Foremost At Sharon LLC
259 Norwood Street, Sharon, MA 02067 · For profit - Limited Liability company · 66 certified beds · (781) 784-6781 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- lower-than-typical staff turnover (36% vs 45% nationally) — better care continuity
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has 2 actual-harm citations
- a high number of inspection citations overall (32) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $26,232 in federal fines (most recent 2024-06-12)
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- about 19% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 21.6% | 16.4% | 15.4% | worse |
| Long-stay residents who lose too much weight | 4.6% | 5.1% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 1.8% | 0.8% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 0.0% | 1.8% | 2.0% | better |
| Long-stay residents with depressive symptoms | 39.8% | 15.5% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 3.8% | 3.4% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 16.5% | 15.4% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 23.7% | 19.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 98.0% | 94.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.5% | 4.2% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 25.7% | 21.2% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 22.0% | 21.4% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.8% | 1.4% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 60.8% | 77.7% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 18.3% | 25.7% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 12.9% | 11.9% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 0.99 | 1.88 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.34 | 1.50 | 1.80 | better |
‡ 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.
40.9% 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 76 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 59.1% 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 44 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 0.29 therapist hours per resident per day in 2026Q1 — more than 46% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 50% 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 40.9%CMS range 30.6–52.7 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.8%CMS range 8.8–15.5 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 59.1% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 50.0% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 54.5% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 98.3% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 95.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.7% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 1.7% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.4%CMS range 4.2–11.7 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.22 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 66 beds and averages 59.7 residents a day — about 90% occupied, or roughly 6 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 3.58 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.59 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.19 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 3.34 hrs/resident/day on weekends vs 3.68 on weekdays — 9% thinner on weekends. RN hours go from 0.65 to 0.44 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 36% is below the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
32 citations, most serious first. The 12 most serious are shown; the remaining 20 are one tap away and print in full.
- Actual harm · G2024-06-12 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide 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 observations, interviews, and records reviewed, the facility failed to ensure one Resident (#23), out of a total sample of 18 residents, received care and treatment to prevent and to promote healing of a pressure injury consistent with professional standards of practice. Specifically, the facility failed to implement treatments as ordered and notify the physician of worsening Moisture-Associated Skin Damage (MASD-inflammation and erosion of the skin caused by prolonged exposure to various sources of moisture, including urine or stool) resulting in a delay in treatment and deterioration of the wound to a stage 2 pressure ulcer (PU- partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer) to the Resident's left ischial tuberosity (bone in the lower part of the pelvis that absorbs weight when you sit). Findings include: Review of the facility's policy titled Pressure Ulcer/Injury Risk Assessment, revised March 2022, indicated but was not limited to the following: -Risk…
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.
- Actual harm · G2024-06-12 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide 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 observations, interviews, and records reviewed, for one Resident (#36), of 18 sampled residents, the facility failed to provide Foley catheter (a tube inserted through the urinary tract into the bladder, connected to a drainage bag to drain urine from the bladder) care and management consistent with professional standards of practice. Specifically, for Resident #36, the facility failed to: -Ensure his/her Foley catheter was properly positioned to ensure adequate drainage from the bladder, -Document care and maintenance of a Foley catheter, -Implement provider orders for Intake and Output (I&O) monitoring to ensure adequate output, and -Notify his/her provider of an abnormal radiology report resulting in Resident #36 being hospitalized for four days due to a malpositioned (wrong or faulty position) Foley catheter resulting in bilateral hydroureteronephrosis (swelling of both kidneys and ureters, a thin tube that drains urine from the kidney to the bladder, which occurs when urine can't drain and builds…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-30 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who developed Moisture-Associated Skin Damage (MASD) to his/her coccyx, the Facility failed to ensure they notified his/her Physician of the Wound Nurse Practitioner's recommendations for wound care and as a result, the treatment recommendations were never implemented.Findings include:Review of the Facility's Policy titled, Change of Condition in a Resident Status, dated 03/2017, indicated the Facility would notify the resident's physician when there had been a need to alter the resident's medical treatment significantly. Review of the Facility Policy titled, Pressure Ulcer/Injury Risk Assessment, dated as revised 03/2022, indicated to document in medical record addressing MD notification if new skin alteration noted with change of plan of care. Resident #1 was admitted to the Facility in August 2025, diagnoses included unspecified dementia, seizures, syncope and collapse, hypertension muscle weakness and type 2 diabetes mellitus.Review of the Wound Nurse Practitioner's Initial Progress Note,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-30 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records reviewed and interviews for one of three sampled residents (Resident # 1), who developed a wound to his/her coccyx and required wound care, and required a sling to his/her left arm due to a fractured left clavicle, the Facility failed to ensure nursing developed and implemented a comprehensive person-centered care plan with interventions, treatment goals and outcomes that addressed, ) his/her wound care needs and 2) care and monitoring needs related to his/her fractured left clavicle. Findings include:Review of the Facility's Policy titled, Comprehensive Care Plans, dated as revised April 2022, indicated that: - a comprehensive, person-centered care plan that includes objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident;- the care planning process will include an assessment of residents' strengths and needs, reflect treatment goals, timetables and objectives in measurable outcomes;- assessments of 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.
- Potential for harm · D2025-12-30 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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 records reviewed and interviews, for one of three sampled residents (Resident #1), who developed an open area to his/her coccyx and sustained a fracture to his/her left clavicle after a fall, the Facility failed to ensure he/she was provided with quality of care that met professional standards of practice when 1) he/she was not seen by the facility's Wound Nurse Practitioner in a timely manner and 2) treatment orders from the Hospital Emergency Department (ED) related to the left clavicle fracture were not implemented.Findings include:Resident #1 was admitted to the Facility in August 2025, diagnoses included unspecified dementia, seizures, syncope and collapse, hypertension muscle weakness and type 2 diabetes mellitus.1) Review of Resident #1's Skin Observation Tools, dated 08/22/25, 08/27/25, and 9/12/25, indicated that a small open area was identified on his/her coccyx and would follow up with the Wound Nurse Practitioner.Review of Resident #1's Nurse Progress Note, dated 09/12/25, indicated that a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-30 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records reviewed and interviews, for one of three sampled residents, (Resident #1), who had developed an open area to his/her coccyx, and was non-weight bearing, required the use of a sling and monitoring by nursing due to a left clavicle fracture, the Facility failed to ensure they maintained a complete and accurate medical record, when 1) there was no nursing documentation related to his/her coccyx wounds characteristics and progress towards healing and 2) there was no nursing documentation on his/her Treatment Administration Record (TAR) or Nurse Progress Notes to support nursing monitored Resident #1's left arm per Hospital Discharge Summary recommendations. Findings Include:Review of the Facility's Policy tilted, Charting and Documentation, dated as revised April 2022, indicated the following:-services provided to the resident to the resident, progress toward the care plan goals or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-06-05 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews, the facility failed to provide residents with adequate supervision and effective interventions to prevent avoidable accidents. Specifically, the facility failed to develop effective interventions to prevent nine falls for one Resident (#26), out of a total sample of 15 residents. Findings include: Review of the facility's policy titled Falls and Fall Risk Managing, revised 3/2022, indicated, but was not limited to, the following: -Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. -The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. -If falling recurs despite initial interventions, staff will implement additional or different…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-06-05 · tag F0909 — failed to maintain a comfortable temperature — patternRegularly 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 observation, record review, and interview, the facility failed to complete an inspection of the bed rails, to identify areas of possible entrapment for three Residents (#1, #19, and #24), out of a sample of 15 residents. Specifically, the facility failed to: 1. For Residents #1 and #19, complete a new assessment of the bed, side rails and mattresses in active use for potential entrapment when the bed mattress was changed from the previously assessed mattresses, placing the Residents who had limited mobility and utilized bilateral side rails, at risk for possible entrapment; and 2. For Resident #24, to ensure the mattress bolster/extender (an object used to fill gaps between the mattress and footboard of a bed) was in place to fill the gap between the mattress and the footboard with the metal bed frame exposed, leaving the Resident at risk for entrapment and/or injury. Findings include: Review of the Food and Drug Administration (FDA) Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, dated 3/10/2006, indicated: The term entrapment describes 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.
- Potential for harm · Dcited before2025-06-05 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to develop, implement and individualize comprehensive care plans for one Resident (#41), out of a total sample of 15 residents. Specifically, the facility failed to ensure a comprehensive care plan was developed to address the use of Buspirone (anti-anxiety), Trazodone (antidepressant also used to treat anxiety) and Sertraline (selective serotonin reuptake inhibitor used to treat anxiety) that identified Resident specific targeted behaviors, non-pharmacological interventions, and measurable goals of treatment. Findings include: Review of the facility's policy titled Comprehensive Care Plans, revised April 2022, included but was not limited to: -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 comprehensive, person-centered care plan will include: -measurable objectives and timeframes; -describe the services that are to be furnished to attain or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-05 · tag F0791 — failed to provide routine dental services — isolatedProvide or obtain dental services for each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record review, for one Resident (#26), of 15 sampled residents, the facility failed to provide timely dental services. Specifically, for Resident #26, the facility failed to initiate replacement of a broken/missing partial upper denture timely. Findings include: Review of the facility's policy titled Dental Services, revised 1/2025, indicated, but was not limited to, the following: -If dentures are damaged or lost, residents will be referred for dental services within 3 days. If the referral is not made within 3 days, documentation will be provided regarding what is being done to ensure that the resident is able to eat and drink adequately while awaiting the dental services; and the reason for the delay. -All dental services provided are recorded in the resident's medical record. Resident #26 was admitted to the facility in October 2024 with diagnoses including dementia and atrial fibrillation. Review of the Minimum Data Set (MDS) assessment, dated 4/7/25, indicated that Resident #26 was moderately cognitively impaired as evidenced by a Brief Interview for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-06-05 · tag F0880 — failed to prevent and control infections — isolatedProvide 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, interviews, and record review, the facility failed to adhere to infection control standards of practice to prevent contamination and the potential spread of infections for one Resident (#41), out of a total sample of 15 residents. Specifically, the facility failed to implement Enhanced Barrier Precautions (EBP: infection prevention practice of wearing gown and gloves to reduce transmission of multi-drug-resistant organisms [MDRO's - bacteria that are resistant to three or more types of antimicrobial drugs]) when the Resident was identified as having wounds on his/her right foot. Findings include: Review of the facility's policy titled Enhanced Barrier Precautions, last revised 9/2022, indicated but was not limited to: -Enhanced barrier precautions are an infection prevention intervention designed to reduce the transmission of multidrug resistant organisms in the facility. The precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with an MDRO as well as those with an increased risk 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.
- Potential for harm · Fcited before2024-06-12 · tag F0880 — failed to prevent and control infections — widespreadProvide 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 document review and interview, the facility failed to maintain an infection prevention and control program to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed to: 1. Ensure a water management program was implemented to minimize the risk of Legionella (bacteria that can cause Legionnaires' disease, a serious type of pneumonia) and other opportunistic pathogens in building water systems by accurately measuring and documenting water temperatures; 2. For Resident #211, ensure staff wore personal protective equipment (PPE) and perform hand hygiene as required for Contact Precautions (infection control precautions used for patients who may be infected with certain infectious agents for which additional precautions are needed to prevent infection transmission); and 3. For Resident #35, properly store an oral syringe to minimize the risk of contamination. Findings include: 1. Review of the facility's policy titled Legionella, last…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 20 citations
- Potential for harm · E2024-06-12 · tag F0848 — patternProvide a neutral and fair arbitration process and agree to arbitrator and venue.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on document review and interview, the facility failed to ensure their arbitration agreement provides for the selection of a neutral venue that is convenient to both parties. Findings include: Review of a list of residents with signed Arbitration Agreements, provided by the facility on 6/6/24 and 6/13/24, indicated a total of 45 residents/representatives had signed the facility's binding Arbitration Agreement. Review of the Arbitration Agreement in use by the facility until 6/5/24, failed to indicate the residents or their representatives had the right to a neutral venue agreed upon by both parties. During an interview on 6/13/24 at 3:30 P.M., Corporate Staff #2 said that last week they updated the facility's Arbitration Agreement to provide for the selection of a neutral venue that is convenient to both parties. He said they have started the process of having residents/representatives that previously signed the Arbitration Agreements sign the updated version. Review of a list of residents provided by Corporate Staff #2 indicated that 11 of 45 residents had signed the updated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-06-12 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, policy review, and record review, the facility failed to notify the Resident's Physician/Physician extender about changes in condition, to re-evaluate the potential need to alter the treatment plan for one Resident (#23), from a total sample of 18 residents. Specifically, the facility failed to notify the physician/physician extender of the deterioration of moisture-associated skin damage (MASD-caused by prolonged exposure to various sources of moisture, including urine or stool, perspiration, wound exudate, mucus, saliva, and their contents) on the Resident's left buttock to a stage 2 pressure ulcer (PU- partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer) and the Wound Consultant's treatment recommendations, resulting in a delay of treatment. Findings include: Review of the facility's policy titled Change of Condition in a Resident Status, dated March 2017, indicated but was not limited to: -the Nurse will notify the resident's physician where there has…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-06-12 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure a Minimum Data Set (MDS) assessment was accurately completed to reflect the status for one Resident (#23), in a total sample of 18 residents. Specifically, the facility failed to ensure the MDS accurately reflected the Resident's pressure ulcer risk. Findings include: Resident #23 was admitted to the facility in July 2017 and had diagnoses including chronic kidney disease and adult failure to thrive. Review of a Norton Plus Pressure Ulcer Scale, dated 4/23/24, indicated Resident #23 had a score of 6.0 (score of less than 10 is very high risk) and was at Very High Risk for developing pressure ulcers. Review of the most recent MDS assessment, dated 4/25/24, indicated Section M-Skin Conditions section M0150 (risk of pressure ulcers) question: Is this resident at risk for developing pressure ulcers? The answer was documented No. During an interview on 6/10/24 at 8:33 A.M., the MDS Coordinator reviewed section M of Resident #23's 4/25/24 MDS and the Norton Pressure Ulcer Risk assessment, dated 4/23/24. She said the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-06-12 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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, interviews, and policy review, the facility failed to ensure care plans were reviewed with the interdisciplinary team (IDT) as required for one Resident (#23), out of a total sample of 18 residents. Specifically, for Resident #23, the facility failed to ensure the comprehensive care plan was revised to reflect a newly developed Stage 2 pressure ulcer (PU- partial thickness skin loss with exposed dermis) and a change in treatment. Findings include: Review of the facility's policy titled Comprehensive Care Plans, revised April 2022, included but was not limited to: - The comprehensive, person-centered care plan is developed within seven days of the completion of the comprehensive assessment (MDS). -Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change. - The Interdisciplinary team must review and update the care plan: a. When there has been a significant change in the residents' condition. b. When the desired…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-06-12 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to implement the Physician's order to monitor blood glucose levels three times per day before meals for one Resident (#34), out of a sample of 18 residents. Findings include: Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated but was not limited to: Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescribers that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. Resident #34 was admitted to the facility in May 2024 with diagnoses which included type two diabetes mellitus without complications, cerebral infarction (stroke), pneumonia, and dysarthria/anarthria (the inability to produce clear,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-06-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to ensure staff provided residents an environment free from accident hazards on one unit (Borderland) of three units in the facility. Specifically, the facility failed to ensure a storage closet and storage area in the shower room was securely locked and hazardous items were not easily accessible to wandering residents. Findings include: On 6/6/24 at 8:16 A.M., the surveyor observed three residents wandering the hallways of the Borderland Unit (secure Dementia Special Care Unit). On 6/6/24 at 8:30 A.M. on the Borderland Unit, the surveyor approached a closed door labeled shower room and entered. Inside the shower room was a storage room with a closed door. The door was unlocked. The surveyor observed the following items in the unlocked and unsecured storage room: -Two oxygen concentrators -2 filled portable oxygen tanks -Three-tiered cart with drawers that contained a bottle of shampoo & body wash and a bottle of Difeel Biotin Pro-Growth Shampoo. On 6/6/24 at 9:29 A.M., the surveyor approached a closed door near the unit…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-12 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
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 monitor adverse consequences of an anticoagulation medication (used to prevent the blood from clotting, a blood thinner) prescribed for one Resident (#34), out of a total sample of 18 residents. Findings include: Review of the facility's policy titled Anticoagulation Therapy, revised 4/2022, indicated but was not limited to: Monitoring and Follow-Up -the staff and physician will monitor for possible complications in individuals who are being anticoagulated, and will manage related problems. -if an individual on anticoagulation therapy shows signs of excessive bruising, hematuria, hemoptysis, or other evidence of bleeding, the nurse will discuss the situation with the physician before giving the next scheduled dose of anticoagulant. Resident #34 was admitted to the facility in May 2024 with diagnoses which included cerebral infarction (stroke), hypertension (high blood pressure), and dysarthria/anarthria (the inability to produce clear, articulate speech). Review of the Minimum Data Set (MDS) assessment,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-12 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, policy review, and interview, the facility failed to ensure the drug regimen was free from unnecessary psychotropic medications for one Resident (#34), out of a total sample of 18 residents. Specifically, the facility failed to monitor Resident #34 for potential adverse consequences and behaviors when administering antidepressant medication. Findings include: Review of the facility's policy titled Psychotropic Medication, revised 4/2022, indicated but was not limited to: -To administer and monitor the effects of psychoactive medications when prescribed. -Monitoring for drug side effects leads to early identification and reporting in accordance with state/federal regulations. Resident #34 was admitted to the facility in May 2024 with diagnoses which included depression, anxiety disorder, cerebral infarction (stroke), and dysarthria/anarthria (the inability to produce clear, articulate speech). Review of the Minimum Data Set (MDS) assessment, dated 5/25/24, indicated Resident #34 had a Brief Interview for Mental Status (BIMS) score of 6 out of 15, which is…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-12 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, records reviewed, policy review, and interviews, the facility failed to ensure it was free from a medication error rate of greater than 5% when 2 out of 3 nurses observed made 2 errors out of 28 opportunities, resulting in a medication error rate of 7.14%. Those errors impacted two Residents (#29 and #1), out of four residents observed. Findings include: Review of the facility's policy titled Medication Administration, dated as revised 4/17, indicated but was not limited to: -Select the drug from the unit dose drawer or stock supply. -Check the label on the medication and confirm the medication name and dose with the Medication Administration Record (MAR). -Check the medication dose. Re-check to confirm the proper dose. 1. For Resident #29, Nurse #2 administered the incorrect formula of Senna (a laxative medication). On 6/10/24 at 8:40 A.M., the surveyor observed Nurse #2 prepare and administer medications to Resident #29 including: -Senna-S (a natural vegetable laxative plus stool softener), 2 tablets Review of Resident #29's Physician's Orders indicated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-06-12 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and policy review, the facility failed to ensure staff stored all drugs and biologicals used in the facility in accordance with currently accepted professional principles. Specifically, the facility failed to: 1. For Resident #51, ensure the medications were administered under direct supervision of a licensed nurse and not left at the bedside; 2. Ensure the medication and treatment carts were locked when not in direct supervision of the licensed nurse; and 3. Ensure safe storage of medications and biologicals according to current standards of practice. Findings include: Review of the facility's policy titled Medication Storage, dated as revised 4/22, indicated but was not limited to the following: -Compartments (including but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-12 · tag F0838 — failed to assess facility resources and resident needs — isolatedConduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
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 document review and interview, the facility failed to implement their facility assessment (a document assessing the capability of the facility and its resources to provide both emergency and day to day care of the population the facility currently serves). Specifically, the facility failed to maintain a bladder scanner (a noninvasive tool used to measure urine volume in the bladder) to aid in the assessment of urine volume in the bladder resulting in Resident #36 being hospitalized for four days due to a malpositioned (wrong or faulty position) Foley catheter resulting in bilateral hydroureteronephrosis (swelling of both kidneys and ureters, a thin tube that drains urine from the kidney to the bladder, which occurs when urine can't drain and builds up in the kidneys and ureters), impaired kidney function, and a urinary tract infection. Findings include: Review of the Facility Assessment, dated 5/21/24, physical environment and building/plant needs, section 3.8, indicated medical supplies and resources…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-04-25 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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, document review, and interview, the facility failed to ensure the dish machine operated at the required temperatures to ensure all dishes, utensils, and cookware were properly cleaned and sanitized in order to prevent illness. Findings include: During the initial tour of the kitchen on 4/19/23 at 7:35 A.M., Dietary Staff #1 said there was no hot water in the dish room, sink sprayer, or dishwasher. She said it gets up to temperature but doesn't hold. She said, I guess the hot water heater exploded about a week ago but they couldn't fix it so had to order a new one, but it hasn't come in yet. Review of the dishwasher manufacturer's instructions for use, dated October 2010, indicated the following: Operating temperatures for all models are as follows: Sanitizing Mode - Hot Water (not a chemical) Minimum Wash Temperatures - 150 Fahrenheit (F), Recommended Wash 150 (F) Minimum Rinse Temperatures - 180 (F), Recommended Rinse 180 (F) Review of the April 2023 High Temperature Dish Machine Temperature Log indicated the following: -Record the wash temp in degrees…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-04-25 · tag F0814 — failed to dispose of garbage properly — widespreadDispose of garbage and refuse properly.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to properly maintain the garbage storage area located behind the facility resulting in a vast debris field in the surrounding wooded area. Findings include: During an observation with interview on 4/19/23 at 3:45 P.M., the surveyor and Food Service Director (FSD) toured the facility's garbage and refuse storage area. The surveyor observed two garbage and refuse dumpsters located in the facility's back parking lot. The wooded area directly behind the dumpsters was heavily littered with garbage and refuse including used personal protective equipment, empty milk cartons, plastic bottles, a pair of scissors in the open position, a metal can lid with jagged edges, boxes, a metal frame, multiple clear small bags filled with assorted trash, a plastic milk crate, etc. A side door was observed in the open position on one of two dumpsters. The FSD said the garbage dumpsters are sometimes overflowed but are supposed to be closed. He said the garbage was scattered deep into the woods. The FSD said the trash gets picked up at least once a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-04-25 · tag F0658 — failed to meet professional standards of care — patternEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, policy review, interview, and observation, the facility failed to maintain professional standards of practice for three Residents (#10, #26 and #16), out of a total sample of 16 residents. Specifically, the facility failed: 1. For Resident #10, to ensure fingersticks (a procedure to test the glucose level using a small amount of capillary blood from the finger) were completed as ordered; 2. For Resident #26, to obtain an order, in a timely manner, for the use of a wander guard monitoring device; and 3. For Resident #16, a. To provide safe medication administration, by leaving medications at the bedside unattended, and b. To maintain a standard expectation of administering medications within one hour of the physician's ordered time. Findings include: 1. Resident #10 was admitted to the facility in November 2011 with a diagnosis of Type 2 diabetes mellitus. Review of the current Physician's Orders for Resident #10 included an order from 2/1/22 for fingersticks once a day before breakfast. Review of the April 2023 Medication Administration Record and 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.
- Potential for harm · Dcited before2023-04-25 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to develop a comprehensive person-centered care plan for wound care for one Resident (#26), out of a total sample of 16 residents. Findings include: Resident #26 was admitted to the facility in December 2022 with diagnoses which included recurrent vulvar cancer and unspecified dementia. Review of the current Physician's Orders indicated a treatment order, dated 3/21/23, to wound wash, air dry, and apply Triad (sterile coating that can be applied directly to the wound, it adheres to wet skin, and keeps the wound covered to facilitate healing) to ulcers twice daily. Review of Nurse Practitioner (NP) #2's Progress Note, dated 3/2/23, indicated the lesion on the right inner labia has grown, wound on right and left labia, and wound NP to assess. Malignant ulcer vulva bilateral anterior instruction: Apply Triad twice daily to protect area. Review of Resident #26's care plan indicated there was no care plan developed for the Resident's current skin issue. During an interview on 4/19/23 at 3:27 P.M., Nurse #3 said Resident #26 had…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-04-25 · tag F0744 — failed to care for residents with dementia — isolatedProvide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to implement recommendations for a dementia medication for Resident (#26) to attain or maintain their highest practicable physical, mental, and psychosocial well-being, out of a total sample of 16 residents. Specifically, the facility failed to address and implement the Psychiatric Nurse Practitioner's (PNP) recommendations to start Namenda, a medication which has been shown helpful with both delaying memory loss and reducing associated anxiety. Findings include: Resident #26 was admitted to the facility in December 2022 with diagnoses which included unspecified dementia without behavioral disturbance and anxiety. Review of the PNP's Progress Note, dated 3/29/23, indicated the following: - Resident #26 expressed anxiety associated with awareness of his/her memory problems, has not been treated for dementia and may benefit from medication. - Namenda has been shown helpful with both delaying memory loss and reducing anxiety associated with it. - Recommend Namenda 5 milligrams (mg) by mouth every morning to treat dementia.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-04-25 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and interview, the facility failed to ensure that staff securely stored medication on the Dementia Special Care Unit (DSCU). Findings include: On 4/20/23 at 8:56 A.M., the surveyor observed an unlocked supply closet in the main hallway of the DSCU. In the closet there was a full case and a half case of bottles of Milk of Magnesia (laxative) medication on the bottom shelf. During an interview on 4/20/23 at 9:14 A.M., the Director of Nurses (DON) said the closet door should be locked at all times. She said the Milk of Magnesia medication should not be stored in that supply closet; it should be stored in the locked medication room.
- Potential for harm · D2023-04-25 · tag F0770 — failed to provide lab services — isolatedProvide timely, quality laboratory services/tests to meet the needs of residents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, interview, and policy review, the facility failed to obtain ordered labs in a timely manner for one Resident (#10), out of a total sample of 16 residents. Findings include: Review of the facility's policy titled Labs and Diagnostics, dated as revised 4/2022, indicated but was not limited to the following: - physician will identify and order diagnostic and lab testing based on need - staff will process requisitions and arrange for tests Resident #10 was admitted to the facility in November 2011 with a diagnosis of type 2 diabetes mellitus. Review of the medical record indicated an order with a start date of 1/26/23, for lab work to be completed on 1/30/23, including: complete blood count (CBC), basic metabolic panel (BMP), and A1C (blood test that measures the average blood sugar over the last 3 months). Review of the laboratory results for January 2023 failed to indicate an A1C lab test was completed. During an interview on 4/20/23 at 8:49 A.M., Nurse #2 said there were no results for a completed A1C test in Resident #10's medical record since June 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.
- Potential for harm · Dcited before2023-04-25 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, policy review, and interview, the facility failed to maintain a complete accurate medical record for two Residents (#56 and #44), out of a total sample of 16 residents plus three closed records reviewed. Specifically, the facility failed to: 1. Maintain a complete closed medical record containing medication regimen review recommendations for Resident #56; and 2. Ensure a discharge order was in place for Resident #44 prior to discharge from the facility. Findings include: Review of the facility's policy titled Medical Record, dated as revised 4/2022, indicated but was not limited to the following: - the medical record is the healthcare team's primary reference and communication tool - the medical record is a complete comprehensive summary of information generated during the course of a resident's stay at the facility, it documents a variety of information including personal, social and medical. - the record contains sufficient information to identify the Resident and his/her diagnosis, treatment, demonstrate the resident's condition and to provide evidence…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · Bcited before2023-04-25 · tag F0641 — patternEnsure 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 record review, interview, and observation, the facility failed for two Residents (#51 and #26), out of a total sample of 16 residents, to ensure the Minimum Data Set (MDS) assessment was completed accurately. Specifically, the facility failed: 1. For Resident #51, to ensure accuracy when coding for a urinary catheter; and 2. For Resident #26, to reflect known falls since admission. Findings include: 1. Resident #51 was admitted to the facility in January 2023 with diagnoses including transient ischemic attack (a brief stroke attack) and major depressive disorder. Review of the most recent MDS assessment, completed upon admission, indicated Resident #51 had an indwelling catheter. The surveyor observed the following during the survey: - 04/19/23 at 8:12 A.M., no evidence of urinary catheter or drainage bag observed while Resident lying in bed - 04/20/23 at 9:42 A.M., Resident self-propelling in his/her wheelchair, no evidence of urinary catheter or drainage bag observed During an interview on 4/20/23 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$26,232 in federal fines across 1 penalty.
- $26,232 — penalty dated 2024-06-12
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.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| DAGAN, AMITAI | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 30% | since 09/01/2020 |
| SHAKOW, RACHEL | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; W-2 MANAGING EMPLOYEE; CORPORATE DIRECTOR | 70% | since 09/01/2020 |
CMS files one row per role, so the 4 rows in the source record cover these 2 parties — each is shown once here with every role it holds. Nothing is omitted.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 74% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.4M paid to related parties — landlords or management companies under common ownership — equal to about 19% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in MA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Massachusetts Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 225134. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-05, 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.