Southbridge Rehabilitation & Health Care Center
84 Chapin Street, Southbridge, MA 01550 · For profit - Limited Liability company · 144 certified beds · (774) 437-1166 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- 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 (F0604) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (31) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing rating is low (1/5)
- its facility-reported quality-measure rating is low (2/5)
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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 2 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 | 2 of 5 |
| Long-stay residentspeople who live here | 3 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 fell from 2 to 1 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 | 11.8% | 16.4% | 15.4% | better |
| Long-stay residents who lose too much weight | 7.1% | 5.1% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 1.2% | 0.8% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 2.0% | 1.8% | 2.0% | typical |
| Long-stay residents with depressive symptoms | 15.1% | 15.5% | 6.5% | typical for the state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 3.0% | 3.4% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 14.8% | 15.4% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 27.9% | 19.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 84.5% | 94.8% | 95.3% | worse |
| Long-stay residents with pressure ulcers | 3.5% | 4.2% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 29.7% | 21.2% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 29.8% | 21.4% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 1.7% | 1.4% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 46.0% | 77.7% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 27.6% | 25.7% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 14.4% | 11.9% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.36 | 1.88 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 2.55 | 1.50 | 1.80 | worse |
‡ 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.
43.3% 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 81 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 14.3% 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 35 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.29 therapist hours per resident per day in 2026Q1 — more than 45% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 22% 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 | 43.3%CMS range 33.9–54.6 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.6%CMS range 7.2–13.9 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 14.3% | 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 | 5.7% | 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 | 2.9% | 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 | 96.3% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 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 | 0.0% | 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 | 7.4%CMS range 4.3–12.5 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.87 | 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 144 beds and averages 133.5 residents a day — about 93% occupied, or roughly 10 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.22 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.20 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.93 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.96 hrs/resident/day on weekends vs 3.32 on weekdays — 11% thinner on weekends. RN hours go from 0.22 to 0.15 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%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
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.
31 citations, most serious first. The 10 most serious are shown; the remaining 21 are one tap away and print in full.
- Potential for harm · Ecited before2026-04-03 · tag F0712 — patternEnsure that the resident and his/her doctor meet face-to-face at all required visits.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews, and record review, the facility failed to ensure one Resident (#107) out of a total sample of 26 residents, was seen by a Physician at the required regulatory frequency for physician visits.Specifically, the facility failed to ensure Resident #107 was seen by a Physician:-for the Resident's initial visit following admission to the facility.-for alternating visits with the Nurse Practitioner (NP) every 30 days for the first 90 days following admission to the facility.-for alternating visits with the NP every 60 days, after the Resident was in the facility for 90 days. Findings include:Resident #107 was admitted to the facility in October 2025 with diagnoses including Chronic Respiratory Failure, Heart Failure, and Hypertension. Review of Resident #107's clinical record on 4/3/26 failed to indicate any evidence the Resident was seen by a Physician since the Resident was admitted to the facility in October 2025 (greater than five months). During an interview on 4/3/26 at 11:00 A.M., the Assistant Director of Nursing (ADON) said resident physician notes were located…
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 before2026-04-03 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, records reviewed and interviews, the facility failed to provide a clean, sanitary or homelike environment for three Residents (#73, #9 and #52) out of a total sample of 26 residents, and in five rooms on two units (Second Floor and Third Floor) out of three resident units to prevent the potential for the spread of infection and maintain resident safety. Specifically, the facility failed to: 1. for Resident #73, clean and maintain a wheelchair in good condition on the Third Floor unit. 2. maintain privacy curtains in a clean and sanitary manner for three rooms out of twelve rooms observed on the Second Floor unit. 3. for Resident #9 and Resident #52, ensure window curtains were maintained in homelike condition on the Third Floor unit. Findings include: Review of the facility policy for Environmental Cleaning and Rounds, last reviewed 1/2026, indicated: -it is the policy of this facility to reduce and/or prevent the spread of infection through indirect contact by cleaning, sanitizing 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 · Dcited before2026-04-03 · 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 observations, interviews, and record review, the facility failed to ensure a grievance was initiated for prompt resolution relative to missing personal items for one Resident (#39) out of a total sample of 26 residents. Specifically, the facility failed to assist Resident #39 in appropriately filing a grievance when he/she reported missing two personal blankets to staff, staff was unable to find the missing blankets and did not report the Resident's complaint and missing personal items to the facility grievance officer as required. Findings include:Review of the facility's Grievance Policy, undated, indicated the following:-Residents have the right to voice grievances .-The facility will make prompt efforts to resolve any grievances in accordance with this policy.-Upon receipt of a grievance, the staff person receiving the grievance shall immediately notify the grievance officer. Resident #39 was admitted to the facility in November 2025 with mild neurocognitive disorder. Review of Resident #39's Minimum Data Set (MDS) Assessment, dated 2/20/26, indicated:-has clear…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-03 · tag F0604 — failed to not use physical restraints improperly — isolatedEnsure that each resident is free from the use of physical restraints, unless needed for medical treatment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and record review the facility failed to ensure one Resident (#129) out of a total sample of 26 Residents, was free from physical restraints. Specifically, the facility failed to ensure Resident #129's wheelchair brakes were unlocked while he/she was seated at a table when the Resident was unable to release the wheelchair brakes independently and was unable to move him/herself from the table. Findings include: Review of the facility policy titled Restraint Management revised August 2018, indicated a physical restraint is any manual, mechanical or physical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body. Also included as restraints are facility practices that meet the definition of a restraint, such as: -using devices in conjunction with a chair, such as trays, tables, bars or belts, that the resident cannot remove easily, that prevent 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 · D2026-04-03 · tag F0685 — isolatedAssist a resident in gaining access to vision and hearing services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interview, the facility failed to ensure that services were provided to maintain hearing abilities for one Resident (#108) out of a total sample of 26 residents. Specifically for Resident #108, the facility failed to assist with providing routine audiology care, when the Resident Representative consented to and requested audiology care services and the Resident was diagnosed with bilateral hearing loss. Findings include: Review of the facility's policy, titled Consultant Services, dated April 2015, indicated: -the facility will identify and facilitate consultant services to meet the resident's needs to ensure optimum care for each resident/patient through consultant services. -If a consultant is required in another specialty area, the Physician must specify the person he/she wishes to use. -once the consultant is identified by the Physician and after the family has been notified and given the permission for the consult, the staff will call the consultant to notify…
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 before2024-12-18 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a comfortable and homelike environment for two Residents (#55 and #37) and on three units (Second Floor, Third Floor and Forth Floor) out of three total units observed. Specifically, the facility failed to: 1. maintain comfortable water temperatures for bathing in resident rooms and unit shower rooms, resulting in Resident #55 and #37 not receiving showers as desired and requested due to cold water temperatures. 2. maintain comfortable water temperatures in resident rooms and for three of three unit shower rooms as needed. Findings include: Review of the facility policy titled Showers, dated April 2015, indicated the following procedure: -Resident/patient will receive a shower, assisted/and given by the nursing staff as desired. -Procedure: >Prepare shower room and equipment >Run water for the shower, checking to ensure that temperature is not greater than 100-102 degrees (*) Fahrenheit (F) -Documentation: >Document the procedure…
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 · E2024-12-18 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to implement the comprehensive person-centered plan of care for two Residents (#88, #104) out of a total sample of 26 residents. Specifically, the facility failed to: 1. For Resident #88, implement the fall risk intervention for non-skid strips to the Resident's bedside and bathroom placing the Resident at risk for falls and injury. 2. For Resident #104, implement the nutritional risk intervention for a lip plate with meals placing the Resident at risk for calorie deficit. Findings include: Review of the facility policy titled Comprehensive Care Plans, date with revision date November 2017 indicated: -The facility is committed to providing residents with all the necessary care and services to enable them to achieve the highest quality of life. -Recognizing each resident as an individual, we identify and meet those needs in a resident centered environment. -Care plans are oriented toward preventing avoidable decline in clinical and functional…
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 before2024-12-18 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to maintain complete and accurate medical records for two Resident's (#77 and #5) out of a total sample of 26 residents. Specifically, the facility failed to: 1. for Resident #77, maintain documentation relative to behavioral health services that the Resident was receiving from a consulting firm. 2. for Resident #5, document that Physician/NPP was notified when Resident #5 had a significant change in condition relative to: A) blood sugar readings greater than 350 mg/dL (milligrams per deciliter) as indicated by a Physician's order, and B) when a laboratory value for Hemoglobin A1C (test that measures the average blood sugar level over the past three months) was out of normal range and noted as high, putting the resident at risk for complications related to hyperglycemia (high blood sugar levels). Findings include: Review of the facility policy titled Consultant Services dated 4/2015, indicated the following: -A note should be recorded on the consultation…
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 · D2024-12-18 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to preserve the dignity of one Resident (#107) out of a total sample of 26 residents. Specifically, the facility failed to ensure that Resident #107's wheelchair was maintained in a clean manner for use by the Resident. Findings include: Resident #107 was admitted to the facility in September 2022 with diagnoses including Dementia, generalized muscle weakness and unsteadiness on feet. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #107: -was severely cognitively impaired as evidenced by Brief Interview for Mental Status (BIMS) score of one out of a possible total score of 15 -used a wheelchair for mobility. Review of Resident #107's clinical medical record indicated the following: -An Activated Health Care Proxy (HCP- a legally appointed person that has authority to make health care decisions for someone that is unable to do so themselves), effective 3/3/21. -A comprehensive, person-centered 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 · Dcited before2024-12-18 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to resolve a grievance timely for one Resident (#40), out of a total sample of 26 residents. Specifically, the facility staff failed to reimburse Resident #40 timely when money was reported missing, an investigation was completed, and the grievance was resolved 80 days after the initial grievance was filed. Findings include: Review of the Grievance Policy, undated, indicated: -Upon receipt of a grievance, the staff person receiving the grievance shall immediately notify the grievance officer. -The grievance officer shall begin the grievance process by logging a summary of the grievance (if oral), the date the grievance was received and by initiating an investigation. -Review of any grievances filed should be completed within seven days. If the review cannot be completed within this timeframe, the grievance officer should communicate the status of the review and an updated time in which it is expected the review will be completed. -Upon completion 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.
Show the remaining 21 citations
- Potential for harm · D2024-12-18 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to provide respiratory care and services consistent with professional standards of practice for two Residents (#81 and #70), out of a total sample of 26 residents. Specifically, the facility failed to: 1. For Resident #81, ensure a Physician's order was in place for the use of oxygen (O2) therapy. 2. For Resident #70, ensure that oxygen therapy was administered as ordered by the Physician. Findings include: Review of the facility policy titled Oxygen Administration Nasal Cannula, revised November 2020, indicated the following: -To deliver low flow oxygen, per the physician's order (generally one to six liters per minute and 24% to 45% concentration) via nasal cannula. 1. Resident #81 was admitted to the facility in October 2020 with diagnoses including Acute Respiratory Failure with Hypoxia, morbid obesity, Chronic Obstructive Pulmonary Disease (COPD) and Congestive Heart Failure (CHF). Review of the COPD care plan indicated the following in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-18 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, and record review, the facility failed to ensure that one Resident (#24) was free from the use of unnecessary medications out of a total sample of 26 residents. Specifically, the facility failed to ensure that Resident #24 did not receive extra doses of Insulin (medication used to control elevated blood sugar levels) when his/her blood sugar was under the 150 mg/dL (milligram per deciliter) level specified by the Physician. Findings include: Review of the facility policy titled Medication Administration by Route or Dosage, revised 3/2017, indicated the following: -Subcutaneous Injections: >Verify medication order on the Medication Administration Record (MAR). >Check against Physician order. Resident #24 was admitted to the facility in April 2017 with diagnoses including Type II Diabetes (DM- chronic condition in which the body has trouble controlling blood sugar and using it for energy). Review of Resident #24's November 2024 Physician's orders indicated: -Lantus (brand name for insulin glargine) Injection 100/milliliters (ml): Inject 50 units subcutaneously at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-12-18 · 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 record review, the facility failed to ensure that medications were stored in a secure and safe manner, and according to professional standards of practice in the second-floor medication storage room. Specifically, the facility failed to store Lorazepam Concentrated Oral Liquid (controlled substance medication [a drug or other substance that is tightly controlled by the government because it may be abused or cause addiction] used to treat anxiety disorders) in a safe manner when the Lorazepam was stored in a black metal box that was not fixed (could be removed) to the inside of the medication refrigerator in the second-floor medication storage room. Findings include: On 12/17/24 at 11:33 A.M., during an observation of the second-floor medication storage room, the surveyor and Unit Manager (UM) #1 observed a black metal box with a padlock located in the medication storage room refrigerator. During an interview at the time, UM #1 said that the black metal box was locked with a padlock because it contained controlled medications that required…
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 · D2024-12-18 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to implement an Antibiotic Stewardship Program for one Resident (#52) out of a total sample of 26 residents. Specifically, for Resident #52, the facility failed to ensure that documentation was reviewed for signs and symptoms of infection prior to requesting an order for antibiotics from the Physician and/or Non-Physician Practitioner (NPP) and administering antibiotics for a suspected urinary tract infection (UTI). Findings include: Review of the facility policy titled Antibiotic Stewardship dated 7/2017, indicated the following: -It is the policy of this facility to treat only symptomatic infection meeting criteria, and to promote antibiotic stewardship to reduce inappropriate antimicrobial use, improve patient care outcomes and reduce possible consequences of antimicrobial use. -When symptoms of an infection are documented . Resident #52 was admitted to the facility in September 2016 with diagnoses including frontotemporal neurocognitive disorder (a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-18 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interview, the facility failed to offer the Pneumococcal Vaccination as recommended to one Resident (#104), for five applicable residents, out of a total sample of 26 residents. Specifically, the facility failed to ensure that Resident #104 was offered the Pneumococcal Conjugate Vaccine (PCV- a vaccine that helps protect against diseases caused by pneumococcal bacteria) at the time of admission or shortly thereafter, putting the Resident at risk for developing facility acquired Pneumonia. Findings include: Review of the facility document titled Procedure for Pneumococcal Vaccination of Residents indicated the following: -Each resident or their representative will be asked on admission if they have previously had any pneumococcal vaccinations and their age at the time of vaccination. The records that accompany the resident will also be used to determine immunization status. -The pneumococcal conjugate vaccine will be offered to all eligible residents . -Adults aged 65 years and older…
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 · D2024-12-18 · tag F0909 — failed to maintain a comfortable temperature — isolatedRegularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to develop a system to conduct regular maintenance and inspections of all bed frames, mattresses, and bed rails (side rails) as part of a regular maintenance program to identify areas of possible entrapment for two Residents (#5 and #70) out of three applicable residents for bed rail use, out of a total sample of 26 residents. Specifically, the facility failed to: 1. For Resident #5, provide inspection documentation for the Resident's bed frame, mattress, and side rails. 2. For Resident #70, provide documentation that the Resident's bed frame, mattress, and side rails were regularly inspected. Findings include: Review of the facility policy titled Restraints: Bed Rail Safety Check, undated, indicated the following: -Regularly inspect each of the seven areas (areas between the mattress and side rails, head board, and foot board) on each bed with restraints. -Maintenance and monitoring of the bed, mattress, and accessories (such as resident/caregiver assist items) should be ongoing. 1. Resident #5 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 · D2024-12-03 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who experienced a change in health status, and had an activated Health Care Proxy (HCP), the Facility failed to ensure nursing notified his/her Health Care Agent (HCA) in a timely manner, when on 11/22/24, Resident #1 required administration of oxygen therapy during the overnight shift due to low oxygen saturation levels, that was new for him/her, however his/her HCA was not notified until the day shift, when he/she was transferred to the Hospital Emergency Department (ED) for evaluation. Findings include: -Review of the Facility Policy, Titled Your Rights and Protections as a Nursing Home Resident, undated, indicated that the Health Care Agent must be notified when the following occurs: -Your physical, mental, or psychosocial status starts to get worse. -You have a life-threatening condition. -Your treatment needs to change significantly Resident #1 was admitted to the Facility in June 2024, diagnoses include prostate cancer, dementia, type 2 diabetes mellitus, and chronic kidney disease.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-10-25 · tag F0641 — patternEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interview, the facility failed to accurately code Minimum Data Set (MDS) assessments for four Residents (#87, #94, #121, and #25) out of a total sample of 26 residents. Specifically, the facility staff failed to accurately code: 1. for falls for Resident's #87 and #94 2. for visual acuity for Resident #121 3. for administration of antipsychotic medication for Resident #25 Findings include: 1a. Resident #87 was admitted to the facility in June 2023 with a diagnosis that included a history of falling. Review of the Resident's Fall Report dated 8/24/23, indicated the following: -Resident was sitting in a chair and scooted out of chair. -Resident landed on his/her coccyx area in front of the chair. -Fall was witnessed, no injuries reported. Review of the Resident's MDS dated [DATE], section J indicated that the Resident had no falls since the prior assessment on 7/20/23. During an interview on 10/24/23 at 8:13A.M., the MDS Nurse said that the MDS dated [DATE], section J was coded…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-10-25 · tag F0712 — patternEnsure that the resident and his/her doctor meet face-to-face at all required visits.
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 two residents (#62 and #90), in a total sample of 26 residents, were seen by a Physician for required visits. Specifically, the attending Physician failed to conduct required visits at least every 30 days for the first 90 days after admission and at least 60 days thereafter, with alternate visits by a Nurse Practitioner (NP). Findings Include: 1. Resident #62 was admitted to the facility in December 2022 with diagnoses including Bipolar Disorder, generalized Anxiety Disorder, major Depression, and Dementia with Lewy Body (a type of progressive Dementia that leads to a decline in thinking, reasoning and independent function). Review of the medical record indicated the following visits: -12/8/22 by the Nurse Practitioner -12/15/22 by the Nurse Practitioner -12/20/22 by the Nurse Practitioner -12/30/22 by the Nurse Practitioner -1/3/23 by the Nurse Practitioner -1/9/23 by the Physician -1/10/23 by the Nurse Practitioner -1/31/23 by the Physician -2/14/23 by the Nurse Practitioner Further review indicated no…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-10-25 · 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 ensure that medications were stored and labeled appropriately for two of six applicable medication carts, and that medications were labeled appropriately for one of three applicable medication storage rooms. Specifically, the facility staff failed to: 1. Store and secure medication in the medication cart before stepping away from the medication cart. 2. Label [NAME]-dose vials of medication at the time that the vial was first opened. Findings include: Review of the facility policy titled Medication Administration - Oral dated June 2015 indicated that Medication carts are always locked when unattended. Review of the facility policy titled Medication Storage Room/Medication Cart Policy dated February 2018 included: -Medications are stored primarily in a locked mobile medication cart which is accessible only to licensed nursing personnel. -The medication cart is to be kept locked at all time (s) when not in use by the Nurse. 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 · D2023-10-25 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and interview the facility failed to ensure that resident identifying information on the medication cart computer screen was secured when the Nurse stepped away from the cart. Findings include: Review of the facility policy titled Medication Storage Room/Medication Cart Policy dated February 2018 included: -The medication cart is to be kept locked at all time (s) when not in use by the Nurse. On 10/24/23 at 4:05 P.M., the surveyor observed Nurse #3 stepping away from an unattended medication cart on the second floor and leaving the computer screen containing Resident identifiable information open and easily viewed by anyone in the vicinity. During an interview on 10/24/23 at 4:08 P.M., when Nurse #3 returned to the medication cart, he said that he should have closed the computer screen before walking away.
- Potential for harm · D2023-10-25 · tag F0622 — isolatedNot transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview the facility failed to maintain the documented clinical transfer paperwork to the hospital in the resident's medical record as required for three Residents (#35, #40 and #96) out of a total sample of 26 residents. Specifically, the facility failed to maintain the appropriate documentation in Resident's (#35, #40 and 96) clinical record that had been communicated to the receiving health care provider to ensure a safe and effective transition of care. Findings include: 1. Resident #35 was admitted to the facility in September 2021 with diagnoses including Quadriplegia (paralysis of all four limbs) and a Traumatic Brain Injury (TBI- head injury that causes serious problems with brain functioning ranging from mild to severe). Review of Resident #35's progress note dated 10/20/23 indicated that Resident #35 had the following low (normal parameters - upper: 90-120/ lower: 60 - 80) blood pressure readings: -62/39 mmHg (millimeters of mercury- measurement) (left arm) -97/55 mmHg (left leg) -85/50 mmHg (left arm) -88/58 mmHg (left arm) Further review 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 · D2023-10-25 · tag F0623 — isolatedProvide 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interview, the facility failed to notify the Resident, the Resident Representative and the Ombudsman of the Resident's transfer from the facility to the hospital in writing as required for two Residents (#78 and #117), out of a total sample of 26 residents. Findings include: Review of the facility policy titled Discharge Planning dated August 2018 indicated the following: -Social Services will ensure systems are implemented to provide written notification to the resident/responsible party prior to transfer/discharge in accordance with Massachusetts Department of Public Health (DPH). - In the event of unplanned transfer to an acute care setting, notice will be provided in writing to the resident/responsible party as soon as practical. 1. Resident #78 was admitted to the facility in October 2020. Review of the Resident's clinical progress notes indicated that the Resident was transferred to the hospital on 6/26/23 but did not indicate that the Resident and/or Resident Representative 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 · D2023-10-25 · tag F0625 — isolatedNotify 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review and interviews the facility failed to issue the written Bed Hold Policy as required to three Residents (#35, #78 and #117) and/or their Representatives, out of a total sample of 26 residents. Findings include: Review of the facility policy for the Reservation of Beds, last revised 11/8/2016, indicated: -this facility will reserve the bed of a hospitalized resident or resident on a leave of absence (LOA) in accordance with facility policies and state and federal regulations. -the facility will reserve the bed of a hospitalized Medicaid resident for up to twenty days provided that the facility does not receive information that the resident is not expected to return to the facility at the same level of care within the twenty-day period. 1. Resident #35 was admitted to the facility in September 2021 with diagnoses including Quadriplegia (paralysis of all four limbs) and a Traumatic Brain Injury (TBI- a head injury that causes serious problems with brain functioning ranging from…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-25 · tag F0694 — isolatedProvide for the safe, appropriate administration of IV fluids for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and interview, the facility failed to provide care for a Peripherally Inserted Central Catheter (PICC- a long catheter inserted through a peripheral vein and into the central vascular system to administer intravenous [IV] treatments over a long period of time) for one applicable Resident (#20), in a total sample of 26 residents. Specifically, the facility staff failed to ensure that weekly PICC line dressing and measurements were obtained as ordered to monitor for infection, infiltration (when fluid leaks out into the tissues under the skin) and migration (movement). Findings include: Review of the facility's policy, Midline/Extended Dwell Catheter Dressing Change dated January 2022, included: -The IV therapy order for care and maintenance is required. -Dressing changes will occur according to the IV Order Form and when the dressing is compromised (drainage/moisture observed, loose, soiled). Resident #20 was admitted to the facility in September 2023 with diagnoses including Acute Osteomyelitis (inflammation of the bone caused by infection) in the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-25 · 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 observation, record review, policy review and interview, the facility failed to provide care consistent with professional standards for one Resident (#117), who required Hemodialysis (a process for purifying blood of a person whose kidneys are not working normally, also referred to as dialysis) out of a total sample of 26 residents. Specifically, the facility staff failed to maintain ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. Findings include: Review of the facility policy titled Hemodialysis dated April 2015 indicated the following: -To provide comprehensive care to residents/patients that receive hemodialysis treatments. -Communication between the facility and the hemodialysis treatment center will occur using a communication book/sheet that consist of: a. Vital Signs. b. A copy of the Medication Administration Record (MAR). c. Any change in condition from the last hemodialysis treatment i.e. changes in weight, medications, behavior, appetite and falls. d. Documentation will be completed prior to dialysis…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-25 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and records reviewed, the facility failed to ensure that records were reviewed monthly by a consultant Pharmacist and monthly Medication Regimen Review (MRR) recommendations were reviewed timely and implemented as required for two residents (#40 and #62) out of a total sample of 26 residents. Specifically, 1. For Resident #40, the facility failed to ensure that the Pharmacy recommendations were reviewed by a Physician as required. 2. For Resident #62, that documentation of recommendations during a monthly MRR were maintained and that recommendations were submitted to the Physician for review. Findings include: Review of the facility policy titled Consultant Services, last revised April 2015, indicated the following: -The Facility will identify and facilitate consultant services to meet the resident's needs, to ensure optimum care for each resident through consultant services. -The charge Nurse will notify the attending Physician of findings and he/she can then order the specific treatments as outlined by the consultant. -A consultant's report or some form 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 · D2023-10-25 · 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 interview and record review, the facility failed to implement a Physician order for one Resident (#120), out of a total sample of 26 residents. Specifically, the facility failed to transcribe an order for Effexor 75 milligrams (mg) to be discontinued after the Psychiatrist ordered the change and the Nurse Practitioner (NP) agreed with the change recommendation. Findings include: Resident #120 was admitted to the facility in June 2023 with diagnoses including Dementia (a group of symptoms that affects memory, thinking and interferes with daily life) and Major Depressive Disorder (MDD- is a mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities.) Review of Resident #120's Behavioral Health Group note dated 7/12/23, indicated the following: -Start patient on Trazodone (antidepressant and sedative) 25 mg by mouth twice a day. -Discontinue Effexor (antidepressant) at this time. Review of the Nursing Note dated 7/19/23, indicated: -Psychiatry in to see patient 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.
- Potential for harm · Dcited before2023-10-25 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and interview, the facility failed to maintain accurate medical records for one Resident (#20) out of a total sample of 26 residents. Specifically, the facility staff signed off on the Treatment Administration Record (TAR) that a Peripherally Inserted Central Catheter (PICC- a long catheter inserted through a peripheral vein then into the central vascular system to administer intravenous (IV) treatments over a long period of time) line dressing was changed, when it had not been changed for the Resident. Findings include: Resident #20 was admitted to the facility in September 2023 with diagnoses including Acute Osteomyelitis (inflammation of the bone cause by infection) in the right shoulder, cutaneous abscess (pus collection under the skin) of the right upper limb (a functional unit of the upper body) and Enterocolitis (an inflammation of the digestive tract, involving the small intestine and colon) due to Clostridium Difficile (c-diff: highly contagious bacterium that causes diarrhea and inflammation of the colon). Review of the medical record…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · Bcited before2024-12-18 · tag F0641 — patternEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interview, the facility failed to ensure the Minimum Data Set (MDS) Assessment was accurately coded for one Resident (#84) out of a total sample of 26 residents. Specifically, the facility staff incorrectly coded Clopidogrel (an antiplatelet [prevents platelets from sticking together] medication) as an anticoagulant on the MDS. Findings include: Resident #84 was admitted to the facility in February 2021 with diagnoses including Atrial Fibrillation (an irregular heart rate which can result in poor blood flow and blood clots forming). Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #84 was currently prescribed an anticoagulant (blood-thinning medication which disrupts blood clot formation). Review of Resident #84's December 2024 Physician's orders indicated: -Clopidogrel 75 mg (milligrams) PO (by mouth) in the morning. -No Physician order for an anticoagulant medication. During an interview on 12/18/24 at 12:19 P.M., the surveyor and MDS Nurse #1 reviewed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · B2024-12-18 · tag F0732 — patternPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to post required nurse staffing information on a daily basis. Specifically, the facility failed to include daily posting of the following: -the resident census information on the daily posting for the facility nurse staffing. -total number and actual hours worked by Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Certified Nurse Aides (CNAs). Findings include: On 12/15/24 at 12:30 P.M., the surveyor observed a paper posting of nurse staffing information for 12/15/24 encased in a plastic sleeve and posted on a wall in the facility lobby area. The nurse staffing information posted contained the following: -the facility name -the current date -the 7:00 A.M. to 3:00 P.M. staff scheduled to work and the shift hours assigned to each staff member. Further review of the nurse staffing information posting did not indicate the facility census number, staff scheduled to work on the 3:00 P.M. to 11:00 P.M. and 11:00 P.M. to 7:00 A.M. shifts, and the total number of hours worked by Registered Nurses (RNs), Licensed Practical…
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 ATHENA HEALTHCARE SYSTEMS — 22 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 | 2 of 5 | 1.5 | +0.5 vs chain |
| Health inspection | 3 of 5 | 1.7 | +1.3 vs chain |
| Staffing | 1 of 5 | 2.1 | -1.1 vs chain |
| Quality measures | 2 of 5 | 2.5 | -0.5 vs chain |
The other 21 homes this chain runs (chain average 1.5★, 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 |
|---|---|---|---|---|
| ATHENA HEALTH CARE SYSTEMS MA R LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 09/01/2012 |
| CHAKALOS-SANTILLI, VALERIE | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 5% | since 09/01/2012 |
| CURTIS, DIANE | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 09/01/2012 |
| MOSIER, MICHAEL | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; W-2 MANAGING EMPLOYEE | 6% | since 09/01/2012 |
| REZENDES, LORRIE | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 09/01/2012 |
| SANTILLI, LAWRENCE | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | 74% | since 05/04/2020 |
| ATHENA HEALTH CARE ASSOCIATES, INC. | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 09/01/2012 |
CMS files one row per role, so the 9 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted.
2 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.
About 88% 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 $2.1M paid to related parties — landlords or management companies under common ownership — equal to about 13% 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 225293. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-03, 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.