident #1), who had been assessed as having moderately impaired cognition, the Facility failed to ensure he/she was provided with an adequate level of staff supervision to prevent an incident of elopement, when on 04/30/26 at 3:00 A.M., Resident #1 was able to exit his/her unit and the Facility, undetected by staff and was found on a loading dock of a neighboring Facility about 150 yards away. Resident #1 was transferred to the Hospital Emergency Department (ED) for evaluation.Findings include:Review of the Facility Policy titled Missing Persons Policy (Absent Without Leave), dated as last revised 08/23/24, indicated the following;-Unit Clinical Staff are required to know the location of each resident at all times of day; and-Unit Charge Nurse is responsible for assuring that each unit resident's location is known and accounted for in a manner that relies upon formal communications and data systems.Review of the report…
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 · D2024-09-20 · tag F0552 — isolatedEnsure that residents are fully informed and understand their health status, care and treatments.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record and policy review, and interview, the facility failed to ensure that one Resident (#307) out of a total sample of 22 residents, was afforded the ability to review/sign documents pertaining to his/her medical care. Specifically, the facility failed to ensure that Resident #307, who was identified as his/her own person and was able to make his/her own decisions, was able to review and sign documentation relative to Advanced Directives (life sustaining measures), side rail consent, self-administration of medication consent and consent for the use of psychotropic medications. Findings include: Review of the facility policy titled MOLST (Massachusetts Medical Orders for Life Sustaining Treatment), dated 1/2014, indicated the following: -The admitting nurse will note the existence of the MOLST form in the nursing notes and on the Physician's Orders. -Confirm with the patient/resident or their legally recognized healthcare agent that the MOLST form in hand has not been revoked or changed by a subsequent MOLST form. -A qualified health care provider, a licensed nurse or…
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 · D2024-09-20 · 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 interview, record and policy review, the facility failed to ensure that Advance Directives (legal documents that provide instructions for medical care and only go into effect if you are unable to communicate your own wishes) were accurate for two Residents (#33 and #37) out of a total sample of 22 residents. Specifically, the facility failed to: 1. for Resident #33, ensure that the MOLST (Medical Orders for Life Sustaining Treatment: a form completed by the Resident to indicate their wishes for treatment to sustain their life in emergency situations in case they are not able to make their wishes known) was maintained as part of the Resident's active medical record and was accessible to facility staff in the event the Resident had a change in condition. 2. for Resident #37, ensure that the Physician's orders matched the Resident's current MOLST. Findings include: Review of the facility policy titled MOLST (Massachusetts Medical Orders for Life Sustaining Treatment), dated January 2014, 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 · D2024-09-20 · 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 observation, interview, record and policy review, the facility failed to provide treatment and services, consistent with professional standards of practice to prevent the development of pressure ulcers (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device)/skin injuries for one Resident (#357) out of a total sample of 22 residents. Specifically, for Resident #357, the facility failed to ensure: 1. that a Licensed Nurse completed an assessment after a Certified Nurses Aide's (CNA) observation of an alteration to the Resident's skin which resulted in the development of pressure ulcers for the Resident. 2. that the Community Physician recommendation for a therapeutic air mattress/alternating pump pad mattress was reviewed with the facility Physician. Findings include: Review of the facility policy titled Skin Conditions (Assessment of), revised January 2023, indicated the following: -It is the policy of the facility to routinely assess and report resident skin condition, implement preventative…
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 · D2024-09-20 · tag F0744 — failed to care for residents with dementia — isolatedProvide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to provide appropriate treatment and interventions for three Residents (#72, #63, and #94) out of a total of 22 sampled residents, who were diagnosed with Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory and loss of judgment), to attain their highest practicable physical, mental, and psychosocial well-being. Specifically, the facility staff failed to: 1a. provide individualized interventions when Resident #72 and Resident #63 were engaged in verbal interactions and Resident #72 directed undignified statements toward Resident #63. 1b. respond timely to Resident #63's requests to disengage in an activity when the Resident voiced that he/she did not want to participate, and the Resident's escalating symptoms and behaviors were not immediately addressed by the Activities staff. 1c. respond promptly to Resident #63 when the Resident initiated a request to use the bathroom. 2. provide appropriate individualized interventions for Resident #94, when the Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-09-20 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record and policy review, the facility failed to ensure that residents were free of significant medication errors during the medication pass process for one Resident (#207) out of five residents observed, out of a total sample of 22 residents. Specifically, for Resident #207, the facility staff failed to administer the Sevelamer medication (phosphate binder -used to control high blood levels of phosphorus in people with chronic kidney disease who are on dialysis [the process of cleansing the blood by passing it through a special machine, necessary when the kidneys are unable to filter the blood]) timely and with meals as required. Findings include: Review of the facility policy titled Medication Administration; Information Needed, revised 5/2012 indicated: -To ensure resident/patient safety, the facility will define what information will be available to the licensed nursing staff who administer medications. -Other resources are available if the licensed staff has questions relating to medication administration, for example: Current Nursing Drug…
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 · D2024-09-20 · 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
Based on interview, policy and record review, the facility failed to maintain complete and accurate medical records for one Resident (#81), out of a total sample of 22 residents. Specifically, For Resident #81, the facility failed to: -maintain accurate documentation of advanced directives (legal documents that provide instructions for medical care and only go into effect if you are unable to communicate your own wishes) when the MOLST (Massachusetts Medical Orders for Life-Sustaining Treatment) form was not signed by the Resident. -maintain accurate documentation of the Resident's code status (advanced directives) on the dialysis (the process of cleansing the blood by passing it through a special machine, necessary when the kidneys are unable to filter the blood) communication sheet sent from the facility to the dialysis center which would inform the dialysis staff on the appropriate response for the Resident in the event of a cardiac emergency. Findings include: Review of the facility policy titled, Physician's orders: Receiving and Noting Of, revised March 2016, 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 · Dcited before2024-09-20 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record and policy review, the facility failed to adhere to infection control standards to prevent the potential transmission of communicable diseases and infections within the facility on two Units (Birch and Cedar) out of three total Units. Specially, the facility failed to ensure: 1. On the Cedar Unit, that staff utilized the indicated Personal Protective Equipment (PPE-items such as gowns, gloves, etc. worn to protect the wearer for exposure to potential infection or from exposing the care recipient to potential infection) while caring for a Resident (#357) on Enhanced Barrier Precautions (EBP - protective barrier gowns and gloves used as an infection control intervention designed to reduce transmission of multi-drug-resistant organisms [MDROs] during high contact resident care). 2. On the Birch Unit, that staff cleaned and disinfected glucometers (multiuse device used to check blood sugar levels) between use on multiple residents. Findings include: 1. Review of the undated facility policy titled Enhanced Barrier Precautions indicated the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-09-20 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record and policy review, the facility failed to ensure that Pneumococcal (any infection caused by bacteria called Streptococcus Pneumoniae, or Pneumococcus that can range from ear and sinus infections to Pneumonia and blood stream infections) Vaccinations were offered to three Residents (#72, #33, #2) out of five applicable residents, out of a total sample of 22 residents, increasing the residents risk for developing facility acquired Pneumococcal infections. Specifically, the facility failed to: 1. Offer Resident #72 an updated Pneumococcal Vaccine when the Resident was not up to date and was eligible to receive an updated vaccine. 2. Offer Resident #33 an updated Pneumococcal Vaccine when the Resident was not up to date and was eligible to receive an updated vaccine. 3. Offer Resident #2 an updated Pneumococcal Vaccine when the Resident was not up to date and was eligible to receive an updated vaccine. Findings include: Review of the facility policy titled Pneumococcal Vaccine, revised…
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 · D2024-09-20 · tag F0887 — isolatedEducate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record and policy review, the facility failed to provide education regarding the benefits and potential risks associated with COVID-19 vaccines for three Residents (#33, #2, and #81), out of five residents reviewed for immunizations, out of a total sample of 22 residents. Specifically, the facility failed: 1. For Resident #33, to provide education regarding the benefits and risks and potential side effects associated with the COVID-19 vaccine prior to administration of the vaccine. 2. For Resident #2, to provide education regarding the benefits and risks and potential side effects associated with the COVID-19 vaccine prior to administration of the vaccine. 3. For Resident #81, to provide education regarding changes in the benefits and risks of additional COVID-19 vaccination doses. Findings include: Review of the facility policy titled Vaccination of Residents, revised August 2016, indicated: -Prior to receiving vaccinations, the resident or legal representative will be provided with information regarding the benefits and potential side effects of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 7 citations
- Potential for harm · D2024-03-06 · tag F0604 — failed to not use physical restraints improperly — isolatedEnsure 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 records reviewed and interviews, for one of three sampled residents (Resident #1), who was moderately cognitively impaired, with hearing, vision and communication deficits, the Facility failed to ensure he/she was free from the use of physical restraints, when on 02/10/24 during the overnight shift, the Nursing Supervisor held Resident #1 by his/her wrists as he/she displayed combative behavior with staff while they tried to meet his/her care needs. Findings include: Review of the Facility's Physical Restraint Policy, dated 11/30/10 indicated the use of a physical restraint affects the dignity, physical and emotional well-being of an individual. The Policy indicated a resident has the right to be free from any physical restraints for the purposes of discipline or convenience. Review of Resident #1's medical record indicated his/her diagnoses included Parkinson's Disease without dyskinesia (involuntary muscle movements), aftercare following joint replacement surgery, atrial fibrillation, asthma, dementia…
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 · F2023-06-27 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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, document review and interview, the facility failed to ensure that staff: 1. Maintained appropriate sanitation of dishware as evidenced by the dish machine not having the required final rinse temperatures. 2. Stored food in accordance with professional standards for food service safety. Findings include: 1. Review of the facility's Cleaning Dishes/ Dish Machine policy, dated 2021, indicated the following: -Staff should check the dish machine gauges throughout the cycle to assure proper temperatures for sanitation. -High Temperature Dishwasher: Wash temperature 150 to 165 degrees Fahrenheit (F), final rinse temperature or sanitization 180 degrees F. During a tour of the kitchen on 6/22/23 at 1:30 P.M., the surveyor observed the following: -The dish machine temperature gauge indicated the required wash temperature to be 150 degrees F, and the required final rinse temperature to be 180 degrees F. -Three consecutive cycles were completed. The wash temperatures were noted to be between 154 and 157 degrees F. A final rinse temperature was not displayed. At this time,…
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 before2023-06-27 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, policy review, record review and interview, the facility failed to maintain infection surveillance for three out of three applicable Residents (#14, #22 and #85) for signs and symptoms of COVID-19 during a facility outbreak. Findings include: Review of the Massachusetts Department of Public Health's Update to Infection Prevention and Control Considerations When Caring for Long-Term Care Resident, including Visitation Conditions, and Communal Dining and Congregate Activities, dated 5/10/23, indicated the following: -Residents included in outbreak testing or who are being tested following an exposure, should be assessed for symptoms of COVID-19 during each shift. Review of the facility's Infection Control-Mitigating Respiratory Illness policy, undated, indicated the following: -Residents included in outbreak testing or who are being tested following an exposure, should be assessed for signs and symptoms of COVID-19 during each shift. During an interview on 6/22/23 at 2:18 P.M., the Director of Nurses (DON) said that a COVID-19 outbreak began in the facility on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-06-27 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal 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 interview and record review, the facility failed to provide the required notification to the Office of the State Long-Term Care Ombudsman for two Residents (#33 and #45), when they were transferred to the hospital. Specifically, the facility staff failed to provide evidence that the required Ombudsman notification was completed as required for Resident's #33 and #45. Findings include: 1. Resident #33 was admitted to the facility in May 2020. Review of the Nursing Progress Notes indicated that Resident #33 was transferred and admitted to the hospital on [DATE]. Review of the Resident's medical record showed no documented evidence that the Office of the State Long-Term Care Ombudsman was notified of the Resident's transfer to the hospital, as required. 2. Resident #45 was admitted to the facility in August 2021. Review of the Resident's clinical record indicated that he/she was transferred to the hospital on 4/28/23 and returned to the facility on 5/2/23. Further review of the Resident's clinical record…
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 · D2023-06-27 · 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 Activities of Daily Living (ADL- basic care tasks that an individual does on a day to day basis such as eating, bathing, dressing, grooming and mobility) for one Resident (#91) out of a total sample of 21 residents. Specifically, the facility staff failed to provide grooming services for a resident who was dependent for ADLs. Findings include: Resident #91 was admitted to the facility in July 2022 with a diagnosis of Macular Degeneration (an eye disease which can result in blurred or no vision in the center of the visual field). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated the resident was severely, cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of six out of a total possible score of 15. Further review of the MDS assessment indicated Resident #91 required extensive assistance for ADLs. During an observation and interview on 6/21/23 at 11:06 A.M., the Resident 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 · D2023-06-27 · tag F0691 — failed to provide colostomy / ostomy care — isolatedProvide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on policy review, record review and interview, the facility failed to provide care and services for an ileostomy (a surgically made opening that connects the lower end of the small intestine [ileum] to the abdominal wall. Through the abdominal wall opening, or stoma, the lower intestine is stitched into place. A wafer (dressing that surrounds the stoma) is then applied to the surrounding skin and allows for a bag to be attached to collect stool) appliance, for one Resident (#205), out of two applicable residents, in a total sample of 21 residents. Findings include: Review of the facility's policy for Colostomy, Ileostomy Care, dated January 2014, indicated the following: -Policy: Ostomy care is provided to monitor bowel patterns, to protect peri-stomal skin from irritation, infection and breakdown, eliminate odors and provide ongoing education for self care of the ostomy. -Procedure: *Inspect the stoma and peri-stomal skin with each pouch (bag) change. *Note any swelling of the stoma, any irritation, bruising, rashes or skin breakdown of stoma or surrounding skin. *Document 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.
- No harm found · B2024-09-20 · tag F0641 — patternEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure that a Minimum Data Set (MDS) Assessment was accurately coded for four Residents (#72, #33, #2, #357) out of a total sample of 22 residents. Specifically, the facility failed to accurately code: 1) For Resident #72, that Pneumonia Vaccination was not up to date. 2) For Resident #33, that Pneumonia Vaccination was not up to date. 3) For Resident #2, that Pneumonia Vaccination was not up to date. 4) For Resident #357, identify the type of urinary catheter in use. Findings include: 1. Resident #72 was admitted to the facility in December 2023, with diagnoses including Dementia (a decline in intellectual functioning, including problems with memory, reasoning and thinking). Review of the MDS (Minimum Data Set) assessment dated [DATE], indicated that Resident #72's Pneumococcal Vaccination was up to date. Review of Resident #72's Massachusetts Immunization Information System (MIIS) record indicated his/her last Pneumococcal Vaccination 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.
“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
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| CELESTE, KATIE | Individual | W-2 MANAGING EMPLOYEE; OPERATIONAL/MANAGERIAL CONTROL | since 03/13/2023 |
| KUBIAK, LISA | Individual | W-2 MANAGING EMPLOYEE; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | since 06/01/2018 |
| MAGUIRE, ROBERT | Individual | W-2 MANAGING EMPLOYEE | since 04/11/2016 |
| CALCIO, JOHN | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | since 04/18/2017 |
| FEGLEY, MARK | Individual | CORPORATE DIRECTOR | since 09/01/2023 |
| GOODMAN, WILLIAM | Individual | CORPORATE DIRECTOR | since 04/18/2017 |
| GOTTLIEB, MICHAEL | Individual | CORPORATE DIRECTOR | since 04/18/2017 |
| HEFFERNAN, REBECCA | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | since 04/18/2017 |
| MCLEAN, ALLAN | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | since 04/18/2017 |
| NAGELSCHMIDT, JOHN | Individual | CORPORATE DIRECTOR | since 09/01/2023 |
| UPTON, DAVID | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | since 04/18/2017 |
| WALSH, BARBARA | Individual | CORPORATE DIRECTOR | since 04/18/2017 |
CMS files one row per role, so the 19 rows in the source record cover these 12 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.
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 225555. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-23, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.