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Alliance Health At Marina Bay

2 Seaport Drive, Quincy, MA 02171 · Non profit - Corporation · 167 certified beds · (617) 769-5106 Medicare & Medicaid certified

Call the home — (617) 769-5106 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0604, F0607, F0609) — most recent Nov 20251 actual-harm citation
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0607, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags

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.

3/5
CMS overall
3 of 5
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

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
500 Victory Rd Ste 3C · (617) 481-6905 · Call to confirm hours
Pharmacy
321 Quincy Shore Dr · (617) 471-0041 · Call to confirm hours
Grocery
333 Victory Rd · (617) 804-1331 · Call to confirm hours
Park
Miwra Haul Rd · (617) 727-5290 · Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 3 of 5
Short-stay residentsrehab / post-hospital 5 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.

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased15.7%16.4%15.4%typical
Long-stay residents who lose too much weight3.2%5.1%5.4%better
Long-stay residents with a catheter left in their bladder1.3%0.8%0.9%worse
Long-stay residents with a urinary tract infection0.9%1.8%2.0%better
Long-stay residents with depressive symptoms6.4%15.5%6.5%typical
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury3.6%3.4%3.3%typical
Long-stay residents whose ability to walk worsened17.8%15.4%16.1%worse
Long-stay residents on antianxiety or hypnotic medication22.0%19.5%18.9%worse
Long-stay residents given the seasonal flu vaccine96.1%94.8%95.3%typical
Long-stay residents with pressure ulcers3.5%4.2%4.7%better
Long-stay residents with worsening bladder/bowel control10.3%21.2%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table12.5%21.4%17.1%better
Short-stay residents who newly got an antipsychotic medication0.6%1.4%1.4%better
Short-stay residents given the seasonal flu vaccine81.2%77.7%79.4%typical
Short-stay residents rehospitalized after admission32.8%25.7%22.6%worse
Short-stay residents with an outpatient ER visit8.3%11.9%12.0%better
Long-stay hospitalizations per 1,000 resident days2.391.881.67worse
Long-stay outpatient ER visits per 1,000 resident days1.421.501.80better

§ 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.

62.8% 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 522 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

62.8%U.S. median 51.5%
Got home and stayed home
13.1%U.S. median 10.7%
Went back to hospital
60.5%U.S. median 56.6%
Met the expected recovery
0.41U.S. median 0.31
Therapy hours / resident / day
0.13hours / resident / day
Physical therapy
0.21hours / resident / day
Occupational therapy
0.07hours / resident / day
Speech therapy

Met the expected recovery: 60.5% 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 238 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 0.41 therapist hours per resident per day in 2026Q1 — more than 71% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 32% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF62.8%CMS range 58.6–67.451.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF13.1%CMS range 10.6–15.610.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge60.5%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge45.4%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge54.2%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified99.3%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting96.4%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened1.6%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.2%CMS range 5.4–9.27.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.811.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.77
RN hours/ resident / day
0.83
LPN hours/ resident / day
2.40
Aide hours/ resident / day
3.99
Total nurse hours/ resident / day
0.67
RN hoursweekends
37.7%
Total nursing turnover
47.6%
RN turnover

How full it usually is: this home is certified for 167 beds and averages 154.0 residents a day — about 92% occupied, or roughly 13 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 3.99 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.77 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.40 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 3.60 hrs/resident/day on weekends vs 4.15 on weekdays — 13% thinner on weekends. RN hours go from 0.81 to 0.67 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 38% is about the same as 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

7
deficiencies at the latest standard inspection (2025-11-21)
7
at the previous standard inspection (2024-09-23)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

26 citations, most serious first. The 11 most serious are shown; the remaining 15 are one tap away and print in full.

  • Actual harm · G2023-06-14 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    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 prevent a decline in range of motion causing the development of a contracture for one Resident (#122), out of a total sample of 31 residents. Findings include: Resident #122 was admitted to the facility in April 2022 with diagnoses the included but were not limited to chronic obstructive pulmonary disease, chronic respiratory failure, unspecified severe protein calorie malnutrition, adult failure to thrive, depression, and other abnormalities of gait and mobility. Review of Resident #122's Minimum Data Set assessment, with an Assessment Reference Date of 5/12/23, indicated the Resident scored 14 out of 15 on the Brief Interview for Mental Status exam, which indicates intact cognition, requires extensive assistance from two staff for bed mobility, hygiene, and eats independently with set up. Further, the MDS indicated that Resident #122 did not have functional limitation of range of motion in his/her upper extremity. On 6/14/23 at 8:05 A.M., the surveyor observed Resident #122 in bed. His/her right hand was…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-11-21 · tag F0692 — failed to prevent malnutrition and dehydration — pattern
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, observation, and interviews, the facility failed to maintain acceptable parameters of nutritional status for one Resident (#131) with an unplanned weight loss, out of a total sample of 30 residents. Specifically, the facility failed for Resident #131 to implement dietary recommendations/interventions after weight loss had been identified, and he/she continued to lose weight. Findings include: Review of the facility's policy titled Consultant Dietician, dated as last revised 11/1/2021, indicated but was not limited to the following:-The consultant Dietician has weekly regular hours of sufficient duration to provide consultation to staff regarding Residents' dietary needs and assistance with the revision and implementation of Nutritional Policies and Procedures.-The Registered Dietician (RD) will provide a comprehensive report to the Executive Director and the Director of Nurses (DON) following each visit. Resident #131 was admitted to the facility in September 2024 with diagnoses which included B-cell lymphoma and diabetes mellitus. 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-11-21 · tag F0759 — failed to keep medication error rate low — pattern
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, records reviewed, and interviews, the facility failed to ensure it was free from a medication error rate of greater than 5% when two out of three nurses observed during a medication pass made five errors out of 27 opportunities, resulting in a medication error rate of 18.52%. Specifically,1. For Resident #161, Nurse #3 prepared his/her medications, failed to identify the Resident and attempted to administer the medications to Resident #162; and,2. For Resident #93, failed to administer the correct does of Calcium plus Vitamin D; and3. For Resident #143, failed to administer the correct form of Vitamin B.Findings include:Review of the facility's policy titled Medication Administration-General Guidelines, last revised 1/2024, indicated but was not limited to:-Medications are administered as prescribed in accordance with good nursing principles and practices.-Five Rights- Right resident, right drug, right dose, right route, and right time, are applied for each medication being administered.-A triple check of these 5 Rights is recommended at three steps in the…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-11-21 · tag F0607 — failed to have anti-abuse policies — isolated
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to implement written policies and procedures for an allegation of abuse for one Resident (#5), out of a total sample of 30 residents. Specifically, the facility failed to initiate their abuse policy after an allegation of abuse was documented and reported on 5/1/25. Findings include:Review of the facility's policy titled Abuse Prohibition, last revised 10/11/22, indicated but was not limited to:-The facility will provide an environment in which the resident is free from abuse, neglect, mistreatment, misappropriation of resident property, or exploitation, including but not limited to freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint that is not required to treat the resident's medical symptoms.-Identifying events, occurrences, patterns, and trends of potential abuse for residents.-Performing internal facility investigations of alleged violations and identification of staff members responsible for investigating incidents and the reporting of the same to proper…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-11-21 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interviews, the facility failed to report an allegation of abuse to the state agency for one Resident (#5), out of a total sample of 30 residents.Findings include:Review of the facility's policy titled Abuse Prohibition, last revised 10/11/22, indicated but was not limited to:-Reporting of all alleged violations of resident abuse to appropriate state agencies utilizing the proper online reporting system with the simultaneous development of corrective actions determined as part of the internal facility investigation to prevent further occurrences of abuse.-The executive director shall assume the overall responsibility to ensure that incident reports are accurately completed and personnel statements are obtained timely to ensure proper completion of the internal facility investigation the executive director shall ensure that the appropriate agency agencies are notified in writing as warranted of abuse allegations in all investigatory findings by utilizing the state documentation tool the initial report shall be submitted to the department immediately but not…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-11-21 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to develop and implement a person-centered care plan for the use of psychotropic medications for one Resident (#163), out of a total sample of 30 residents. Specifically, the facility failed for Resident #163 to ensure a care plan had been developed for the use of Ativan/Lorazepam (anti-anxiety medication), to monitor for adverse effects/side-effects of the medication, and to monitor for targeted behaviors. Findings include: Review of the facility's policy titled Comprehensive Person-Centered Care Planning, dated as last revised 9/22/22, indicated but was not limited to the following:-The facility is required to develop a comprehensive person-centered care plan for each resident that is consistent with resident rights and includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs.-Reviewed and revised by the interdisciplinary team, after each assessment, including comprehensive and quarterly review assessments. Review of the facility's policy titled Psychotropic…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-11-21 · tag F0699 — isolated
    Provide care or services that was trauma informed and/or culturally competent.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to assess and develop a person-centered plan of care which included trauma informed approaches and identified triggers to avoid potential re-traumatization for one Resident (#160) with a history of trauma, out of a total sample of 30 residents.Findings include: Review of the facility's policy titled Trauma Informed Care Program, revision date 10/16/22, included but was not limited to the following:-Procedures: residents will be screened for past trauma and for signs/symptoms of traumatic stress upon admission, quarterly, annually, and as needed. -If the result of the screen indicates the presence of trauma or traumatic stress, further assessment will be completed. The interdisciplinary team, in collaboration with the resident and with the approved resident's representative will create a culturally sensitive plan of care to help prevent re-traumatization and to optimize quality of life. Individualized resident triggers will be identified as able.-These plans of care shall include the identified trigger, prevention,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-11-21 · 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 interviews, the facility failed to prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure for Resident #163 that staff performed hand hygiene and donned (put on) gloves and/or used utensils while handling ready to eat food during breakfast service/meal preparation. Findings include:Review of the Food and Drug Administration (FDA) Food Code 2022 indicated:3-301 Preventing Contamination by Employees3-301.11 Preventing Contamination from Hands.(A) FOOD EMPLOYEES shall wash their hands as specified under S 2-301.12. (B) Except when washing fruits and vegetables as specified under S3-302.15 or as specified in (D) and (E) of this section, FOOD EMPLOYEES may not contact exposed, READY-TO-EAT FOOD with their bare hands and shall use suitable UTENSILS such as deli tissue, spatulas, tongs, single-use gloves, or dispensing EQUIPMENT. Review of the facility's policy titled Proper Food Preparation, dated as last revised 9/1/24, indicated but was not limited to the following:-All…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-09-23 · tag F0759 — failed to keep medication error rate low — pattern
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure it was free from a medication error rate of greater than five percent when one of two nurses made seven errors out of 40 opportunities, totaling a medication error rate of 17.5%. These errors impacted one Resident (#14), out of three residents observed. Specifically, the nurse administered the wrong dose of Buspar (for anxiety), Neurontin (for seizures or nerve pain), and Tylenol (for mild to moderate pain), and failed to administer Anoro Ellipta (inhaler for lung conditions), Fluticasone Propionate (inhaler for lung conditions), Ipratropium Bromide (aerosol for lung conditions), and Lidocaine patches (local anesthetic for pain management) as ordered. Findings include: Review of the facility's policy titled Administration Procedures for All Medications, dated as last revised 2024, indicated but was not limited to the following: -Review 5 rights 3 times -Check Medication Administration Record (MAR) for order -Check the label against the order on the MAR Review of the facility's policy titled Physician…

    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 · Ecited before2024-09-23 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to properly label and date food products, and to maintain safe and clean equipment in four of five nourishment kitchenettes. Findings include: Review of the facility's policy titled Food & Nutrition Services, revised 12/5/21, indicated but was not limited to the following: - Food brought in by family or visitors will be in a secure container/bag, dated and will be subject to disposal based on sanitary, safe consumption. - If there are leftovers, the Facility will label the leftovers and store them in accordance with the Facility's policies for use and storage of foods, including but not limited to, policies relating to food sanitation. On 9/17/24 at 9:09 A.M., the surveyor made the following observations on the Cityside Unit nourishment kitchenette: - The inside of the microwave had orange and brown residue and food…

    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 · D2024-09-23 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure one Resident (#303) was informed of and actively participated in his/her baseline plan of care within the first 48 hours following admission, out of a total sample of 31 residents. Findings include: Review of the facility's policy titled Baseline Care Plan, dated as revised 8/15/23, indicated but was not limited to: - a baseline care plan is developed within 48 hours of admission to the facility Process: - interview resident, obtain physician orders, complete admission nursing assessment and begin interdisciplinary (IDT) assessment, review transfer information, develop baseline care plan with IDT, continue to gather information - the facility will provide the resident with a summary of the baseline care plan that includes but is not limited to: initial goals of the resident, summary of resident's medications and dietary instructions, any services and treatments to be administered by the facility Resident #303 was admitted to 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
Show the remaining 15 citations
  • Potential for harm · D2024-09-23 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and document review, the facility failed to ensure professional standards of care were met for two Residents (#145 and #14), out of a total sample of 31 residents. Specifically, the facility failed: 1. For Resident #145, to administer care (one to one (1:1) assist during intake by mouth (PO)) in accordance to physician's orders; and 2. For Resident #14, to follow the standard of medication preparation and administration and document missed or refused medications that were ordered by the physician. Findings include: Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated: Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber's that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place,…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-23 · 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, interview, and document review, the facility failed to ensure all medications used in the facility were stored and labeled in accordance with currently accepted professional principles. Specifically, the facility failed to: 1. Ensure staff properly labeled all medications stored in one of four medication carts reviewed once opened; and 2. Provide a permanently affixed compartment for the storage of a schedule IV (potential for misuse and dependence) controlled substance in one of two medication room refrigerators reviewed. Findings include: Review of the facility's policy titled Medication Storage in the Facility, revised 2024, indicated but was not limited to the following: -Controlled substances that require refrigeration are stored within a locked box within the refrigerator. This box must be attached to the inside of the refrigerator. -Certain medications or package types, such as IV solutions, multiple dose injectable vials, ophthalmics, nitroglycerin tablets, blood sugar testing…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-23 · 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

    Based on resident and staff interviews, observation, and meal test trays on two of three units, the facility failed to prepare and serve meals in a manner conserving flavor, were palatable, and served at safe and appetizing temperatures. Findings include: Review of Resident Council Meeting Minutes, dated 6/26/24, indicated several residents were concerned about food temperatures and receiving cold food. During a Resident Council Meeting held on 9/18/24 at 1:00 P.M. by the survey team, 14 out of 14 residents present at the meeting said there was a concern about cold food temperatures across all mealtimes. On 9/19/24 at 11:30 A.M., the surveyor requested a lunch test tray to the Harborside Two Unit. The food truck left the kitchen at 11:53 A.M. and arrived at 11:55 A.M. on the unit. The test tray was conducted with the Dietitian observing at 12:06 P.M. with the following results in degrees Fahrenheit (F): - Sweet and Sour Chicken: 138.8 F - Mixed Vegetable (Carrots, Broccoli, Cauliflower): 108.7 F: soft, lacking flavor, cold to taste - Rice: 116.5 F: bland tasting, cold to taste -…

    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 · D2024-09-23 · 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 for one Resident (#114), out of a total sample of three residents observed on a medication pass, infection prevention and control measures were implemented to prevent the potential transmission of infections. Specifically, the facility failed to ensure staff followed basic infection control practices, including hand hygiene, resulting in potential cross contamination (transfer of pathogens from one surface to another). Findings include: Review of the facility's policy titled Handwashing/Hand Hygiene, dated as last revised August 2017, indicated but was not limited to the following: When to wash hands (at a minimum) -Before and after direct patient/resident contact -After completing tasks at one patient/resident area before moving to another station -Before procedures, such as administering medications -After contact with items/surfaces in patient/resident areas When to use the alcohol hand sanitizer -After contact with resident intact skin -Before entering the resident rooms -Before exiting 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-13 · 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 records reviewed and interviews for one of three sampled residents (Resident #1), who complained of abdominal pain and experienced multiple episodes of diarrhea for several days which interfered with his/her ability to participate in rehabilitation therapy, the Facility failed to ensure nursing notified his/her Physician in a timely manner of his/her change in condition, in an effort to obtain orders to meet his/her care and treatment needs. Findings Include: Review of the Facility Policy titled, Condition: Significant Change, dated as last revised 2/16/16, indicated that professional staff will promptly communicate with the physician, resident, and family regarding changes in condition. The Policy further indicated that the notification including date, time, and by whom, shall be documented in the clinical record by appropriate personnel. Resident #1 was admitted to the Facility in December 2022, diagnoses included sepsis (an infection in the blood), pneumonia, chronic obstructive pulmonary disease, respiratory failure, cerebral vascular accident (interruption in 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-06-14 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, policy review, and interview, the facility failed to provide a dignified dining experience for one Resident (#113), out of a total sample of 31 residents. Specifically, staff stood over the Resident while feeding him/her meals, rather than seated at eye level. Findings include: Review of the facility's policy titled Resident Rights, dated as revised 11/28/21, indicated: *The Resident has the right to be treated with respect and dignity. Resident #113 was admitted to the facility in November 2021 with diagnoses including malignant neoplasm part of bronchus or lung and dementia. Review of the most recent Minimum Data Set (MDS) assessment, dated 5/5/23, indicated that Resident #113 was assessed by staff to have severe cognitive impairment and is rarely/never understood. The MDS further indicated Resident #113 was totally dependent on staff for all Activities of Daily Living (ADLs). On 6/12/23 at 8:22 A.M., the surveyor observed a Certified Nursing Assistant (CNA) feeding Resident #113. The CNA was standing over Resident #113 while feeding him/her, the Resident's…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-06-14 · tag F0604 — failed to not use physical restraints improperly — isolated
    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 observation, record review, and interview, the facility failed to ensure one Resident (#113) was free from restraints, out of a total sample of 31 residents. Specifically, for Resident #113 the facility failed to assess the use of pillows under the fitted sheet on both sides of the bed as a potential restraint. Findings include: Review of the facility's policy titled 'Restraints', dated as revised 10/20/21, indicated the following: Purpose: Therapeutic use of a device used as a restraint may be used when all other interventions or alternatives to a restraint are not effective. Procedure: 1. If a restraint is used a licensed therapist and/or a nurse will assess the resident for appropriate interventions and a plan of care will be developed. Documentation within the medical record will include verification that: - The resident has medical symptoms for which the restraints have been determined to achieve or maintain the highest level of mental, physical, and psychosocial well-being. Resident #113 was admitted to the facility in November 2021 with diagnoses including malignant…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-06-14 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, policy review, and interview, the facility failed to report to the Department of Public Health's (DPH's) Health Care Facility Reporting System (HCFRS) a possible misappropriation of a discharged resident's property. Specifically, a family member completed a facility Complaint/Concern/Grievance Report form, which alleged 100 dollars was taken from a drawer. Findings include: Review of the facility's policy titled Abuse Prohibition, with a revision date: 10/11/2022, indicated the following: Definition: Misappropriation of Resident Property: the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. Examples include taking the resident's money or clothing or using a resident's telephone. Further, the policy indicated: Reporting/Responses; All alleged violations of incidents included within the definition of abuses, mistreatment, neglect, involuntary seclusion, or misappropriation of resident property shall be reported to the Department of Public Health, Division 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-06-14 · 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 observation, record reviews, and staff interviews, the facility failed to ensure that the Minimum Data Set (MDS) assessments were coded accurately for two Residents (#85 and #142), out of a total sample of 31 residents. Specifically, the facility failed to: 1. For Resident #85, accurately code a dental status; and 2. For Resident #142, accurately code the MDS as a discharge to the community. Findings include: 1. Resident #85 was admitted to the facility in May 2022 with diagnoses that included hypertension, cerebral infarction, anxiety, and depression. Review of the MDS, with an Assessment Reference Date of 5/8/23, indicated Resident #85 scored a 3 out of 15 on the Brief Interview for Mental Status exam, indicating severe cognitive impairment. The MDS further indicated Resident #85 requires limited assistance from one person for hygiene including brushing his/her teeth. During an observation and interview on 6/12/23 at 8:15 A.M., and 2:19 P.M., the surveyor observed Resident #85 to have one front upper…

    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 before2023-06-14 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and staff interviews, the facility failed to ensure two Residents (#79 and #53), who required supervision with meals, received the supervision, and failed to implement an individualized care plan for heel boots for one Resident (#44), out of a total sample of 31 residents. Findings include: 1. Resident #79 was admitted to the facility in June 2018, and had diagnoses that included dysphagia (difficulty chewing and swallowing) and hemiplegia (paralysis of one side of the body). Review of the most recent Minimum Data Set (MDS) assessment, dated 3/18/23, indicated that on the Brief Interview for Mental Status (BIMS) exam Resident #79 scored a 13 out of a possible 15, indicating intact cognition. The MDS further indicated Resident #79 required extensive assistance from staff for eating. On 6/12/23 at 7:55 A.M., the surveyor observed Resident #79 in bed with multiple unopened cups of thickened liquids on the bedside table in front of him/her. There were instructions posted on the overbed wall indicating Resident #79 needs to sit upright when eating and…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-06-14 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure for one Resident (#122) that nail care was provided, out of a total sample of 31 residents. Findings include: Resident #122 was admitted to the facility in April 2022 with diagnoses that included but was not limited to chronic obstructive pulmonary disease, chronic respiratory failure, unspecified severe protein calorie malnutrition, adult failure to thrive, depression, other abnormalities of gait and mobility. Review of Resident #122's most recent Minimum Data Set (MDS) assessment, dated 5/12/23, indicated Resident #122 scored 14 out of 15 on the Brief Interview for Mental Status exam, indicating intact cognition. The MDS further indicated Resident #122 has no behavior of rejecting care and requires extensive assistance from staff for hygiene care. During an interview and observation on 6/12/23 at 7:53 A.M., the surveyor observed Resident #122 in bed. Resident #122 had greasy hair with flakes present. Resident #122 said he/she does not get out of bed and that staff wash him/her in bed. On 6/14/23 at…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-06-14 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to provide standards of quality care for one Resident (#65), out of a total sample of 31 residents. Specifically, the facility failed to identify areas of discoloration on Resident #65's left hand and areas of discoloration on both right and left forearms. Findings include: Review of the facility's policy titled Skin Management Program, not dated, indicated the following: -Purpose: to minimize the development of any type of ulcers and other skin issues through the systematic and regular inspection of the skin, and to ensure early detection and intervention for all skin problems. Policy: 2. Residents will undergo weekly body check by the licensed nurse. The facility will utilize the weekly body check form in the EHR (electronic health record.) 3. Certified Nursing Assistants will inspect the skin of each resident during daily care and whenever skin care is provided and report to the Licensed Nurse any changes to the resident's skin. Resident #65 was admitted to the facility in September 2021 with diagnoses that…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-06-14 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review, and interviews, the facility failed to ensure that a Resident (#113) received treatment and care in accordance with professional standards of practice, out of a total sample of 31 residents. Specifically, for Resident #113 the facility failed to complete a wound dressing change to bilateral heels and apply heel protectors per physician's order. Findings include: Review of facility's policy titled Skin Management Program, dated as revised 10/12/2022, indicated: * Based on comprehensive assessment of the resident the facility will ensure that the resident receives care consistent with professional standards of practice to prevent pressure injury /pressure ulcer (PI/PU) and does not develop a pressure injury/pressure ulcer unless resident's clinical condition demonstrates it was unavoidable. The residents with a pressure injury/pressure ulcer will receive the necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing. * The Licensed Nurse…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-06-14 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, policy review, and interview, the facility failed to identify a possible hazard for one Resident (#98), out of a total sample of 31 residents. Specifically, Resident #98 had a heating pad in his/her room. Findings include: Review of the facility's policy titled Equipment Use and Monitoring, dated 7/2/21, indicated the following: * Policy: The facility will monitor use of equipment used by the resident and ordered by the MD (medical doctor) to ensure needs are being met with continued use. Examples of equipment to track use include: any electronics brought in by the resident. * Process: Maintenance will check resident's own equipment prior to use for safety and on a periodic basis. Resident #98 was admitted to the facility in June 2022 with diagnoses that included unspecified cord compression, fibromyalgia, and cervical disc disorder with myelopathy (compression of the spinal cord in the neck). Review of the most recent Minimum Data Set (MDS) assessment, dated 6/1/23, indicated Resident #98 is cognitively intact with a score of 15 out of 15 on 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-06-14 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, policy review, and interview, the facility failed to ensure it was free from a medication error rate of greater than 5% when 2 out of 2 nurses observed made 3 errors out of 26 opportunities resulting in a medication error rate of 11.5%. Those errors impacted 2 Residents (#13 and #118), out of 4 residents observed. Findings include: Review of the facility's policy titled Medication Administration Procedures, undated, indicated the following: -review the 5 rights of medication administration three times. -review and confirm medication orders for each individual resident on the medication administration record prior to administering medications to each resident. 1. For Resident #13, the facility failed to administer the correct form of aspirin. On 6/13/23 at 9:05 A.M., on the Seaport Unit, the surveyor observed Nurse #3 prepare the following medications for Resident #13. * Adderall (used to treat attention deficit disorder) extended release 20 milligrams (mg), 2 capsules (40 mg total). * Amlodipine (used to treat high blood pressure) 5 mg 1 tablet.…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction

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

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to ALLIANCE HEALTH & HUMAN SERVICES — 8 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 3 of 53.8-0.8 vs chain
Health inspection 3 of 53.8-0.8 vs chain
Staffing 4 of 53.4+0.6 vs chain
Quality measures 4 of 53.5+0.5 vs chain
The other 7 homes this chain runs (chain average 3.8★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
ALLIANCE HEALTH INCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 08/01/1999
LUMENT REAL ESTATE CAPITAL LLCOrganization5% OR GREATER MORTGAGE INTERESTsince 12/31/2024
BRUNETTI, TAMMYIndividualCORPORATE DIRECTORsince 03/06/2019
CALKINS, ANDREWIndividualCORPORATE DIRECTORsince 03/06/2017
CORRIDAN, LINDAIndividualCORPORATE DIRECTORsince 09/17/2008
GRADY, FRANCISIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 06/22/2016
GRAY, ALFREDIndividualCORPORATE DIRECTORsince 03/06/2019
JANISKO, JEROMEIndividualCORPORATE DIRECTORsince 01/25/1999
JENNINGS, MICHAELIndividualCORPORATE DIRECTORsince 09/25/2024
JONES, ERIKIndividualCORPORATE DIRECTORsince 11/26/2018
MOURTZINOS, ARTHURIndividualCORPORATE DIRECTORsince 06/19/2014
RILEY, JAMESIndividualCORPORATE DIRECTORsince 09/20/2006
ROBBINS, CHRISTOPHERIndividualCORPORATE DIRECTORsince 11/17/1999
ZAMPINE, PETERIndividualCORPORATE DIRECTORsince 11/30/2016
KEMP, PAULIndividualCORPORATE OFFICERsince 06/22/2016
LAVALLEE, THOMASIndividualCORPORATE OFFICERsince 06/22/2016
ALLIANCE HEALTH MANAGEMENT SERVICES LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/03/2025
GALLEGO, CAILINIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/03/2025
OSTREM, MARKIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2016

CMS files one row per role, so the 23 rows in the source record cover these 19 parties — each is shown once here with every role it holds. Nothing is omitted.

3 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.

$22.5M
Net patient revenuemost recent cost report
-4.2%
Operating marginrevenue minus expenses
$968K
Related-party expense4% of expenses
Who pays — share of resident-days
Medicaid 50%Medicare 13%Other / private 37%

This home reported $968K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$428per resident / day
operating cost
$13,013per month
≈ monthly operating cost
$411per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in MA

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Massachusetts Medicaid page.

Typical monthly cost in Massachusetts
$14,448/mo
Nursing home (semi-private)
$15,817/mo
Nursing home (private)
$9,600/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 225680. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-11-21, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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