Madonna Manor Nursing Home

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.

43.6% 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 52 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 50.0% 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 54 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 0.17 therapist hours per resident per day in 2026Q1 — more than 16% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 27% 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 129 beds and averages 70.2 residents a day — about 54% occupied, or roughly 59 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 4.03 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.79 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.12 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 3.75 hrs/resident/day on weekends vs 4.15 on weekdays — 10% thinner on weekends. RN hours go from 0.88 to 0.55 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 15% 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.

29 citations, most serious first. The 15 most serious are shown; the remaining 14 are one tap away and print in full.

• Actual harm · G2024-08-21 · tag F0580 — failed to tell family and doctor about changes — isolated
  Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and document review, the facility failed to notify the physician of an ongoing and significant weight loss for one Resident (#26), out of a total sample of 18 residents. Findings include: Review of the facility's policy titled Weight Loss Policy, dated as reviewed 2/2024, indicated but was not limited to the following: - all confirmed weight loss of 5 pounds (lbs.) or more within one month is reported to the dietician, the weight information is recorded in the chart - staff must also report any continuing trends of monthly weight loss, even if it is below 5 lbs. - the dietician is responsible for determining if weight loss is significant, unplanned (weight loss greater than (>) 5% in one month, 10% in 6 months) - the physician is to be notified by nursing staff of any significant weight loss Resident #26 was admitted to the facility in December 2023 and has diagnoses including: Hypothyroidism and dysphagia (difficulty swallowing). The Brief Interview for Mental Status (BIMS), dated 6/14/24, indicated the Resident was cognitively intact with a score of 15 out 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 Rights Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2024-08-21 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
  Provide enough food/fluids to maintain a resident's health.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and documentation review, the facility failed to ensure acceptable parameters of nutritional status were maintained for one Resident (#26), out of 18 sampled residents. Specifically, the facility failed to ensure ideal or usual body weight was maintained and interventions implemented and re-evaluated to prevent significant and ongoing weight loss for the Resident which was unplanned and undesired. Findings include: Review of the facility's policy titled Weight Loss Policy, dated as reviewed 2/2024, indicated but was not limited to the following: - all confirmed weight loss of 5 pounds (lbs.) or more within one month is reported to the dietician, the weight information is recorded in the chart - staff must also report any continuing trends of monthly weight loss, even if it is below 5 lbs. - the dietician is responsible for determining if weight loss is significant, unplanned (weight loss greater than (>) 5% in one month, 10% in 6 months) - if the dietician determines weight…

  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
• Actual harm · G2023-09-06 · 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 #2), whose Plan of Care indicated he/she required physical assistance of one staff member with toileting which included assistance with hygiene care needs, utilized bed/chair alarms for safety and was assessed by nursing at high risk for falls, 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 08/30/23, Certified Nurse Aide (CNA) #1 brought Resident #2 into the bathroom, transferred and positioned him/her onto the toilet (which was not alarmed), CNA #1 then exited the bathroom and Resident #2's room, leaving him/her unattended and unassisted by a staff member. A short time later Resident #2 was heard calling out for help, and was found lying on his/her back on the floor near the recliner in his/her room complaining of left hip pain. after he/she had transferred him/herself off of the toilet and ambulated unassisted by…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2023-09-06 · 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 #2), who was assessed by nursing at high risk for falls, whose Plan of Care indicated that he/she required physical assistance with toileting care needs, including transfers on and off the toilet, the Facility failed to ensure he/she was provided with the required level of staff assistance to maintain his/her safety, in an effort to prevent incidents/accidents resulting in an injury. On 08/30/23, Certified Nurse Aide (CNA) #1 brought Resident #2 into the bathroom, assisted with transferring and positioning him/her on the toilet (which was not equipped with an alarm) and then left the bathroom and Resident #2's room leaving him/her unattended by a staff member. A short time later, Resident #2 was heard calling out for help, and was found lying on his/her back on the floor in his/her room near the recliner complaining of left hip pain. Upon assessment, Resident #2's left leg was noted to be externally rotated. Resident #2 was…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2023-07-19 · 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 observation, record review, policy review, and interviews, the facility failed to ensure its staff provided each resident an environment free of accident hazards and adequate supervision and assistance devices to prevent potential accidents or injuries. Specifically, the facility failed: 1. For one Resident (#48), out of a total sample of 19 residents, to ensure effective interventions were implemented to prevent three falls, including one with injury, requiring transfer to an acute care hospital; and 2. To ensure the Treatment Room door was closed and locked, exposing wandering residents to an environment with medication and medical supply hazards, on one of three units. Findings include: 1. Review of the facility's policy titled Fall Prevention Program, last reviewed 10/2022, included but was not limited to: -Residents who experience a fall will have an incident report and resident incident investigation follow up. -Immediate interventions will be implemented. -The nurse manager or shift supervisor…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-09-11 · tag F0761 — failed to label and store drugs safely — isolated
  Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure medications were accurately labeled and stored in accordance with acceptable professional standards. Specifically, in one of three medication carts reviewed the facility failed to ensure medications were stored in their original packaging. Findings include: Review of the facility's policy titled Medication Storage in the Facility, dated March 2021, indicated but was not limited to:-The provider pharmacy dispenses medications in containers that meet regulatory requirements, including standards set forth by the United State Pharmacopeia (USP). Medications are kept in these containers. Nurses may not transfer medications from one container to another.-All medications dispensed by the pharmacy are stored in the container with the pharmacy label. On 9/10/25 at 12:48 P.M., the surveyor observed a medicine cup containing several unlabeled medications, in the 2nd floor [NAME] Unit medication cart third drawer. The medicine cup included eight pills:-one…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-09-11 · tag F0804 — failed to serve food at safe, palatable temperature — isolated
  Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure residents received food prepared by methods that conserve nutritive value, flavor and appearance and was palatable, attractive and at a safe and appetizing temperature for one of two test trays. Findings include:Review of Resident Council Minutes indicated the following resident concerns and facility solutions:- 7/3/25: food trays are warm, but not hot and meals are delivered at incorrect times. The Food Service Director (FSD) is training new staff, and the metal plate warmer was not functioning and was being fixed.- 8/7/25: FSD attended meeting and explained to residents the piece of equipment (metal plate warmer) that was not working in the main kitchen. On 9/10/25 at 11:00 A.M., 10 of 17 residents in attendance of the Resident Council Meeting said food was cool or lukewarm and that trays were coming later than scheduled. On 9/11/25 at 8:00 A.M., the surveyor requested a test tray to the second floor unit and made the following observations:-…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-09-11 · tag F0812 — failed to store, cook, and serve food safely — isolated
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to:1. Ensure the main kitchen grout and coving was maintained in a sanitary and safe condition; and2. Ensure ready to eat foods (food which does not require cooking or further preparation prior to consumption) were handled utilizing proper hand hygiene to prevent cross contamination (transfer of pathogens from one surface to another) during tray line service. Findings include:1. Review of the 2022 Food Code by the Food and Drug Administration (FDA), revised January 2023, indicated but was not limited to the following:1-2 Definitions 1-201 Applicability and Terms Defined1-201.10 Statement of Application and Listing of Terms.Easily Cleanable.(1) Easily cleanable means a characteristic of a surface that: (a) Allows effective removal of soil by normal cleaning methods; (b) Is dependent on the material, design, construction, 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.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-09-11 · tag F0840 — isolated
  Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility failed to ensure one Resident (#9), out of a total sample of 18 residents, was referred to see a Neurologist as recommended by the Psychiatrist and the Primary Physician.Findings include:Resident #9 was admitted to the facility in October 2022 with a diagnosis of history of bipolar disorder and anxiety.Review of the Minimum Data Set (MDS) assessment, dated 7/2/25, indicated Resident #9 scored 10 out of 15 on the Brief Interview for Mental Status, indicating the Resident had a moderate cognitive impairment. Review of Section S indicated Resident #9 was their own healthcare decision maker. Review of the medical record indicated Resident #9 had a telehealth visit with the Psychiatrist on 6/16/25. The Subsequent Nursing Facility Visit summary indicated Resident #9 became weepy while talking about his/her condition of involuntary movements/tremors. The Recommendations section indicated Due to {his/her} concerns that tremors have been depressing for {him/her}, consider referral to Neurology for consultation and recommendations 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.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-09-11 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, record review, and interviews, the facility failed to ensure infection prevention and control measures were implemented to prevent the potential transmission of infections for one Resident (#33), out of a total sample of three residents observed for medication administration. Specifically, the facility failed to ensure staff followed safe injection standard practices, by recapping used needles after the administration of insulin.Findings include:Review of the facility's policy titled Specific Medication Administration Procedures, dated March 2021, indicated but was not limited to the following:-Injectable medication administration: To administer medications via subcutaneous route in a safe and effective manner.-Discard syringe and needle in designated area.-Activate needle safety feature.-Do not recap needleReview of the Occupational Safety and Health Administration (OSHA) Fact Sheet (DSG FS-3519) titled Protecting Yourself When Handling Contaminated Sharps, dated 1/2011, indicated sharps are objects that can penetrate a worker's skin, such as needles If blood…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-09-11 · tag F0887 — isolated
  Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
  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 employee record review and interview, the facility failed to ensure the new hire employee records contained evidence of the 2024-2025 COVID-19 vaccination for two of five newly hired employees. Specifically, the facility failed to ensure the employee record contained evidence of the COVID-19 vaccination or proof the newly hired employees were offered an updated COVID-19 vaccine when he/she was eligible. Findings include: Review of the facility's policy titled COVID-19 Personnel Vaccination Requirement, dated as revised 5/2023, indicated but was not limited to:-All nursing homes must ensure that all personnel are up to date with vaccination against COVID-19, unless such administration is medically contraindicated or on the basis of a sincerely held religious belief-Vaccinations against COVID -19 will be made available to staff as arranged by the infection control nurse Review of the Centers for Disease Control and Prevention (CDC) guidance, Staying up to date with COVID-19 vaccinations, dated as revised…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-12-02 · tag F0842 — failed to keep accurate, complete medical records — isolated
  Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who required physical assistance from staff for positioning, the Facility failed to ensure they maintained a complete and accurate medical record, related to Certified Nurse Aide (CNA) Positioning Sheets, when daily documentation by CNA's (for all three shifts) was not consistently completed and positioning sheets were often left completely blank. Findings Include: Review of the Facility's Policy tilted CNA Documentation, dated as revised 10/05/2021, indicated the Certified Nurses' Aides will provide accurate documentation daily on each shift using the Electronic Medical Record (EMR). Resident #1 was admitted to the Facility in May 2023, diagnoses included Parkinson's disease, spinal stenosis (narrowing of space within the spine) of cervical region, muscle weakness, contracture (tightening of muscles, and tendons causing joints to become stiff) of unspecified joint, and hypertension, Review of Resident #1's Significant Change in Status Minimum Data (MDS) Assessment, dated 07/18/24, 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.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-08-21 · tag F0565 — failed to support the resident council — pattern
  Honor the resident's right to organize and participate in resident/family groups in the facility.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on a resident group meeting, staff interviews, and document review, the facility failed to ensure concerns from the Resident Council were documented to ensure they were acted upon timely and included the facility response. Findings include: Review of the facility's policy titled Resident Council, dated as reviewed 9/2023, indicated but was not limited to the following: - the home will listen to and follow up on residents' complaints and grievances through Resident Council meetings and individual resident requests - distribute minutes of the last meeting to the administrator and resident council president - notify department heads of complaints when presented - schedule department head to answer complaints of residents at the next council meeting or immediately, if required - each facility shall have a resident council consisting of representatives elected by facility residents elected annually Review of the Resident Council Meeting Minutes from February 2024 through July 2024 indicated the residents in attendance at those meetings had no concerns for any department for 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 · E2024-08-21 · tag F0585 — failed to handle grievances — pattern
  Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interviews, document review, and observations, the facility failed to have information on how to file a grievance in resident care and public areas and have forms accessible, so residents and/or visitors were able to anonymously notify the facility of their concerns. Findings include: Review of the facility's policy titled Resident/Staff/Family Member Grievances, dated as reviewed 4/2023, indicated but was not limited to the following: - any resident/staff/family member or designated representative who has a complaint or suggestion, shall report to the charge nurse or social worker on the unit involved, or complete a grievance form - the nurse or social worker will respond appropriately, after assessing the nature of the complaint and will complete the grievance form if one has not already been completed - the grievance report itself will be submitted to the Administrator/Department head as soon as possible - grievances, actions taken and results are to be documented on the grievance report and kept on file in the Administrator's office Review of the facility Grievance Book…

  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 · E2024-08-21 · tag F0604 — failed to not use physical restraints improperly — pattern
  Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review, interview, and document review, the facility failed to evaluate the use of a one-piece jumpsuit as a restraint for one Resident (#67), to ensure it was the least restricted device and necessary, out of a total sample of 18 residents. Findings include: Review of the facility's policy titled Physical Restraint Policy, dated as reviewed 4/2024, indicated but was not limited to the following: - restraints will only be used in circumstances in which the resident has medical symptoms that warrant the use of the restraint - the need for restraint use if assessed by the interdisciplinary team as needed, quarterly and with any significant changes for residents with restraints - the facility follows a systematic process of evaluation and care planning prior to using restraints Resident #67 was admitted to the facility in February 2023 and had diagnoses including: dementia without behavioral disturbance and late onset Alzheimer's disease. Review of the Minimum Data Set (MDS) assessment for Resident #67, dated 7/17/24, indicated the Resident had a Brief Interview 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.

  Freedom from Abuse, Neglect, and Exploitation 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

$43,011 in federal fines across 1 penalty.

• $43,011 — penalty dated 2024-08-21

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 DIOCESAN HEALTH FACILITIES — 5 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

The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.

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 $250K 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