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Meadows Of Central Massachusetts (the)

111 Huntoon Memorial Highway, Rochdale, MA 01542 · For profit - Corporation · 135 certified beds · (508) 892-6804 Medicare & Medicaid certified

Call the home — (508) 892-6804 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Behavioral-health or dementia-care citation — no harm found (F0740)2 actual-harm citations$85,733 in federal fines
Insights

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

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • a high payroll-based staffing rating (4/5)
  • lower-than-typical staff turnover (33% vs 45% nationally) — better care continuity
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has 2 actual-harm citations
  • 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 $85,733 in federal fines (most recent 2024-02-20)

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.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 3 of 5

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
813 Southbridge St · (508) 832-0173 · Call to confirm hours
Pharmacy
861 Southbridge St · (508) 832-8800 · Call to confirm hours
Grocery
711 Southbridge St · (508) 832-5841 · Call to confirm hours
Park
1040 Stafford St · 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 3 of 5
Long-stay residentspeople who live here 5 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 improved from 1 to 4 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 rating4★
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 increased12.6%16.4%15.4%better
Long-stay residents who lose too much weight2.1%5.1%5.4%better
Long-stay residents with a catheter left in their bladder1.1%0.8%0.9%worse
Long-stay residents with a urinary tract infection1.4%1.8%2.0%better
Long-stay residents with depressive symptoms4.2%15.5%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury2.7%3.4%3.3%better
Long-stay residents whose ability to walk worsened10.7%15.4%16.1%better
Long-stay residents on antianxiety or hypnotic medication38.8%19.5%18.9%worse
Long-stay residents given the seasonal flu vaccine87.0%94.8%95.3%typical
Long-stay residents with pressure ulcers5.7%4.2%4.7%worse
Long-stay residents with worsening bladder/bowel control5.4%21.2%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table16.5%21.4%17.1%typical
Short-stay residents who newly got an antipsychotic medication2.5%1.4%1.4%worse
Short-stay residents given the seasonal flu vaccine75.8%77.7%79.4%typical
Short-stay residents rehospitalized after admission29.2%25.7%22.6%worse
Short-stay residents with an outpatient ER visit14.2%11.9%12.0%worse
Long-stay hospitalizations per 1,000 resident days0.731.881.67better
Long-stay outpatient ER visits per 1,000 resident days1.301.501.80better

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.

50.1% 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 34 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

50.1%U.S. median 51.5%
Got home and stayed home
9.3%U.S. median 10.7%
Went back to hospital
0.06U.S. median 0.31
Therapy hours / resident / day
0.06hours / resident / day
Physical therapy

Therapy staffing: this home’s payroll records show 0.06 therapist hours per resident per day in 2026Q1 — more than 3% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 84% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF50.1%CMS range 32.2–64.351.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.3%CMS range 5.7–13.510.7%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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identifiednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 dischargenot 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 staynot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.981.02Oct 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

0.56
RN hours/ resident / day
1.70
LPN hours/ resident / day
2.36
Aide hours/ resident / day
4.62
Total nurse hours/ resident / day
0.16
RN hoursweekends
32.7%
Total nursing turnover
33.3%
RN turnover

How full it usually is: this home is certified for 135 beds and averages 63.4 residents a day — about 47% occupied, or roughly 72 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.62 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.56 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.36 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 3.93 hrs/resident/day on weekends vs 4.90 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.72 to 0.16 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 33% is below the national median of 45%. 1 administrator has left in the past year.

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

Inspection trend

1
deficiencies at the latest standard inspection (2026-02-02)
11
at the previous standard inspection (2024-10-11)

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

Inspection deficiencies

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

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.

29 citations, most serious first. The 12 most serious are shown; the remaining 17 are one tap away and print in full.

  • Actual harm · G2023-07-19 · 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 observation, record review and interview, the facility failed to obtain treatment orders for one Resident (#20), out of three applicable Residents, in a total sample of 15 Residents. Specifically, the facility failed to obtain treatment orders when skin breakdown was initially observed and resulted in the development of a Pressure Ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) for Resident #20. Findings include: Resident #20 was admitted to the facility in January 2023 with a diagnosis of Cerebral Infarction (stroke). Review of the Minimum Data Set (MDS) Assessment, dated 5/19/23, indicated the Resident had a Staff Assessment for Mental Status completed which indicated: -the Resident was severely impaired for daily decision-making skills -had a Gastrostomy tube (G-tube: a surgically placed tube into the abdomen to give direct access for supplemental feeding) -had a Tracheostomy tube (an opening surgically created through the neck into the trachea (windpipe) to allow air to fill the lungs) -was totally dependent for Activities of…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2023-07-19 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    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 policy review, record review and interview, the facility failed to provide appropriate treatment and services to prevent a decline in bladder continence for one Resident (#43) out of a total sample of 15 Residents. Specifically, the facility failed to provide treatment and services for Resident #43, who was cognitively intact, aware of his/her toileting needs and had a desire to maintain urinary continence. Findings include: Review of the facility's Quality of Care policy, dated June 2021, indicated: -The facility will ensure that the resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his/her clinical condition is or becomes such that continence is not possible to maintain. Review of the facility's Bowel and Bladder Program policy, dated June 2021, indicated, but not limited to, the following: -All residents admitted to the facility will have a bowel and bladder Continence Evaluation performed at the time of admission, in…

    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 · D2026-02-02 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and records reviewed, the facility failed to ensure care and services were provided to one Resident (#29) out of a total sample of 17 residents, in accordance with professional standards of practice.Specifically, the facility failed to obtain laboratory services as ordered by the Physician, including Complete Blood Count (CBC), Liver Function Test (LFT), and Valproic Acid level, putting the resident at risk for adverse side effects related to the use of Depakote (anticonvulsant) medication.Findings include:Review of [NAME], Manual of Nursing Practice 11ed, dated 2019 indicated the following: -The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated the following:-Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized…

    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 · F2024-10-11 · tag F0727 — failed to provide required RN coverage — widespread
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on the record review and interview, the facility failed to to utilize the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, as required placing all residents at risk for not having their clinical needs met either directly by the RN or indirectly by the Licensed Practical Nurse (LPN) or Certified Nurses Aides (CNA) that the RN was responsible for overseeing with provision of resident care. Specifically, the facility failed to: 1. Provide the services of a RN for at least eight consecutive hours a day, seven days a week when no staffing waivers were in place for three days for the period of 4/1/24 to 6/30/24. 2. Designate a Registered Nurse to serve as the Director of Nursing (DON) on a full time basis when no staffing waivers were in place. Findings include: 1. Review of the PBJ Staffing Data Report, dated Quarter 3: 2024 (April 1 - June 30), indicated the following: -One Star Staffing Rating Triggered = Star Staffing Rating Equals 1 -Excessively Low Weekend Staffing Triggered = Submitted Weekend Staffing data is excessively low…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-10-11 · tag F0760 — failed to prevent significant medication errors — pattern
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record and policy review, the facility failed to ensure one Resident (#108) out of a total sample of 17 residents, was free of significant medication errors. Specifically, for Resident #108, the facility failed to ensure that: -pain medications were administered timely as ordered by the Physician, when the Resident experienced pain and scheduled pain medications were ordered, which increased the Resident's risk for prolonged pain. -intravenous (IV: administered directly into a vein) antibiotics (medications used to treat infection) were administered timely as ordered by the Physician, when the Resident required IV antibiotics to treat an active infection, which increased the Resident's risk for illness. -anticoagulant (blood thinner) medication was administered timely as ordered by the Physician, when the Resident had a diagnosis of chronic embolus (a blood clot, air bubble, piece of fatty deposit, or other object which has been carried in the bloodstream lodges in a blood vessel) and Thrombosis (blood clot that forms inside a vessel and obstructs…

    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 · D2024-10-11 · 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 observation, interview, record and policy review, the facility failed to identify and notify the Physician/Nurse Practitioner (NP) timely of a change in urinary catheter (also known as a Foley catheter - a flexible tube inserted into the bladder to drain urine outside of the body) condition for one Resident (#210) out of a total sample of 17 residents. Specifically, Resident #210, the facility failed to monitor and assess bleeding from the urinary catheter and notify the Physician/NP timely for required interventions, resulting in hospitalization for gross hematuria (excessive blood in the urine). Findings include: Review of the facility's policy titled Urinary Catheter Insertion, Maintenance and Removal, revised August 2024, indicated: -Indwelling urinary catheters may be beneficial to patients to assist with draining of urine. -To reduce the risk of infection and other negative outcomes, urinary catheters must be placed with care on the correct patients, maintained with appropriate technique, and removed when no longer necessary. Review of the facility's policy untitled…

    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 · D2024-10-11 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record and policy review, the facility failed to provide a homelike environment, relative to accessibility of the call bell, for one Resident (#108) out of a total sample of 17 residents. Specifically, for Resident #108, the facility failed to ensure ready access to his/her call device when the Resident was dependent on staff for his/her care needs and was able to use an alternate call pad device (altered device for a call light that is activated by being tapped rather than pressed by a finger or thumb), which increased the Resident's risk for not having his/her care needs met timely and appropriately. Findings include: Review of the facility's policy titled Call Devices for Patients, dated March 2018 and last reviewed December 2023, indicated the following: -Appropriate devices shall be made available to help facilitate patient communication needs. -If the patient cannot demonstrate appropriate use of the standard call light, the Nurse shall evaluate the patient's ability to use alternative call devices, . -If the patient demonstrates appropriate…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-10-11 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record and policy review, observation, and interview, the facility failed to develop a plan of care for appropriate treatment and services related to limited range of motion for one Resident (#42), out of a total sample of 17 Residents. Specifically, for Resident #42, the facility failed to develop a plan of care relative to positioning for the Resident after he/she was assessed and recommendations made by Rehabilitative Services for a specialty wheelchair and molded lateral supports (fitted equipment that help reinforce body support and reduce postural deformity). Findings include: Review of the facility policy titled Comprehensive Resident Centered Care Plans, last revised December 2021, indicated: -Updating care plans: 1. Care plans are modified between care plan conference when appropriate to meet the resident's current needs, problems, and goals. 2. Stand up meetings of the Director of Nursing (DON), Social Services Coordinator, MDS coordinator, Registered Dietician, Activities Director, 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 · Dcited before2024-10-11 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    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, record and policy review, the facility failed to provide urinary catheter (also known as a Foley catheter - a flexible tube inserted into the bladder to drain urine outside of the body) care and services according to professional standards of practice for three Residents (#210, #44 and #42) out of a total sample of 17 residents, which increased the Residents' risk for urinary catheter complications. Specifically, the facility failed to: 1. For Resident #210, identify that the Resident was admitted to the facility with a urinary catheter, resulting in delayed monitoring and assessment of the Resident's urinary catheter and obtaining Physician orders to implement catheter care and management when hematuria (blood in urine) was identified. 2. For Resident #42, obtain a Physician's order for a specific type of external urinary catheter. 3. For Resident #44, insert the right size of Foley catheter ordered by the Physician. Findings include: Review of the facility's policy titled…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-11 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record and policy review, the facility failed to provide care and services for assisted nutrition and hydration in accordance with the Physician order for one Resident (#46), who required Total Parenteral Nutrition (TPN: method of providing nutrition where a liquid formula is given into a vein through an intravenous catheter (IV) to provide most of the nutrients a resident needs, used when a resident cannot or should not eat or drink by mouth) of one resident who required TPN, out of a total sample of 17 residents. Specifically, the facility failed to provide Clinimix E (IV nutritional product containing amino acids [building blocks of protein] with electrolytes [electrically charged minerals that play important roles in the body] in Dextrose [simple sugar] with Calcium [mineral needed by the body]) and SMOFlipids (IV nutritional product containing calories and essential fatty acids) infusions to Resident #46 in accordance with the Physician's order, increasing 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-11 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record and policy review, and interview, the facility failed to ensure that care and services for pain management consistent with professional standards of practice were provided in a timely manner for one Resident (#108) out of a total sample of 17 residents. Specifically, the facility failed to provide pain management interventions in a timely manner for Resident #108 when the Resident was experiencing severe pain and was dependent on staff to receive pharmacological (medication) and non-pharmaceutical interventions to treat pain. Findings include: Review of the facility's policy titled Pain Assessment and Management, dated March 2016 and last reviewed December 2023, indicated the following: -Pain is an unpleasant sensory and emotional experience . -Breakthrough pain is pain that increases above the pain addressed by the ongoing analgesics (drug used to treat pain). -Management of a patient's pain includes individualized assessment, intervention, and evaluation of pain and pain relief. -A patient's self-report of pain will be accepted as the most reliable…

    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 · D2024-10-11 · 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 and policy review, and interview, the facility failed to ensure that one Resident (#6) out of a total sample of 17 resident was free of medication errors. Specifically, the facility failed to: -ensure that antibiotic medication (Clindamycin) ordered for Resident #6 was administered for seven days as ordered and not 12 days as indicated on the Medication Administration Record (MAR). Findings include: Review of the facility's policy titled Medication Management Administration of Medications, revised October 2024, indicated: -Licensed personnel may only administer medications that have been dispensed by the pharmacy, including those stocked in the automated drug distribution cabinet (ADC). -Medications will be obtained from the ADC or medication storage area for one patient at a time, then administered to that patient. Resident #6 was admitted to the facility in August 2024, with diagnosis of Stage 4 Pressure Ulcer (full thickness tissue loss that exposes bone, muscle, or tendon) of the left buttock. Review of Resident #6's October 2024 Physician orders…

    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
Show the remaining 17 citations
  • Potential for harm · D2024-10-11 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    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 of practice. Specifically, the facility failed to ensure staff properly labeled all medications stored in one of three medication carts reviewed. Findings include: Review of the facility's policy titled Medication Labeling and Storage, dated 2001, indicated but was not limited to the following: 1. Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices. 2. The medication label includes, at a minimum: a. medication name (generic and/or name brand); b. prescribed dose; c. strength; d. expiration date, when applicable; e. resident's name; f. route of administration; and g. appropriate instructions and precautions. On 10/9/24 at 11:46 A.M., the surveyor and Nurse #5 reviewed the medication cart on the First Floor and observed the following: -One Albuterol Sulfate…

    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 · Dcited before2024-10-11 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record and policy review, the facility failed to implement infection control measures to stop the spread of infection for two Residents (#6 and #46) out of 17 sampled residents, and on one Unit out of two units. Specifically, the facility failed to: 1. Ensure that Enhanced Barrier Precautions (EBP) and Infection control practice were maintained for Resident #6. 2. Ensure that infection control practices were adhered to during a PICC (peripherally inserted central catheter - a long flexible tube that is inserted into a vein in the arm and threaded into a large vein near the heart) line dressing change for Resident #46. 3. Ensure that a glucometer machine (glucose meter: a small, portable device that measure the amount of glucose (sugar) in the blood) was appropriately disinfected between Resident use. Findings include: Review of the facility's policy titled Enhanced Barrier Precautions, revised August 2022, indicated: -Enhanced barrier precautions (EBP's) are used as an infection prevention and control intervention to reduce the spread of multi-drug…

    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 · Fcited before2023-07-19 · tag F0880 — failed to prevent and control infections — widespread
    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 interview, the facility failed to follow infection control guidelines relative to: 1. Placing one Resident (#16) on Contact Precautions (intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment) when diagnosed with a Multidrug-Resistant Organism (MDRO) and an infection. 2. Not placing Residents that met criteria on Enhanced Barrier Precautions (use of gowns and gloves for specific high contact resident care activities associated with MDRO transmission). 3. Completing an assessment and creating a plan to minimize the risk of Legionella (a serious type of lung infection that occurs when small droplets of water are breathed in or accidentally swallowing water containing the Legionella bacteria) outbreak. Findings include: 1. Resident #16 was admitted to the facility in November 2022 with diagnoses including Respiratory Failure with hypoxia, Venous Ulcer of left calf and Varicose (enlarged)Veins of bilateral legs. Review of the facility Infection Control:…

    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 · E2023-07-19 · tag F0726 — failed to have competent, trained nursing staff — pattern
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to ensure yearly Licensed Staff Competencies included the care and services for residents receiving Dialysis (process of removing excess water and toxins from the blood in people whose kidneys no longer perform these functions naturally) treatment. Findings include: Review of the facility Matrix (a form that identifies pertinent care categories for residents residing in the facility) indicated there were currently three residents residing in the facility that were receiving Dialysis treatments. Review of the yearly Licensed Staff Competency form indicated no competency was in place for the care and services of a Dialysis resident. During an interview on 7/18/23 at 4:31 P.M., the Assistant Director of Nurses (ADON) said the facility accepts residents requiring Dialysis treatments. She further said the yearly Licensed Staff Competencies did not include the care and services of a Dialysis resident as required.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-07-19 · 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, policy review and interview, the facility failed to serve and distribute food in accordance with professional standards for food service safety. Specifically, the facility failed to maintain appropriate cold food and beverage temperatures during meal service to minimize the risk of food-borne illness. Findings include: Review of the facility's Food Preparation policy, revised September 2017, indicated: -The Dining Service Director/Cook will be responsible for food preparation techniques which minimize the amount of time that food items are exposed to temperatures greater than 41 degrees Fahrenheit (F) and/or less than 135 degress F, per state regulation. -All foods will be held at appropriate temperatures, greater than 135 degrees F for hot holding, and less than 41 degrees F for cold food holding. During an observation of meal service on 7/18/23 at 11:53 A.M., the following were identified concerns: -Two large, full trays of pre-poured milk glasses were being served. No cooling system was in place underneath the trays of milk glasses. -A large tray containing…

    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 · E2023-07-19 · tag F0909 — failed to maintain a comfortable temperature — pattern
    Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on document review, policy review and interview, the facility failed to conduct inspection of all bed frames, mattresses, and bed rails, if any, as part of a regular maintenance program to identify areas of possible entrapment. Specifically, beds with air mattresses were not inspected to identify areas of possible entrapment. Findings include: Review of the facility's Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, dated 3/10/06, included: -Evaluation of the dimensional limits of gaps in beds is one component of overall assessment and mitigation strategy to reduce entrapment. -If a powered air mattress is replacing a mattress on a bed system that meets the recommendations in the guidance with the original mattress, the resulting bed system with the new air mattress may pose a risk of entrapment. Review of the facility's Bed Gap Inspection form, dated 2/28/23, indicated the following beds had an air mattress and were not inspected: -102A -105A -105B -106B -114B -205B -207B -208B -214A -215A -215B -220B -222B -223A -223B -225B. During an interview…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-19 · tag F0637 — isolated
    Assess the resident when there is a significant change in condition
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure that staff completed a Significant Change in Status Assessment (SCSA) for one Resident (#43), out of total sample of 15 Residents. Specifically, the facility failed to ensure that its staff completed the SCSA following a decline in Resident #43's functional status after a fall that resulted in a hip fracture. Findings include: Review of the facility's Resident Assessment Instrument policy, dated September 2021, indicated: -A SCSA Minimum Data Set (MDS) is required if the resident has a decline or improvement from baseline in two or more areas of the resident's functional status. Resident #43 was admitted to the facility in April 2022 with diagnoses including a history of falls and an abnormal gait and mobility. Review of the MDS assessment, dated 1/6/23, indicated the Resident was: -independent with bed mobility -a limited assist for ambulation -supervised for transfers and toileting -continent of bladder and bowel Review of the clinical record indicated the Resident sustained an unwitnessed fall on 2/15/23 while…

    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 before2023-07-19 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, policy review, record review and interview, the facility failed to follow the care plan for one Resident (#23) and failed to develop a care plan for one Resident (#43), out of a sample of 15 residents. Specifically, the facility failed to ensure that its staff: 1. Followed the care plan related to the hourly rate an enteral feeding (liquid nutrients delivered via a tube that is inserted into the stomach) was to be administered for Resident #23. 2. Developed a care plan related to urinary incontinence (lack of voluntary control over urination or defecation) for Resident #43. Findings include: 1. For Resident #23 the facility failed to ensure its staff administered an enteral feeding per the Physician's order. Resident #23 was admitted to the facility in May 2022 with a diagnosis that included Gastrostomy (g-tube: a tube inserted directly into the stomach for nutrients, medications and fluids to be administered) status. Review of a Registered Dietician's (RD) progress note, dated 7/5/23,…

    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 · D2023-07-19 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to review and revise the comprehensive care plan relative to a positioning device, for one Resident (#22) out of a total sample of 15 Residents. Findings include: Resident #22 was admitted to the facility in May 2021 with diagnoses including Cerebral Infarction (stroke - sudden loss of blood circulation to an area of the brain), and left sided Hemiplegia (paralysis) and Hemiparesis (muscle weakness or partial paralysis). During an interview on 7/13/23 at 8:22 A.M., the Resident said he/she had a stroke and was very weak on his/her left side. The surveyor observed the Resident lying in bed and covered with a blanket. Review of the Physical Therapy Progress and Discharge summary, dated [DATE], indicated the following: -Resident not a candidate for Botox (used to reduce the stiffness or spasticity of muscles) injection and would benefit from consistent splint schedule to maintain bilateral knee range of motion (ROM). -Resident was issued…

    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 · D2023-07-19 · tag F0694 — isolated
    Provide 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to provide care for a Peripherally Inserted Central Catheter (PICC- a long catheter inserted through a peripheral vein then into the central vascular system to administer intravenous (IV) treatments over a long period of time) for one applicable Resident (#16), in a total sample of 15 Residents. Specifically, the facility failed to ensure PICC line flushes, dressing changes and tubing changes were completed and documented for Resident #16. Findings Include: Resident #16 was admitted to the facility in November 2022 with diagnoses including Respiratory Failure with Hypoxia (when the respiratory system cannot adequately provide oxygen to the body) and Venous Ulcer (wound caused by abnormal or damaged veins) of left calf and Varicose (enlarged) Veins of bilateral legs. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident was cognitively intact as evidenced by a score of 15 out of 15 on the Brief Interview for…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-19 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to provide care and services consistent with professional standards for one Resident (#37), out of two applicable residents, in a total sample of 15 Residents. Specifically, the facility failed to: a. Consistently evaluate and document the status of an Arteriovenous (A/V) fistula (a surgical connection of an artery to a vein to provide blood flow for dialysis). b. Coordinate delivery of medications with the Resident's dialysis treatment schedule to ensure the Resident received all medications, as ordered by the Physician. Findings include: Resident #37 was admitted to the facility in April 2023 with a diagnosis of End Stage Renal Disease (ESRD - when the kidneys are no longer able to work at a level needed for day-to-day life). Review of the Facility Dialysis Management Policy, revised 1/2019, included, but not limited to: -Evaluate and document Arteriovenous Fistula every shift on the Medication Administration Record (MAR) or Treatment…

    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 · D2023-07-19 · tag F0710 — isolated
    Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's 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 observation, record review and interview, the facility failed to notify the Physician when there was a change in the status of skin integrity for one Resident (#20), out of a total sample of 15 Residents. Findings include: Resident #20 was admitted to the facility in January 2023 with a diagnosis of Cerebral Infarction (a stroke). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident was severely impaired for daily decision-making skills, had a Gastrostomy tube (a surgically placed tube into the abdomen to give direct access for supplemental feeding) and a Tracheostomy tube (an opening surgically created through the neck into the trachea (windpipe) to allow air to fill the lungs). Review of a Nurse's note dated 6/23/23, indicated that the Certified Nursing Assistant (CNA) reported two open areas on the right gluteal fold (the horizontal skin crease that forms below the buttocks, separating the upper thigh from the buttocks). The note included the measurements of the two…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-19 · tag F0740 — failed to provide behavioral / mental-health care — isolated
    Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on policy review, record review and interview, the facility failed to provide Behavioral Healthcare Services for one Resident (#38) out of a sample of 15 residents, when such services were indicated by a Psychiatric Clinician. Findings include: Review of the facility policy for Treatment/Services for Mental/Psychosocial Concerns, dated December 2021, indicated the following: -The facility will ensure that a resident who displays or is diagnosed with a mental disorder or psychosocial adjustment difficulty .receives appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychological well being. Resident #38 was admitted to the facility in February 2022 with diagnoses that included Schizophrenia, Major Depressive Disorder and Anxiety Disorder. Review of a Psychiatric consult, dated 8/8/22, indicated the Resident told the Clinician that he/she was always depressed. The Clinician recommended the following: -Increase morning dose of Klonopin (antianxiety medication) to 1 milligram (mg). -Increase Zoloft (antidepressant…

    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 · D2023-07-19 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to obtain a routine medication for one Resident (#16), out of a total sample of 15 Residents, resulting in negative symptoms that required further medical management. Findings include: Resident #16 was admitted to the facility in November 2022 with diagnoses including Respiratory Failure with Hypoxia (when the respiratory system cannot adequately provide oxygen to the body) and Venous Ulcer (wound caused by abnormal or damaged veins) of left calf and Varicose (enlarged) Veins of bilateral legs. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident was cognitively intact as evidenced by a score of 15 out of 15 on the Brief Interview for Mental Status (BIMS) Assessment. Review of a Physician's order dated 5/12/23, indicated Methadone Hydrochloride (HCL) (a narcotic that treats moderate to severe pain and narcotic drug addiction), 10 milligrams (mg), give five tablets by mouth, two times a day for pain, give 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-07-19 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    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 an ordered medication, causing the Resident to experience negative symptoms which required further intervention for one Resident (#16), out of a total sample of 15 residents. Findings include: Resident #16 was admitted to the facility in November 2022 with diagnoses including Respiratory Failure with Hypoxia (when the respiratory system cannot adequately provide oxygen to the body) and Venous Ulcer (wound caused by abnormal or damaged veins) of left calf and Varicose (enlarged) Veins of bilateral legs. Review of the Minimum Data Set (MDS) Assessment, dated 5/19/23, indicated the Resident was cognitively intact as evidenced by a score of 15 out of 15 on the Brief Interview for Mental Status (BIMS) Assessment. Review of a Physician's order dated 5/12/23, indicated for Methadone Hydrochloride (HCL) (a narcotic that treats moderate to severe pain and narcotic drug addiction), 10 milligrams (mg), give five tablets by mouth, two times a day for pain, give a total of 50 mg. Review of the May 2023 Medication…

    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 · D2023-07-19 · tag F0791 — failed to provide routine dental services — isolated
    Provide or obtain dental services for each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to provide recommended dental services for one Resident (#38) out of a total sample of 15 residents. Specifically, the facility failed to ensure that its staff: 1. Implemented a recommendation for an antibiotic (to treat tooth infection) in a timely manner. 2. Provided follow-up dental services for tooth extractions due to a tooth infection. Findings include: Resident #38 was admitted to the facility in February 2022. Review of a Dental consult, dated 12/6/22, indicated the following: -Resident's teeth badly deteriorated and have become symptomatic. -Recommend that the Resident be seen by an oral surgeon for removal of all remaining teeth. Discussed with staff. -Request for an order of Ibuprofen and Amoxicillin (antibiotic) for the short term until treatment can be arranged. Review of a Nursing progress note, dated 12/7/22, indicated that per the Dentist's recommendation, the facility staff would follow up with a Dental Surgeon appointment.…

    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 · D2023-07-19 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    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 policy review, record review and interview, the facility failed to offer Pneumococcal Vaccination to one Resident (#35) of five applicable Residents, out a total sample of 15 Residents, unless the immunization was medically contraindicated or the resident had already been immunized. Specifically, the facility staff failed to offer, educate the Resident/Resident Representative on the benefits and risks, and administer the Center for Disease Control and Prevention (CDC)'s recommended Pneumococcal Conjugate Vaccine (PCV) 15 or 20, when the member had previously received the Pneumococcal Polysaccharide Vaccine (PPSV) 23 vaccine at the age sixty-five. Findings include: Review of the facility's Influenza and Pneumococcal Immunization policy, date December 2021, indicated: -All staff and residents are to be offered the Pneumococcal Vaccination in accordance with the CDC and the Advisory Committee on Immunization Practices (ACIP) recommendations. Review of the CDC's ACIP for the Pneumococcal Vaccine…

    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

“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

$85,733 in federal fines across 13 penalties.

  • $4,938 — penalty dated 2024-02-20
  • $4,938 — penalty dated 2024-02-12
  • $14,814 — penalty dated 2024-01-22
  • $4,938 — penalty dated 2024-01-08
  • $4,587 — penalty dated 2024-01-02
  • $13,762 — penalty dated 2023-12-11
  • $4,587 — penalty dated 2023-11-06
  • $4,587 — penalty dated 2023-10-30
  • $4,587 — penalty dated 2023-10-23
  • $4,587 — penalty dated 2023-10-17
  • $4,587 — penalty dated 2023-10-10
  • $4,235 — penalty dated 2023-10-02
  • $10,586 — penalty dated 2023-09-11

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 VIBRA HEALTHCARE — 3 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 4 of 54.0≈ chain avg
Health inspection 4 of 53.3+0.7 vs chain
Staffing 4 of 53.7+0.3 vs chain
Quality measures 3 of 54.3-1.3 vs chain
The other 2 homes this chain runs (chain average 4.0★, 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
VIBRA HEALTHCARE II, LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 09/01/2013
HOLLINGER, BRADIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICERNO PERCENTAGE PROVIDEDsince 09/01/2013
CREDIT SUISSE AGOrganization5% OR GREATER SECURITY INTERESTsince 07/22/2020
MPT OF ROCHDALE - VIBRA, LLCOrganization5% OR GREATER SECURITY INTERESTsince 08/30/2019
DIOP, BABACARIndividualW-2 MANAGING EMPLOYEEsince 05/10/2021
HAUCK, DAVIDIndividualCORPORATE OFFICERsince 10/04/2018
HOLLINGER, KELLYIndividualCORPORATE OFFICERsince 03/01/2020
NIEMUTH, TRISHAIndividualCORPORATE OFFICERsince 01/01/2022

CMS files one row per role, so the 9 rows in the source record cover these 8 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.

$7.1M
Net patient revenuemost recent cost report
-28.4%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 61%Medicare 4%Other / private 35%

A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. 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

$398per resident / day
operating cost
$12,096per month
≈ monthly operating cost
$310per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2024). 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 225668. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-02, 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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