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Port Rehabilitation And Healthcare Center

6 Hale Street, Newburyport, MA 01950 · For profit - Corporation · 123 certified beds · (978) 462-7373 Medicare & Medicaid certified

Call the home — (978) 462-7373 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0607) — cited Dec 2024
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
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607) — 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 (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing rating is low (1/5)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 4 of 5

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1 Wallace Bashaw Jr. Way, Suite 2003 · (978) 465-0635 · Call to confirm hours
Pharmacy
173 High St · (978) 462-2232 · Call to confirm hours
Grocery
25 Storey Ave · (978) 462-0711 · Call to confirm hours
Park
40 Low St · (978) 465-4188 · 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 4 of 5
Long-stay residentspeople who live here 4 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 fell from 4 to 3 stars. From monthly CMS archive snapshots.

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

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased14.2%16.4%15.4%typical
Long-stay residents who lose too much weight2.8%5.1%5.4%better
Long-stay residents with a catheter left in their bladder0.5%0.8%0.9%better
Long-stay residents with a urinary tract infection0.6%1.8%2.0%better
Long-stay residents with depressive symptoms40.8%15.5%6.5%worse 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 injury4.4%3.4%3.3%worse
Long-stay residents whose ability to walk worsened14.2%15.4%16.1%better
Long-stay residents on antianxiety or hypnotic medication18.6%19.5%18.9%typical
Long-stay residents given the seasonal flu vaccine100.0%94.8%95.3%typical
Long-stay residents with pressure ulcers1.8%4.2%4.7%better
Long-stay residents with worsening bladder/bowel control32.0%21.2%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table15.2%21.4%17.1%better
Short-stay residents who newly got an antipsychotic medication1.1%1.4%1.4%better
Short-stay residents given the seasonal flu vaccine96.6%77.7%79.4%better
Short-stay residents rehospitalized after admission21.7%25.7%22.6%typical
Short-stay residents with an outpatient ER visit12.6%11.9%12.0%typical
Long-stay hospitalizations per 1,000 resident days1.741.881.67typical
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.

60.6% 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 515 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

60.6%U.S. median 51.5%
Got home and stayed home
13.5%U.S. median 10.7%
Went back to hospital
44.6%U.S. median 56.6%
Met the expected recovery
0.38U.S. median 0.31
Therapy hours / resident / day
0.14hours / resident / day
Physical therapy
0.19hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 44.6% 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 305 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 0.38 therapist hours per resident per day in 2026Q1 — more than 64% 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 SNF60.6%CMS range 56.7–64.451.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF13.5%CMS range 10.9–16.610.7%Oct 2022–Sep 2024worse than U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge44.6%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 discharge34.4%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 discharge41.3%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 identified91.5%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 setting93.4%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 discharge100.0%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 stay0.2%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 worsened2.5%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 hospitalization4.6%CMS range 2.8–7.27.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.901.02Oct 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

0.51
RN hours/ resident / day
1.12
LPN hours/ resident / day
2.03
Aide hours/ resident / day
3.66
Total nurse hours/ resident / day
0.24
RN hoursweekends
55.9%
Total nursing turnover
67.9%
RN turnover

How full it usually is: this home is certified for 123 beds and averages 121.6 residents a day — about 99% occupied, or roughly 1 bed typically open. It runs essentially full — expect a waiting list. 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 3.66 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.51 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.03 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 3.18 hrs/resident/day on weekends vs 3.85 on weekdays — 18% thinner on weekends. RN hours go from 0.62 to 0.24 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 56% is about the same as the national median of 45%. 2 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

8
deficiencies at the latest standard inspection (2025-08-28)
3
at the previous standard inspection (2024-09-12)

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.

22 citations, most serious first. The 10 most serious are shown; the remaining 12 are one tap away and print in full.

  • Potential for harm · Ecited before2025-08-28 · 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 observations, record reviews and interviews, the facility failed to ensure food was stored and distributed in accordance with professional standards of food safety to prevent the possible spread of foodborne illness in at risk residents. Specifically, 1. a. The facility failed to ensure food stored in the walk-in refrigerator was not stored and available after the use by date, b. The facility failed to ensure a loaf of bread was not stored after the use by date on one of three nourishments kitchens, and 2. Dietary Staff #1 a. failed to contain facial hair with a beard cover while in the food distribution area. Dietary Staff #1 failed to change his gloves and perform hand hygiene after resting his gloved hands on his facial hair and his nose and proceeded to pick up plate pallets and place them on multiple meal trays in preparation for the meal service line, potentially contaminating the meal trays. b. Dietary Staff #2 failed to properly dispose of used gloves during the lunch meal distribution. Dietary…

    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 · D2025-08-28 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and interview, the facility failed to ensure treatment and care was provided in accordance with standards in quality of care for one Resident (#12), out of a total sample of 25 residents. Specifically, for Resident #12, who has a known risk and care planned for the risk of bruising, bleeding and skin tears, the facility failed to identify areas of injury on his/her lower right leg. Findings include:Resident #12 was admitted to the facility in May 2024 with diagnoses that include, but are not limited to unspecified dementia, bipolar disorder, delusional disorders and heart disease. Review of the most recent Minimum Data Set (MDS) assessment, dated 7/16/25, indicated Resident #12 had a staff assessment for mental status that indicated Resident #12 as having severe cognitive impairment. Further, the MDS indicated Resident #12 required substantial/maximal assistance for shower/bathing and was dependent on lower body dressing. During an observation on 8/26/25 at 10:35 A.M., Resident #12 was in his/her bed. Resident #12's lower legs were exposed, and…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-28 · 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 observations, interviews and record review, the facility failed to maintain professional standards in managing and caring for urinary catheter devices for one Resident (#54) out of a total sample of 25 residents. Specifically, the facility failed to ensure the urinary catheter drainage bag was not directly touching the floor.Findings include:Review of the facility policy titled Catheter Care, Urinary, revised August 2022, indicated:-The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections.-Infection Control: Be sure the catheter tubing and drainage bag are kept off the floor.Resident #54 was admitted to the facility in July 2025 with diagnoses including obstructive uropathy (a condition in which the flow of urine is blocked) and dementia.Review of the most recent Minimum Data Set (MDS) assessment, dated 7/18/25, indicated Resident #54 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 4 out of 15. This MDS also indicated Resident #54 had an indwelling urinary…

    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 · D2025-08-28 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure for one Resident (#12), out of 7 residents reviewed for nutrition, out of a total sample of 25 residents, that a severe weight loss experienced by Resident #12 was addressed timely. Specifically, Resident #12's documented weight on 6/3/25 was 126.2 pounds and on 7/2/25 Resident #12's documented weight was 112.4 pounds, which is a body weight loss of 11.22 percent, which meets the criteria for severe weight loss. The clinical record failed to indicate a weight was retaken to confirm the weight loss, and the Registered Dietitian (RD) failed to conduct a nutritional assessment timely. A nutritional assessment by the RD was conducted 7/16/25, which was 14 days after Resident #12 experienced severe weight loss. Findings include: Review of the facility's policy entitled Weight Assessment and Interventions with a revision dated March 2022 included but not limited to the following:Residents weights are monitored for undesirable or…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-28 · 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 observations, interview and record review, the facility failed to provide care and maintenance of a Peripherally Inserted Central Catheter (PICC: a flexible tube inserted through a vein in one's arm and passed through to the larger veins near the heart, used to deliver medications intravenously [IV]), consistent with professional standards of practice for one Resident (#110) out of a total sample of 25 Residents. Specifically, the facility failed to change the PICC line dressing and measure the external length of the catheter as indicated in the physician's orders. Findings include:Review of facility policy titled Central Venous Catheter Care and Dressing Changes, dated as revised October 2024, indicated the following:-The purpose of this procedure is to prevent complications associated with intravenous therapy, including catheter- related infections that are associated with contaminated, loosened, soiled or wet dressings.-1. Assess central venous access devices with each infusion and at least daily:-2. Measure the length of the external central vascular access device with…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-28 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interviews and record review, the facility failed to ensure that respiratory care and services, consistent with professional standards of practice, were provided for one Resident (#26) out of sample of 25 residents. Specifically, the facility failed to obtain a physician's order for oxygen administration. Findings include:Review of facility policy titled Oxygen Administration, dated as Revised October 2010, indicated the following:-Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Resident #26 was admitted in May 2025 with diagnoses that include gastrointestinal hemorrhage, acute respiratory failure, muscle weakness and pressure ulcer stage 3. Review of the most recent Minimum Data Set (MDS) Assessment, dated 8/12/25, indicated a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating intact cognition. The MDS further indicated the use of continuous oxygen therapy. On 8/26/25 at 8:02 A.M., the surveyor observed Resident #26 awake in bed. The Resident was…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-28 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record review the facility failed to provide care and services consistent with professional standards of practice for one Resident (#41) who required renal dialysis (a life sustaining treatment that helps the body remove extra fluids and waste products from the blood when the kidneys are not able to) out of a total sample of 25 residents. Specifically, The facility failed to ensure ongoing assessment of the Resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility.The facility failed to ensure an emergency kit including clamps were kept with the Resident in case of emergency related to a tunneled hemodialysis catheter (a plastic tube used for exchanging blood between a patient and a hemodialysis machine).Findings include: Review of the facility policy titled 'End-Stage Renal Disease, Care of a Resident with', dated September 2010, indicated residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care.-If there is…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-28 · 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, record review and interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed to implement Enhanced Barrier Precautions for a central dialysis catheter for one Resident (#41), with a central dialysis catheter port, out of a total sample of 25 residents.Findings include:Review of the facility policy, titled 'Enhanced Barrier Precautions', dated December 2024, indicated: Enhanced Barrier Precautions (EBPs) are utilized to prevent the spread of multi-drug-resistant organisms (MDROs) to residents.-EBPs refer to infection prevention and control interventions designed to reduce the transmission of MDROs during high contact resident care activities.-EBPs apply when a resident has a wound or indwelling medical device.-indwelling medical devices include central lines, catheters, feeding tubes, and tracheostomies.-EBPs employ targeted gown…

    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 before2024-12-12 · tag F0607 — failed to have anti-abuse policies — isolated
    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 interviews and records reviewed, for one of three sampled residents (Resident #1), and for one of three sampled employees (Certified Nurse Aide #1), and the Facility failed to ensure staff implemented and followed their abuse policy related to reporting of abuse allegations and employment requirements. 1) On 11/22/24, although Nurse #1 and the Charge Nurse were aware that Resident #1 had made an allegation that CNA #1 had slapped him/her on the arm during care, neither of them reported the allegation of abuse immediately to the Administrator or Director of Nurses, who were not made aware until three days later, and 2) prior to working at the facility, a Massachusetts Nurse Aide Registry (NAR) check was not conducted on Certified Nurse Aide (CNA) #1, as required. Findings include: 1) The Facility Policy titled Abuse, Neglect, Mistreatment, Misappropriation of Resident Property and Exploitation, revised 10/2022, also indicated that mandated reporters have a legal obligation to report all actual, suspected or alleged cases of abuse. The Policy indicated an immediate report…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-09-12 · 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 observations, record review and interviews, the facility failed to develop and implement a comprehensive person-centered care plan for one Resident (#104) out of a total sample of 26 residents. Specifically: 1a. For Resident #104, the facility failed to develop a plan of care for a stage 3 pressure ulcer that was present on admission to the facility and, 1b. For Resident #104, the facility failed to implement bed and chair alarms as indicated in the falls plan of care. Findings Include: Review of facility policy titled Interdisciplinary Care Planning, dated as revised 4/2024, indicated the following: -Care planning schedules are developed and coordinated by the Case Manager and/ or Social Services, in collaboration with the MDS (Minimum Data Set) Coordinator and nursing department. -The care plan process is not limited to developing a written plan but also addresses the ongoing execution of care, treatment, and services with a person- centered approach. The plan is continually reevaluated and modified to ensure the resident's needs are met. The plan includes: -Integrating…

    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
Show the remaining 12 citations
  • Potential for harm · D2024-09-12 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility delayed the implementation of a wound treatment for two days after discovering a new wound for one Resident (#1) out of a total sample of 26 residents. Findings include: Review of the facility policy titled, Pressure Injury Prevention & Treatment Program, dated February 2022, indicated the following: Policy: The facility is committed to providing a comprehensive, interdisciplinary, and evidence-based approach to: -implement individualized person-centered interventions to attempt to stabilize, reduce or remove underlying risk factors. Documentation A. Modify the care plan to meet the changing needs of the resident and utilizing a person-centered care approach. Resident #1 was admitted to the facility in June 2022 with diagnoses including diabetes, osteoarthritis, and muscle weakness. Review of Resident #1's most recent Minimum Data Set, dated [DATE], indicated the Resident scored a 15 out of a possible 15 on the Brief Interview for Mental Status…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-12 · 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 and interviews the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted professional principles. Specifically, the facility failed to ensure that insulin pens were labeled with resident name, open and expiration dates in one out of three medication carts observed. Findings Include: Review of facility policy titled Medication Storage in the Facility, dated as revised December 2019, indicated the following: -Certain medications or package types, such as IV solutions, multiple dose injectable vials, ophthalmics, nitroglycerin tablets, blood sugar testing solution and strips, once opened require an expiration date shorter than the manufacturer's expiration date to insure medication purity and potency. -Drugs dispensed in the manufacturer's original container will carry manufacturer's expiration date. Once opened, these will be good to use until the manufacturer's expiration date is reached unless the medication is: -1. In a multi-dose injectable vial…

    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 before2024-01-11 · tag F0607 — failed to have anti-abuse policies — isolated
    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 records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure they implemented and followed their abuse policy, when after being made aware that Resident #1's family member physically restrained him/her in his/her wheelchair to prevent him/her from getting up, the Facility did not conduct an investigation into the incident and did not report the use of the restraint to their State Agency, as required. Findings include: The Facility Policy titled Abuse, Neglect, Mistreatment, Misappropriation of Resident Property and Exploitation, dated 10/2022, indicated residents had the right to be free from abuse, which included corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's symptoms. The Policy indicated that when alleged violations were observed by or reported to or suspected by an employee, they would immediately notify the Administrator or designee, and the person who received notification would initiate an investigation, identify and interview all involved…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-01-11 · 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 records reviewed and interviews, for one of three sampled residents (Resident #1), who was assessed by nursing as being at high risk for falls, and whose care plan interventions included that he/she required the use of pressure sensitive alarms at all times when in bed and/or chair, the Facility failed to ensure staff consistently implemented and followed interventions identified in his/her Plan of Care, that his/her pressure sensitive alarms were in place and functioning, and as a result, Resident #1 experienced falls two day in a row and sustained skin tears with each fall. Findings include: The Facility Policy titled, Interdisciplinary Care Planning, dated 11/2017, indicated the Facility would assess each resident's individual needs and provide effective person-centered care that met professional standards of quality of care. The Facility Policy titled, Falls Management Program, dated 01/2018, indicated an avoidable accident was defined as an accident that occurred because the Facility failed to…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-11 · 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

    Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was assessed by nursing as being at high risk for falls and required the use of pressure sensitive alarms in an effort to prevent falls, the Facility failed to ensure he/she was provided with the necessary functional safety devices to maintain his/her safety, when on 8/20/23 after he/she was found on the floor after a fall, it was determined that his/her pressure sensitive alarm was not in place, and on 8/21/23 the pressure sensitive alarm was knowingly disabled by a staff who left Resident #1 alone in the bathroom and he/she was found a short time later on the floor by staff. Resident #1 sustained multiple skins tears as result of both falls. Findings include: The Facility Policy titled Accident and Incidents, dated 01/2020, indicated: -an incident was defined as any event that occurred by chance or arising from unknown cause which was not consistent with the desired operation of the Facility or the care of the residents. -All accidents or incidents must be reported and investigated and…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-11 · tag F0760 — failed to prevent significant medication errors — isolated
    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 record reviewed and interviews, for one of three sampled residents (Resident #1), whose physician's orders included the administration of Warfarin (an anticoagulant) which required blood laboratory work to be completed and reported to the physician so new orders could be obtained for the Warfarin, the Facility failed to ensure that he/she was free from significant medication errors, when due to a transcription error by nursing, the blood laboratory work was not ordered and obtained, therefore new physician orders for the Warfarin were not obtained, and Resident #1 went two weeks without receiving his/her Warfarin, placing him/her at increased risk for the development of blood clots. Findings include: The Facility Policy, titled General Guidelines for Medication Administration, dated 12/2019, indicated medications would be administered safely and without unnecessary interruptions, and the right resident, drug, dose, route and time would apply for each medication. The Facility Policy, titled Anticoagulant Monitoring, dated 01/2016, indicated residents on anticoagulation…

    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 · D2024-01-11 · 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, for one of three sampled residents (Resident #1), the Facility failed to ensure it maintained a complete and accurate medical record related to Activities of Daily Living care provided by Certified Nurse Aides. Findings include: The Facility Policy titled Documentation Expectations, dated 03/01/21, indicated documentation would be complete and conducted in a timely manner. Resident #1 was admitted to the Facility in July 2023, diagnoses included left femur fracture, history of falls, atrial fibrillation, end stage renal disease, and cognitive communication deficit. Review of the Shower Schedule for the Clipper Unit, undated, indicated Resident #1 was scheduled to receive showers three times weekly on Monday, Wednesday, and Friday, (so from 07/14/23 through 08/23/23, Resident #1 should have received a total of 20 showers), Review of Resident #1's Point of Care ADL Category Report, dated 07/14/23 through 08/23/23 indicated Resident #1 only received four showers during this time frame (which were on 07/30/23, 08/06/23, 08/14/23, and 08/22/23).…

    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 before2023-09-07 · 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 store and prepare food in accordance with professional standards for food service safety. Findings include: Review of the undated facility policy titled Refrigerator Guidelines, indicated the following: -Label and date all leftovers and refrigerate immediately -Label and date food items when removing from the freezer to thaw On 9/5/23 at 6:59 A.M., the following observations were made during the initial walk through of the kitchen: -Whipped cream in an open piping bag, unlabeled and undated in the walk-in refrigerator. -Shredded carrots, unlabeled and undated in the walk-in refrigerator. -Five boxes containing food items stored directly on the freezer floor -Two beverages from a local franchise stored in direct contact with resident drinks in the reach-in refrigerator. -A tin foil pan containing chili in the freezer, the wrap was ripped exposing the chili to open air; there was ice buildup present on the chili. During an interview on 9/5/23 at 7:11 A.M.,…

    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 · Dcited before2023-09-07 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure the plan of care was implemented for 1 Resident (#76) out of a total sample of 25 residents. Findings include: Review of the Minimum Data Set (MDS) dated [DATE], indicated Resident #76 is supervised with one person assist for meals. Further review of the MDS indicated that Resident #76 scored a 9 out of 15 on the Brief Interview for Mental Status exam indicating moderate cognitive impairment. Review of the care plan dated 8/12/23, indicated Resident #76 is supervised with meals. On 9/5/23, at 8:25 A.M., the surveyor observed Resident #76 in bed, eating a puree diet without staff present. On 9/6/23, at 8:14 A.M., the surveyor observed Resident #76 in bed sleeping with a meal tray, untouched, on the over the bed table. The surveyor also observed that no staff were present in the room. On 9/6/23, at 8:39 A.M., the surveyor observed Resident #76 in bed eating without staff present in the room. During an interview on 9/06/23, at 11:58…

    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 · D2023-09-07 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review the facility failed to revise the plan of care for one Resident (#105) out of a total of 25 sampled Residents. Findings include: Resident #105 was admitted to the facility in April 2023 with diagnoses including vascular dementia and dysphagia. Review of Resident #105 Minimum Data Set assessment dated [DATE] indicated Resident #105 scored 8 out of a possible 15 on the Brief Interview for Mental Status Exam indicating moderate cognitive impairment. The MDS also indicated Resident #105 requires assistance with eating. During an interview on 9/5/23 at 8:13 A.M., Resident #105 said I have a swallowing problem. The surveyor then observed a sign taped to the wall above Resident #105's bed indicating: Cue to perform second swallow after food/liquid intake. The surveyor observed Resident eating his/her breakfast alone in his/her room and occasionally coughing and clearing his/her throat. On 9/5/23 at 12:15 P.M., the surveyor observed staff deliver Resident #105's lunch meal to him/her…

    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 · D2023-09-07 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review the facility failed to provide care in accordance with professional standards for two Residents (#105 and #21) out of a total of 25 sampled residents. Specifically the facility failed to 1.) For Resident #105 the facility failed to obtain labs as ordered by the physician resulting in Resident #105 not receiving Warfarin (a blood thinning medication) for 10 days; and 2.) For Resident #21 the facility failed to ensure a.) Nurse #1 transcribed a physician's order accurately for a duoneb nebulizer (inhalation solution containing a combination of albuterol and ipratropium) and b.) failed to ensure nursing completed an accurate 24 hour review of physician orders for accuracy. Findings include: 1.) For Resident #105 the facility failed to ensure nursing obtained labs as ordered by the physician resulting in Resident #105 not receiving Warfarin (a blood thinning medication) for 10 days. Resident #105 was admitted to the facility in April 2023 with diagnoses including vascular dementia…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-07 · tag F0909 — failed to maintain a comfortable temperature — isolated
    Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
    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 that a system was developed to conduct comprehensive inspections of resident's beds, bed frames and bed rails to reduce the potential hazard of entrapment for beds in the facility. Specifically, the facility failed to identify a seven inch bed gap for one Resident (#122) out of a total sample of 25 residents. Findings include: Review of the facility policy titled, Siderails, Guidelines for Use Of, effective November 2017, indicated the following: -Maintenance staff are responsible for inspecting facility and resident care equipment including beds, side rails, and mattresses to identify areas of possible entrapment in accordance with FDA guidelines. Review of the Food and Drug Administration (FDA) Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, dated 03/10/2006 content deemed current as of 08/23/2018, indicated the following: The term entrapment describes an event in which a resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed frame.…

    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.

    Environmental 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 ATLAS HEALTHCARE — 29 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 2 of 53.6-1.6 vs chain
Health inspection 3 of 53.1-0.1 vs chain
Staffing 1 of 52.3-1.3 vs chain
Quality measures 4 of 54.4-0.4 vs chain
The other 28 homes this chain runs (chain average 3.6★, per CMS)
2 of 5Atlas Post Acute At Woodbury Country ClubWoodbury, NJ 2 of 5Haverhill Rehabilitation And Healthcare CenterHaverhill, MA 2 of 5Rossville Rehabilitation And Healthcare CenterBaltimore, MD 2 of 5The Elms Rehab And Healthcare Center Of CranburyCranbury, NJ 2 of 5Village Green Rehabilitation And Healthcare CenterBristol, CT 2 of 5Wynwood Rehabilitation And Healthcare CenterCinnaminson, NJ 3 of 5Atlas Rehabilitation And Healthcare At Daughters OClifton, NJ 3 of 5Atlas Rehabilitation And Healthcare At WashingtonSewell, NJ 3 of 5Masconomet Rehabilitation And Healthcare CenterTopsfield, MA 3 of 5Nemasket Rehabilitation And Healthcare CenterMiddleborough, MA 3 of 5Oak Knoll Rehabilitation And Healthcare CenterFramingham, MA 3 of 5Roland Park Rehabilitation And Healthcare CenterBaltimore, MD 4 of 5Atlas Rehabilitation And Healthcare At MaywoodMaywood, NJ 4 of 5Cedar Grove Respiratory And Nursing CenterWilliamstown, NJ 4 of 5Hathorne Hill Rehabilitation And Healthcare CenterDanvers, MA 4 of 5Meadowbrook Respiratory And Nursing CenterMatawan, NJ 4 of 5Mystic Meadows Rehabilitation And Nursing CenterLittle Egg Harbor Tw, NJ 4 of 5Shrewsbury Rehabilitation And Nursing At SouthgateShrewsbury, MA 4 of 5Sippican Rehabilitation And Healthcare CenterMarion, MA 4 of 5Suffield House Rehabilitation And Healthcare CenteSuffield, CT 4 of 5Towson Rehabilitation And Healthcare CenterTowson, MD 5 of 5Atlas Rehabilitation & Healthcare At West DeptforWest Deptford, NJ 5 of 5Birchwood Rehabilitation And Healthcare CenterCranford, NJ 5 of 5Bride Brook Rehabilitation & Nursing CenterNiantic, CT 5 of 5Manchester Rehabilitation And Healthcare CenterManchester, CT 5 of 5Pendleton Rehabilitation And Nursing CenterMystic, CT 5 of 5Vernon Rehabilitation And Healthcare CenterVernon, CT 5 of 5Waterfront Rehabilitation And Healthcare CenterRaritan, NJ

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
WHITTIER MOP OPERATIONS HOLDINGS LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 02/28/2025
JMH FAMILY LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST; LIMITED PARTNERSHIP INTEREST; ADP OF THE SNFNO PERCENTAGE PROVIDEDsince 02/28/2025
JMH FAMILY TRUSTOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST; LIMITED PARTNERSHIP INTEREST; ADP OF THE SNFNO PERCENTAGE PROVIDEDsince 02/28/2025
MLS FAMILY LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST; LIMITED PARTNERSHIP INTEREST; ADP OF THE SNFNO PERCENTAGE PROVIDEDsince 02/28/2025
MLS FAMILY TRUSTOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST; LIMITED PARTNERSHIP INTEREST; ADP OF THE SNFNO PERCENTAGE PROVIDEDsince 02/28/2025
SGS FAMILY LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST; LIMITED PARTNERSHIP INTEREST; ADP OF THE SNFNO PERCENTAGE PROVIDEDsince 02/28/2025
SGS FAMILY TRUSTOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST; LIMITED PARTNERSHIP INTEREST; ADP OF THE SNFNO PERCENTAGE PROVIDEDsince 02/28/2025
WHITTIER 6 OPERATIONS HOLDINGS LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST; LIMITED PARTNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 02/28/2025
MILLER, NACHUMIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; LIMITED PARTNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 02/28/2025
BAK, PINCHOSIndividualCORPORATE OFFICER; ADP OF THE SNFsince 02/28/2025
WHITTIER OPCO MANAGER LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/28/2025
CARDENAS, SANDRAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/28/2025
LANOUE, TRACEYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/28/2025
OLENIO, CHRISTOPHERIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/28/2025
SONNENSCHEIN, MOSHEIndividualOPERATIONAL/MANAGERIAL CONTROL; TRUSTEE OF THE SNF; ADP OF THE SNFsince 02/28/2025
GLEN OAK 11, LLCOrganizationLIMITED PARTNERSHIP INTERESTsince 02/28/2025
MALT FAMILY TRUSTOrganizationLIMITED PARTNERSHIP INTERESTsince 02/28/2025
SGS 2010 FAMILY TRUSTOrganizationLIMITED PARTNERSHIP INTERESTsince 02/28/2025
TYH 2017 TRUSTOrganizationLIMITED PARTNERSHIP INTERESTsince 02/28/2025
GOLDBERGER, SHLOMOIndividualADP OF THE SNFsince 02/28/2025

CMS files one row per role, so the 42 rows in the source record cover these 20 parties — each is shown once here with every role it holds. Nothing is omitted.

13 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.

$18.5M
Net patient revenuemost recent cost report
+1.6%
Operating marginrevenue minus expenses
$1.2M
Related-party expense7% of expenses
Who pays — share of resident-days
Medicaid 43%Medicare 23%Other / private 34%

This home reported $1.2M paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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

$434per resident / day
operating cost
$13,187per month
≈ monthly operating cost
$441per 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 225271. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-28, 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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