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Vantage Health & Rehab Of New Bedford

200 Hawthorn Street, New Bedford, MA 02740 · For profit - Limited Liability company · 80 certified beds · (774) 319-2868 Medicare & Medicaid certified

Call the home — (774) 319-2868 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0607, F0609, F0610) — most recent Feb 20261 actual-harm citation$9,318 in federal fines
Insights

The public record raises real questions here. Weigh the concerns below carefully.

Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609, F0610) — 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 (31) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $9,318 in federal fines (most recent 2024-04-24)
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (1/5)
  • nursing-staff turnover (70%) runs well above the national median (45%)

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.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 3 of 5

Location & what’s nearby

Urgent care / clinic
60 Brigham St · (508) 999-6245 · Call to confirm hours
Pharmacy
101 Page St · (508) 973-5449 · Call to confirm hours
Grocery
51 Chancery St · (508) 997-2651 · Call to confirm hours
Park
201 Brownell St · (508) 992-1194 · 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 3 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 1 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 rating1★
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 increased7.9%16.4%15.4%better
Long-stay residents who lose too much weight10.3%5.1%5.4%worse
Long-stay residents with a catheter left in their bladder1.0%0.8%0.9%typical
Long-stay residents with a urinary tract infection4.7%1.8%2.0%worse
Long-stay residents with depressive symptoms15.5%15.5%6.5%typical for the 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 injury5.5%3.4%3.3%worse
Long-stay residents whose ability to walk worsened8.1%15.4%16.1%better
Long-stay residents on antianxiety or hypnotic medication16.0%19.5%18.9%better
Long-stay residents given the seasonal flu vaccine98.4%94.8%95.3%typical
Long-stay residents with pressure ulcers3.7%4.2%4.7%better
Long-stay residents with worsening bladder/bowel control26.8%21.2%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table19.4%21.4%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.9%1.4%1.4%better
Short-stay residents given the seasonal flu vaccine49.5%77.7%79.4%worse
Short-stay residents rehospitalized after admission28.0%25.7%22.6%worse
Short-stay residents with an outpatient ER visit10.3%11.9%12.0%better
Long-stay hospitalizations per 1,000 resident days2.221.881.67worse
Long-stay outpatient ER visits per 1,000 resident days1.581.501.80better

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.

51.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 123 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

51.5%U.S. median 51.5%
Got home and stayed home
12.4%U.S. median 10.7%
Went back to hospital
51.4%U.S. median 56.6%
Met the expected recovery
0.37U.S. median 0.31
Therapy hours / resident / day
0.15hours / resident / day
Physical therapy
0.19hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 51.4% 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 109 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 0.37 therapist hours per resident per day in 2026Q1 — more than 63% 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 SNF51.5%CMS range 42.7–60.851.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF12.4%CMS range 9.0–16.510.7%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 discharge51.4%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 discharge44.0%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 discharge51.4%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 identified98.0%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 setting97.4%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 discharge97.6%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 stay1.3%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 worsened1.3%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 hospitalization7.4%CMS range 4.5–10.87.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.021.02Oct 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

0.39
RN hours/ resident / day
0.65
LPN hours/ resident / day
1.41
Aide hours/ resident / day
2.45
Total nurse hours/ resident / day
0.30
RN hoursweekends
69.8%
Total nursing turnover
72.7%
RN turnover

How full it usually is: this home is certified for 80 beds and averages 67.9 residents a day — about 85% occupied, or roughly 12 beds typically open. It usually has some room. 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 2.45 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.39 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.41 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 1.90 hrs/resident/day on weekends vs 2.68 on weekdays — 29% thinner on weekends — a notable drop. RN hours go from 0.43 to 0.30 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 70% is well above the national median of 45%. 3 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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

11
deficiencies at the latest standard inspection (2026-02-20)
9
at the previous standard inspection (2025-02-27)

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.

31 citations, most serious first. The 11 most serious are shown; the remaining 20 are one tap away and print in full.

  • Actual harm · G2024-04-24 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was assessed by nursing as being at risk for falls and required the use of a chair alarm in an effort to prevent falls, the Facility failed to ensure his/her assistive devices were functioning properly to prevent incidents and/or accidents resulting in an injury. On 4/07/24 after Resident #1 was found on the floor in the hallway after a fall, it was determined that his/her chair alarm was found to be in the off position and therefore had not sounded to alert staff that he/she was in motion. Resident #1 sustained a laceration to the left side of his/her head, was transferred to the Hospital Emergency Department for evaluation, required staples to close the laceration, was diagnosed with multiple fractures as a result of the fall and was admitted for treatment. Findings include: Review of the Facility's Policy titled, Fall Policy, dated 10/2022 indicated the following: -it is the policy of the facility to ensure 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-02-20 · tag F0585 — failed to handle grievances — pattern
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on document review and interview, the facility failed to implement their grievance process and attempt to resolve grievances in a timely manner for one Resident (#25), out of a total sample of 17 residents.Findings include: Review of the facility's policy titled Grievance Policy, dated 1/5/26, indicated but was not limited to the following: - [Corporate Name] shall ensure that residents, family members, responsible parties are provided with a mechanism to communicate concerns, conflicts, complaints, grievances or opportunities for improvement in care and services- grievance forms are available for the resident, family, responsible party to complete on first floor bulletin board, through resident council activity staff, and with social services- it is the responsibility of all staff who hear a grievance to report it to their supervisor- investigation and resolution of grievances shall be completed in a timely manner (within 5 working days of receipt of the grievance form)- the individual initiating the grievance will be notified of the findings and method of resolution by 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 · E2026-02-20 · tag F0607 — failed to have anti-abuse policies — pattern
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on document review and interview, the facility failed to implement their abuse policy for injuries of unknown origin for one Resident (#25), out of a total sample of 17 residents. Findings include: Review of the facility's policy titled Abuse, Neglect and Exploitation, undated, indicated but was not limited to the following: - It is the responsibility of our employees, agency staff, facility consultants, attending physicians, family members, visitors, etc. to promptly report any incidents or suspected incidents of neglect or resident abuse, including injuries of unknown source to facility management- The abuse coordinator in the facility is the Director of Nurses (DON)- To help with recognition of incidents of abuse the following definitions of abuse are provided: injury of unknown source is defined as an injury that meets both of the following conditions: 1. the source of the injury was not observed by any person or the source of the injury could not be explained by the resident AND 2. the injury is suspicious because of the extent of the injury; location of the injury;…

    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 · E2026-02-20 · tag F0609 — failed to report abuse allegations — pattern
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on document review and interview, the facility failed to report injuries of unknown origin for one Resident #25, out of a total sample of 17 residents.Findings include: Review of the facility's policy titled Abuse, Neglect, and Exploitation, undated, indicated but was not limited to the following: - It is the responsibility of our employees, agency staff, facility consultants, attending physicians, family members, visitors, etc. to promptly report any incidents or suspected incidents of neglect or resident abuse, including injuries of unknown source to facility management- The abuse coordinator in the facility is the Director of Nurses (DON)- To help with recognition of incidents of abuse the following definitions of abuse are provided: injury of unknown source is defined as an injury that meets both of the following conditions: 1. the source of the injury was not observed by any person or the source of the injury could not be explained by the resident AND 2. the injury is suspicious because of the extent of the injury; location of the injury; number of injuries observed at…

    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 · E2026-02-20 · tag F0610 — failed to investigate and act on abuse reports — pattern
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on document review and interview, the facility failed to investigate injuries of unknown origin for one Resident (#25), out of a total sample of 17 residents. Findings include: Review of the facility's policy titled Abuse, Neglect, and Exploitation, undated, indicated but was not limited to the following: - It is the responsibility of our employees, agency staff, facility consultants, attending physicians, family members, visitors, etc. to promptly report any incidents or suspected incidents of neglect or resident abuse, including injuries of unknown source to facility management- The abuse coordinator in the facility is the Director of Nurses (DON)- To help with recognition of incidents of abuse the following definitions of abuse are provided: injury of unknown source is defined as an injury that meets both of the following conditions: 1. the source of the injury was not observed by any person or the source of the injury could not be explained by the resident AND 2. the injury is suspicious because of the extent of the injury; location of the injury; number of injuries…

    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 · Ecited before2026-02-20 · 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

    Based on observation, interview, and document review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed to maintain an infection prevention and control program which included a complete and accurate system of surveillance to identify any trends or potential infections. Findings include:Review of the facility's policy titled Infection Prevention and Control Program, dated December 2023, indicated, but was not limited to, the following:-An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.-The elements of the infection prevention and control program consist of coordination/oversight, policies/procedures, surveillance, data analysis, antibiotic stewardship, outbreak management,…

    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 · E2026-02-20 · tag F0881 — failed to use antibiotics responsibly — pattern
    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 and interview, the facility failed to implement an antibiotic stewardship program which included antibiotic use protocols and monitoring of antibiotic use in accordance with the facility's antibiotic stewardship program. Findings include:Review of the facility's policy titled Antibiotic Stewardship Program, last revised December 2016, indicated but was not limited to the following:-Antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program.-The purpose of our antibiotic stewardship program is to monitor the use of antibiotics in our residents.-When a culture and sensitivity is ordered lab results and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued. Review of the facility's policy titled Antibiotic Stewardship Review and surveillance of Antibiotic Use and Outcomes, last revised December 2016, indicated but was not limited to the following:-Antibiotic usage and…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-02-20 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on document review and interview, the facility failed to develop baseline care plans for two Residents (#78 and #79), out of a total sample of 17 residents. Specifically, the facility failed to develop a baseline care plan:1. For Resident #78, that included the necessary care of a colostomy (a surgical procedure where a portion of the large intestine is brought through the abdominal wall to carry stool out of the body) and Foley catheter (a tube inserted through the urinary tract into the bladder, connected to a drainage bag); and2. For Resident #79, that included strategies to mitigate future falls and offer a copy of those care plans to the Resident/healthcare proxy (HCP).Findings include:Review of the facility's policy titled Care Plans - Baseline, dated 2017, indicated but was not limited to the following: - a person-centered baseline care plan to meet the resident's immediate needs shall be developed for each resident within 48 hours of admission-baseline care plans include a minimum of: physician orders, initial goals based on admission orders, therapy and social…

    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 before2026-02-20 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide services that met professional standards by failing to implement physician's orders to discontinue Oxycodone (a pain medication), for one Resident (#5), out of a total sample of 17 residents, resulting in Resident #5 receiving the medication for 22 extra days. Findings include:Review of [NAME], Manual of Nursing Practice 11th edition, dated 2019, indicated the following:-The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated:-Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescribers that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-20 · 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 document review and interview, the facility failed to ensure that monthly medication regimen reviews (MRR) were communicated to the provider and addressed in a timely manner for one Resident (#5), out of a total sample of 17 residents. Specifically, the facility failed to ensure recommendations by the pharmacy consultant to clarify two as needed (PRN) albuterol orders (respiratory inhaler), review risk versus benefit of Paxil (Paroxetine, an antidepressant) medication dosing of extended release (ER) 50 milligrams (mg) daily which is over the daily recommended dose of 37.5mg and recommend Narcan order (reverses opioid overdose) as needed (PRN) due to history of recent opioid overdose, was reviewed and responded to by the provider timely. Findings include:Review of the facility's policy titled Medication Regimen Reviews, undated, indicated but was not limited to the following:-The Consultant Pharmacist shall review the medication regimen of each resident at least monthly.-The Consultant Pharmacist will provide the Director of Nursing Services and Medical Director with a…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-20 · tag F0805 — failed to prepare food in a form residents can eat — isolated
    Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to ensure the appropriate modified texture diet was prepared and served for one test tray. Specifically, the facility failed to ensure broccoli was prepared and served in a form designed to meet the individual needs of Residents on a dysphagia advanced diet. Findings include:Review of facility's Diet Guide Sheet indicated the facility was to serve chopped broccoli florets to residents on a dysphagia advanced diet with their lunch on 2/18/26. On 2/18/26 at 12:11 P.M., a test tray was performed; the meal requested included dysphagia advanced texture. The test tray included broccoli florets and stalks. The surveyor observed the florets ranged approximately between dime-sized to quarter-sized and the stalks ranged approximately between dime-sized to nickel-sized on the test tray. On 2/18/26 at 12:11 P.M., the surveyor sampled two broccoli stalks noting the flesh was very tender and easily crushed between the tongue and roof of the mouth while the outer skin remained intact. On 2/18/26 at 12:25 P.M., the surveyor observed one…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
Show the remaining 20 citations
  • Potential for harm · Dcited before2026-02-20 · 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 interview and record review, the facility failed to maintain complete medical records for two Residents (#5 and #72), out of a sample of 17 residents. Specifically, the facility failed: 1. For Resident #5, to ensure the medical record accurately reflected advance directives as indicated on the Resident's Massachusetts Medical Orders for Life Sustaining Treatment form (MOLST); and2. For Resident #72, to ensure the medical record included the physician's documentation of encounters with the Resident from May 2025 through August 2025. Findings include: 1. Review of the facility's policy titled Advance Directives, dated as revised September 2022, indicated but was not limited to the following: -The resident has the right to formulate an advance directive, including the right to accept or refuse medical treatment. Advance directives are honored in accordance with state law and facility policy. -The Director of Nursing (DON) or designee notifies the attending physician of advance directives (or changes in advance directives) so that appropriate orders can be documented in 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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-02-27 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to ensure the main kitchen floor was maintained in a sanitary and safe condition. Findings include: Review of the 2022 Food Code by the Food and Drug Administration (FDA), revised 1/2023, indicated but was not limited to the following: -6-501.12 Cleaning, Frequency and Restrictions. (A) PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean. (B) Except for cleaning that is necessary due to a spill or other accident, cleaning shall be done during periods when the least amount of FOOD is exposed such as after closing. -6-501.13 Cleaning Floors, Dustless Methods. (A) Except as specified in (B) of this section, only dustless methods of cleaning shall be used, such as wet cleaning, vacuum cleaning, mopping with treated dust mops, or sweeping using a broom and dust-arresting compounds. (B) Spills or drippage 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-02-27 · tag F0838 — failed to assess facility resources and resident needs — pattern
    Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on document review and interview, the facility failed to develop and implement their facility assessment (a document assessing the capability of the facility and its resources to provide both emergency and day to day care of the population the facility currently serves). Specifically, the facility failed to ensure active involvement of all required members when conducting the facility assessment. Findings include: Review of the Centers for Medicare and Medicaid Services (CMS) guidance, dated 6/18/24, indicated but was not limited to the following: -In conducting the facility assessment, the facility must ensure active involvement of the following participants in the process: a. Nursing home leadership and management, including but not limited to, a member of the governing body, the medical director, an administrator, and the director of nursing; and b. Direct care staff, including but not limited to, Registered Nurses, Licensed Practical Nurses/Licensed Vocational Nurses, Nursing Assistants, and representatives of the direct care staff, if applicable c. The facility must also…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-02-27 · 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

    Based on observations, interview, and records reviewed, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and potential transmission of communicable diseases and infections for five Residents (#227, #50, #30, #23, and #38), out of a total sample of 19 residents. Specifically, the facility failed to: 1. For Residents #227, #50, and #30, ensure staff maintained Transmission Based Precautions as indicated; 2. For Resident #23, ensure that the oxygen concentrator was maintained in a clean/sanitary condition; and 3. For Resident #38, ensure that Enhanced Barrier Precautions were maintained as indicated. Findings include: 1. Review of the facility's policy titled Isolation- Categories of Transmission-Based Precautions, dated as revised October 2018, indicated but was not limited to: -Transmission based precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-27 · 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 and interview, the facility failed to ensure the Resident Representative was notified of a fall for one Resident (#58), out of a total sample of 18 residents. Specifically, the facility failed to ensure the activated Health Care Proxy (HCP- health care agent designated by the resident when competent who has the authority to consent for health care decisions when a resident has been declared, by a physician, not to be competent to make his/her own health care decisions) was notified of an elopement attempt resulting in the Resident wandering to the basement of the building. Findings include: Resident #58 was admitted to the facility in July 2024 with diagnoses including but not limited to dementia and history of repeated falls. Review of the Minimum Data Set (MDS) assessment, dated 1/2/25, indicated Resident #48 had a Brief Interview for Mental Status (BIMS) score of 0 out of a possible 15 which indicated the Resident had a severe cognitive impairment. Review of Section E, titled Behavior indicates Resident #48 wandered 4-6 times during the Assessment Review…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-27 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and document review, the facility failed to ensure two Residents (#54, #51) were informed of and actively participated in his/her baseline plan of care within the first 48 hours following admission, out of a total sample of 19 residents. Findings include: Review of the facility's policy titled Care Plans - Baseline, revised 5/2022, indicated but was not limited to the following: -A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission. -The resident and their representative will be provided a summary of the baseline care plan that includes, but is not limited to the following: a. The initial goals of the resident; b. A summary of the resident's medications and dietary instructions; c. Any services and treatments to be administered by the facility and personnel acting on behalf of the facility; and d. Any updated information based on the details of the comprehensive care plan, as necessary. 1. Resident #54 was admitted to the facility in July 2024 with diagnoses including…

    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 · D2025-02-27 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure a comprehensive care plan was developed and implemented for one Resident (#72), in a total sample of 19 residents. Specifically, the facility failed for Resident #72, to implement a care plan and individualized interventions related to changes in their mood including crying. Findings include: Review of the facility's policy titled Care Plans, Comprehensive Person-Centered, dated March 2022 indicated but was not limited to: -The comprehensive, person-centered care plan: includes measurable objectives and timeframes; -describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; -includes the resident's stated goals upon admission and desired outcomes; -reflects currently recognized standards of practice for problem areas and conditions; -when possible, interventions address the underlying source(s) of the problem area(s), not just the symptoms or triggers; -assessments of residents are ongoing and care plans 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-27 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and records reviewed for one Resident (#227) of 19 sampled residents, the facility failed to ensure a resident was provided care in accordance with professional standards of practice. Specifically, for Resident #227, the facility failed to administer medications as ordered. Findings include: Review of [NAME], Manual of Nursing Practice 11th edition, dated 2019 indicated the following: -The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated the following: -Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations.…

    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 · D2025-02-27 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and staff interview, the facility failed to provide showers for two dependent Residents (#23 and #34), in a total sample of 19 residents. Findings include: 1. Resident #23 was admitted to the facility in September 2021 with diagnoses which included unspecified lack of coordination, muscle weakness, and unspecified fracture of the right femur. Review of the Minimum Data Set (MDS) assessment, dated 2/6/25, indicated the Resident scored 13 out of 15 on the Brief Interview for Mental Status (BIMS) indicating he/she was cognitively intact. The MDS indicated the Resident had bilateral impairment of the lower extremities and was dependent for showering/bathing. Review of Resident #23's care plan for Activities of Daily Living (ADL), dated 9/5/24, indicated that he/she was dependent on staff for shower/bathing, personal hygiene, toileting hygiene, and upper/lower body dressing. During an interview on 2/24/25 at 12:30 P.M., the Resident and the Resident's daughter both said that the Resident does not get a shower since he/she was not able to walk. The Resident said…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-27 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure all drugs and biologicals were stored in a safe and secure manner as required. Specifically, the facility failed to ensure medications were not left unattended in Resident #7's room. Findings include: Review of the facility's policy titled Administering Oral Medications, dated 2001, indicated the following: -Remain with the resident until all medications have been taken. Resident #7 was admitted to the facility in May 2021 with diagnoses including but not limited to Parkinson's disease and dementia. Review of the Minimum Data Set (MDS) assessment, dated 12/18/24, indicated Resident #7 had a Brief Interview for Mental Status (BIMS) score of 7 out of a possible 15 which indicated severe cognitive impairment. On 2/25/25 at 8:12 A.M., the surveyor observed Resident #7 sitting on the edge of the bed eating breakfast. Next to the Resident's breakfast tray there was a medication cup with eight pills in it. Resident #7 was unable to identify any of the medications or say when they received the 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 · D2025-02-11 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records reviewed, interviews, and observations, for one of three sampled residents (Resident #1), who was assessed by nursing as being at high risk for skin breakdown with actual pressure injuries (localized damage to the skin and underlying soft tissue usually over a bony prominence which can present as intact skin or an open ulcer and may be painful), the Facility failed to ensure Resident #1 received wound care treatment that was consistent with professional standards of practice when, on 02/11/25, during a dressing change observation, Nurse #1 did not follow Physician's Treatment Orders for Resident #1's dressing change and did not follow facility policy and procedure for wound care. Findings Include: Review of the Facility Policy, titled Non-Sterile Dressing Change, dated August 2016, indicated the following: -Designated staff member will use non-sterile dressing technique for all dressing changes unless otherwise indicated by physician; -Clean aseptic should be used; -Bring equipment to resident's…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-11 · 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 observations, for one of three sampled residents (Resident #1), who required wound care dressing changes to be completed by nursing, the Facility failed to ensure they maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and potential transmission of communicable diseases and infections, when on 02/11/25, during a dressing change observation, Nurse #1 did not utilize the necessary infection control precautions, protocols or procedures, increasing the risk for the spread of an infection. Findings Include: Review of the Facility Policy, titled Non-Sterile Dressing Change, dated August 2016, indicated the following: -Designated staff member will use non-sterile dressing technique for all dressing changes unless otherwise indicated by physician; -Clean aseptic should be used; -Bring equipment to resident's room; -Provide privacy to resident, explain procedure; -Prepare a clean, dry work area at bedside; -Use disinfectant solution to prepare…

    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 before2024-12-02 · 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 records reviewed and interviews of one of three sampled residents (Resident #3), the Facility failed to ensure they maintained a complete and accurate medical/clinical record when weekly Skin Assessment User Defined Assessments (UDA) were not consistently completed by Nursing, as required. Finding include: Review of the Facility Policy titled Visual Body Check, dated 8/2017, indicated that the Team Leader (Nurse responsible for the Resident) will do a body check on the residents shower day before the shower is given and findings are documented in Point Click Care (PCC, the Facilities Electronic Medical Record). Resident #3 was admitted to the Facility in November 2018, diagnoses include Parkinson's Disease, congestive heart failure, depression, chronic obstructive pulmonary disease, and chronic pain. Review of Resident #3's Physician Order, dated 08/18/24, indicated he/she was to have a weekly skin assessment on the evening shift, every Friday. The Physician Order also indicated nursing staff was to complete the User Defined Assessment (UDA) in the Point Click Care (PCC,…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-09-24 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records reviewed and interviews for one of three sampled residents (Resident #1), who was dependent on the physical assistance of staff with Activities of Daily Living (ADL) and positioning, the Facility failed to ensure they maintained a complete and accurate medical record, related to Certified Nurse Aide (CNA) ADL Flow Sheets and Positioning Sheets, when daily documentation by CNA's (for all three shifts) was not consistently completed, with flow sheets and positioning sheets left blank. Findings include: Review of the Facility Policy titled, CNA Electronic Documentation Policy, dated 03/2012, indicated that the facility shall ensure proper and accurate documentation that monitor the Activity of Daily Living (ADL's) of each resident. The Policy indicated that the positioning sheets will be done on paper and the CNA will input at the Kiosk -Electronic Medical Record (EMR) on a shift to shift basis, the care provided to each resident. Resident #1 was admitted to the Facility in October 2022, diagnoses…

    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 · E2023-12-19 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interviews, the facility failed to ensure that each resident received food prepared by methods that conserve nutritive value, flavor, and appearance, and was palatable, attractive, and at a safe and appetizing temperature for one of two test trays. Specifically, the facility failed to provide a pureed meal that was palatable and visually appealing. Findings include: On 12/12/23 at 11:57 A.M., the surveyor observed lunch meal service and observed a puree meal delivered to a resident on the One [NAME] Unit. The puree meal was presented as two flat half circles filling the plate, one half of the plate was a deep green color, and the other half of the plate was a light brown color. The plate presentation of the puree foods did not look appealing. On 12/14/23 at 11:55 A.M., the surveyor observed lunch meal service and observed the pureed meal was plated as two round, flat, liquefied circles on the plate. One circle was white, the other circle was orange in color. The surveyor requested a pureed test tray. The test tray was made at 11:55 A.M. and reached the One…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-12-19 · tag F0842 — failed to keep accurate, complete medical records — pattern
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to maintain a complete and accurate medical record for one Resident (#44), out of a total of 17 sampled residents. Specifically, the facility failed to ensure that nursing staff documented monitoring of a hematoma identified on 4/4/23. Findings include: Resident #19 was admitted to the facility in November 2018 with diagnoses including congestive heart failure and muscle weakness. Review of the Minimum Data Set assessment, dated 10/17/23, indicated Resident #19 had impaired short- and long-term memory, moderately impaired decision-making skills and was dependent on staff for activities of daily living. Review of a Nurse's Note, dated 4/4/23, indicated Resident #19 showed a nurse his/her left lower extremity which had a large hematoma (An injury that causes blood to collect and pool under the skin. A hematoma is similar to a bruise, but the damage that causes it occurs in larger blood vessels. It can lead to swelling, discoloration, and…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-12-19 · 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 observations, interviews, and record review, for one Resident (#55) of 17 sampled residents, the facility failed to ensure a reasonable accommodation was made. Specifically, the facility failed to ensure the call system button was accessible to the Resident to call for assistance per facility policy. Findings include: Review of the facility's policy titled Resident Call System Policy, dated as revised October 2022, indicated but was not limited to: -when in their rooms and toilet and bathing areas, residents will have a means of directly contacting caregivers. Resident #55 was admitted to the facility in August 2023 with the following diagnoses: cerebral infarction (stroke) and hemiplegia (paralysis) affecting the left side. Review of the Minimum Data Set (MDS) assessment, dated 9/22/23, indicated Resident #55 was moderately cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 11 out of 15. On 12/13/23 at 2:04 P.M., the surveyor observed Resident #55 lying in bed with the curtain pulled, repeatedly yelling for help and calling out 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 Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-12-19 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, for one Resident (#12) of 17 sampled residents, the facility failed to provide Foley catheter (a flexible tube inserted into the bladder to drain urine outside of the body) care consistent with professional standards related to infection control prevention. Specifically, the facility failed to maintain/secure the Resident's Foley catheter drainage bag away from contaminated surfaces, date his/her catheter bag, and change the Foley catheter device as ordered. Findings include: Review of Centers for Disease Control and Prevention's Guidelines for Prevention of Catheter-Associated Urinary Tract Infections, dated 2009, indicated but was not limited to: -Do not rest the catheter bag on the floor. Review of the Agency for Healthcare Research and Quality (AR) Safety Program for Long-term Care: Catheter Care and Maintenance, dated March 2017, indicated, but was not limited to: -Drainage bags should be kept off the floor at all times to avoid the risk of infection. Review of the facility's policy titled Catheter Care and Maintenance,…

    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 · D2023-12-19 · 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

    Based on record review, policy review, and interview, the facility failed to ensure for one Resident (#56) of 17 sampled residents, the facility failed to ensure the Resident's drug regimen was free from unnecessary drugs, without adequate monitoring for signs/symptoms of adverse consequences (i.e., side effects) to ensure the safe administration of medications. Specifically, the facility failed to monitor for adverse side effects of an anticoagulant (blood thinning medication to prevent clots), including signs/symptoms of bruising, bleeding, and deep vein thrombosis (DVT-blood clot). Findings include: Review of the facility's policy titled Anticoagulation Therapy, indicated, but was not limited to: -Observe for signs of bleeding: 1. blood in urine or stool (black, tarry stools) 2. bleeding of gums, nose 3. small purplish, hemorrhagic spots on skin 4. excessive and easy bruising 5. bleeding from tumors, ulcers, or lesions 6. confusion, change in mental status Review of Xarelto's manufacturer's guidelines indicated but was not limited to: -Xarelto may cause serious side effects,…

    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 before2023-12-19 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and policy review, the facility failed to ensure staff stored all drugs and biologicals in accordance with facility policy. Specifically, the facility failed to ensure medications were not stored past their expiration and/or discard date. Findings include: Review of the facility's policy titled Medication Storage, dated January 2023, indicated but was not limited to: -Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled or without secure closures are immediately removed from stock A. On 12/14/23 at 9:45 A.M., the surveyor observed Nurse #2 during medication administration. The surveyor observed Nurse #2 remove a bottle of multivitamin with minerals from the top drawer of the medication cart with expiration date of 11/23. Nurse #2 continued with medication administration and administered the medication to a resident. During an interview on 12/14/23 at 9:49 A.M., Nurse #2 confirmed the expiration date on the administered multivitamin with minerals was November 2023. Nurse #2 said 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.

    Pharmacy Service 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

$9,318 in federal fines across 1 penalty.

  • $9,318 — penalty dated 2024-04-24

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to VANTAGE CARE — 10 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 1 of 52.4-1.4 vs chain
Health inspection 2 of 52.7-0.7 vs chain
Staffing 1 of 52.8-1.8 vs chain
Quality measures 3 of 52.3+0.7 vs chain
The other 9 homes this chain runs (chain average 2.4★, per CMS)

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
BROWN, YOSSIIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST50%since 07/03/2024
YUROWITZ, SAMIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER50%since 07/03/2024
TORRES, EFRAINIndividualCONTRACTED MANAGING EMPLOYEEsince 07/03/2024
SPECTOR, SAMIndividualW-2 MANAGING EMPLOYEEsince 07/03/2024

CMS files one row per role, so the 5 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted.

Follow the money — this home’s finances

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

$8.7M
Net patient revenuemost recent cost report
-14.2%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 76%Medicare 12%Other / private 12%

About 76% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. 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

$410per resident / day
operating cost
$12,474per month
≈ monthly operating cost
$359per 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 225481. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-20, 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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