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Windsor Nursing & Retirement Home

265 N Main St, South Yarmouth, MA 02664 · Non profit - Corporation · 120 certified beds · (508) 394-3514 Medicare & Medicaid certified

Call the home — (508) 394-3514 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Resident-funds citation (F0565)1 actual-harm citation$12,386 in federal fines
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • 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
Worth asking about
  • it has a citation for mishandling residents’ money or property (F0565)
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $12,386 in federal fines (most recent 2023-10-12)
  • its facility-reported quality-measure rating is low (1/5)

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

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

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 1 of 5

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
257 Station Ave · (508) 394-2017 · Call to confirm hours
Pharmacy
465 Station Ave · (508) 394-0926 · Call to confirm hours
Grocery
1026 Champlin Ave · (315) 790-5188 · Call to confirm hours
Park
Flax Pond0.3 mi
Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 1 of 5
Long-stay residentspeople who live here 2 of 5
Short-stay residentsrehab / post-hospital 1 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 3 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased25.9%16.4%15.4%worse
Long-stay residents who lose too much weight7.1%5.1%5.4%worse
Long-stay residents with a catheter left in their bladder0.4%0.8%0.9%better
Long-stay residents with a urinary tract infection2.0%1.8%2.0%typical
Long-stay residents with depressive symptoms27.0%15.5%6.5%worse than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury4.4%3.4%3.3%worse
Long-stay residents whose ability to walk worsened26.0%15.4%16.1%worse
Long-stay residents on antianxiety or hypnotic medication19.2%19.5%18.9%typical
Long-stay residents given the seasonal flu vaccine80.7%94.8%95.3%worse
Long-stay residents with pressure ulcers4.8%4.2%4.7%typical
Long-stay residents with worsening bladder/bowel control13.6%21.2%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table19.8%21.4%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.9%1.4%1.4%better
Short-stay residents given the seasonal flu vaccine80.4%77.7%79.4%typical
Short-stay residents rehospitalized after admission30.7%25.7%22.6%worse
Short-stay residents with an outpatient ER visit12.1%11.9%12.0%typical
Long-stay hospitalizations per 1,000 resident days1.551.881.67typical
Long-stay outpatient ER visits per 1,000 resident days2.171.501.80worse

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.

48.2% 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 149 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

48.2%U.S. median 51.5%
Got home and stayed home
8.7%U.S. median 10.7%
Went back to hospital
19.4%U.S. median 56.6%
Met the expected recovery
0.24U.S. median 0.31
Therapy hours / resident / day
0.15hours / resident / day
Physical therapy
0.06hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 19.4% 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 72 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.24 therapist hours per resident per day in 2026Q1 — more than 31% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 30% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF48.2%CMS range 40.0–57.751.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF8.7%CMS range 5.8–12.710.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge19.4%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge19.4%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge30.6%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified82.3%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting98.6%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge96.8%98.7%Oct 2024–Sep 2025CMS 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 stay0.7%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened3.7%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.4%CMS range 4.2–10.37.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.891.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.63
RN hours/ resident / day
0.86
LPN hours/ resident / day
2.42
Aide hours/ resident / day
3.91
Total nurse hours/ resident / day
0.28
RN hoursweekends
37.7%
Total nursing turnover
26.7%
RN turnover

How full it usually is: this home is certified for 120 beds and averages 88.6 residents a day — about 74% occupied, or roughly 31 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.91 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.63 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.42 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 4.14 on weekdays — 19% thinner on weekends. RN hours go from 0.77 to 0.28 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 38% is about the same as the national median of 45%.

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

Inspection trend

6
deficiencies at the latest standard inspection (2026-03-19)
8
at the previous standard inspection (2025-01-09)

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

Inspection deficiencies

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

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

24 citations, most serious first. The 11 most serious are shown; the remaining 13 are one tap away and print in full.

  • Actual harm · G2023-10-12 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review, observation, and interview, the facility failed for one Resident (#88), out of a total sample of 19 residents, to provide care and implement pressure prevention interventions resulting in the development of facility acquired pressure ulcers (injuries to the skin and underlying tissue resulting from prolonged pressure exerted over areas of the body) on both the left and right buttocks and right heel of Resident #88. Findings include: Review of the facility's policy titled Skin Integrity Management, dated as revised on 3/16/22, indicated but was not limited to the following: - Based on assessment the facility will ensure that residents receive the necessary treatment and services consistent with professional standards of practice to prevent the occurrence of pressure ulcers - Refer to pressure ulcer prevention protocol Review of the facility's policy titled Pressure Ulcer Prevention Protocol, dated as revised December 2015, indicated but was not limited to the following: -…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-03-19 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to properly label and date thickened liquids, by not indicating open dates, in one of one nourishment kitchenettes and two of two resident unit refrigerators and failed to ensure one opened thickened liquid was refrigerated after opening in one of one nourishment kitchenettes.Findings include: Review of the 2022 Food Code by the Food and Drug Administration (FDA), revised 1/2023, indicated but was not limited to the following:3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking.(B) Except as specified in (E) - (G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-03-19 · tag F0839 — pattern
    Employ staff that are licensed, certified, or registered in accordance with state laws.
    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 and record review, the facility failed to ensure professional staff were licensed, certified, or registered in accordance with applicable State laws. Specifically, the facility failed to ensure a nurse assigned to direct resident care had an active license as a Registered Nurse. Findings include:According to the Massachusetts Board of Registration in Nursing a Registered Nurse is the designation given to an individual who is licensed to practice professional nursing, holds ultimate responsibility for direct and indirect nursing care, is a graduate of a Board approved school for professional nursing, and is currently licensed as a Registered Nurse pursuant to M.G.L. c. 112. Review of the employee file for Nurse #5 indicated the nurse was hired on [DATE] and their Registered Nurse (RN) License expired on [DATE]. The printed License Verification did not include a date the information was obtained. Review of the job description for Nurse #5 indicated the primary purpose of the position was 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-03-19 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record review, the facility failed to implement safe smoking strategies for one Resident (#1), out of two sampled residents who smoked cigarettes. Specifically, the facility failed to ensure the safe smoking strategy of wearing a smoking apron (flame-resistant protective garment designed for individuals, often in wheelchairs, to shield themselves and their clothing from hot ashes) was implemented for Resident #1 while smoking.Findings include:Resident #1 was admitted to the facility in May 2019. Review of the Minimum Data Set assessment, dated 2/9/26, indicated Resident #1 scored 12 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident had a moderate cognitive impairment. During an interview on 3/18/26 at 2:10 P.M., Resident #1 said he/she smoked one to two cigarettes per day. The Resident said he/she had not gotten up for the day yet and planned to go to the next smoking break. Review of the Nursing Annual Assessment, dated 3/8/26, indicated Resident #1 wished to smoke cigarettes and lacked adequate judgement toward…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-19 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure one Resident (#10), out of a total of sample of 19 residents, was provided with a therapeutic diet based on his/her comprehensive assessment and as ordered by the physician. Specifically, the facility failed to ensure he/she was administered the correct enteral feeding (delivering nutrition directly into the gastrointestinal tract for individuals unable to consume enough food by mouth) formula based on their nutritional needs.Findings include:Review of the facility's policy titled Enteral Tube Medication Administration, effective date 6/1/10, indicated but was not limited to:-The facility assures the safe and effective administration of enteral formulas and medications via enteral tubes.-Selection of enteral formulas are based on nursing assessment of the resident's condition, in consultation with the physician, dietitian, and consultant pharmacist.Resident #10 was admitted to the facility in January 2026 with diagnoses including malignant neoplasm of supraglottis (cancerous growth in the upper part of…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-19 · tag F0887 — isolated
    Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and personnel record review, the facility failed to ensure the new hire employee records maintained documentation to indicate staff were provided education and offered information on obtaining the 2025-2026 COVID-19 vaccination for two out of five newly hired employees. Findings include: Review of the facility's policy titled COVID-19 Vaccine Requirements Residents and Staff, reviewed in March 2024, indicated the following:-Employees are required to be up to date with COVID-19 vaccine per DPH (Department of Public Health)-{Facility} educates staff about the vaccines, offers, and administers the vaccines, and documents vaccination status according to state and federal guidelines-Personnel declining the vaccine must include a statement certifying he or she received information about the risks and benefits of COVID-19 vaccine Food Service Director #3 was hired on 1/5/26. Review of the employee file failed to indicate the new employee had been offered the most recent COVID-19 vaccination. Nurse #5 was hired on 2/6/26. Review of the employee file failed to indicate 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-01-09 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to ensure residents in two of three dining rooms had a comfortable and homelike dining experience. Findings include: During dining observations throughout survey on 1/2/25, 1/3/25, 1/6/25, and 1/7/25, surveyors observed the following: On 1/2/25 at 9:14 A.M., the surveyor observed seven residents in the A Unit dining room. There were no tablecloths or placemats observed in the dining room. All residents were served their meal from the food truck to the table. All meal plates remained on the heating elements and residents were observed to eat breakfast off the serving trays. Meal covers were stacked on the table. On 1/2/25 at 12:15 P.M., the surveyor observed 13 residents in the Main Dining room. The tables were observed to have white tablecloths, cloth napkins, flower centerpieces, water glasses, porcelain coffee cups and silverware. Staff were observed to serve juices/water and coffee prior to meals being served from the adjacent kitchen. Residents were observed to eat lunch from plates which were removed from heating elements…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-01-09 · tag F0685 — pattern
    Assist a resident in gaining access to vision and hearing services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure audiology services were offered to ensure the highest practicable level of care for one Resident (#76), out of a total sample of 19 residents. Specifically, for Resident #76, when their hearing aids went missing, the facility failed to offer/provide alternative treatment, and/or to assist in arranging audiology services to obtain new hearing aids, resulting in a 98-day delay in services. Findings include: Review of the facility's policy titled Resident/Patient Belongings Policy, dated 1/20/17, indicated but was not limited to the following: -Staff will respond in a timely manner to concerns about a missing item. -An investigation will be initiated to assist in locating missing belongings. -The results of the investigation will be reviewed with the resident and/or responsible party. Review of the facility's policy titled Consulting Services; Podiatry/Dental/Optometry/Audiology, dated 11/22/16, indicated but was not limited to the following: -Services are offered to all residents as a means of providing…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-01-09 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and document review, the facility failed to ensure all medications used in the facility were stored and labeled in accordance with currently accepted professional standards in two of two medication carts reviewed. Findings include: Review of the facility's policy titled Storage of Medications, dated as revised 6/10/22, indicated but was not limited to the following: -Orally administered medications are kept separate from externally used medications, such as lotions -Outdated, contaminated or deteriorated medications and those in containers without secure closures are immediately removed from stock, and disposed -Medication storage areas are kept clean Review of the facility's policy titled Administration Procedures for all Medications, dated 9/20/13, indicated but was not limited to the following: -Check expiration date on package/container before administering any medication. When opening a multidose container, place the date on the container. -Once removed from the package or container, unused or partial doses should be disposed of. 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-01-09 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to handle ready-to-eat food (food which does not require cooking or further preparation prior to consumption) utilizing proper hand hygiene to prevent cross contamination (transfer of pathogens from one surface to another). In addition, to ensure the use of gloves was limited to a single use task. Findings include: Review of the 2022 Food Code by the U.S. Food and Drug Administration (FDA), revised 1/2023, indicated but was not limited to the following: - 3-301.11 Preventing Contamination from Hands. (A) FOOD EMPLOYEES shall wash their hands as specified under § 2-301.12. (B) Except when washing fruits and vegetables as specified under §3-302.15 or as specified in (D) and (E) of this section, FOOD EMPLOYEES may not contact exposed, READY-TO-EAT FOOD with their bare hands and shall use suitable UTENSILS such as deli tissue, spatulas,…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-01-09 · tag F0842 — failed to keep accurate, complete medical records — pattern
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure an accurate medical record for one Resident (#84), out of a total sample of 19 residents. Specifically, the facility failed to ensure the medical record indicated the dietary recommendation for Mirtazapine (antidepressant used for an appetite stimulant) had been reviewed by the provider timely. Findings include: Resident #84 was admitted to the facility in September 2024 with diagnoses including dementia, anxiety, depression, obsessive-compulsive disorder (OCD), and had a history of falls with traumatic subdural hematoma. Review of the Minimum Data Set (MDS) assessment, dated 9/23/24, indicated he/she scored 11 out of 15 on the Brief Interview for Mental Status (BIMS) indicating he/she had moderate cognitive impairment. Review of the weights documented in the medical record indicated the following: 9/18/24: 155.8 pounds (lbs.) 9/28/24: 130.4 lbs. 10/12/24: 124.2 lbs. 10/28/24: 124.8 lbs. 12/16/24: 112.8 lbs. Review of the Dietitian's progress note, dated 10/17/24, indicated Resident #84 continues to present with…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
Show the remaining 13 citations
  • Potential for harm · Dcited before2025-01-09 · tag F0585 — failed to handle grievances — isolated
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to initiate the grievance process on behalf of one Resident (#76), out of a total sample of 19 residents. Specifically, for Resident #76, the facility failed to initiate an investigation when his/her hearing aids were determined to be missing, file a grievance for the missing hearing aids, and follow the grievance process, resulting in a 98-day delay in offering and/or providing alternative audiology services. Findings include: Review of the facility's policy titled Resident/Patient Belongings Policy, dated 1/20/17, indicated but was not limited to the following: -Staff will respond in a timely manner to concerns about a missing item. -An investigation will be initiated to assist in locating missing belongings. -The results of the investigation will be reviewed with the resident and/or responsible party. Review of the facility's policy titled Grievance Policy, dated as last revised 9/20/19, indicated but was not limited to the following: -All residents and/or their representatives may voice grievances/complaints…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-09 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, interview, and observation, the facility failed to follow professional standards of practice for one Resident (#197), out of a total sample of 19 residents. Specifically, the facility failed to follow and provide care in accordance with the physician's order for management of the Resident's right upper extremity Peripherally Inserted Central Catheter (PICC-a thin flexible tube inserted into a vein in the upper arm and guided into a large vein above the right side of the heart called the superior vena cava) which included dressing changes, measurement of the external length of the catheter and upper arm, and monitoring of the insertion site for signs/symptoms of infection. Findings include: 1. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, Advisory Ruling Number 9324, dated as revised July 10, 2002, indicated: -Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber's that are received by a variety of methods (i.e., written,…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-09 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interview, the facility failed to ensure post-fall interventions were developed and implemented to mitigate the risk of future falls resulting in two falls in three months, one of which resulted in a head strike causing bruising for one Resident (#78), out of a total sample of 19 residents. Findings include: Review of the facility's policy titled Fall Risk Reduction, dated as last revised 11/2/23, indicated but was not limited to the following: -All residents will be assessed for fall risk factors. Those determined to have risk factors will receive individualized interventions based on the risk factors to reduce risk for falls and minimize the actual occurrence of falls. -Complete a Resident Fall Risk Assessment on admission, readmission, change in condition. -Develop individualized plan of care. -Include fall interventions on [NAME] and Care Plan. -Review and revise Care Plan/[NAME] regular to ensure individualized. -Review resident new admit/new fall weekly for four…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-10-12 · tag F0565 — failed to support the resident council — pattern
    Honor 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 interviews, policy review, and review of Resident Council Minutes, the facility failed to ensure that grievances brought forward through Resident Council from 4/27/23 through 9/26/23 were addressed and promptly resolved as required. Findings include: Review of the facility's Grievance Policy, last revised 9/20/19, indicated but was not limited to: -The resident has the right to voice grievances to the facility such as 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 stay. -Affiliate leadership will investigate, document, and follow up on all formal concerns and grievances registered by any resident or resident representative. -The facility Administrator will serve as the Grievance Official who is responsible for overseeing the grievance process including receiving and tracking grievances through to their conclusion, leading any necessary investigations by the facility, issuing written grievance decisions to the resident. -Upon…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-10-12 · tag F0585 — failed to handle grievances — pattern
    Honor 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 policy review, review of Resident Council Minutes, grievance review, and resident and staff interviews, the facility failed to ensure that staff: 1. Addressed and promptly resolved several grievances brought forward during Resident Council Meetings held on 4/27/23 through 9/26/23; and 2. For Resident #88, the facility failed to ensure the grievance process was implemented and concerns resolved in a timely manner. Findings include: Review of the facility's Grievance Policy, last revised 9/20/19, indicated, but was not limited to: -The resident has the right to voice grievances to the facility such as 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 stay. -Affiliate leadership will investigate, document, and follow up on all formal concerns and grievances registered by any resident or resident representative. -The facility Administrator will serve as the Grievance Official who is responsible for overseeing the grievance process…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-10-12 · tag F0685 — pattern
    Assist a resident in gaining access to vision and hearing services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, observations, policy review, and interviews, the facility failed to assist one Resident (#43) and their family, out of a total sample of 19 residents, in sourcing a replacement hearing device after the loss of the Resident's hearing aids. Findings include: Review of the facility's policy titled Overcoming Communication barriers, dated as revised 10/27/22, indicated but was not limited to the following: - it is the facility policy to reduce communication barriers and provide methods to ensure adequate communication between residents and staff and enable residents to maintain social interaction to the extent possible - the interdisciplinary team will assess the resident for communication barriers upon admission, annually and whenever a potential communication problem becomes evident - adaptive tools for communication will be maintained in a location accessible to the resident and staff providing care - the resident's care plan will identify methods instituted to assist in communicating needs Resident #43 was admitted to the facility in August 2022 with…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-12 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure that individualized, resident-centered, comprehensive care plans were developed and consistently implemented for one Resident (#32), out of a total sample of 23 residents. Specifically, the facility failed to ensure a care plan was developed for the use of psychotropic medications that included individualized, resident-centered, targeted signs/symptoms or behaviors. Findings include: Review of the facility's policy titled Care Planning, last revised 10/28/22, included but was not limited to: -The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that include measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. -The purpose is to provide effective and person-centered care to the resident. -The Standardized Care Plans, MUST be individualized for the resident by adding Care Needs/Preferences, interventions, and resident…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-12 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and policy review, the facility failed for two Residents (#82 and #302) to ensure respiratory equipment and tubing was managed and stored in a sanitary way to prevent the potential of contamination from environmental debris and germs. Findings include: Review of the facility's policy titled Oxygen and Respiratory Equipment, dated 2/27/13, indicated but was not limited to the following: - Respiratory equipment used on an as needed basis should be contained in a closable plastic bag when not in use to prevent contamination 1. Resident #82 was admitted to the facility in September 2021 with diagnoses including chronic obstructive pulmonary disease (COPD). The most recent Brief Interview for Mental Status (BIMS) was a score of 15 out of 15 which indicated the Resident was cognitively intact. During an observation with interview on 10/5/23 at 2:12 P.M., the surveyor observed a nebulizer machine (a machine used to turn liquid medications into a fine mist for inhalation) and tubing sitting on the window ledge with the mouthpiece touching the wall and not…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-12 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on policy review, interview, and record review, the facility failed to ensure for one Resident (#17), of one resident receiving hemodialysis, that treatment, care and services were consistent with professional standards of practice. Specifically, the facility failed to ensure the medical record reflected ongoing communication and collaboration with the Dialysis Center regarding the exchange of pertinent information before and after dialysis treatment. Findings include: Review of the facility's policy titled Dialysis Residents, Coordination of Care of, revised 11/19/18, indicated but was not limited to the following: -The Dialysis Center and the nursing facility shall maintain ongoing communication and coordination between the nursing facility and dialysis center to ensure the provision of continuity of care as outlined in the resident's comprehensive care plan. - A communication book that travels with the resident to and from the dialysis clinic. The clinic and the facility communicate in writing and/or orally, the status of the resident's condition and recommendation for 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-12 · tag F0849 — isolated
    Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, hospice contract review, and staff interview, the facility failed to ensure for one Resident (#44), out of a total sample of 19 residents, that hospice services were provided in accordance with the agreement between the hospice and the facility. Specifically, the facility failed to ensure a current signed recertification statement for hospice eligibility and ongoing documentation of hospice staff visits were available in the medical record to ensure prompt and effective communication and continuity of care for the Resident. Findings include: Review of the facility Hospice Agreement, dated March 2023, indicated but was not limited to the following: - all members of the hospice team will document their care and services provided at each visit to the hospice patient and the documentation will be placed in the nursing facility medical record Review of the medical record for Resident #44 on 10/10/23 indicated the following: - the Resident signed a consent for hospice services on 6/5/23, and had a current physician order for hospice services in place - 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2026-03-19 · tag F0582 — pattern
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN/ CMS-10055) was completed and signed to ensure the Resident/Resident Representative was fully informed of the services being discontinued and a determination was made to continue or discontinue services at a skilled level of care for two Residents (#10, #52), out of three sampled residents who received beneficiary notification, as required by Centers for Medicare & Medicaid Services (CMS). Findings include:The SNF ABN (CMS-10055) notice is administered to a Medicare recipient when the facility determines that the beneficiary no longer qualifies for Medicare Part A skilled services and the resident has not used all of the Medicare benefit days for that episode. The SNF ABN provides information to residents/beneficiaries so that they can decide if they wish to continue receiving the skilled services that may not be paid for by Medicare and assume financial responsibility. 1. Resident #10 was admitted to the facility in January 2026,…

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

    Resident Rights Deficiencies · No revisit needed
  • No harm found · B2023-10-12 · tag F0623 — pattern
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    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 written notice for transfer and discharge was provided to Residents and/or Resident Representatives prior to hospital transfers for one Resident (#17), out of a total sample of 19 residents, and one Resident (#100), out of a total of three closed records. Findings include: Review of the facility's policy titled Admission/Transfer/Discharge Rights, revision date 11/10/17, indicated but was not limited to: -Normally all transfers and discharges require 30 days' notice to the resident except in the case of these four specific exceptions: -The health or safety of the individuals in the nursing facility would be endangered and this is documented in the resident's record by a physician. -The resident's health improves sufficiently to allow a more immediate transfer of discharge and the resident's attending physician documents this in the resident's record. -An immediate transfer or discharge is required by the resident's urgent medical needs, and this is documented in the resident's medical record by 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2023-10-12 · tag F0625 — pattern
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on policy review, record review, and interview, the facility failed to provide written notification of the bed hold policy to the Resident or Resident Representative prior to discharge to the hospital for two Residents (#91 and #17), in a total sample of 19 residents and one Resident (#100), out of a total of three closed records. Findings include: Review of the facility's policy titled Bed Hold Policy, dated 2/2017, indicated but was not limited to: -Policy: It is the policy to provide a written bed hold notice to the resident and/or resident's representative before the facility transfers a resident to the hospital or goes on a therapeutic leave. -Procedure: -Upon transfer to the hospital or therapeutic leave, the facility will provide the resident and/or resident representative a written bed hold notice. -The written behold notice will include the following: -The duration of the state bed hold policy. -The reserve bed payment policy. -When a resident is permitted to return. -This notice will also be provided at the time of transfer. Review of the Facility Acute Care Transfer…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

$12,386 in federal fines across 1 penalty.

  • $12,386 — penalty dated 2023-10-12

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.

Part of a chain

This home belongs to INTEGRITUS HEALTHCARE — 14 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 2 of 52.8-0.8 vs chain
Health inspection 3 of 52.9+0.1 vs chain
Staffing 4 of 53.4+0.6 vs chain
Quality measures 1 of 52.7-1.7 vs chain
The other 13 homes this chain runs (chain average 2.8★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
FAIRVIEW EXTENDED CARE SERVICES INCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 03/29/1990
INTEGRITUS HEALTHCARE INCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL100%since 02/01/2022
BREWER, SCOTTIndividualW-2 MANAGING EMPLOYEEsince 12/22/2021
GINGRAS, MARCIE JOIndividualCORPORATE OFFICERsince 12/13/2021
JONES, WILLIAMIndividualCORPORATE OFFICERsince 02/01/1993
INTEGRITUS HEALTHCARE MANAGEMENT SERVICES INCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 02/01/2022

CMS files one row per role, so the 7 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted.

3 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

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

$11.6M
Net patient revenuemost recent cost report
-6.9%
Operating marginrevenue minus expenses
$1.1M
Related-party expense9% of expenses
Who pays — share of resident-days
Medicaid 75%Medicare 13%Other / private 13%

About 75% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.1M paid to related parties (affiliated landlords or management companies) in its most recent cost report. 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

$366per resident / day
operating cost
$11,126per month
≈ monthly operating cost
$342per day
avg. revenue, all payers

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

What families pay in MA

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 225349. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-19, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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