Stone Rehabilitation And Senior Living
277 Elliot Street, Newton Upper Falls, MA 02464 · Non profit - Other · 82 certified beds · (617) 562-0023 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- a high payroll-based staffing rating (4/5)
- lower-than-typical staff turnover (29% vs 45% nationally) — better care continuity
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0600), cited Apr 2025
- it has 2 actual-harm citations
- a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $16,195 in federal fines (most recent 2024-02-06)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 11.8% | 16.4% | 15.4% | better |
| Long-stay residents who lose too much weight | 0.9% | 5.1% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.6% | 0.8% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.4% | 1.8% | 2.0% | better |
| Long-stay residents with depressive symptoms | 26.4% | 15.5% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 1.6% | 3.4% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 7.7% | 15.4% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 9.0% | 19.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 94.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.7% | 4.2% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 14.5% | 21.2% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 17.5% | 21.4% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 0.7% | 1.4% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 96.0% | 77.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 24.8% | 25.7% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 6.7% | 11.9% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 3.32 | 1.88 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.09 | 1.50 | 1.80 | better |
‡ 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.
68.0% 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 119 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 32.7% 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 101 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 0.30 therapist hours per resident per day in 2026Q1 — more than 48% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 23% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 68.0%CMS range 59.0–76.5 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.5%CMS range 8.2–15.5 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 32.7% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 16.8% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 30.7% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 99.3% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.7% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.7% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.9%CMS range 4.2–11.1 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.80 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 82 beds and averages 76.0 residents a day — about 93% occupied, or roughly 6 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.89 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.64 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.29 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 3.49 hrs/resident/day on weekends vs 4.05 on weekdays — 14% thinner on weekends. RN hours go from 0.72 to 0.44 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 29% is below the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
23 citations, most serious first. The 12 most serious are shown; the remaining 11 are one tap away and print in full.
- Actual harm · Gcited before2024-02-06 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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), whose Plan of Care indicated that he/she required the use of a Spryte lift (mobility stand aid that supports a person's body weight to help them stand up from a seated position) with assistance of two staff members for transfers from chair to bed, the Facility failed to ensure nursing staff implemented and followed interventions identified in his/her Plan of Care while meeting his/her needs to transfer, when on 01/14/24, Certified Nurse Aide (CNA) #1 transferred Resident #1 from his/her wheelchair into bed without the use of a Spryte lift and without another staff member present to assist her. As CNA #1 turned and sat Resident #1 on the side of the bed, his/her left leg hit the side rail, which resulted in a laceration (open wound) to his/her left lower extremity, which required eight sutures to close. Findings include: Review of the Facility's Policy, titled Care Plans-Comprehensive, undated, indicated the following: -an…
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.
- Actual harm · G2024-02-06 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records reviewed and interviews for one of three sampled residents (Resident #1), who required the use of a Spryte lift (mobility stand aid that supports a person's body weight to help them stand up from a seated position) with assistance of two staff members for transfers from chair to bed, the Facility failed to ensure he/she was provided with the necessary level of staff assistance and assistive device to maintain his/her safety, in an effort to prevent an incident/accident resulting in an injury, when on 01/14/24, Certified Nurse Aide (CNA) #1 transferred Resident #1 from wheelchair into bed without the use of a Spryte lift and without another staff member present to assist her. Resident #1's left leg hit the side rail of the bed during the completion of the transfer, and he/she sustained a laceration (open wound) to his/her left lower extremity, which required eight sutures to close. Findings include: Review of the Facility's Policy, titled Activities of Daily Living, undated, indicated the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-03-11 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and interview the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections on two of two units. Specifically:1.The facility failed to disinfect vital sign machines between residents.2. The facility failed to ensure staff opened personal milk cartons in a sanitary manner.Findings include: 1. On 3/11/26 at 6:48 A.M., the surveyor observed a nurse taking vital signs on a resident. The Nurse then exited the room with the vital signs tower, and without disinfecting the tower or equipment, entered another resident's room and took their vital signs. At 6:51 A.M., the nurse exited the second resident's room after checking vital signs, and without disinfecting the vital signs tower, entered the room of a third resident and obtained vital signs on the resident. At 6:53 A.M., the nurse exited the third resident's room, and without disinfecting the vital signs tower, entered the room of a fourth resident 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.
- Potential for harm · Dcited before2026-03-11 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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, record review and interview, the facility failed to develop and implement a comprehensive person- centered care plan for two Residents (#34 and #66) out of a total sample of 21 residents. Specifically,1.For Resident #34 the facility failed to develop a comprehensive person-centered care plan within seven days of completing the Admission/ 5-day Minimum Data Set assessment.2. For Resident #66 the facility failed to implement the use of ted stockings (compression stockings) and Geri-sleeves (used to protect fragile skin). Findings include: Review of facility policy, titled Care Plans, undated, indicated the following: -An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. 1. Our facility's Care Planning/ Interdisciplinary Team, in coordination with the resident. his/her family or representative, develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-11 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure assistance with Activities of Daily Living (ADLs) was provided for one Resident (#34) out of a total sample of 21 residents. Specifically, for Resident #34 the facility failed to provide supervision/ touching assistance with meals as per the plan of care.Findings include:Resident #34 was admitted to the facility in January 2026 with diagnoses that included metabolic encephalopathy, sleep apnea, dysphagia (difficulty swallowing) and pneumonitis due to inhalation of food and vomit. Review of the Minimum Data Set (MDS) assessment, dated 1/30/26, indicated a Brief Interview for Mental Status score of 8 out of a possible 15, indicating moderate cognitive impairment. Further review of the MDS indicated supervision or touching assistance was required for eating. Further review indicated that rejection of care was not a behavior exhibited by the resident. On 3/10/26 at 8:39 A.M., the surveyor observed Resident #34 sitting up in his/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.
- Potential for harm · D2026-03-11 · tag F0694 — isolatedProvide 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 observation, 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 (#6), out of a total sample of 21 residents. Specifically, for Resident #6, the facility failed to ensure that the insertion site was able to be visualized. Findings include:Review of facility policy titled PICC Line Management, undated, indicated the following:-Nurse should inspect PICC line site evert shift and report to MD/NP any signs of infiltration, infection, increased redness or swelling, pain or any other issues.-PICC line dressings should be changed at least weekly with a transparent dressing.Resident #6 was admitted to the facility in February 2026 with diagnoses that included encounter for orthopedic aftercare, broken internal left hip prosthesis and history of falling. Review of the Minimum Data…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-11 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure that respiratory care and services, consistent with professional standards of practice, were provided for one Resident (#73) out of a sample of 21 residents. Specifically, for Resident #73, the facility failed to provide oxygen to the Resident as indicated in the physician's orders.Findings include:Review of facility policy titled Oxygen Administration, undated, indicated the following:-Verify that there is a physician's order for this procedure unless needed for emergent reasons. Review physician's orders or facility protocol for oxygen administration. Resident #73 was admitted to the facility in February 2026 with diagnoses that included dementia, depression and acute respiratory failure with hypoxia. Review Resident #73's Minimum Data Set (MDS), dated [DATE], indicated a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating intact cognition. Further review of the MDS indicated the use of continuous oxygen…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-04-09 · tag F0759 — failed to keep medication error rate low — patternEnsure medication error rates are not 5 percent or greater.
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 it was free from a medication error rate of greater than 5% when two out of two nurses observed made ten errors out of 33 opportunities, resulting in a medication error rate of 30.3%. Those errors impacted two Residents (#44 and #76) out of two residents observed. Specifically, 1. For Resident # 44, Nurse #5 administered the wrong dose of Mucinex. 2. For Resident #76, Nurse #3 omitted nine medications, three of those medications were controlled substances and administered an as needed medication in replacement of a scheduled medication when the Resident did not ask for an as needed medication. Findings include: Review of facility policy titled 'Administering Medications', undated, indicated the following: -Policy Statement: Medications shall be administered in a safe and timely manner, and as prescribed. -4. Medications must be administered in accordance with the orders, including any required time frame. -9. The individual…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-04-09 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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 properly follow sanitation and food handling practices to prevent the risk of foodborne illness in accordance with professional standards for food service safety. Review of the facility policy titled Food Handling, undated, indicated the following: - Food will be stored, prepared, handled and served so that the risk of foodborne illness is minimized. Critical Factors in Foodborne Illness 1. This facility recognizes that the critical factors implicated in foodborne illness are: c. Contaminated equipment; and d. Unsafe food sources. Minimizing Foodborne Illness 2. With these factors as the primary focus of preventative measures, this facility strives to minimize the risk of foodborne illness to our residents. Employee Training in Food Handling Practices 3. All employees who handle, prepare or serve food will be training in the practices of safe food handling and preventing foodborne illness. Employees will demonstrate knowledge in these practices prior to working with food or serving food to residents. The surveyor made the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-09 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility failed to keep one Resident (#68) free from verbal abuse out of a total sample of 19 residents. Specifically, Nurse #8 threatened to move Resident (#68) to the TV room alone if the resident did not stop yelling. Findings include: Review of the facility policy titled Abuse Prevention Program, undated, indicated the following: Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. Preventing Abuse 1. Our facility is committed to upholding our residents' right to be free from abuse, neglect and exploitation, from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual. 2. Our facility does not condone resident abuse by anyone, 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.
- Potential for harm · Dcited before2025-04-09 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and records reviewed, the facility failed to meet professional standards of practice for two Residents (#21 and #8 ) out of a total of sample of 19 residents. Specifically, 1. For Resident #21, the facility failed to clarify two physician orders for a Lidocaine patch (a patch used to treat pain) prior to administration. 2. For Resident #8, the facility failed to ensure an air mattress was checked for proper function as per the physician's orders. Findings include: 1. Resident #21 was admitted to the facility in February 2025 with diagnoses that included multiple fractures of ribs, right side, subsequent encounter for fracture with routine healing, cognitive communication deficit, and Alzheimer's disease. Review of Resident #21's most recent Minimum Data Set (MDS) assessment, dated 3/1/25, indicated he/she scored a 9 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident has moderately impaired cognition. On 4/9/25 at 8:54 A.M., the surveyor observed Resident #21 propelling him/herself in a wheelchair in the hall. Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-09 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and records reviewed, the facility failed to provide treatment and care in accordance with professional standards of practice for one Resident (#282), out of a total sample of 19 residents. Specifically, the facility failed to follow physician orders to obtain daily weights for a resident with a diagnosis of congestive heart failure (a condition when the heart muscle doesn't pump blood as well as it should causing a potential for fluid buildup/weight gain), and administer a diuretic (medication used to eliminate excess fluid) if weight is elevated, when Resident #282 was found to have a seven pound weight gain in two days. Findings Include: Review of the facility policy titled Weight Assessment and Intervention, undated, included but was not limited to: -The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents. -Weight Assessment/ Weight Measurements 1. The nursing staff will measure resident weighs on admission or within 24 hours, if resident is able or willing to participate, and as…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 11 citations
- Potential for harm · Dcited before2025-04-09 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
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 respiratory care services were provided in accordance with standards of professional practice for 2 Residents (#12 and #57), out of a total sample of 19 residents. Specifically, 1. For Resident #12 the facility failed to ensure the CPAP (a CPAP is Continuous Positive Airway Pressure, a non-invasive respiratory treatment used to treat sleep apnea and other respiratory conditions) was administered in accordance with the medical plan of care, the provider was notified that the CPAP was not administered as ordered, and failed to ensure the CPAP equipment was clean and, 2. For Resident #57 the facility failed to ensure a person-centered care plan was developed for the use of supplemental oxygen. Findings include: Review of the facility's policy titled CPAP/BiPAP, not dated indicated Purpose: 1 To provide the spontaneously breathing resident with continuous positive airway pressure with or without supplemental oxygen. 2. To improve…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-09 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure that a recommendation made by the Consultant Pharmacist during the Monthly Medication Review (MMR) was addressed for one Resident (#31), of five residents reviewed, out of a total sample of 19 residents. Specifically, the facility failed to inform the provider that Resident #31's medications were not evaluated by the psychiatric services provider. Findings include: Resident #31 was readmitted to the facility in January 2023 and has diagnoses that include but are not limited to chronic obstructive pulmonary disease, major depressive disorder, recurrent, moderate, generalized anxiety disorder, and cognitive communication deficit. Review of the most recent Minimum Data Set assessment, dated 2/1/25, indicated that Resident #31 scored a 15 out of 15 on the Brief Interview for Mental Status exam, indicating he/she as having intact cognition. Further review of the MDS indicated high-risk drug class medications administered to Resident #31 included antianxiety and antidepressant medication. Review of the document titled…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-09 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews and policy review, the facility failed to ensure staff stored drugs and biologicals in accordance with State and Federal laws. Specifically, 1. The facility failed to ensure medication carts were locked when unattended on the first-floor unit. 2. The facility failed to ensure drugs and biologicals were stored in locked compartments and that only authorized personnel have access to the medication on the first-floor unit. Findings include: Review of the facility policy titled 'Storage and Labeling of Medications' undated, indicated The Facility shall store all drugs and biologicals in a safe, secure, and orderly manner. 1. Drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received. On 4/8/25 at 6:46 A.M., the surveyor observed a medication cart unlocked and unattended on the first-floor nursing station. The surveyor was able to access the medication cart and open the drawers. During an interview on 4/8/25 at 6:48 A.M., Nurse #7 said the medication cart should be locked if unattended.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-09 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record review, the facility failed to maintain accurate medical records for two Residents (#21 and #74 ), out of a total sample of 19 residents. Specifically, 1. The facility failed to accurately document they administered a physician ordered medication when they did not, and 2. The facility failed to document the daily fluids consumed by the Resident on the day shift. Findings include: Resident #21 was admitted to the facility in February 2025 with diagnoses that included multiple fractures of ribs, right side, subsequent encounter for fracture with routine healing, cognitive communication deficit, and Alzheimer's disease. Review of Resident #21's most recent Minimum Data Set (MDS) assessment, dated 3/1/25, indicated he/she scored a 9 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident has moderately impaired cognition. Review of Resident #21's physician order, dated 2/12/25, indicated Lidocaine External Patch 4 % (Lidocaine) Apply to Right ribs topically two times a day for Right rib fractures. Apply to Right…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-02 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and interview the facility failed for one Resident (#12), to complete the Minimum Data Set (MDS) assessment that accurately reflects the Resident's status, out of a total sample of 20 residents. Specifically, the MDS assessment indicated Resident #12 was receiving hospice care services, when he/she was not. Findings include: Resident #12 was admitted to the facility in August 2017 and has diagnoses that include but not limited to chronic obstructive pulmonary disease, dementia, and adult failure to thrive. Review of the most recent MDS assessment, dated 3/24/24 indicated Resident #12 scored a 3 out of 15 on the Brief Interview for Mental Status exam, indicating he/she has a severe cognitive impairment and is dependent on staff for daily care including toileting, hygiene, bathing, and dressing. Further, the MDS assessment indicated Resident #12 was receiving hospice care while a resident. On 4/30/24 at 8:01 A.M. Resident #12 was observed in his/her bed. Resident #12 had his/her eyes closed and was observed to be small stature and frail. Review of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-05-02 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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 ensure comprehensive resident centered care plans were developed for two Residents (#10, and #221) out of a total sample of 20 Residents. Specifically the facility failed to; 1.) develop an individualized comprehensive resident centered care plan related to the monitoring and care of a pacemaker for Resident #10 and Resident #221. Findings include: Review of the facility policy titled Pacemaker Policy, undated, indicated: - Residents will be assessed upon admission for pacemaker insertion. - On going monitoring of pacemaker is based on pacemaker and cardiologist. - Need for follow up appointments are decided by cardiology team. 1a.) Resident #10 was admitted to the facility in August 2023 with diagnoses that included Parkinson's disease, dysphagia, presence of cardiac pacemaker, and contractures of the right and left hand. Review of Resident #10's most recent Minimum Data Set (MDS) assessment, dated 4/13/24, indicated a Brief Interview for Mental Status (BIMS) score of 11 out of a possible 15 which indicated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-05-02 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, policy review and interviews, the facility failed to meet professional standards of quality for one Resident (#24) out of a total sample of 20 residents. Specifically, for Resident #24, the facility failed to implement physician's orders to notify the Physician or Nurse Practitioner of a weight change. Findings include: Review of the facility policy titled Physician/ Family Notification, undated, indicated The Nurse Supervisor or Charge Nurse will notify a resident's Attending Physician or On-Call Physician when there has been: i. Instructions to notify the physician of changes in the resident's condition. Resident #24 was admitted to the facility in September 2023 with diagnoses that included congestive heart failure, adult failure to thrive, dysphagia and muscle weakness. Review of Resident #24's Minimum Data Set (MDS) assessment, dated 2/24/24, indicated a Brief Interview for Mental Status (BIMS) score of 9 out of a possible 15 indicating that the Resident has moderate cognitive impairment. Review of Resident #24's Physician's orders indicated the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-05-02 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview the facility failed for one Resident (#14), to provide activities of daily living, out of a total sample of 20 residents. Specifically, for Resident #14, who is assessed to be dependent on staff for daily care, the staff failed to provide fingernail care. Findings include: Review of the facility's policy titled 'Activities of Daily Living' not dated indicated the following: In order to protect the safety and well-being of staff and residents, and to promote quality of care, this facility provides assistance with activities of daily living (ADL) as needed. Review of the facility's policy entitled 'Care of Fingernails/Toenails, not dated indicated the following: The purposes of this procedure are to clean the nail bed, to keep fingernails trimmed, and to prevent infections. General Guidelines, included 1. Nail care includes daily cleaning and regular trimming. Resident #14 was admitted to the facility in May 2019 and has diagnoses that include but not limited 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.
- Potential for harm · D2024-05-02 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record review for one Resident (#171), out of 20 total sampled residents, the facility failed to provide the necessary treatment and services to prevent the development and promote healing of pressure ulcers. Specifically, the facility failed to implement a physician's order to offload the heels of Resident #171, who has a stage 3 pressure ulcer on his/her left heel. Findings include: Resident #171 was admitted to the facility in April 2024 with diagnoses that included stage 3 pressure ulcer to the left heel, adult failure to thrive and spondylosis. Review of Resident #171's Nursing Assessment, dated 4/25/24, indicated the Resident was alert and oriented times two (person and time). During an interview on 4/30/24 at 7:52 A.M., Resident #171 said he/she has a wound on his/her left heel and said no one has offered to place a pillow or anything under his/her heels. On 4/30/24 at 7:52 A.M. and 1:21 P.M., the surveyor observed the Resident in bed with their heels directly on the mattress. On 5/1/24 at 8:34 A.M. and 10:44 A.M., the surveyor observed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-02 · tag F0805 — failed to prepare food in a form residents can eat — isolatedEnsure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to provide food in a form to meet the needs of one Resident (#47) out of a sample of 20 Residents. Specifically, the facility failed to provide a soft and bite sized diet as ordered by the physician and provide the International Dysphagia Diet Standardization Initiative (IDDSI) level 6 diet as indicated by Speech Language Pathology. Findings Include: Review of the facility policy titled Nutrition - Clinical Protocol, undated, indicted the following: - The Physician will authorize, and the staff will implement appropriate general or cause-specific interventions, as indicated, with careful consideration of the following: - Chewing and swallowing abnormalities: Modifications in food or fluid consistency in the diet will be ordered (if determined necessary by the Physician) only after careful consideration of the resident's preferences, the overall condition of the resident, and a review of the underlying problems related to the chewing 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.
- Potential for harm · Dcited before2024-05-02 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and interview the facility failed to implement procedures to ensure the prevention of infection for one Resident (#65), out of three applicable residents who have an indwelling urinary catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag), out of a total sample of 20 residents. Findings include: Review of the facilities policy, titled 'Catheter Care, Urinary,' Level III, not dated, indicated the following: The purpose of this procedure is to prevent catheter-associated urinary tract infections. Infection Control 2. b. Be sure the catheter tubing and drainage bag are kept off the floor. Resident #65 was admitted to the facility in October 2023 and has diagnoses that include but not limited to vascular dementia and neuromuscular dysfunction of bladder. Review of the Minimum Data Set (MDS) assessment, dated 4/6/24, indicated Resident #65 scored a 13 out of 15 on the Brief Interview for Metal Status exam, indicating he/she is cognitively intact. The MDS also indicated that Resident #65 is dependent on staff for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$16,195 in federal fines across 1 penalty.
- $16,195 — penalty dated 2024-02-06
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| ALEXANDER, MICHAEL | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | since 06/01/2018 |
| LIPRESTI, NICHOLAS | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | since 04/24/2024 |
| LOCHIATTO, JOYCE | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | since 06/01/2017 |
| MAMUYA, WILFRED | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | since 06/01/2021 |
| QUINTANA, JAIME | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | since 04/24/2024 |
| RIESKE, DENNIS | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | since 06/03/1996 |
| SHEPLER, CHRISTOPHER | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | since 06/01/2020 |
| BERMAN, ADAM | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | since 03/28/2023 |
| SANTERRE, JENNIFER | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/28/2023 |
| CHELSEA JEWISH LIFECARE INC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/28/2023 |
| ALLEY, SUZANNE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/13/2020 |
| BLAKE, EDWARD | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 10/23/2023 |
| CARREIRO, SILVIO | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 04/06/2015 |
| CHARLES, NAISSA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/15/2024 |
| CRESCENZO, DONNA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/28/2023 |
| DUBREIUL, DARCI | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 06/01/2025 |
| MERCHANT, ASIF | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2016 |
| MULLEN, ELIZABETH | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/28/2023 |
| PALLAS, GREGORY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/20/1984 |
CMS files one row per role, so the 42 rows in the source record cover these 19 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
1 organizational owner 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.
This home reported $522K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in MA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Massachusetts Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 225683. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-11, 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.