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Care One At New Bedford

221 Fitzgerald Drive, New Bedford, MA 02745 · For profit - Limited Liability company · 154 certified beds · (508) 996-4600 Medicare & Medicaid certified

Call the home — (508) 996-4600 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0604) — cited Jan 2023
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
  • lower-than-typical staff turnover (30% vs 45% nationally) — better care continuity
Worth asking about
  • 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
  • a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags

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

Urgent care / clinic
4 Welby Rd · (774) 627-9125 · Call to confirm hours
Pharmacy
2968 Acushnet Ave · (508) 998-3457 · Call to confirm hours
Grocery
2941 Acushnet Ave · (508) 998-7500 · Call to confirm hours
Park
51 Mill 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 held steady at 3 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased27.1%16.4%15.4%worse
Long-stay residents who lose too much weight5.7%5.1%5.4%typical
Long-stay residents with a catheter left in their bladder1.8%0.8%0.9%worse
Long-stay residents with a urinary tract infection0.8%1.8%2.0%better
Long-stay residents with depressive symptoms2.6%15.5%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury2.4%3.4%3.3%better
Long-stay residents whose ability to walk worsened36.9%15.4%16.1%worse
Long-stay residents on antianxiety or hypnotic medication22.5%19.5%18.9%worse
Long-stay residents given the seasonal flu vaccine96.5%94.8%95.3%typical
Long-stay residents with pressure ulcers4.4%4.2%4.7%typical
Long-stay residents with worsening bladder/bowel control28.6%21.2%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table16.3%21.4%17.1%typical
Short-stay residents who newly got an antipsychotic medication1.3%1.4%1.4%typical
Short-stay residents given the seasonal flu vaccine79.8%77.7%79.4%typical
Short-stay residents rehospitalized after admission28.4%25.7%22.6%worse
Short-stay residents with an outpatient ER visit14.2%11.9%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.791.881.67typical
Long-stay outpatient ER visits per 1,000 resident days1.031.501.80better

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.

63.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 367 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

63.2%U.S. median 51.5%
Got home and stayed home
11.0%U.S. median 10.7%
Went back to hospital
65.9%U.S. median 56.6%
Met the expected recovery
0.40U.S. median 0.31
Therapy hours / resident / day
0.19hours / resident / day
Physical therapy
0.17hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 65.9% 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 223 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 0.40 therapist hours per resident per day in 2026Q1 — more than 68% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 26% 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 SNF63.2%CMS range 57.5–68.751.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.0%CMS range 8.7–13.410.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge65.9%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge55.6%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge56.0%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified99.3%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 setting81.6%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge96.1%98.7%Oct 2024–Sep 2025CMS 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 stay0.7%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 worsened2.3%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 hospitalization7.0%CMS range 4.3–10.37.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.921.02Oct 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

0.72
RN hours/ resident / day
0.61
LPN hours/ resident / day
2.28
Aide hours/ resident / day
3.60
Total nurse hours/ resident / day
0.44
RN hoursweekends
29.9%
Total nursing turnover
23.1%
RN turnover

How full it usually is: this home is certified for 154 beds and averages 142.4 residents a day — about 92% occupied, or roughly 12 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.60 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.72 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.28 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.24 hrs/resident/day on weekends vs 3.75 on weekdays — 13% thinner on weekends. RN hours go from 0.83 to 0.44 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 30% is below the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

7
deficiencies at the latest standard inspection (2025-08-05)
3
at the previous standard inspection (2024-05-22)

Deficiencies are more than at the previous inspection — worsening. 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.

29 citations, most serious first. The 10 most serious are shown; the remaining 19 are one tap away and print in full.

  • Potential for harm · E2025-08-05 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — pattern
    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

    Based on interviews and records reviewed, the facility failed to ensure one Resident (#57), out of a total sample of 27 residents, received care and treatment to promote healing of a pressure ulcer. Specifically, the facility failed for Resident #57, to implement treatments from the wound consultant physician for an unstageable pressure ulcer (wound covered with necrotic (dead) tissue making it difficult to determine stage) of the coccyx.Findings include:Resident #57 was admitted to the facility in September 2024 with diagnoses including Parkinson's Disease and muscle weakness.Review of Resident #57's Minimum Data Set (MDS) assessment, dated 7/4/25, indicated he/she had an unhealed unstageable pressure ulcer and was receiving pressure ulcer/injury care.On 7/30/25 at 9:32 A.M., Resident #57 said he/she had a wound on their buttock region and said it had been present since last fall.Review of Resident #57's care plans indicated he/she had actual skin breakdown related to an unstageable coccyx wound. The care plan interventions included but were not limited to: wound consult as needed,…

    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 before2025-08-05 · tag F0812 — failed to store, cook, and serve food safely — pattern
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential of foodborne illness to residents who are at high risk. Specifically, the facility failed to:1. Properly label and date food products and maintain safe/clean equipment in three nourishment kitchenettes; and2. Handle ready-to-eat food (food which does not require cooking or further preparation prior to consumption) utilizing proper hand hygiene to prevent cross contamination (transfer of pathogens from one surface to another). Findings include:1. Review of the facility's policy titled Foods Brought by Family/Visitors, dated October 2017, indicated but was not limited to the following:- Food brought to the facility by visitors and family is permitted. Facility staff will strive to balance resident choice and a homelike environment with the nutritional and safety needs of residents.- Food brought by family/visitors that is left with resident to consume later…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-08-05 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed to maintain a water management program to prevent the growth of Legionella (bacteria that can cause legionellosis (illness caused by Legionella) including a pneumonia-type illness called Legionnaires' disease) and other opportunistic waterborne pathogens.Findings include: Review of the facility's policy titled Legionella Water Management Program, dated as revised September 2022, indicated but was not limited to:-As part of the infection prevention and control program, our facility has a water management program, which is overseen by the water management team-The purposes of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease-The water…

    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 · Dcited before2025-08-05 · 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, interview, and record review, the facility failed to develop, implement and individualize a comprehensive care plan for one Resident (#137), out of a total sample of 27 residents. Specifically, the facility failed to ensure a comprehensive care plan related to Resident #137's right hand contracture (shortening/tightness to the muscle, tendons, ligaments, skin and other tissues resulting in difficulty moving the affected joint) was developed and implemented.Findings include: Review of the facility's policy titled Care Plans, Comprehensive Person-Centered, dated March 2022, indicated but was not limited to the following:- A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.- The comprehensive, person-centered care plan describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental…

    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 before2025-08-05 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure one Resident (#94) was administered medications in accordance with professional standards of quality, in a total sample of 27 residents. Specifically, the facility failed to ensure that nurses administering medications ensured Resident #94 had taken the medications.Findings include:Review of the facility's policy titled Administering Medications, dated as revised in April 2019, indicated the following:-only persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so-medications are administered in accordance with prescriber orders, including any required time frameResident #94 was admitted to the facility in September 2024.Review of the Minimum Data Set (MDS) assessment, dated 6/24/25, indicated Resident #94 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating the Resident was cognitively intact.Review of the medical record indicated Resident #94 was advised of their right to self-administer medication on 9/13/24…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-08-05 · 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

    Based on observation, document review, and interview, the facility failed to maintain complete and accurate medical records for two Residents (#2 and #10), out of a total sample of 27 residents. Specifically the facility failed to:1. Ensure Resident #2 had documentation in their medical record of their full diagnoses and psychiatric history, including a historical diagnosis of Schizoaffective disorder; and2. Ensure Resident #10's medical record contained only his/her health information.Findings include:1. Resident #2 was admitted to the facility in April 2025 with diagnoses including: Metabolic encephalopathy, bipolar disorder, anxiety disorder, and major depressive disorder recurrent. Review of the Minimum Data Set (MDS) assessment, dated 6/3/25, indicated the Resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14 out of 15. Further review of the MDS indicated diagnoses of other neurological conditions, and anxiety, depression, and bipolar disorder under the psychiatric/mood disorder diagnoses section. Review of the diagnoses list for Resident…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-03 · 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 records reviewed, interviews and observations for one of three nursing units (Unit #1), with two (2) medication administration carts (A & B), the facility Failed to ensure it provided a separate locked, permanently affixed compartment for storage of medications that were controlled substances and/or other drugs subject to abuse, when both medication administration carts narcotic boxes were able to be opened without the use of a key, making these medications easily accessible. Findings include: Review of the Facility Policy titled Medication Storage in the Facility, dated as last revised 2/2019, indicated that medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and record keeping in the facility in accordance with federal, state and other applicable laws and regulations. The Policy indicates that Schedule II-V medications and other medications subject to abuse or diversion are stored in a permanently affixed, double-locked compartment separate from all other medications.…

    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 before2025-02-03 · 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 records reviewed, interviews, and observation, for one of seven (7) sampled residents (Resident #7) who should have been on Enhanced Barrier Precautions (EBP-an infection control intervention designed to reduce transmission of Multi-Drug-Resistant Organisms (MDRO) in nursing homes) related to wound care needs, the Facility failed to ensure nurses were aware of the need to use EBP's and implemented the necessary infection control practices during the provision of care. Findings include: Review of the facility's policy titled Enhanced Barrier Precautions (EBP) dated as last revised August 2023, indicated that EBP's are utilized to prevent the spread of multi-drug-resistant organisms (MDRO's) to residents. The Policy further indicated the following; -EBP's employ targeted gown, and gloves use during high contact resident care activities when contact precautions do not otherwise apply; -Gloves and gown are applied prior to performing the high contact resident care activity such as dressing, bathing, providing hygiene, and changing brief or assisting with toileting; -EBP's are…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-05-22 · tag F0760 — failed to prevent significant medication errors — pattern
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews, record review, and policy review, the facility failed to ensure for three Residents (#11, #73, and #133), out of a total sample of 25 residents, that the Residents were free from significant medication errors. Specifically, the facility failed to ensure pain medicine was administered according to the pain scale indicated in the physician's orders. Findings include: Review of the facility's policy titled Pain - Clinical Protocol, revised October 2022, indicated but was not limited to: -Staff will use a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level. Review of the facility's policy titled Administering Medications, revised April 2019, indicated but was not limited to: -Medications are administered in accordance with prescriber orders. -If a dosage is believed to be inappropriate or excessive for a resident, the person preparing or administering the medication will contact the prescriber, the resident's attending physician or the facility's medical director to discuss the concerns. Standard 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-22 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, interview, and policy review, the facility failed to act promptly upon recommendations made by the Consultant Pharmacist during the monthly Medication Regimen Reviews (MRR) for one Resident (#133), out of a total sample of 25 residents. Specifically, for Resident #133 the Pharmacist failed to review and report irregularities related to the administration of a medication. Findings include: Review of the facility's policy titled Consultant Pharmacist Reports, effective date February 2019, indicated but was not limited to: -Comments and recommendations concerning medication therapy and apparent irregularities will be reported in a timely manner to ensure the resident's safe and appropriate medication utilization. Resident #133 was admitted to the facility in April 2024 with diagnoses including chronic kidney disease and diabetes with diabetic neuropathy. Review of the Minimum Data Set (MDS) assessment, dated 4/13/24, indicated Resident #133 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Review of Resident…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
Show the remaining 19 citations
  • Potential for harm · Fcited before2023-01-30 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, document review, and interview, the facility failed to properly store and label food in the facility kitchen and on 3 out of 3 unit nourishment kitchens in accordance with professional standards of practice to ensure food safety. Specifically, the facility failed to: a. properly label beverage items in 1 of 2 freestanding refrigerators in the kitchen, and b. ensure food and beverages were properly stored and labeled in 3 out of 3 unit nourishment kitchens. Findings include: a. On 1/23/23 at 8:20 A.M., the surveyor, with Dietary Staff #1 present, observed seven trays of hard plastic cups filled with various liquids stored on shelving inside one of two stand up refrigerators. The cups/trays were not labeled as to when they were prepared or the use by dates. Dietary Staff #1 said the cups were filled the night before with various nectar thick liquids and were good for 24 hours. She said they should have had a sticker label on them to indicate when they were filled and what the use by date 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-01-30 · tag F0895 — widespread
    Have a Compliance and Ethics Program.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on interview, the facility failed to develop, implement, and maintain a comprehensive Compliance and Ethics program as required. Findings include: During an interview on 1/30/23 at 2:42 P.M., the Administrator said the facility does not have a Compliance and Ethics program or committee and was unable to provide any written standards, policies and procedures for a Compliance and Ethics program. He said if there were any ethical concerns, they would use corporate's legal department. .

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-01-30 · tag F0656 — failed to write and follow a full care plan — pattern
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, interview, and policy review, the facility failed to ensure that individualized, comprehensive care plans were developed and consistently implemented for seven Residents (#11, #19, #68, #86, #112, #28, and #80), out of 28 sampled residents. Specifically, the facility failed to: 1. For Resident #11, develop a comprehensive care plan for: a. frequent urinary tract infections, Extended Spectrum Beta-Lactamase (ESBL: enzymes that break down and destroy some commonly used antibiotics, including penicillins and cephalosporins, and make these drugs ineffective for treating infections) and prophylactic use of Hiprex (medication used to prevent or control returning urinary tract infections caused by certain bacteria), and b. the use of psychotropic medications that identified target behaviors, non-pharmacological interventions and measurable goals of treatment; 2. For Resident #19, develop a comprehensive care plan for the use of psychotropic medications that identified target behaviors, non-pharmacological interventions and measurable goals of treatment; 3. For…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-01-30 · tag F0658 — failed to meet professional standards of care — pattern
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, policy review, and interview, the facility failed to ensure that staff provided care and services according to accepted standards of clinical practice for nine Residents (#53, #62, #112, #86, #19, #68, #63, #232, and #80), out of a total sample of 28 residents. Specifically, the facility failed: 1. For Resident #53, to ensure diabetic management; 2. For Resident #62, to ensure orders were in place for monitoring hyper/hypoglycemia with treatment interventions to address the potential for hyper/hypoglycemia; 3. For Resident #112, to ensure orders were in place for: a. monitoring for signs and symptoms of hyper/hypoglycemia, b. FSBS (finger stick blood sugars) to obtain blood glucose levels in order to implement a sliding scale, and c. FSBS to obtain blood glucose levels in order to implement the hypoglycemic protocol; 4. For Resident #86, to ensure orders were in place for: a. monitoring for signs and symptoms of hyper/hypoglycemia, b. FSBS to obtain blood glucose levels in order to implement a sliding scale, and c. FSBS to obtain blood glucose…

    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 · E2023-01-30 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
    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 observation, policy review, record review, and interview, the facility failed to provide the necessary respiratory care and services in accordance with professional standards of practice for two Residents (#85 and #62), in a total sample of 28 residents. Specifically, the facility failed: 1. For Resident #85, to ensure that Oxygen (O2) was administered according to physician's orders, maintain consistent documentation of Oxygen liter flow, and ensure proper care and storage of respiratory equipment; and 2. For Resident #62, to ensure proper care and storage of respiratory equipment. Findings include: Review of the facility's policy titled Oxygen Administration, revised October 2010, indicated but was not limited to the following: -Adjust the oxygen delivery device so the proper flow of oxygen is being administered -After completing the oxygen set up or adjustment, the following information should be recorded in the resident's medical record: the rate of oxygen flow, route, and rationale 1. Resident #85 was admitted to the facility with diagnoses including shortness 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 · E2023-01-30 · tag F0886 — failed to test for COVID-19 as required — pattern
    Perform COVID19 testing on residents and staff.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on document review, observation, and interview, the facility failed to ensure staff conducted testing and specimen collection in a manner that was consistent with current standards of practice set forth by the Centers for Disease Control and Prevention (CDC) and manufacturer's guidelines during a COVID-19 outbreak in the facility. Findings include: Review of the manufacturer's guidelines for the use of the Celltrion DiaTrustTM COVID-19 Ag Rapid Test indicated but was not limited to the following: Test Procedure 1. [Mid-turbinate Nasal Swab] Tilt patient's head back 70 degrees. Use a flocked tapered swab. While gently rotating the swab, insert it less than one inch (about 2 cm) into nostril parallel to the palate until resistance is met at turbinate. Rotate the swab several times against nasal wall. Remove swab, insert it into the other nostril and repeat the process. Test method 1. Prepare an aluminum pouch containing the test device and place it on the testing surface along with the test tube filled with the extraction buffer and filter cap. 2. Release the test device from…

    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 · D2023-01-30 · 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

    Based on observation, record review, and interviews, the facility failed to ensure a reasonable accommodation was made for one Resident (#68), out of a total sample of 28 residents. Specifically, the facility failed to ensure the call system button was accessible to the Resident in order to summon assistance when needed. Findings include: Resident #68 was admitted to the facility in December 2022 with diagnoses including hemiplegia and hemiparesis affecting the right dominant side. On 1/26/23 at 8:47 A.M., the surveyor observed Resident #68 lying in bed resting. The Resident's right hand was contracted and resting on top of the bed sheet and his/her left hand was holding onto the side rail on the left side of the bed. Resident #68 told the surveyor that he/she wanted someone to come and get him/her cleaned and dressed for the day. The surveyor observed the Resident had no way to alert staff that he/she was in need of assistance as the call bell system controller was out of reach and tied tightly in a knot around the side rail on the Resident's right side which is paralyzed. 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-01-30 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, document review, and interview, the facility failed to notify the resident's representative (family member) of a room change for one Resident (#80), out of a total sample of 28 residents. Findings include: Resident #80 was admitted to the facility in December 2022 with diagnoses including dementia, complete atrioventricular (AV) heart block with the presence of a cardiac pacemaker, and congestive heart failure. During an interview on 1/24/23 at 1:47 P.M., Resident #80's spouse said the facility did not call when the Resident's room was changed and moved closer to the nurses' station following a fall last Friday night (1/20/23). The spouse said when he/she came to visit last Saturday (1/21/23) she/he went to the Resident's room and he/she was not in the room. The spouse said she/he was really nervous because she/he didn't know where the Resident was. The Resident's spouse reiterated that she/he was never called/notified about the room change following a fall. Review of the Facility Incident Report, dated 1/21/23 at 12:15 A.M., indicated the Resident's spouse…

    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 · D2023-01-30 · 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

    Based on observation, record review, interview, and policy review, the facility failed to assess and re-evaluate the use of a Velcro alarmed seatbelt as a restraint for one Resident (#19), out of a total sample of 28 residents. Findings include: Review of facility's policy titled Use of Restraints, last revised April 2017, indicated but was not limited to the following: -Physical Restraints are defined as any manual method 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 restricts normal access to one's body. -The definition of restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which the staff applied it given that the resident's physical condition, and this restricts his/her typical ability to change position or place, that device is considered a restraint. -Restraints may only be used if/when the resident has a specific medical symptom that cannot be addressed by…

    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 · D2023-01-30 · 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

    Based on record review, interviews and policy review, the facility failed to ensure nutritional status was maintained for one Resident (#68), out of a total sample of 28 residents. Specifically, the facility failed to follow their policy for weight monitoring. Findings include: Review of the facility's policy titled Weight Assessment and Intervention, last revised March 2022, indicated the following: -Residents are weighed upon admission and at intervals established by the interdisciplinary team such as weekly for four weeks, then monthly unless otherwise indicated or as ordered. -A weight change of 5 lbs. (pounds) or more in a patient weighing more than 100 lbs. or of 2 lbs. in a patient weighing less than 100 lbs. since the last weight assessment will be retaken for validation. If the weight is verified, nursing will notify the Dietitian. For non-significant weight changes either the dietitian or provider is notified upon consideration of the resident's overall clinical condition. -The Dietitian will follow-up within 1 week. -The Dietitian will discuss undesired weight changes…

    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 · D2023-01-30 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, record review, and policy review, the facility failed to ensure enteral nutrition provided via a gastrostomy tube (G-tube- a feeding tube in abdomen used to provide nutrition) were provided in accordance with professional standards and physician's orders for one Resident (#100), out of 5 residents in the facility with feeding tubes, and a total sample of 28 residents. Findings include: Review of the facility's policy, Enteral Nutrition Feedings, last revised 7/26/13, included but was not limited to: -Intermittent feeding: enteral feeding delivered over a specified period of time or until a specified volume of formula is delivered. -Process: - Verify Physician's order - Review resident care plan and provide for any special needs of the resident - Ensure that equipment and devices are working properly by performing any calibrations, or checks as instructed by the manufacturer - Hold enteral feeding if gastric residual volume is 500 ml or greater (or according to order) and notify practitioner Resident #100 was admitted to the facility in December…

    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 · D2023-01-30 · tag F0694 — isolated
    Provide for the safe, appropriate administration of IV fluids for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on policy review, record review, and interview, the facility failed to ensure that care and treatment of a Mid-line catheter (venous access device-VAD-which is located directly in the basilic vein of the arm and terminates at the axilla) was provided in accordance with the facility's policy/protocols for one Resident (#233), out of a total sample of 28 residents. Specifically, the facility failed to ensure staff assessed/documented the condition of, and the length of, the Mid-line catheter once it was discontinued/removed, according to the facility's policy/protocols. Findings include: Review of the facility's policy titled Mid-line Catheter Removal, dated June 2016, indicated but was not limited to the following: -The nurse must verify that entire length of catheter has been removed by comparing catheter length to length recorded on insertion record or by x-ray -Examine catheter's integrity and confirm entire catheter has been removed by comparing catheter length to insertion record length. -Document in the resident's chart. Resident #233 was admitted to the facility 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-01-30 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary 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 interview and record review, the facility failed to ensure that for one Resident (#82), out of a total sample of 28 residents, that each resident's drug regimen was free from unnecessary drugs. Specifically, the facility failed to monitor for potential adverse consequences related to the use of an anticoagulant (blood thinner) medication. Findings include: Review of the manufacturer's (Bristol-[NAME] Squibb) website, revised September 2016, indicated Plavix (Clopidogrel) is a P2Y12 platelet inhibitor indicated for acute coronary syndrome, recent myocardial infarction (MI), recent stroke, or established peripheral arterial disease to reduce the rate of MI and stroke. Adverse Reactions -Bleeding, including life-threatening and fatal bleeding, is the most reported adverse reaction Resident #28 was admitted to the facility with diagnoses including peripheral vascular disease, diabetes mellitus type 2, heart failure, and atherosclerotic heart disease of native coronary artery with unspecified angina…

    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 before2023-01-30 · 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, interview, document, and policy review, the facility failed to ensure all medications used in the facility were labeled in accordance with currently accepted professional principles. Specifically, the facility failed to ensure staff properly labeled all medications stored in 1 out of 3 medication carts reviewed and properly disposed of an outdated medication. Findings include: Review of the facility's policy titled, Storage of Medications, revised [DATE], indicated but was not limited to the following: -Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed -The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner On [DATE] at 1:51 P.M., the surveyor reviewed the Acushnet medication cart with Nurse #4 and observed the following: -One opened bottle of Brimonidine/Timolol (Combigan) 0.2/0.5% ophthalmic solution (used to treat high pressure inside the eye) inside…

    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 before2023-01-30 · 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

    Based on record review and interview, the facility failed to ensure staff maintained medical records that were accurate for one Resident (#82), out of a total sample of 28 residents. Specifically, the Resident's medical record demonstrated discrepancies with their advanced directive. Findings include: Review of the facility's policy titled, Advance Directives, revised September 2022, indicated but was not limited to the following: -The plan of care for each resident is consistent with his or her documented treatment preferences and/or advance directive -Changes or revocations of a directive must be submitted in writing to the administrator. The interdisciplinary team will be informed of changes and/or revocations so that appropriate changes can be made in the resident medical record and care plan. Resident #82 was admitted to the facility with diagnoses including neurocognitive disorder with Lewy bodies (abnormal deposits of a protein in the brain which can lead to problems with thinking, movement, behavior and mood), transient ischemic attack (TIA), legal blindness, major…

    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 before2023-01-30 · 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 observation, policy review, and interview, the facility failed to ensure infection control practices were implemented during medication pass. Findings include: Review of the facility's policy titled Handwashing/Hand Hygiene, revised August 2015, indicated but was not limited to the following: -Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water before preparing or handling medications 1. On 1/24/23 at 9:26 A.M., the surveyor observed the following infection control breeches during Nurse #1's medication pass: -Nurse #1 accidentally knocked over a small stack of plastic medication cups. Nurse #1 picked up a medication cup which was lying on its side using her thumb (on the outside of the cup) and index finger (on the inside of the cup) to pick it up and place it on the medication cart. Nurse #1 then began pouring the medications into the medication cup. Nurse #1 brought the medications to the Resident. -Nurse #1 performed hand hygiene and continued with her medication administration. Nurse #1…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-01-30 · tag F0881 — failed to use antibiotics responsibly — isolated
    Implement a program that monitors antibiotic use.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, policy review, and interview, the facility failed to implement the Antibiotic Stewardship protocols by not monitoring the continued/appropriate use of prophylactic antibiotics for two Residents (#80 and #11), in a total sample of 28 residents. Findings include: Antibiotic Stewardship is a program that promotes the appropriate use of antibiotics. This includes a system of monitoring to improve resident outcomes and reduce antibiotic resistance. The facility is responsible for ensuring that the antibiotic is prescribed for the correct indication, dose, and duration to appropriately treat the resident, while also attempting to reduce the development of antibiotic-resistant organisms. According to the Centers for Disease Control and Prevention (CDC), the core elements of Antibiotic Stewardship included but were not limited to the following: -Facility leadership commitment to safe and appropriate antibiotic use -Implement policy(ies) or practice to improve antibiotic use -Track measures of antibiotic use in the facility Antibiotic usage/surveillance tools,…

    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
  • No harm found · Bcited before2025-08-05 · tag F0641 — pattern
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for two Residents (#13 and #7), out of seven residents reviewed. Specifically, the facility failed: 1. For Resident #13, to accurately reflect if the Resident was utilizing a restraint on the most recent quarterly MDS and;2. For Resident #7, to accurately reflect if the Resident was being administered insulin on the two most recent quarterly MDSs.Findings include:1. Resident #13 was admitted to the facility in August 2022.Review of the facility provided Matrix (Form CMS-802) on 7/30/25 indicated Resident #13 had a physical restraint.Review of the MDS assessment, dated 5/15/25, indicated Resident #13 had a restraint of a bed rail, used less than daily.During an interview with observation on 7/30/25 at 8:30 A.M., Resident #13 said he/she had limited range of motion on their left upper extremity. The surveyor observed Resident #13 in bed with bilateral bed rails on the upper portion of the bed only, which did not restrict movement.During an interview on 8/5/25 at 9:51…

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

    Resident Assessment and Care Planning Deficiencies · No revisit needed
  • No harm found · Bcited before2024-05-22 · tag F0641 — pattern
    Ensure 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 accurately complete the Minimum Data Set (MDS) assessment for five Residents (#127, #11, #133, #13, and #141), out of 25 sampled residents. Specifically, the facility failed: 1. For Resident #127, to ensure a formal assessment instrument/tool was accurately coded on the MDS; 2. For Resident #11, to ensure an antianxiety medication was accurately coded on the MDS; 3. For Resident #133, to ensure a diuretic medication was accurately coded on the MDS; 4. For Resident #13, to ensure an antipsychotic medication was accurately coded on the MDS; and 5. For Resident #141, to ensure the accurate discharge location was accurately coded on the MDS. Findings include: Review of the facility's policy titled Certifying Accuracy of the Resident Assessment, last revised 2019, indicated but was not limited to: - Policy Statement: Any person completing a portion of the Minimum Data Set/MDS (Resident Assessment Instrument) must sign and certify the accuracy of that…

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

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

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to CAREONE — 37 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 3 of 53.4-0.4 vs chain
Health inspection 3 of 52.9+0.1 vs chain
Staffing 4 of 53.2+0.8 vs chain
Quality measures 3 of 54.4-1.4 vs chain
The other 36 homes this chain runs (chain average 3.4★, per CMS)
1 of 5Care One At MillburyMillbury, MA 1 of 5Care One At RandolphRandolph, MA 1 of 5Careone At OradellOradell, NJ 2 of 5Care One At BrooklineBrookline, MA 2 of 5Care One At NewtonNewton, MA 2 of 5Care One At RedstoneEast Longmeadow, MA 2 of 5Care One At WeymouthWeymouth, MA 2 of 5CareOne At Hanover TownshipWhippany, NJ 2 of 5Careone At MiddletownAtlantic Highlands, NJ 2 of 5Rehab & Nursing Ctr Greater PittsburghGreensburg, PA 3 of 5Care One At LexingtonLexington, MA 3 of 5Care One At LowellLowell, MA 3 of 5CareOne At Madison AvenueMorristown, NJ 3 of 5CareOne At MoorestownMoorestown, NJ 3 of 5CareOne at New MilfordNew Milford, NJ 3 of 5Careone At East BrunswickEast Brunswick, NJ 3 of 5Careone At Ridgewood AvenueParamus, NJ 3 of 5Careone At WellingtonHackensack, NJ 4 of 5Care One At ConcordW Concord, MA 4 of 5Care One At Essex ParkBeverly, MA 4 of 5Care One At NorthamptonNorthampton, MA 4 of 5CareOne At TeaneckTeaneck, NJ 4 of 5CareOne at The HighlandsEdison, NJ 4 of 5Careone At CresskillCresskill, NJ 4 of 5Careone At EveshamMarlton, NJ 4 of 5Careone At LivingstonLivingston, NJ 4 of 5Careone At ParsippanyParsippany Troy Hill, NJ 4 of 5Careone At Somerset ValleyBound Brook, NJ 5 of 5Care One At HolyokeHolyoke, MA 5 of 5Care One At PeabodyPeabody, MA 5 of 5Care One At WilmingtonWilmington, MA 5 of 5CareOne At WallWall, NJ 5 of 5Careone At HolmdelHolmdel, NJ 5 of 5Careone At ValleyWestwood, NJ 5 of 5Careone At WayneWayne, NJ 5 of 5River Glen Health Care CenterSouthbury, CT

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
THCI OF MASSACHUSETTS, LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 07/01/2003
CARE REALTY, LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 04/30/2002
DES-I 2016 GRATOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 12/01/2021
STRAUS, DANIELIndividual5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 07/01/2003
STRAUS, MOSHAELIndividual5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 07/01/2003
BARUCH, DAVIDIndividualW-2 MANAGING EMPLOYEE; CORPORATE OFFICERsince 12/01/2021
HEALTHBRIDGE MANAGEMENT LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 07/01/2003

CMS files one row per role, so the 8 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted.

4 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$19.1M
Net patient revenuemost recent cost report
-1.1%
Operating marginrevenue minus expenses
$3.1M
Related-party expense16% of expenses
Who pays — share of resident-days
Medicaid 64%Medicare 13%Other / private 23%

This home reported $3.1M paid to related parties — landlords or management companies under common ownership — equal to about 16% 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

$376per resident / day
operating cost
$11,425per month
≈ monthly operating cost
$372per 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 225650. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-05, 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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