Regalcare At Quincy
211 Franklin Street, Quincy, MA 02169 · For profit - Limited Liability company · 71 certified beds · (781) 775-7185 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- it has 1 actual-harm citation
- a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $10,773 in federal fines (most recent 2023-09-19)
- its payroll-based staffing score sits well above its independent inspection score
- its independent health-inspection rating is low (1/5)
- its facility-reported quality-measure rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 4 to 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 26.8% | 16.4% | 15.4% | worse |
| Long-stay residents who lose too much weight | 10.4% | 5.1% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 1.3% | 0.8% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 3.8% | 1.8% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 26.6% | 15.5% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 1.2% | 3.4% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 22.8% | 15.4% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 2.8% | 19.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 95.5% | 94.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.8% | 4.2% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 20.6% | 21.2% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 14.6% | 21.4% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.4% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 83.9% | 77.7% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 29.2% | 25.7% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 15.4% | 11.9% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.49 | 1.88 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.91 | 1.50 | 1.80 | typical |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
45.1% 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 147 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 44.2% 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 43 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 0.24 therapist hours per resident per day in 2026Q1 — more than 32% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 102% of this home’s weekday level — it runs therapy at close to weekday levels right through the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 45.1%CMS range 37.3–51.6 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 12.1%CMS range 8.3–16.3 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 44.2% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 41.9% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 39.5% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 86.4% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.7%CMS range 4.0–11.6 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.92 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 71 beds and averages 56.0 residents a day — about 79% occupied, or roughly 15 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.73 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.76 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.02 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 3.30 hrs/resident/day on weekends vs 3.90 on weekdays — 16% thinner on weekends. RN hours go from 0.90 to 0.42 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
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
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 11 most serious are shown; the remaining 18 are one tap away and print in full.
- Actual harm · Gcited before2023-09-19 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on records reviewed, interviews, and observations for one of three sampled residents (Resident #1), who had severe cognitive impairment, poor safety awareness, was legally blind and required supervision to physical assistance of one staff member with wheelchair mobility, the Facility failed to ensure he/she was provided with an adequate level of supervision and staff assistance in effort to maintain his/her safety to prevent accidents/incidents resulting in serious injury. On 8/01/23 Resident #1, who resided on the Main side of his/her unit, wheeled him/herself towards the ramp on his/her unit that lead to the [NAME] side of the unit. Resident #1 was unable to control his/her wheelchair as it rolled down the ramp, and as the wheelchair came to an abrupt stop at the bottom of the ramp, he/she fell forward out of the wheelchair and onto the floor. Resident #1 required emergent transfer to the Hospital Emergency Department for evaluation, where he/she was diagnosed with multiple fractures, a subarachnoid hemorrhage (bleeding in the space between the brain tissue covering the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-04-08 · tag F0558 — failed to accommodate residents' needs and preferences — patternReasonably accommodate the needs and preferences of each resident.
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 four Residents (#11, #30, #33, #35), out of a total sample of 15 residents, had their call bell devices accessible and within reach to utilize them to call for staff assistance while in their rooms. Findings include: Review of the facility's policy titled Answering Call Lights, revised 3/2022, indicated but was not limited to the following: - The purpose of this procedure is to respond to the resident's requests and needs. - Guidelines: 4.) Be sure that the call light is plugged in at all times; 5.) When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. A. Resident #11 was admitted to the facility in December 2024 with diagnoses including history of falling, adult failure to thrive, and anxiety. Review of Resident #11's Minimum Data Set (MDS) assessment indicated he/she was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 9 out of 15. During an observation with interview on 4/6/25 at 8:48 A.M.,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-04-08 · tag F0585 — failed to handle grievances — patternHonor 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 observation, interviews, and document review, the facility failed to ensure that residents were fully aware of the grievance process. Specifically, for 10 of 10 residents attending the resident group meeting during the facility survey, the facility failed to ensure residents were aware of and had access to grievance forms, and were aware they could formulate grievances anonymously, should they choose not to alert a staff member of their concern(s). Findings include: Review of the facility's policy titled Grievance, last revised 3/2022, indicated but was not limited to: -The resident and/or resident representative will be made aware of the right to voice grievances orally, in writing, and anonymously. -If a resident, and/or health care representative, or another interested family member of a resident has a complaint, a staff member should encourage and assist the resident, or person acting on the resident's behalf, to file a written grievance with the facility using the Grievances/Complaint Report form. -Grievances and complaints may be submitted orally or in writing. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-04-08 · tag F0656 — failed to write and follow a full care plan — patternDevelop 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 document review, observation, and interview, the facility failed to develop, implement and individualize comprehensive plans of care for five Residents (#202, #4, #12, #33, and #36) out of a total sample of 15 residents. Specifically, the facility failed: 1. For #202, to individualize and implement the pain and risk for pain care plan; 2. For Resident #4, to develop and implement a care plan for the use of Seroquel (an antipsychotic medication) that included Resident-specific targeted behaviors, interventions and measurable goals of treatment; 3. For Resident #12, to develop and implement a care plan for the use of Seroquel that included Resident-specific targeted behaviors, interventions and measurable goals of treatment; 4. For Resident #33, to develop and implement a care plan intervention after he/she sustained a fall; and 5. For Resident # 36, to develop and implement a care plan for his/her oxygen use. Findings include: Review of the facility's policy titled Comprehensive Assessments and the Care Delivery Process, dated as revised 2/2025, indicated but was not limited…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-04-08 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure 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 and interview, the facility failed to ensure two Residents (#41 and #36), out of a total sample of 18 residents, were free of accident hazards. Specifically, the facility failed: 1. For Resident #41, to ensure a wound treatment cart was locked when unattended by licensed staff to prevent unauthorized access to potentially harmful items; and 2. For Resident #36, to ensure the Resident's freestanding oxygen cylinder was properly stored. Findings include: 1. Review of the facility's policy titled Medication Storage, revised March 2022, indicated but was not limited to the following: -The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. -The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. -Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-04-08 · tag F0694 — patternProvide for the safe, appropriate administration of IV fluids for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to provide care and maintenance of a Peripherally Inserted Central Catheter (PICC-a flexible tube inserted through a vein in one's arm and passed through to larger veins near the heart, used to deliver medications intravenously (IV)), consistent with professional standards of practice for one Resident (#200), out of a total sample of 18 residents. Specifically, the facility failed to: -ensure documentation of PICC line dressing changes -measure and document the external catheter length to ensure the PICC line had not migrated (moved from the heart to another area, which could have significant impact on treatment, or cause serious harm) -measure and document arm circumference -measure and document the total catheter length when the PICC line was pulled out by the Resident to ensure the catheter was intact. Findings include: Review of the facility's policy titled Central Venous Catheter Care and Dressing Changes, revised April 2022, indicated but was not limited to the following: Purpose: -The purpose of this…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-04-08 · tag F0758 — failed to limit and justify psychotropic drugs — patternImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
2. Resident #12 was admitted to the facility in February 2025 and had diagnoses including anxiety and depression. Review of the MDS assessment, dated 2/20/25, indicated Resident #12 was cognitively intact as evidenced by a BIMS score of 13 out of 15, had anxiety, depression (other than bipolar) and received antipsychotic medication daily. Review of the medical record indicated but was not limited to: -Quetiapine Fumarate 100 mg at bedtime (2/13/25) Review of February 2025 and March 2025 MARs indicated Quetiapine was administered as ordered by the physician. Further review of the medical record failed to indicate any resident-specific targeted behaviors were identified and monitored for Resident #12's use of Quetiapine. During an interview on 4/8/25 at 11:48 A.M., NP #1 said he did not know why Resident #12 was prescribed Quetiapine and could not identify any resident-specific targeted behaviors/signs or symptoms for its use. During an interview on 4/8/25 at 2:25 P.M., Unit Manager #1 and the Regional Nurse reviewed Resident #12's medical record. They said they did not know why the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-04-08 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and document review, the facility failed to ensure all drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles. Specifically, the facility failed to: 1. Ensure medication carts were locked when not in direct supervision of the licensed nurse on one of two units; 2. Ensure two of two medication rooms were locked when not in direct supervision of the licensed nurse; and 3. Ensure the over the counter (OTC) medication room was locked when not in direct supervision of the licensed nurse on one of one units. Findings include: Review of the facility's policy titled Medication Storage, revised March 2022, indicated but was not limited to the following: -The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. -The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. -Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-04-08 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure 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 observations, interviews, and meal test tray results, the facility failed to serve meals that were palatable and at appetizing temperatures on two of two units. Findings include: Review of the facility's policy titled Daily Food Temperature Checks, last revised 8/15/24, indicated but was not limited to: - It is the policy of the facility that temperatures be recorded at each meal to assure that all meals be served to the residents within the proper temperature range. - Cold food or beverage is to be at or below 41 degrees or hot food or beverage will be maintained at or above 135 degrees. During the Resident Council Meeting, on 4/7/25 at 1:00 P.M., 5 out of 10 residents, who actively participated, said the food at breakfast and lunch would come up cold and the facility needed to ensure there were enough staff passing trays. On 4/8/25 at 7:37 A.M., the surveyor requested a breakfast tray to the Second Floor Unit. The food truck left the kitchen at 7:44 A.M., and arrived at the unit at 7:46 A.M. The test tray was conducted with Dietary Aide #2 at 7:55 A.M., with the following…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-04-08 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to 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 food was properly stored in the walk-in freezer in the main kitchen; 2. Ensure to properly date, label, and store food and drink items in one of two kitchenettes; 3. Ensure, a. the wall in the main kitchen behind the dishwashing station was kept in a clean and sanitary manner; b. the counter next to the sink in one of two kitchenettes was kept in a clean and sanitary manner; 4. Ensure staff wore hair restraints in the main kitchen during meal preparation and service; and Findings include: Review of the 2022 Food Code by the U.S. Food and Drug Administration (FDA) indicated but was not limited to: -2-402 Hair Restraints 2-402.11 Effectiveness. (A) Except as provided in (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-04-08 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed to: 1. Implement a complete and accurate infection surveillance plan to identify, track and monitor for infection; 2. Ensure treatment carts were secured and locked to prevent Resident #41 from gaining unauthorized access resulting in infection control concerns; and 3. For Resident #36, ensure oxygen concentrator filters were clean and free of debris. Findings include: 1. Review of the facility's policy titled Infection Surveillance, revised 2/2024, indicated but was not limited to the following: - The Infection Preventionist (IP) will conduct ongoing surveillance for Healthcare-Associated Infections (HAIs) and other epidemiologically significant infections that have a substantial impact on potential…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 18 citations
- Potential for harm · D2025-04-08 · tag F0655 — isolatedCreate 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
Based on record review, policy review, and interview, the facility failed to ensure staff developed baseline or comprehensive care plan within 48 hours of the resident's admission, which included the instructions needed to provide effective and person-centered care to the resident which meet professional standards of quality care for one Resident (#12), in a total sample of 18 residents. Specifically, the facility failed to ensure a baseline care plan was developed for the Resident's: a. diagnosis of Post Traumatic Stress Disorder (PTSD-results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being); and b. use of the antipsychotic medication Quetiapine (Seroquel). Findings include: Review of the facility's policy titled Baseline Care Plan, last revised 4/2022, indicated but was not limited to: -A baseline care plan to meet the resident's immediate needs…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-08 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to provide care and services consistent with professional standards for two Residents (#29 and #4), out of a total sample of 15 residents. Specifically, the facility failed to: 1. Ensure a physician's order for the application of compression stockings were applied to Resident #29 daily; and 2. Ensure a healthcare proxy (HCP) invocation was completed for Resident #4 in accordance with the standard of practice. Findings include: Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated but was not limited to: Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber 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, consistent with current…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-08 · tag F0699 — isolatedProvide 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 record review and interview, the facility failed to assess a history of trauma and failed to assess and to develop a plan of care accounting for Resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization for one Resident (#12), with a history of trauma, out of a total sample of 18 residents. Findings include: Review of the facility's policy titled Trauma Informed Care, last revised 4/2022, indicated but was not limited to: -Purpose: To guide staff in appropriate and compassionate care specific to individuals who have experienced trauma. -Nursing staff are trained on screening tools, trauma assessment and how to identify triggers associated with re-traumatization. - As part of the comprehensive assessment, identify a history of trauma or interpersonal violence when possible. -Identifying past trauma or adverse experiences may involve record review or the use of screening tools. -Utilize trained and qualified staff members who have established a rapport with the resident to assess him or her for previous trauma. Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-08 · tag F0700 — isolatedTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
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 assess one Resident (#12), out of a sample of 18 residents, for the use of a bed rail. Specifically, the facility failed to assess the risk of entrapment from the use of a bed rail (side rails, bed side rails, safety rails, grab bars and assist bars: adjustable position, rigid bars that attach to the sides of a bed, ranging in sizes from full to one-half, one-quarter, or one-eighth lengths), review the risks and benefits of side rails and obtain informed consent from the resident prior to installation of a bed rail. Findings Include: Review of the facility's policy titled Proper Use of Side Rails Policy, last revised 4/2022, indicated but was not limited to: -An assessment will be conducted to identify the reason for using side rails and the risk of entrapment. When used for mobility or transfer, an assessment will include a review of the resident's: -Bed mobility -Ability to change positions, transfer to and from bed or chair, and to stand and toilet -Risk of entrapment from the use of side rails -That the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-08 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record review, the facility failed to ensure monthly Medication Regimen Review (MRR) recommendations made by the pharmacy consultant were addressed timely and maintained as part of the permanent medical record for two Residents (#12 and #4), out of a total sample of 18 residents. Specifically, the facility failed: 1. For Resident #12, to ensure the February 2024 consultant pharmacist recommendation was acted upon timely by the physician to add instructions for Trelegy Ellipta inhaler (used to treat chronic obstructive pulmonary disease (COPD) and works by opening airways, reducing inflammation, and keeping the airways open and improving lung function) orders; and 2. For Resident #4, to ensure recommendations left by the consultant pharmacist were addressed in a timely manner, for a clarification for the continued appropriate use of Seroquel (an antipsychotic medication), including a rationale for the medication. Findings include: Review of the facility's policy titled Medication Regimen Review, dated November 2021, indicated but was not limited 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.
- Potential for harm · Dcited before2025-04-08 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on document review and interview, the facility failed for two Residents (#4 and #202), out of a total sample of 15 residents, to maintain a complete and accurate medical record. Specifically, the facility failed to: 1. Ensure the healthcare proxy (HCP) activation form was completed for Resident #4, including the cause and nature of the document, which were left blank; and 2. Ensure the administration of Tramadol (a pain medication) was documented on the medication administration record (MAR) for Resident #202 each time it was administered. Findings include: 1. Review of Massachusetts healthcare proxy act M.G.L. C 201 D, Section 6 indicated, but was not limited to the following: The authority of a health care agent shall begin after a determination is made, pursuant to the provisions of this section, that the principal lacks the capacity to make or to communicate health care decisions. Such determination shall be made by the attending physician according to accepted standards of medical judgment. The determination shall be in writing and shall contain the attending physician'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.
- Potential for harm · Ecited before2024-05-15 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to maintain two of two resident nourishment kitchenettes in a clean and sanitary condition. Findings include: Review of the facility's policy titled Unit Kitchenettes, dated 8/15/23, indicated but was not limited to the following: -It is the policy of the Facility that unit kitchenettes be used for resident nourishments and snacks. These areas are to be maintained in a sanitary manner. Fridges, cabinets, counters, floors, and microwaves, where applicable, should be checked for cleanliness at a minimum when they are being stocked. Additionally, housekeeping will do a deep clean of refrigerators and microwaves weekly. The floors and rubbish removal will follow the same schedule as the unit where kitchenette is contained. On 5/10/24 at 10:35 A.M., the surveyor observed the resident kitchenette on the Third-floor and made the following observations: -The cabinet under the sink was a metal pest trap. Around the pest trap opening there were mice droppings and dried liquid stains. In the back right corner of the cabinet were dried…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-05-15 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, document review, and policy review, the facility failed to ensure staff properly labeled all drugs and biologicals used in the facility in accordance with currently accepted principles. Specifically, the facility failed to ensure staff properly labeled all medications stored in one of three medication carts reviewed once opened. Findings include: Review of the facility's policy titled Medication Storage in the Facility, revised [DATE], indicated but was not limited to the following: -Certain medications or package types, such as intravenous solutions, multiple dose injectable vials, once opened, require an expiration date shorter than the manufacturer's expiration date to ensure medication purity and potency. -Drugs dispensed in the manufacturer's original container will carry the manufacturer's expiration date. Once opened, these will be good to use until the manufacturer's expiration date is reached unless the medication is a multi-dose injectable vial or an item for which the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-15 · tag F0777 — isolatedProvide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to notify the physician (MD) and/or nurse practitioner (NP) of an abnormal chest X-ray for one Resident (#41), out of one of three closed records reviewed. Findings include: Review of the facility's policy titled Labs and Diagnostics, dated 4/2022, indicated but was not limited to the following: Assessment and Recognition -The physician will identify and order diagnostics and lab testing based on diagnostic and monitoring needs. -The staff will process test requisitions and arrange for tests. -The laboratory, diagnostic radiology provider, or other testing source will report test results to the facility. Review by Nursing staff -If the staff who first receive or view lab or diagnostic test results cannot follow the remainder of this procedure for reporting and documenting the results and their implications another nurse in the facility (supervisor, charge nurse, etc.) should follow or coordinate the procedure. Deciding how urgently to contact the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-11-21 · tag F0553 — failed to let residents help plan their care — patternAllow resident to participate in the development and implementation of his or her person-centered plan of care.
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 three of three sampled residents (Resident #1, Resident #2, and Resident #3), the Facility failed to ensure the residents and/or their family members or legal representatives participated in the development and implementation of their person-center care plans, which included conducting and inviting residents and/or their Representatives to an interdisciplinary care plan meeting following the completion of their comprehensive admission Minimum Data Set (MDS) assessments. Findings include: Review of the Facility Policy titled, Comprehensive Care Plans, dated as last revised 4/2022, indicated that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The Policy also indicated that the Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative develops and implements a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-21 · tag F0675 — failed to support quality of life — isolatedHonor each resident's preferences, choices, values and beliefs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on records reviewed, interviews, and observations for one of three sampled residents (Resident #1), who was morbidly obese, incontinent of both bowel and bladder, and who required the assistance of two staff members with the use of a mechanical lift device to transfer in and out of bed, the Facility failed to ensure services provided were consistent with Resident #1's comprehensive assessment and plan of care, in an effort to maintain his/her Quality of Life. On 11/21/23, Resident #1 was observed out of bed in his/her wheelchair at 9:41 A.M. and observed again at 4:14 P.M. still in his/her wheelchair and per Resident #1's interview, he/she had not been provided with incontinent care or assisted with repositioning for comfort during that time. Finding include: Review of the Facility Policy titled, Activities of Daily Living (ADL), dated as last revised 3/2022, indicated that residents will be provided care, treatment, and services as appropriate to maintain or improve as able, their ability to carry out ADL's to ensure that their ADL's do not decline. The Policy further…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-11-21 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on records reviewed, interviews and observations of one of three sampled residents (Resident #1) the Facility failed to ensure they maintained a complete and accurate medical record including but not limited to Activities of Daily Living (ADL) Flow Sheets that were to be completed by Certified Nurse Aides (CNA's) that should contain daily documentation of care provided to the resident by staff each shift. Findings include: Based on the Facility Policy titled, Charting and Documentation, dated as last revised 4/2022, indicated services provided to the resident, progress towards the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical records. Resident #1 was admitted to the Facility in September 2023, diagnoses included bilateral lower extremity cellulitis (infection of the skin), atrial fibrillation, diabetes mellitus, morbid obesity, and anxiety. Review of Resident #1's admission Minimum Data Set (MDS) Assessment, dated 10/06/23 indicated that Resident #1 required total…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-09-19 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on records reviewed and interviews, for one of three sampled residents (Resident #4), who had experienced a fall in the community resulting in significant head trauma requiring his/her need for hospitalization, and who upon admission to the facility was assessed by nursing to be at increased risk for falls, the Facility failed to ensure services provided by nursing met professional standards of care, when on 10/08/23, after Resident #4 had an unwitnessed fall to the floor and self-reported to nursing that he/she bumped his/her head, neurological assessments were not consistently completed by nursing, as required. Findings include: Review of the Facility Policy titled Neurological Assessment, dated as last revised 4/2022, indicated that a neurological assessment is indicated for the following reasons: -Upon a physician order; -Following an unwitnessed fall; -Following a fall if other accident/incident involving head trauma; or -When indicated by the resident's condition. The Policy indicated Neurological Signs are to include the following; -Determine resident's orientation to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-12-27 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
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 staff promoted and facilitated Resident self-determination relative to the manner of bathing for one Resident (#27), out of a total sample of 14 residents. Findings include: Resident #27 was admitted to the facility in February 2022 with diagnoses which included major depressive disorder, left fibula fracture, and abnormal gait and mobility. Review of the Minimum Data Set (MDS) assessment, dated 11/21/22, indicated Resident #27 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Further review of the MDS indicated it was very important for the Resident to choose between tub bath, shower, bed bath, or sponge bath. In addition, the Resident was totally dependent on staff for showering and bathing. During an interview on 12/21/22 at 11:45 A.M., Resident #27 said he/she would like to take a shower as it would make him/her feel better. Resident #27 said it might be difficult to get into the shower chair, but staff do not offer a shower and he/she is provided with a bed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-12-27 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, policy review, and interview, the facility failed to ensure nursing staff followed professional standards of practice during medication administration and observed the Resident's consumption of medications prior to leaving the room for one Resident (#204), out of a total sample of 14 residents. Findings include: A review of the facility's policy titled Oral Medication Administration, dated as revised 4/22, indicated but was not limited to the following: -Remain with the resident until all medications have been taken. Resident #204 was admitted to the facility in December 2022 with diagnoses which included right hip hemiarthroplasty (replacement), diabetes mellitus, Alzheimer's disease, and dementia. Review of the Minimum Data Set (MDS) assessment, dated 12/16/22, indicated Resident #204 had a Brief Interview for Mental Status (BIMS) score of 4 out of 15 which indicated the Resident had severely impaired cognition. Review of the current Physician's Orders indicated but was not limited to: -Aspirin EC tablet delayed release 81 milligrams (mg) 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.
- No harm found · B2025-04-08 · tag F0908 — failed to keep essential equipment working — patternKeep all essential equipment working safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to maintain equipment in safe working order. Specifically, the facility failed to maintain: 1. One of two microwaves located in the resident kitchenettes on the third floor; 2. The food processor in the main kitchen used for resident food; and 3. The plate warmer in the main kitchen used to heat residents' plates. Findings include: Review of the facility's policy titled Marinating [sic] Functional Equipment, last revised 1/18/23, indicated but was not limited to: - It is the policy of this Facility that Kitchen Equipment will be maintained functionally as designed. - Kitchen equipment is maintain [sic] functional. - Anytime kitchen equipment is damaged or fails to operate properly, the FSD (Food Service Director) and Maintenance are to be notified. 1. On 4/6/25 at 9:12 A.M., the surveyor observed the microwave on the third-floor unit kitchenette and observed the microwave door open button not in operational order. The surveyor pushed the door open button the microwave five times and the door did not open. On 4/6/25 at 12:14…
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.
- No harm found · B2022-12-27 · tag F0582 — patternGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on the Beneficiary Protection Notification Review, the facility failed to issue the appropriate Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) and Notice of Medicare Non-coverage (NOMNC) forms in advance of last covered Medicare day for one Resident (#7), out of three sampled residents. Findings include: The SNF ABN notice is administered to a Medicare recipient when the facility determines the beneficiary no longer qualifies for Medicare Part A skilled services and the resident has not used all of the Medicare benefit days for that episode. The NOMNC (form CMS-10123) provides information to convey notice to the beneficiary of his or her right to an expedited review of a Medicare service termination. Resident #7 had a last covered day of Part A Service on 10/13/22. A review of the SNF Beneficiary Protection Notification Review indicated the healthcare proxy (HCP) signed both the SNF ABN and the NOMNC form on 10/19/22, six days after the Medicare benefit ended. There was no indication the HCP was made aware of the last covered Medicare day prior to 10/19/22 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.
- No harm found · B2022-12-27 · tag F0640 — patternEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
What the surveyor found here — the official record, unedited, may be distressing
Based on Minimum Data Set (MDS) assessment review and staff interview, the facility failed to encode and electronically transmit the MDS data to the Centers for Medicare and Medicaid Services (CMS) processing system, for one Resident (#30), out of three resident assessments reviewed. Findings include: Resident #30 was admitted to the facility in December 2021 with diagnoses which included stroke and heart failure. Review of Resident #30's MDS assessment, dated 9/26/22, indicated the MDS was not transmitted as required electronically no later than 14 calendar days after the MDS completion date. During an interview on 12/27/22 at 8:23 A.M., the MDS Nurse said the Resident #30's Annual MDS assessment, dated 9/26/22, was missed and had not been transmitted to the CMS processing system.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$10,773 in federal fines across 1 penalty.
- $10,773 — penalty dated 2023-09-19
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 REGALCARE — 9 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 1 of 5 | 1.7 | -0.7 vs chain |
| Health inspection | 1 of 5 | 1.9 | -0.9 vs chain |
| Staffing | 3 of 5 | 3.0 | ≈ chain avg |
| Quality measures | 2 of 5 | 2.2 | -0.2 vs chain |
The other 8 homes this chain runs (chain average 1.7★, 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 / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| RC OPCO HOLDCO LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 09/01/2022 |
| MIRLIS, ELIYAHU | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; W-2 MANAGING EMPLOYEE; CORPORATE OFFICER | 99% | since 09/01/2022 |
CMS files one row per role, so the 4 rows in the source record cover these 2 parties — each is shown once here with every role it holds. Nothing is omitted.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 75% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $828K paid to related parties — landlords or management companies under common ownership — equal to about 11% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in MA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Massachusetts Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 225522. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-08, 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.