Clifton Rehabilitation Nursing Center
500 Wilbur Avenue, Somerset, MA 02725 · For profit - Corporation · 142 certified beds · (508) 675-7589 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- 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
- a high payroll-based staffing rating (4/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- 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
- it has a citation for mishandling residents’ money or property (F0565)
- a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- about 18% 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 | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 4 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 3 to 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
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 | 19.7% | 16.4% | 15.4% | worse |
| Long-stay residents who lose too much weight | 5.7% | 5.1% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.8% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.7% | 1.8% | 2.0% | better |
| Long-stay residents with depressive symptoms | 12.4% | 15.5% | 6.5% | better 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 | 2.1% | 3.4% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 19.5% | 15.4% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 23.2% | 19.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 97.6% | 94.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.4% | 4.2% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 21.9% | 21.2% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 7.5% | 21.4% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.2% | 1.4% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 86.5% | 77.7% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 25.9% | 25.7% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 17.1% | 11.9% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.63 | 1.88 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 1.27 | 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.
65.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 571 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 75.4% 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 358 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 0.72 therapist hours per resident per day in 2026Q1 — more than 92% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 14% 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 | 65.2%CMS range 61.8–68.3 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 8.1%CMS range 6.1–9.9 | 10.7% | Oct 2022–Sep 2024 | better than 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 | 75.4% | 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 | 68.4% | 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 | 72.1% | 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 | 99.6% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.8% | 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 | 2.1% | 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 | 7.9%CMS range 6.0–11.1 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.46 | 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 142 beds and averages 128.6 residents a day — about 91% occupied, or roughly 13 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.29 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.72 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.72 is at or above 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 3.63 hrs/resident/day on weekends vs 4.56 on weekdays — 21% thinner on weekends — a notable drop. RN hours go from 0.84 to 0.41 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 about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are 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.
27 citations, most serious first. The 10 most serious are shown; the remaining 17 are one tap away and print in full.
- Potential for harm · D2026-04-14 · tag F0557 — isolatedHonor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on records reviewed and interviews, for two of three sampled residents (Resident #1 and Resident #2), who were alert, oriented, and able to make their needs known, the Facility failed to ensure both residents were treated in a dignified and respectful manner when Certified Nurse Aide (CNA) #1 was witnessed by other staff members engaging in a verbal confrontation with both residents, during which CNA #1 became increasingly angry, raised his/her voice, spoke disrespectfully to Resident #1, and while questioning Resident #2, CNA #1 was heard using profane language.Findings include:Review of the Facility's Residents Rights Policy, dated 11/2021, indicated residents have the right to be treated with respect and dignity.Resident #1 was admitted to the Facility in January 2026, with diagnoses including lumbar disc disease/spinal stenosis, cerebral infarct, facial weakness, hemiplegia, dysarthria, dysphagia, intertrochanteric fracture of the right femur, and anxiety.Review of Resident #1's Minimum Data Set (MDS) Assessment, dated 02/09/26, indicated he/she had intact cognition, 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.
- Potential for harm · Fcited before2025-05-30 · 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 observation, interview, and record review, 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 maintain a water management program to prevent the growth of Legionella (bacteria that can cause legionellosis (illness caused by Legionella) including a pneumonia-type illness called Legionnaires' disease and a mild flu-like illness called Pontiac fever) and other opportunistic waterborne pathogens. Findings include: Review of Centers for Medicare and Medicaid Services (CMS) Memo QSO-17-30- Hospitals/CAHs/NHs, revised 7/6/2018, indicated but was not limited to the following: Facilities must have water management plans and documentation that, at a minimum, ensure each facility: -Conducts a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas,…
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 · E2024-04-10 · tag F0565 — failed to support the resident council — patternHonor the resident's right to organize and participate in resident/family groups in the facility.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on documentation review and interview, the facility failed to act promptly and demonstrate their response to concerns brought forth by the Resident Council. Findings include: Review of the facility's policy titled Resident Council Meetings, undated, indicated but was not limited to the following: - the facility shall act upon concerns of the council, make attempts to accommodate recommendations and communicate its decision to the council. Review of the Resident Council Minutes from November 2023 to March 2024 indicated but were not limited to the following: November 28, 2023: -Several residents had concerns with not getting selected menu items as ordered for their meals -Voiced concerns of cold food and not wanting to ask nursing staff to reheat it, because they are too busy The Activity Director (AD) informed the residents he would forward their concerns to the Food Service Director (FSD) December 27, 2023 -Voiced concerns about cold food -Voiced concerns about not receiving menu items as preferred and ordered in their selected menus The residents requested the FSD attend 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 before2024-04-10 · tag F0656 — failed to write and follow a full care plan — patternDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, interview, observation, and policy review, the facility failed for four Residents (#78, #29, #74, and #1), out of 26 sampled residents, to develop and implement individualized resident-centered care plans to meet the residents' needs. Specifically, the facility failed: 1. For Resident #78, to ensure a care plan was developed for the Resident's treatment of insomnia using an as needed (PRN) psychotropic medication; 2. For Resident #29, to implement fall care plan interventions, specifically to ensure the call light was wrapped with bright colored tape for better visibility and to ensure the anti-slip material to prevent the Resident from sliding off the wheelchair was in place; 3. For Resident #74, to implement fall care plan interventions, specifically to ensure the anti-slip material to prevent the Resident from sliding off the chair was in place; and 4. For Resident #1, to develop and implement a care plan for the use of a compression sleeve and glove to treat their lymphedema (tissue swelling caused by an accumulation of fluid that's usually drained…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-04-10 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on resident and staff interviews, observation, and meal test tray results on two of three units, the facility failed to prepare and serve meals in a manner that conserved flavor, were palatable, and served at safe and appetizing temperatures. Findings include: During initial resident screening on 4/7/24, the survey team identified the following concerns expressed by residents about food palatability: - Resident #83 said the food is cold all the time and coffee and or tea is always cold. - Resident #107 said the food is okay, but it is frequently cold. - Resident #9 said the food is always cold. - Resident #321 said the food has a weird consistency and strange flavors. Resident #321 said the food is often cold and he/she does not always like the way the food tastes. - Resident #1 said the food lacks flavor. - Resident #56 said the food was okay, but drinks like coffee and tea are often not hot. Resident #56 said soups are often cold. - Resident #86 said breakfast food is not good and eggs are cold. Review of Resident Council Meeting Minutes, dated 12/27/23, indicated several…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-04-10 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, policy review, and interview, the facility failed to follow their policy and professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to properly label and date food products, and maintain safe and clean equipment in three of three nourishment kitchenettes. Findings include: Review of the facility's policy titled Use and Storage of Food Brought in by Family or Visitors, undated, indicated but was not limited to: - It is the right of the residents of this facility to have food brought in by family or other visitors, however, the food must be handled in a way to ensure the safety of the resident. - Family members or other visitors may bring the resident food of their choosing. - The facility may refrigerate labeled and dated prepared items in the nourishment refrigerator. - The prepared food must be consumed by the resident within three days. - If not consumed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-04-10 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and policy review, the facility failed to follow infection control practices including: 1. Ensuring staff performed hand hygiene in between resident care and with glove changes during the medication pass; and 2. Ensuring staff disinfected blood glucose monitoring equipment per policy. Findings include: 1. Review of the facility's policy titled Hand Hygiene, undated, indicated but was not limited to the following: -All staff will perform proper hand hygiene procedures to prevent the spread of infection. -The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning (putting on) gloves, and immediately after removing gloves. -Hand Hygiene Table attached to the policy indicated but was not limited to the following occurrences when staff should perform hand hygiene: a. Between resident contacts. b. After handling contaminated objects. c. Before performing invasive procedures. d. Before applying and after removing personal protective equipment (PPE), including gloves. e. Before…
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 · D2024-04-10 · tag F0585 — failed to handle grievances — isolatedHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews, review of grievance documentation, and policy review, the facility failed to formulate grievances and failed to ensure the prompt resolution of grievances for the following: 1. Concerns brought forward by Resident #121 and their Family Member regarding long call light wait times and response from staff; and 2. Concerns brought forward by Resident #86 and their Family Member regarding missing items. Findings include: Review of the facility's policy titled Resident and Family Grievances, undated, indicated the following: -Prompt efforts to resolve include facility acknowledgement of a complaint/grievance and actively working toward resolution of that complaint/grievance. -A resident or family member may voice grievances with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and other residents, and other concerns regarding their LTC (long term care) stay. -Grievances may be voiced in the following forums: verbal complaint to a staff member or Grievance Official. -A staff member receiving the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-04-10 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide 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 observation, interview, and record review, the facility failed to provide necessary respiratory care and services for three Residents (#4, #221, #32), out of a total sample of 26 residents. Specifically, the facility failed: 1. For Resident #4, to ensure oxygen tubing was changed and stored in a plastic bag when not in use per facility policy; 2. For Resident #221, to store the Resident's Bilevel positive airway pressure (BiPAP) respiratory tubing and nasal pillow in a sanitary way when not in use by the Resident to prevent potential contamination by germs and environmental debris; and 3. For Resident #32, to ensure oxygen tubing was changed and stored in a plastic bag when not in use per facility policy. Findings include: Review of the facility's policy titled Oxygen Administration, undated, indicated but was not limited to: - Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. - Change oxygen tubing and mask/cannula weekly and as needed…
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 · D2024-04-10 · 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, interview, and policy review, the facility failed to ensure one Resident (#78), out of 26 sampled residents, had a documented rationale and appropriate monitoring in place for the ongoing, as needed (PRN) use of a psychotropic medication. Findings include: Review of the facility's policy titled Use of Psychotropic Medications, undated, indicated but was not limited to the following: - residents are not given psychotropic medications unless the medication is necessary to treat a specific condition, as diagnosed and documented in the medical record - PRN orders for psychotropic medications shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration - if the attending physician/practitioner believes it is appropriate to extend the PRN order beyond 14 days, he/she will document their rationale in the resident's medical record and indicate a duration for the PRN order Resident #78 was admitted to the facility in November 2023 with the following diagnoses: mood…
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 17 citations
- Potential for harm · Dcited before2024-04-10 · 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
Based on observation, 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: 1. For Resident #8, to ensure the morning medications were administered under direct supervision and not left at the bedside; 2. For Resident #106, to ensure Saline 0.65% Nasal Spray (for dryness) was stored in the medication cart and not left at the bedside; and 3. For Resident #112, to ensure Fluticasone Propionate Nasal Spray (for allergies) was stored in the mediation cart and not left at the bedside. Findings include: Review of the facility's policy titled Medication Administration, undated, indicated but was not limited to the following: -Medications are administered by licensed nurses in accordance with professional standards of practice. -Observe resident consumption of medication. Review of the facility's policy titled Resident Self-Administration of Medication, undated, indicated but was not limited to the following: -A resident may only…
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 before2022-11-01 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interview, the facility failed to ensure that food is stored, prepared, and distributed in accordance with professional standards. Specifically, the facility failed to: 1.) Ensure that food was stored, prepared, and distributed under sanitary conditions; 2.) Ensure staff restrained their hair and changed their gloves/wash their hands when the gloves became contaminated while working in the kitchen; 3.) Ensure the concentration of the sanitizer in the third sink (of the three-bay sink) was at the correct concentration to sanitize pots and pans and reduce potential pathogens; and 4.) Ensure 3 of 3 kitchenette/refrigerators were maintained in a sanitary manner to store food and fluid. Findings include: 1.) During the initial kitchen tour on 10/25/22 at 8:45 A.M., the surveyor, accompanied by the Food Manager (FM), observed the following sanitation concerns: -The ice cream chest had frost buildup on all four walls. The chest gasket was torn and had mold on it. There 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.
- Potential for harm · F2022-11-01 · tag F0813 — widespreadHave a policy regarding use and storage of foods brought to residents by family and other visitors.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and policy review, the facility failed to have an effective policy which addressed the reheating of residents' food brought in from home in accordance with professional standards to ensure food safety. Specifically, the facility failed to provide a thermometer and adequate reheating instructions to reheat residents' food brought in from home to an internal temperature of 165 degrees Fahrenheit (F) to prevent potential foodborne illnesses. Findings include: Review of the Food and Drug Administration (FDA) Food Code (2017) indicated reheating foods in the microwave as follows: -Reheated cooked foods present a risk because they have passed through the danger zone multiple times during cooking, cooling, and reheating. The PHF/TCS (Potentially Hazardous Foods/Time and Temperature Control for Safety) food that is cooked and cooled must be reheated so that all parts of the food reach an internal temperature of 165 degrees F for at least 15 seconds before service. Review of the facility's policy titled Foods Brought to Residents, not dated, indicated 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 before2022-11-01 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, policy review, and interview, the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access on 2 out of 3 units. Findings include: Review of the facility's policy titled Medication Storage, undated, indicated the following: - All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. - During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. From 10/25/22 through 11/01/22, the surveyor observed the following: 1.) East Two Unit Treatment Cart: - On 10/25/22 at 2:05 P.M., the East Two treatment cart, located in the hallway to the right of the nurses' station, was unlocked and unsupervised and easily accessible to residents and visitors. The surveyor was able to open three of the drawers and observed numerous…
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 · E2022-11-01 · tag F0791 — failed to provide routine dental services — patternProvide or obtain dental services for each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, policy review, and interview, the facility failed to ensure staff obtained timely dental services to replace a missing lower denture for one Resident (#71), out of 29 total sampled residents, resulting in a delay of eight months. Specifically, the facility failed to: 1. Consult the denture service provider regarding missing lower denture when first identified as missing, resulting in a four-month (March to July) delay in requesting an initial dental exam; 2. Follow up with dental service provider regarding prior approval/consent for replacement of denture from July to November resulting in an additional delay of four months; and 3. Notify family representative of dental services provided. Findings include: Review of the facility's policy titled Dental Services, dated 4/2022, indicated but was not limited to the following: -Assistance is provided to the residents of the facility who are in need of or are requesting dental services. -The facility assists residents by: a. Making appointments -Lost or damaged dentures-facility will assist in: a. Facilitating 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.
- Potential for harm · Ecited before2022-11-01 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff and resident interviews, and review of food temperature logs, the facility failed to ensure that food and drink are palatable, attractive, and served at a safe and appetizing temperature for 2 out of 3 units. Findings include: During an interview on 10/25/22 at 9:40 A.M., Resident #124 said the food is not great. During an interview on 10/25/22 at 9:45 A.M., Resident #30 said his/her supper was cold the previous night. During an interview on 10/25/22 at 9:55 A.M., Resident #34 said he/she received hot dogs that were not cooked. During an interview on 10/25/22 at 1:05 P.M., Resident #31's family member said that the soup is always cold. During an interview on 10/25/22 at 1:57 P.M., Resident #29 said the food is cold all the time, including the coffee. Resident #29 said he/she is not happy with the food at all,. During an interview on 10/25/22 at 4:30 P.M., Resident #238 said the food is not hot enough, and the soup does not taste good. During a meeting with the residents on 10/26/22 at 1:00 P.M., the surveyor asked how the food tasted. Two of seven…
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 · E2022-11-01 · tag F0838 — failed to assess facility resources and resident needs — patternConduct 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
Based on Facility Assessment review and staff interviews, the facility failed to identify resources based on the resident population to determine the necessary care, support services, and educational resources needed to care for residents. Specifically, the facility failed to address the use of agency staff and the education and resources needed for the continued use of agency staff to fill licensed nurse staff positions. Findings include: Review of the Facility Assessment, last updated 10/14/22, indicated the facility has 142 licensed beds with an average daily census of 135. Review of the Facility Assessment Tool failed to indicate information on the resources needed for the continued usage of agency staff regarding the use of an abbreviated orientation when the agency staff worked at the facility. An abbreviated orientation would include abuse protocols, fire safety, knowing where emergency equipment is (e.g., automated external defibrillator), use of telephone systems, and knowing where supplies are. During an interview on 11/1/22 at 11:09 A.M., the Staff Development Coordinator…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-11-01 · tag F0609 — failed to report abuse allegations — isolatedTimely 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 policy review, record review, and interview, the facility failed to ensure staff reported bruises of unknown origin to the Department of Public Health (DPH) within the required timeframe for one Resident (#103), out of a total sample of 29 residents. Findings include: Review of the facility's policy titled Patient Abuse, Mistreatment, Neglect, Exploitation and Misappropriation (undated), included but was not limited to: -Any employee or volunteer who knows or suspects an incident of resident abuse, mistreatment, neglect, and misappropriation of patient property is legally responsible for reporting such incident of concern to the Administrator and/or the Department of Public Health (DPH) Complaint Unit. -The Administrator/Supervisor will immediately (within 24 hours of notification of the alleged issue): -The Administrator or designee will then perform a detailed investigation and notify the DPH within the appropriate timeframe as outlined per statute. Resident #103 was admitted to the facility in December 2019 with diagnoses including Alzheimer's dementia. Review of 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 before2022-11-01 · 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 observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for two Residents (#93 and #105), out of a total sample of 29 residents. Specifically, the facility failed: 1. For Resident #93, to develop a comprehensive care plan integrating hospice services into the facility care plan; and 2. For Resident #105, to develop a comprehensive care plan to address chronic urinary tract infections (UTIs). Findings include: Review of the facility's policy titled Baseline Care Plan, undated, included but was not limited to: -In the event that the comprehensive assessment and comprehensive care plan identified a change in the resident's goals, or physical, mental, or psychosocial functioning, which was otherwise not identified in the baseline care plan, those changes shall be incorporated into an updated summary provided to the resident and his or her representative, if applicable. This will be provided by the MDS nurse/ designee by the completion date of the comprehensive care plan. 1. Resident #93 was admitted to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-11-01 · 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 ensure staff followed professional standards of practice for not following physician's orders for one Resident (#59), out of 29 total sampled residents. Specifically, the facility failed to: 1. Provide the supplemental bolus of nutritional support through the gastrostomy tube (G-tube, an opening into the stomach for delivery of nutrition and hydration) within the physician ordered parameters; 2. Provide the physician ordered water flushing of the g-tube consistently; and 3. Accurately monitor the daily fluid intake and output (I&O) every shift indefinitely as ordered by the physician. Findings include: Resident #59 was admitted to the facility in June 2018 with diagnoses which included cerebral infarct (stroke), dementia, and G-tube. Review of the Minimum Data Set (MDS) assessment, dated 9/9/22, indicated Resident #59 scored a 4 out of 15 on the Brief Interview for Mental Status (BIMS) assessment, indicating that he/she had severe impaired cognition. Further review of the MDS indicated nutritional needs through the feeding…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-11-01 · 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, record review, policy review, and interview, the facility failed to: 1. Ensure adequate supervision and safety interventions were developed and consistently implemented to maintain safety to prevent additional falls; and 2. Follow the falls policy for documentation and assessments of falls for two Residents (#105, #69), out of a total sample of 29 residents. Findings include: Review of the facility's policy titled Fall Prevention Program, not dated, indicated but was not limited to the following: - each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls - when a resident experiences a fall the facility will: - assess the resident - complete a post fall assessment - complete an incident report - review the resident's care plan and update as indicated - document all assessments and actions Review of the facility's policy titled Fall Risk Assessment, not dated, indicated but was not limited to the following: - monitor the effectiveness of the care plan…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-11-01 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, policy review, and interview, the facility failed to ensure that each resident receives a comprehensive nutrition assessment upon admission for three Residents (#236, #122 and #106), from a total sample of 29 residents. Specifically, the dietitian failed to follow the facility policy and complete a comprehensive nutrition assessment for each new admission to determine if the resident was at nutritional risk and provide nutrition interventions when appropriate. Findings include: Review of the facility's policy titled Weight Monitoring, revised on 9/1/22, indicated but was not limited to: POLICY: Based on the comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as body weight or desirable weight range, and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicated otherwise. Compliance Guidelines: - A comprehensive nutritional assessment will be completed upon admission on residents to identify those at risk 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 · D2022-11-01 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews, record reviews, and policy review, the facility failed to ensure professional standards were followed for one Resident (#88), out of a total sample of 29 residents. Specifically, the facility failed to: 1. Ensure physician's orders were in place for dialysis; 2. Ensure ongoing communication and collaboration with the dialysis facility by completing the communication sheets; 3. Inform the Dialysis Center of a positive laboratory result for clostridium difficile colitis (C. Diff) (Bacteria that causes diarrhea and inflammation of the colon); and 4. Inform the Dialysis Center of two new physician prescribed medications to treat the C. Diff. Findings include: Review of the facility's policy titled Hemodialysis, undated, indicated but was not limited to the following: -The licensed nurse will communicate to the dialysis facility via telephonic communication or written format, such as a dialysis communication form or other form, that will include, but not limit itself to: a. Timely medication administration (initiated, held, discontinued) by the nursing home and/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 · D2022-11-01 · tag F0726 — failed to have competent, trained nursing staff — isolatedEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and education review, the facility failed to ensure the nursing staff received appropriate competencies and skill sets necessary for the care and treatment of residents. Specifically, the facility failed to ensure agency staff were provided education on facility specific emergency procedures. Findings include: According to the Board of Nursing 244 CMR 9.00 standards of conduct, a competency is defined as the application of knowledge and the use of affective, cognitive, and psychomotor skills, required for the role of a nurse licensed by the Board and for the delivery of safe nursing care in accordance with acceptance standards of practice. Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully. During an interview on 11/1/22 at 11:09 A.M., the Staff Development Coordinator (SDC) said the facility is utilizing agency staff to fill open positions for licensed nurses. She said there is no formal training given for agency staff.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-11-01 · tag F0773 — isolatedProvide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interviews, the facility failed to ensure the physician and/or nurse practitioner (NP) was notified of laboratory results which fell out of the clinical range for one Resident (#88), out of a total sample of 29 residents. Specifically, the delay in notification resulted in a three day delay in the Resident receiving treatment for clostridium difficile colitis (C. Diff) infection. Resident #88 was admitted to the facility in September 2022 with diagnoses of severe kidney disease, end stage renal disease, dependent on renal dialysis, and diabetes. Review of the Minimum Data Set (MD'S) assessment, dated 9/28/22, indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the Resident had intact cognition. The MDS also indicated the Resident received dialysis. Review of the current Physician's Orders indicated but was not limited to the following: -10/11/22- Obtain specimen for C. Diff secondary to foul smelling loose stools -10/15/22 - Start Flagyl 500 milligrams (mg) tablet three times a day for two weeks secondary to C. Diff.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-11-01 · 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 observations, interviews, medical record review, and policy review, the facility failed to establish and maintain an infection prevention and control program to help prevent the development and potential transmission of communicable diseases and infections in the facility for one Resident (#88), out of a total sample of 29 residents. Specifically, the facility failed to: 1.) Ensure that healthcare personnel perform hand hygiene, and don (put on) and doff (take off) the appropriate personal protective equipment (PPE) prior to entering a resident's room and while providing high contact care to a Resident on Contact Precautions for an active Clostridium difficile (C. diff) infection; 2.) Ensure that healthcare personnel perform hand hygiene per facility policy during meal pass for a Resident on Contact Precautions for an active Clostridium difficile (C. diff) infection; and 3.) Ensure that healthcare personnel perform hand hygiene per facility policy during a clean dressing change. Findings include: Resident #88 was admitted to the facility in September 2022 with diagnoses 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 · D2022-11-01 · tag F0881 — failed to use antibiotics responsibly — isolatedImplement 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 their Antibiotic Stewardship Program to promote and monitor the appropriate use of antibiotics for one Resident (#236), from a total sample of 29 residents. Specifically, the facility failed to complete Antibiotic Surveillance Tracking Forms (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 4/2021, indicated the following, but not limited to: POLICY: -Antibiotic Stewardship includes an assessment process, use of evidence-based criteria, efforts to identify the microbe responsible for the disease, selecting the appropriate antibiotic along with appropriate documentation. PROCEDURE: -If antibiotic therapy is ordered, documentation should include: rationale/diagnosis, medication, dose, route and duration of therapy. -Prophylactic medication used in the facility should be limited based on practitioner documentation 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.
“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
No federal fines in the current CMS record.
Part of a chain
This home belongs to MICHAEL FEIST — 7 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 3.6 | +0.4 vs chain |
| Health inspection | 4 of 5 | 3.1 | +0.9 vs chain |
| Staffing | 4 of 5 | 3.3 | +0.7 vs chain |
| Quality measures | 4 of 5 | 4.3 | -0.3 vs chain |
The other 6 homes this chain runs (chain average 3.6★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| CLIFTON REHAB PROPERTY COMPANY LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 10/20/2021 |
| FEIST, MICHAEL | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | 100% | since 10/20/2021 |
CMS files one row per role, so the 4 rows in the source record cover these 2 parties — each is shown once here with every role it holds. Nothing is omitted.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $4.5M paid to related parties — landlords or management companies under common ownership — equal to about 18% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in MA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Massachusetts Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 225402. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-30, 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 →
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