Andover Forest Post Acute Care Center

Location & what’s nearby

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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

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.

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.

50.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 73 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 58.3% 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 36 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 0.19 therapist hours per resident per day in 2026Q1 — more than 20% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 15% 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.

Staffing

How full it usually is: this home is certified for 142 beds and averages 114.9 residents a day — about 81% occupied, or roughly 27 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.59 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.44 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.11 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 3.08 hrs/resident/day on weekends vs 3.80 on weekdays — 19% thinner on weekends. RN hours go from 0.55 to 0.18 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 39% is about the same as the national median of 45%. 1 administrator has left in the past year.

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

Inspection trend

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

40 citations, most serious first. The 15 most serious are shown; the remaining 25 are one tap away and print in full.

• Immediate jeopardy · J2024-04-12 · tag F0805 — failed to prepare food in a form residents can eat — isolated
  Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure diets as ordered by the physician were served in proper form for one Resident (#68) out of a total of 29 sampled residents. Specifically, on 1/22/24, Resident #68 was served a lunch meal, not in accordance with the diet order, resulting in Resident #68 choking and requiring the Heimlich maneuver (an emergency procedure which involves abdominal thrusts to dislodge foreign bodies or food from the throats of choking victims). Findings include: Review of the facility's Therapeutic Diets Policy, dated November 2022 indicated: Therapeutic diets shall be prescribed by the attending physician. A therapeutic diet must be prescribed by the attending physician and order should match the terminology used by food services. The food services manager will establish and use a tray identification system to ensure that each resident receives his or her diet as ordered. Review of the American Red Cross Resources regarding Adult/Child Choking, undated,…

  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
• Actual harm · Gcited before2023-09-26 · 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 severely cognitively impaired and was observed by several nursing staff to display exit seeking behaviors, the Facility failed to ensure a comprehensive person-centered care plan was developed and implemented related to his/her risk for elopement. On 09/14/23 Resident #1 exited the unit in his/her wheelchair through a fire door exit into a stair well, fell from his/her wheelchair down several stairs onto a landing and sustained a left ankle fracture. Findings Include: Review of the Facility Policy titled Person-Centered Care Plan, dated as revised 10/24/22, indicated a comprehensive individualized Care Plan will be developed within seven days after completion of the comprehensive assessment. The Policy indicated that for newly admitted patients, the comprehensive Care Plan must be completed within seven days of the completion of the comprehensive assessment and no more than twenty-one days after admission. The…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2023-09-26 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records reviewed and interviews for one of three sampled residents (Resident #1) who was severely cognitively impaired, was wheelchair bound, and who had been observed since admission to exit seeking behaviors, the Facility failed to ensure he/she was provided with an adequate level of supervision in an effort to maintain his/her safety in an effort to prevent an incident/accident resulting in an injury. On 09/14/23, prior to being transferred out of bed, Resident #1 verbalized to Certified Nurse Aide (CNA) #1 that he/she was going away and shortly afterwards he/she had exited the unit through an alarmed fire exit door and was found on the landing at the bottom of the staircase. Resident #1 was transferred to the Hospital Emergency Department for evaluation and was diagnosed with a left ankle fracture. Findings Include: The Facility Policy titled Elopement of a Patient, dated as revised 10/24/22, indicated an elopement was defined as any situation in which a patient leaves the premises or a safe area…

  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 · Past Non-Compliance
• Actual harm · Gcited before2023-08-29 · 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), whose Plan of Care indicated he/she was dependent on two staff members for bed mobility and positioning, and had a known behavior of sliding him/herself off the bed and onto the floor, with an intervention to keep the bed in the lowest position when in bed, the Facility failed to ensure nursing staff consistently implemented and followed interventions from his/her Plan of Care while meeting his/her care needs. On 08/12/23, Certified Nurse Aide (CNA) #1 provided care including turning and repositioning to Resident #1 while he/she was in bed, without another staff member present to assist her. During care CNA #1 left the room to get linens, leaving Resident #1 unattended and unassisted by a staff member, with the bed in the raised position. While CNA #1 was gone, Resident #1 rolled off the bed, hit his/her forehead on the nightstand, and landed on the floor. Resident #1 sustained an injury to his/her left eyebrow area, 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.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2023-08-29 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who required physical assistance from two staff members for bed mobility, the Facility failed to ensure he/she was provided with the necessary level of staff assistance to maintain his/her safety and prevent an incident/accident resulting in injury. On 08/12/23, Certified Nurse Aide #1, provided care to Resident #1, which included repositioning him/her, without another staff member present to assist her. CNA #1 rolled Resident #1 onto his/her side in bed, left him/her like that , and left him/her alone in bed while she went across the hall to get linen. Resident #1 rolled off his/her bed, hit the left side of his/her forehead on the nightstand, and landed on the floor. Resident #1 sustained an injury to his/her left eyebrow area, was transferred to the Hospital Emergency Department for evaluation and treatment and required five sutures and two staples to close his/her head wound. Findings include: The Facility Policy,…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2026-04-16 · tag F0842 — failed to keep accurate, complete medical records — pattern
  Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to document accurately in the medical record for four Residents (#29, #13, #82 and #4) out of a total sample of 30 residents. Specifically, 1.For Residents (a.) #29 and (b.) #13, the facility inaccurately documented blood pressure vital signs. 2. For Resident (a.) #82 the facility failed to accurately document the setting of an air mattress. (b). #4 the facility failed to accurately document the use of tubi grips. Findings include:1 (a). Resident #29 was admitted to the facility in March 2026 with diagnoses including dependence on renal dialysis. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] indicated a Brief Interview for Mental Status exam score of 14 out of 15 indicating intact cognition. Review of Resident #29's dialysis care plan initiated 3/4/26 indicated the following: -I currently have an alteration to my integumentary system due to left arm fistula (a surgically created connection between an artery and a…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-04-16 · tag F0641 — isolated
  Ensure each resident receives an accurate assessment.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to accurately complete the Minimum Data Set (MDS) assessments for two Residents (#2 and #5) out of a total sample of 30 residents. Specifically,1.) For Resident #2, the facility coded the Resident as having a diagnosis of Schizophrenia, in error. 2.) For Resident #5 the facility coded the Resident as having had an injection of insulin in error. Findings include:1.) Resident #2 was admitted to the facility in November 2018 and has diagnoses that include vascular dementia with psychotic disturbance and major depressive disorder. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE], indicated the Director of Nursing (DON) coded on the MDS that Resident #2 has a diagnosis of Schizophrenia. Review of prior MDS's dated 11/28/25, 8/28/25, and 7/10/25 failed to indicate Resident #2 has a diagnosis of Schizophrenia. Review of the Level I PAS (pre-admission screen), dated 11/17/18, failed to indicate a diagnosis of Schizophrenia. 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.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-04-16 · 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 implement physician orders for two Residents (#4 and #82) out of a total sample of 30 residents. Specifically:For Resident #4 the facility failed to implement tubi grips (used for support and compression) daily.For Resident #82 the facility failed to implement the correct air mattress setting.Findings include:Review of the facility policy titled Physician Orders, dated as revised November 2025, indicated that physician orders are to be implemented in accordance with professional standards. 1. Resident #4 was admitted to the facility in August 2021 with diagnoses including peripheral vascular disease, heart disease and kidney disease. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #4 scored an 11 out of 15 on the Brief Interview for Mental Status exam, indicating moderately impaired cognition. The MDS further indicated that Resident #4 requires substantial to maximal assist with activities 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.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-04-16 · tag F0814 — failed to dispose of garbage properly — isolated
  Dispose of garbage and refuse properly.
  What the surveyor found here — the official record, unedited, may be distressing

  Based on observation and interview the facility failed to dispose of garbage and refuse properly. Findings include:On 4/14/26 at 8:07 A.M., the surveyor observed the edge of the property to contain the following:a. three rusted metal drum barrels.b. a rusted refrigerator c. a rusted wheelchaird. a grey wheeled plastic cart covered with a white sheete. two nightstandsf. white paper items scattered in the adjoining woodsg.14 plastic red and black milk crates scattered in the adjoining woods. During an interview on 4/15/26 at 3:40 P.M., the Regional Director of Maintenance said that the accumulation of discarded barrels, refrigerator, wheelchair etcetera should not have been allowed to occur. The Regional Maintenance Director said that there was no process in place to ensure that refuse does not accumulate outside.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-03-26 · tag F0658 — failed to meet professional standards of care — pattern
  Ensure services provided by the nursing facility meet professional standards of quality.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure four Residents (#101, #94, #210, and #206) received care in accordance with professional standards of practice, out of a total sample of 27 residents. Specifically, 1. For Resident #101, the facility failed to ensure nursing obtained physician's orders for a cervical collar (a neck brace which is used to support and immobilize a person's neck.) 2a. For Resident #210, the facility failed to ensure the nurse documented acetaminophen as administered timely. 2b. For Resident #94, the facility failed to ensure the nurse documented acetaminophen as administered timely. 3. For Resident #206, the facility failed to obtain and monitor external measurements of a peripherally inserted central catheter (also known as a PICC line, is a long, flexible tube (catheter) that is inserted into a vein in your upper arm. After insertion, the catheter is threaded to a central vein near the heart. The PICC line can be used to deliver fluids and…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-03-26 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
  Provide care and assistance to perform activities of daily living for any resident who is unable.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and interviews, the facility failed to provide assistance with Activities of Daily Living (ADLs) for dependent residents for three Residents (#98, #88, #49) out of a total sample of 27 residents. Specifically, the facility failed to: 1. For Resident #98, the facility failed to provide assistance with bathing. 2. For Resident #88, the facility failed to provide supervision while eating during mealtimes. 3. For Resident #49, the facility failed to ensure staff provided assistance with managing denture care and ensuring dentures were available for meals. Findings include: Review of the facility policy titled 'Activities of Daily Living (ADL)', dated 1/23/24, indicated, but was not limited to the following: - Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. - Appropriate care and services will be provided for residents who are unable to carry out…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-03-26 · tag F0761 — failed to label and store drugs safely — pattern
  Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on 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 medications with shortened expiration dates were dated once opened in three out of three medication carts observed. 2. The facility failed to ensure the medication room was locked when unattended. 3. The facility failed to ensure treatment carts were locked when unattended. Findings include: Review of the facility policy titled 'Storage, Labeling of OTC (over the counter) Medication, Destruction and Disposal of Medication', revised 11/9/24, indicated: - No discontinued, outdated, or deteriorated medications should be available for use in the facility. All such medications are destroyed per policy. - Expired medications are to be removed from areas medication carts prior to or at the time of expiration. - Compartments containing medications should be locked when not in use. Trays of carts used to transport such items should be left unattended. (Note: Compartments include, but are…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-03-26 · tag F0578 — failed to honor advance directives / code status — isolated
  Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure advanced directives for one Resident (#94), out of total sample of 27, were executed in accordance with standards of practice. Specifically, the facility failed to ensure Resident #94 signed his/her own MOLST (Medical Orders for Life Sustaining Treatment). Findings include: Review of the Facility's policy, titled Advanced Directive, dated as revised October 2024 indicated, Policy: It is the policy, of this facility to ensure residents 'right to request, refuse, and/or discontinue treatment to participate and refuse to participate in experimental research, and formulate an advice directive'. Definitions: Medical Orders for Life-Sustaining Treatment (MOLST) paradigm form is a form designed to improve patient care by creating a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency, taking the patient's current medical condition into…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-03-26 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
  Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
  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 ensure a safe and homelike environment for one Resident (#405), out of 27 total sampled residents. Specifically, the facility failed to ensure Resident #405's nightstand was functional, safe, and in good repair. Findings include: Review of the facility policy titled 'Equipment and Supplies', revised 11/5/24, indicated: - Equipment in disrepair will be removed from service until in safe and proper working condition. Resident #405 was admitted to the facility in March 2020 with diagnoses including dementia and cataract. Review of the most recent Minimum Data Set (MDS) assessment, dated 2/26/25, indicated Resident #405 was rarely/never understood and had severe cognitive impairment based on a Staff Assessment for Mental Status. This MDS also indicated Resident #405 required supervision or touching assistance to walk up to 150 feet and supervision or touching assistance to eat. On 3/24/25 at 8:07 A.M., the surveyor observed Resident #405 in bed. There was a nightstand directly next to the right side of the…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-03-26 · 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 record review and interview, the facility failed to document the communication needs of one Resident (#97), out of a sample of 27 residents. Specifically, the facility failed to develop a care plan identifying Resident #97's preferred language of communication. Findings include: A review of the facility policy titled 'Residents and Families with Limited English Proficiency' revised 10/16/24 indicated the following: -The facility offers language services at no charge to the individuals with limited English proficiency. -The language and communication needs of the individual are documented in the electronic medical record. Resident #97 was admitted to the facility in February 2025 with diagnoses including dementia. A review of the Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 indicating Resident #97 had intact cognition. Further review of the MDS indicated that Resident #97's preferred language is Spanish and he/she wants 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.

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

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

Fines & penalties

$44,265 in federal fines across 3 penalties.

• $25,847 — penalty dated 2024-04-12
• $10,517 — penalty dated 2023-09-26
• $7,901 — penalty dated 2023-08-29

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

Part of a chain

This home belongs to STERN CONSULTANTS — 22 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 →

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

CMS files one row per role, so the 31 rows in the source record cover these 14 parties — each is shown once here with every role it holds. Nothing is omitted.

6 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.

About 88% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.9M paid to related parties — landlords or management companies under common ownership — equal to about 16% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. 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