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Oceanside Rehabilitation And Nursing Center

44 South Street, Rockport, MA 01966 · For profit - Limited Liability company · 76 certified beds · (978) 546-6311 Medicare & Medicaid certified

Call the home — (978) 546-6311 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0609) — cited Jun 2023
Insights

On the public record, this home looks stronger than most — but visit before you decide.

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)
  • no federal fines or payment denials on record
  • lower-than-typical staff turnover (35% 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 a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

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

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
231 Gloucester Crossing Rd · (978) 283-8223 · Call to confirm hours
Pharmacy
Walgreens1.2 mi
33 Whistlestop Mall · (978) 546-7521 · Call to confirm hours
Grocery
5 Dock Sq · (978) 546-0010 · Call to confirm hours
Park
2 High 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 5 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 4 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 2 to 5 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 rating5★
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 increased3.3%16.4%15.4%better
Long-stay residents who lose too much weight2.3%5.1%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.8%0.9%better
Long-stay residents with a urinary tract infection0.0%1.8%2.0%better
Long-stay residents with depressive symptoms61.6%15.5%6.5%worse 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 injury0.4%3.4%3.3%better
Long-stay residents whose ability to walk worsened5.7%15.4%16.1%better
Long-stay residents on antianxiety or hypnotic medication21.3%19.5%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%94.8%95.3%typical
Long-stay residents with pressure ulcers3.0%4.2%4.7%better
Long-stay residents with worsening bladder/bowel control4.7%21.2%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table33.6%21.4%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.0%1.4%1.4%better
Short-stay residents given the seasonal flu vaccine84.1%77.7%79.4%typical
Short-stay residents rehospitalized after admission29.7%25.7%22.6%worse
Short-stay residents with an outpatient ER visit13.7%11.9%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.751.881.67typical
Long-stay outpatient ER visits per 1,000 resident days1.061.501.80better

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.

52.9% 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 67 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

52.9%U.S. median 51.5%
Got home and stayed home
10.6%U.S. median 10.7%
Went back to hospital
87.2%U.S. median 56.6%
Met the expected recovery
0.18U.S. median 0.31
Therapy hours / resident / day
0.10hours / resident / day
Physical therapy
0.07hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Met the expected recovery: 87.2% 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 39 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 0.18 therapist hours per resident per day in 2026Q1 — more than 17% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 9% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF52.9%CMS range 41.1–62.651.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.6%CMS range 6.7–14.910.7%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 discharge87.2%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge71.8%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge74.4%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final 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 stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.3%CMS range 3.5–13.27.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.831.02Oct 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

0.71
RN hours/ resident / day
0.61
LPN hours/ resident / day
1.81
Aide hours/ resident / day
3.13
Total nurse hours/ resident / day
0.42
RN hoursweekends
35.4%
Total nursing turnover
22.2%
RN turnover

How full it usually is: this home is certified for 76 beds and averages 65.9 residents a day — about 87% occupied, or roughly 10 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.13 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.71 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.81 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 2.89 hrs/resident/day on weekends vs 3.23 on weekdays — 10% thinner on weekends. RN hours go from 0.83 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 35% is below the national median of 45%.

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

Inspection trend

5
deficiencies at the latest standard inspection (2025-06-10)
10
at the previous standard inspection (2024-07-17)

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.

30 citations, most serious first. The 10 most serious are shown; the remaining 20 are one tap away and print in full.

  • Potential for harm · E2025-06-10 · tag F0803 — failed to meet residents' dietary needs — pattern
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    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 serve what was listed on the menu or provide a substitution for two lunch meals. Specifically, on 6/8/25 the facility failed to serve sour cream with the baked potato during the lunch meal and on 6/9/25 the facility failed to add meat to the baked ziti according to the facility's recipe during the lunch meal. Findings include: Review of the policy titled, Food Presentation, undated, indicated the following: - Foods are prepared according to standard recipes. During the resident group meeting on 6/8/25 at 1:30 P.M. the surveyor met with Residents and the following complaints were made by four residents: - Menus were not always followed. - Should have condiments like sour cream with a baked potato. On 6/8/25 at 12:10 P.M., the surveyor observed lunch being delivered to residents' rooms. The main lunch meal consisted of a slice of pork, brussels sprouts, a baked potato, margarine, and watermelon. Review of the recipe for lunch, 6/8/25, indicated the baked potato was to be served with sour cream. During an…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-06-10 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to serve food that was palatable, and at a safe and appetizing temperature, on two of two units. Findings include: Review of the facility policy titled, Food Serving Temperatures, not dated, indicated that foods will be maintained at proper holding temperatures to ensure food safety. The temperature of potentially hazardous cold foods will not be greater than 45 F (degrees Fahrenheit) when served to the resident. Review of the facility policy titled, Food Presentation, not dated, indicated that foods will be served at proper temperatures. Hot foods hot and cold foods cold. During the initial tour of the facility on 6/8/25 the surveyors met with residents. Thirteen residents voiced dissatisfaction with the temperature and/or taste of the food served at the facility. During the resident group meeting on 6/8/25 at 1:30 P.M. the surveyor met with Residents and the following complaints were made by four residents: - The foods that were cold were not always…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-10 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, observation and interviews, the facility failed to ensure one Resident (#36) out of a total sample of 18 residents did not self-administer medication without an assessment or physician's order. Findings include: Review of the facility policy titled Self-Administration of Medications dated as revised February 2021 indicated that as part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident. Further review indicated that if it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan. Resident #36 was admitted to the facility with diagnoses including asthma, amputation of toe multiple sites and depression. Review of the Minimum Data Set assessment, dated 5/5/25, indicated that Resident #36 is cognitively intact as evidence by a score of 15 out of 15 on the Brief Interview for Mental Status exam.…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-10 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review, and interviews, the facility failed to ensure that respiratory care and services, consistent with professional standards of practice, were provided for one Resident (#27) out of sample of 18 residents. Specifically, for Resident #27, the facility failed to change oxygen tubing as indicated in the physician's orders and the facility failed to ensure staff consistently stored oxygen tubing in a sanitary manner when not in use. Findings include: Review of the facility policy titled, Oxygen Administration, dated as revised October 2010, indicated the purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Resident #27 was admitted to the facility in April 2024 with diagnoses including chronic respiratory failure, chronic obstructive pulmonary disease (COPD), and dyspnea (difficulty breathing). Review of the most recent Minimum Data Set (MDS) assessment, dated 3/28/25,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-10 · tag F0806 — failed to honor food preferences — isolated
    Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
    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 consistently accommodate resident food allergies for one Resident (#26) out of a total sample of 18 residents. Specifically, for Resident #26 a. the facility failed to ensure the kitchen did not serve the Resident eggs which were listed as an allergy on his/her diet ticket, and eggs are served/offered 17 times during a 28 day menu cycle and b. the facility failed to consistently document food allergies in the medical record and on the diet ticket, including an allergy to peaches on his/her diet ticket which is offered as a dessert five times during a 28 day menu cycle. Findings include: Review of the facility policy titled, Food Allergies, undated, indicated during hours of food service operation, the kitchen will make reasonable accommodations for patients with life threatening allergies and all other food allergies. 1. Obtain copy of diet prescription order form with specific food allergies from nursing services. 2. Dietary services will list food allergies on tray card. 3. Dietary services will make…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-07-17 · 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 observations, interviews and policy review, the facility failed to properly store food items to prevent the risk of foodborne illness and in accordance with professional standards for food service safety. Findings include: Review of the facility policy titled Preventing Foodborne Illness - Food Handling, revised July 2014, indicated the following: - Food will be stored, prepared, handled and served so that the risk of foodborne illness is minimalized. - Functioning of the refrigeration and food temperatures will be monitored at designated intervals throughout the day and documented according to state-specific requirements. Federal standards require that refrigerated food be stored below 41 degrees F (Fahrenheit). The surveyor made the following observations during the initial kitchen walkthrough on 7/16/24 at 7:15 A.M.: In the reach-in refrigerator: - A hanging thermometer displaying a temperature of 50 degrees Fahrenheit. Resident food was stored in the refrigerator and the refrigerator felt warm and had a musty smell to it. - A container containing what resembled red…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-07-17 · tag F0881 — failed to use antibiotics responsibly — pattern
    Implement a program that monitors antibiotic use.
    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 implement an Antibiotic Stewardship Program to promote and monitor the appropriate use of antibiotics which are used to guide decisions for evaluating antibiotic prescribing patterns in accordance with the Antibiotic Stewardship Program. Findings include: Review of the Centers for Disease Control and Prevention (CDC) guidance titled: The Core Elements of Antibiotic Stewardship for Nursing Homes, undated, indicated but was not limited to the following: - The purpose of an antibiotic stewardship program is to improve the use of antibiotics in healthcare to protect patients and reduce the threat of antibiotic resistance. - Antibiotic stewardship refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. - The CDC recommends that all nursing homes take steps to improve antibiotic prescribing practices and reduce inappropriate use. - Any action taken to improve antibiotic use is expected to reduce adverse events,…

    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 · E2024-07-17 · tag F0908 — failed to keep essential equipment working — pattern
    Keep all essential equipment working safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interview and policy review, the facility failed to ensure that equipment in the kitchen was functioning properly. Specifically, the facility failed to ensure that a reach-in refrigerator was operating at the proper temperature while resident food was being stored inside of it. Findings include: Review of the facility policy titled Preventing Foodborne Illness - Food Handling, dated and revised July 2014, indicated the following: - Functioning of the refrigeration and food temperatures will be monitored at designated intervals throughout the day and documented according to state-specific requirements. Federal standards require that refrigerated food be stored below 41 degrees F (Fahrenheit). The surveyor made the following observations during the initial kitchen walkthrough on 7/16/24 at 7:15 A.M.: In the reach-in refrigerator: - A hanging thermometer displaying a temperature of 50 degrees Fahrenheit. Resident food was stored in the refrigerator and the refrigerator felt warm and had a musty smell to it. During the revisit to the kitchen on 7/17/24 at 7:45…

    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 · Dcited before2024-07-17 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and policy review, the facility failed to develop an individualized, comprehensive care plan for one Resident (#43) out of a total sample of 18 residents. Specifically, the facility failed to develop a comprehensive care plan for Resident #43 related to Type 2 Diabetes Mellitus . Findings include: Review of the facility policy titled Care Plans, Comprehensive Person-Centered, dated March 2022, indicted the following: - 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 interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. - The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment and no more than 21 days after…

    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 before2024-07-17 · 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 observation, record review, and interview, the facility failed to follow professional standards of nursing practice for one Resident (#10) out of a total sample of 18 residents. Specifically, the facility failed to obtain a physician order for an air mattress prior to the resident using one. Findings include: Resident #10 was admitted to the facility in June 2023 with diagnoses including unspecified dementia, moderate protein-calorie malnutrition and polyosteoarthritis. Review of Resident #10's most recent Minimum Data Set Assessment (MDS) dated [DATE], indicated that the Resident had a Brief Interview for Mental Status (BIMS) score of 5 out of a possible 15 indicated severe cognitive impairment. Further review of Resident #10's MDS indicated that he/she requires assistance with all activities of daily living. The surveyor made the following observations: - On 7/16/24 at 7:34 A.M. and 11:58 A.M., Resident #10 was observed laying in his/her bed which was an air mattress set to 80 pounds. - On 7/17/24 at…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
Show the remaining 20 citations
  • Potential for harm · D2024-07-17 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure nursing staff provided assistance with Activities of Daily Living (ADLs) for two dependent Residents (#44 and #32) out of a total sample of 18 residents. Specifically: 1. For Resident #44, the facility failed to ensure assistance was provided with bed mobility and eating as indicated in the plan of care. 2. For Resident #32, the facility failed to ensure supervision with meals was provided as indicated in the plan of care. Findings include: The facility policy titled Activities of Daily Living (ADL), Supporting, revised March 2018, indicated the following: -Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: d. dining (meals ad snacks). 1. Resident #44 was admitted to the facility in February 2024 with diagnoses that included stage 4 pressure ulcer 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
  • Potential for harm · D2024-07-17 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and interviews, the facility failed to ensure that one Resident (#13) received treatment and care in accordance with professional standards of practice out of a total sample of 18 residents. Specifically, for Resident #13 the facility failed to: 1a. Change the Residents' PICC (A peripherally inserted central catheter (PICC), is a long, thin tube that's inserted through a vein in your arm and passed through to the larger veins near your heart) line dressing when the insertion site was unable to be visualized, 1b. Measure the PICC line on admission and with the dressing change on 7/10/24 as ordered, 2. Transcribe a new treatment order from the hospital discharge paperwork. Findings Include: Review of the facility's policy titled Central Venous Catheter Care and Dressing Changes, dated 3/22, indicated The purpose of this procedure is to prevent complications associated with intravenous therapy, including catheter related infections that are associated with contaminated,…

    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 · D2024-07-17 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure the air mattress was set at the appropriate setting for one Resident (#44) with a stage 4 pressure ulcer out of a total sample of 18 residents. Findings include: The facility policy titled Prevention of Pressure Injuries, revised April 2020, indicated the following: -1. Select appropriate support surfaces based on the resident's risk factors, in accordance with current clinical practice. Set according to manufacturer guidance. Review of the manufacturers guidance for the air mattress that Resident #44 utilizes indicated: -Determine the patient's weight and set the control to that weight setting on the control unit. Resident #44 was admitted to the facility in February 2024 with diagnoses that included stage 4 pressure ulcer of sacral region and dysphagia (difficulty chewing and swallowing). Review of the most recent Minimum Data Set (MDS) , dated 5/2/24, indicated that on the Brief Interview for Mental Status, Resident #44 scored a 2…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-07-17 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and interviews, the facility failed to ensure accurate medical records for one Resident (#32) out of a total sample of 18 residents. Specifically, for Resident #32, the facility failed to accurately document the level of supervision received during meals. Findings Included: Resident #32 was admitted to the facility in February 2024 with diagnoses including dysarthria (poor articulation of words) following other cerebral vascular disease and dysphagia (difficulty swallowing). Review of Resident #32's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 3 out of a possible 15, which indicated he/she had severe cognitive impairment. Further review of the MDS indicated Resident #32 is on a mechanically altered diet, require change in texture of food or liquids (e.g., pureed food, thickened liquids). On 7/16/24 at 8:25 A.M.,12:19 P.M. and 12:32 P.M., and 7/17/24 at 8:25 A.M. and 8:33 A.M., Resident #32 was…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-07-17 · 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 observations, policy review and interviews the facility failed to ensure nursing staff performed hand hygiene appropriately during the medication administration task. Findings include: Review of the facility policy titled Handwashing/Hand Hygiene, dated as revised August 2019, indicated This facility considers hand hygiene the primary means to prevent the spread of infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 7. Use an alcohol-based hand rub containing at least 62% alcohol; or , alternatively , soap (antimicrobial or non-antimicrobial)and water for the following situations: b. Before and after direct contact with residents c. Before preparing or handling medications i. After contact with residents' skin k. After handling used dressings, contaminated equipment, etc. l. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident m. After removing gloves. 9. The use of gloves does not replace hand washing/hand hygiene.…

    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 · D2024-03-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had dementia and was known by staff to wander the hallways and had exhibited exit seeking behaviors, the Facility failed to ensure that Resident #1 was provided with an adequate level of supervision in an effort to maintain his/her safety to prevent an elopement. On 02/15/24, at some point during the evening shift, unbeknownst to staff, Resident #1 exited the Facility, staff only became aware of the elopement after he/she was found outside by a staff member who was returning to the facility from a break, and saw him/her sitting on the pavement in the front parking lot. Resident #1 was brought back onto the facility, he/she was noted to be shivering as it was cold outside and was assessed to have abrasions on his/her toes. Findings include: The Facility policy titled Wandering and Elopements, dated 03/2019, indicated the Facility would identify residents who were at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment. Resident #1 was…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2023-06-26 · tag F0881 — failed to use antibiotics responsibly — widespread
    Implement a program that monitors antibiotic use.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review, policy review and interview, the facility failed to implement their Antibiotic Stewardship Program to promote and monitor the appropriate use of antibiotics and failed to complete Antibiotic usage audit tools (Line Listings), which are used to guide decisions for evaluating antibiotic prescribing patterns in accordance with the Antibiotic Stewardship Program. Findings include: Review of the facility policy titled Antibiotic Stewardship, dated as revised December 2016 failed to indicate that the facility will track and trend the use of antibiotics in order to determine their appropriate use. During an interview on 1/30/23, at 1:00 P.M., the Assistant Director of Nursing (ADON) said that she had not implemented an antibiotic stewardship program that analyzed the use of antibiotics for the appropriate antibiotic for the organism, dose, duration or route.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-06-26 · tag F0638 — pattern
    Assure that each resident’s assessment is updated at least once every 3 months.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on records review and interview, the facility failed to ensure Quarterly Minimum Data Set assessments (MDS) were completed per the Centers for Medicare and Medicaid Services (CMS) required timeframe for 7 Residents (#1, #8, #10, #11, #26, #35, and #49) out of a total sample of 21 residents. Findings include: Review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual indicated the Quarterly MDS Assessment must be completed no later than 14 calendar days after the Assessment Reference Date (ARD-refers to the last day of the observation period that the assessment covers for the resident). 1. Resident #1 was admitted in March 2021. Review of the MDS significant change assessment with an assessment reference date (ARD) of 12/29/23, was completed 17 days late on 1/29/23, and had not been exported yet to CMS. 2. Resident #8 was admitted to the facility in October 2017. Review of the Quarterly MDS with an ARD of 11/23/22, was completed 32 days late on 1/8/23. 3. Resident #10 was admitted to the facility in September 2022.…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-06-26 · tag F0656 — failed to write and follow a full care plan — pattern
    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 3.) For Resident #44 the facility failed to monitor the Resident during meals per his/her plan of care. Resident #44 was admitted to the facility in March 2022 with diagnoses including dementia and dysphagia. Review of Resident #44's most recent Minimum Data Set assessment dated [DATE] indicated he/she is moderately cognitively impaired and requires continuous supervision for cueing and encouragement for eating. Review of the care plan dated as revised on 1/11/23, indicated a nutrition problem with interventions including to monitor the Resident for signs/symptoms of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, and refusing to eat. On 1/29/23, at 12:20 P.M., the surveyor observed Resident #44 in the dining room with a meal in front of her/him and not eating. The surveyor observed that no staff were in the dining room monitoring Resident #44 for signs/symptoms of dysphagia or cueing or encouraging her/him to eat. On 1/29/23, at 12:31 P.M., Nurse #1…

    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 · E2023-06-26 · tag F0692 — failed to prevent malnutrition and dehydration — pattern
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviewed and interviews, the facility failed to implement dietary preferences, a plan of care for supervision during meals, failed to implement the weight policy and failed to identify and address significant weight losses for 2 Residents (#26 and #11) out of a total sample of 21 Residents. Finding include: Review of the facility policy titled, Weight Assessment and Intervention, dated as revised March 2022, indicated that Resident weights are monitored for weight loss. *any weight change of 5% or more since the last weight assessment is retaken the next day for confirmation. -the threshold for significant unplanned weight loss will be based on the following criteria, 1 month 5% loss is significant; greater than 5% is severe. -care planning for weight loss includes the physician, nursing staff, the dietician, the resident and or his/her legal surrogate (health care agent). 1.) For Resident #26 the facility failed to implement dietary preferences, a plan of care of care 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 · Ecited before2023-06-26 · 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 and interview, the facility failed to perform hand hygiene to prevent cross contamination during observations of the lunch meal in the main kitchen. Findings include: During observations of the lunch meal on 1/30/23 at 11:43 A.M. the surveyor observed the following: *A dietary aide changed his gloves without washing his hands. *At 11:50 A.M. the Food Service Director (FSD) entered the kitchen pushing a truck. Without performing hand hygiene, he went to a box of gloves to put on a pair. The FSD dropped one on floor, bent to pick it up, retrieved a new one, and put on the pair of gloves without washing his hands and joined the tray line. *At 11:52 A.M., the cook stopped to prepare a grilled cheese sandwich. Without removing the gloves he was wearing or performing hand hygiene, he proceeded to prepare the stove and slices of bread from a loaf. The cook then walked over to the refrigerator and opened the door. The [NAME] then obtained pieces of cheese and began preparing the grilled cheese sandwich all wearing the same gloves without removing them or performing hand…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-06-26 · tag F0880 — failed to prevent and control infections — pattern
    Provide 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, record review and interview the facility failed to maintain an infection control program designed to help prevent and identify the development and transmission of disease and infection and failed to ensure infection control measures were implemented to prevent the spread of infection on 2 of 2 units. Findings include: Review of the facility policy titled Infection prevention and Control Program indicated that surveillance tools are used for recognizing the occurrence of infections, recording their number and frequency, detecting outbreaks and epidemics, and detecting unusual pathogens with infection control implications. 1. Review of the infection control program failed to indicate the monitoring, tracking and analyzing of infections in the facility for the months of November and December of 2022. During an interview on 1/30/23, at 1:00 P.M., the Assistant Director of Nursing (ADON) said that she did not have a complete line listing of infections in the facility for the months of November…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-06-26 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, policy review and interview, the facility failed to report a sexual abuse allegation to the state agency within 2 hours as required, after finding 2 Residents (#3, #19) in bed together out of a total of 21 sampled Residents. Findings include: Review of the facility's Abuse Investigating and Reporting Policy, dated July 2017, indicated: *All alleged violation of abuse, neglect, exploitation or mistreatment will be reported immediately, but not later than two hours if the alleged violation involves abuse or has resulted in serious bodily injury. Resident #19 was admitted to the facility in November 2022 with diagnoses including vascular dementia and delirium. Review of his/her most recent Minimum Data Set assessment, dated 11/16/22, indicated he/she was severely cognitively impaired and he/she requires assistance with bathing and dressing. Review of his/her clinical record indicated his/her health care proxy was activated, meaning he/she cannot make his/her own decisions. Resident #3 was admitted to the facility in June 2014 with diagnoses including stroke 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-06-26 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 1 Resident (#8) out of a total sample of 21 residents. Findings include: Resident #8 was admitted to the facility in October 2017 with diagnoses including Autism, lymphedema and depression. Review of the MDS dated [DATE], indicated that Resident #8 does not wear glasses and is able to see fine detail and regular print in newspapers and books. On 1/29/23, at 8:10 A.M., the surveyor observed Resident #8 wearing a pair of glasses with tape on the left lens and frame. The surveyor also observed another pair of glasses on the bedside table that was broken. Review of the medical record indicated that Resident #8 was last seen by the eye doctor on 12/21/18. Further review indicated that the ophthalmology group assessment, dated 12/21/18, indicated Resident #8 required glasses for reading. Further review indicated that the eye doctor recommended that Resident #8 be re-evaluated in 12 to 15…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-06-26 · 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 observation, interview and record review, the facility failed to meet professional standards of practice for 1 Resident (#1) in a total sample of 21 Residents. Specifically, for Resident #1, the facility failed to properly assess his/her ability to operate his/her power wheelchair. Findings include: Review of the American Nursing Associations Scope and Standards of Nursing Practice, 2010, pg 32, indicated the following: Standard 1. Assessment: The Registered Nurse (RN) collects comprehensive data pertinent to the consumer's health and/or the situation. Competencies: Collects comprehensive data including but not limited to physical functional, psychosocial, emotional, cognitive, age related, environmental, spiritual/transpersonal and economic assessments in a systemic and ongoing process while honoring the uniqueness of the person. Resident #1 was admitted to the facility in March 2021 with diagnoses including hemiplegia and hemiparesis following unspecific cerebrovascular disease effecting left…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-06-26 · tag F0685 — isolated
    Assist a resident in gaining access to vision and hearing services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to provide routine vision services for 1 Resident (#8) out of a total sample of 21 residents. Findings include: Review of the facility policy titled Sensory Impairments-Clinical Protocol dated as revised March 2018 failed to indicate that residents will be provided with routine vision services. Resident #8 was admitted to the facility in October 2017 with diagnoses including Autism, lymphedema and depression. On 1/29/23, at 8:10 A.M., the surveyor observed Resident #8 wearing a pair of glasses with tape on the left lens and frame. The surveyor also observed another pair of glasses on the bedside table with one side disconnected (broken). Review of the doctor's orders dated 1/23/22, indicated an order for opthomology consults as needed. Review of the medical record indicated that Resident #8 had a signed consent for vision services dated October 2017. Further review indicated Resident #8 was last seen by the eye doctor on 12/21/18. Further review indicated that the ophthalmology group assessment, dated 12/21/18, diagnosed…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-06-26 · 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, interview and record review, the facility failed to ensure it was free from a medication error rate of greater than 5 percent. Two of 3 nurses observed made 5 errors in 27 opportunities resulting in a medication error rate of 18.52%. These errors impacted 2 Residents (#1 and #49) out of 3 residents observed. Findings include: Review of the facility policy titled Administering Oral Medications and dated as revised October 2010 failed to indicate that medications are to be administered within the professionally accepted standard of within 1 hour of ordered time. 1. For Resident #1 the facility failed to administer medications within the professionally accepted standard of within 1 hour of the ordered time. Review of the current doctor's orders indicated an order for the following: A. Divalproax 250 mg (milligrams) 2 times a day at 8:00 A.M. and 10:00 P.M. B. Valacylovir 500 mg 1 tablet at 9:00 A.M. and 5:00 P.M. C. Baclofen 10 mg 1/2 tablet at 9:00 A.M. and 20 mg at bedtime D. Tylenol 500 mg 2 tablets two times a day at 9:00 A.M. and 5:00 P.M. During 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 · D2023-06-26 · 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 and interview the facility failed to store medications in a safe manner in 1 out of 1 medication carts and 1 of 1 treatment carts. Findings include: Review of the facility policy titled Storage of Medications and dated as revised November 2020 indicated that drugs and biological's used in the facility are stored in locked compartments . only persons authorized to prepare and administer medications have access to locked medications. Further review indicated that unlocked medication carts are not left unattended and that medications requiring refrigeration are stored in a refrigerator. 1. On 1/29/23, at 7:02 A.M. the surveyors observed a treatment cart on the Seaside unit unlocked. The surveyors observed that there were no nursing staff in the area and were able to open the treatment cart and have access to its' contents. On 1/30/23 at 6:53 A.M., the surveyor observed a treatment cart on the Seaside unit unlocked. The surveyor observed that there was no nursing staff in the area and were able to open the treatment cart and have access to its' contents During an…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-06-26 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interviews, the facility failed to ensure its staff maintained complete and accurate medical records for 1 Resident (#10 ) out of 21 sampled residents. Specifically, the facility failed to ensure that staff documented complete and accurate skin checks. Findings include: Review of the facility policy titled, Prevention of Pressure Injuries, dated as revised April 2020, indicated to complete a comprehensive assessment weekly and upon any changes in condition. The policy indicated to document and evaluate changes in the skin. Resident #10 was admitted to the facility in September 2022 with diagnosis including muscle wasting, dehydration and cognitive communication deficit. Review of Resident #10's quarterly Minimum Data Set assessment, dated 12/1/22, indicated he/she could make self understood and he/she could usually understand others. Review of physician's order dated, 9/15/22, Weekly skin assessment every evening shift on Thursday. Review of the Treatment Administration Record (TAR), dated January 2023, indicated the skin check was completed on 1/5/23,…

    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
  • No harm found · C2023-06-26 · tag F0582 — widespread
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview the facility staff failed to inform 3 out of 3 Residents or their representatives with potential liability for payment for non-covered services including estimated cost of services. Findings include: The Advanced Beneficiary Notice (SNFABN) is a form which provides information to Residents and/or their beneficiaries so that they can decide if they wish to continue receiving the skilled services they are receiving at the facility that may not be paid for by Medicare and assume financial responsibility. During review of 3 Residents who had been taken off of their Medicare Part A benefit the facility failed to provide the required SNFABN form. During an interview with Corporate Nurse #1 at approximately 2:00 P.M., she said the facility was unable to provide evidence that the forms were provided to the Residents as required.

    Resident Rights Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

Owner / managerTypeRoleSince
HOROWITZ, AKIVAIndividualDIRECT OWNERSHIP INTERESTsince 07/09/2021
HOWARD, PAMELAIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/08/2025
MAJEKODUNMI, AKINDELEIndividualADP OF THE SNFsince 04/08/2025

CMS files one row per role, so the 5 rows in the source record cover these 3 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$3.4M
Net patient revenuemost recent cost report
-50.1%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 80%Medicare 8%Other / private 11%

About 80% 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. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

Cost & finances

$472per resident / day
operating cost
$14,348per month
≈ monthly operating cost
$314per day
avg. revenue, all payers

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

What families pay in MA

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 225456. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-10, 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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