Bear Hill Healthcare And Rehabilitation Center
11 North Street, Stoneham, MA 02180 · For profit - Limited Liability company · 169 certified beds · (781) 438-8515 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- 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
- it has 1 actual-harm citation
- a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $16,146 in federal fines (most recent 2023-12-14)
- about 17% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 5 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 | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 5 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
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 | 5.4% | 16.4% | 15.4% | better |
| Long-stay residents who lose too much weight | 3.6% | 5.1% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.8% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.6% | 1.8% | 2.0% | better |
| Long-stay residents with depressive symptoms | 32.5% | 15.5% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 0.2% | 3.4% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 4.3% | 15.4% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 17.7% | 19.5% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 99.3% | 94.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.6% | 4.2% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 16.0% | 21.2% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 19.9% | 21.4% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 1.6% | 1.4% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 92.1% | 77.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 27.7% | 25.7% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 6.6% | 11.9% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.66 | 1.88 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 1.38 | 1.50 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
57.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 526 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 73.4% 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 214 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 0.35 therapist hours per resident per day in 2026Q1 — more than 60% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 46% 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 | 57.9%CMS range 53.3–61.5 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.2%CMS range 9.3–13.3 | 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 | 73.4% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 72.0% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 72.0% | 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 | 57.2% | 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 | 98.6% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 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 | 2.1% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.2%CMS range 4.3–9.1 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.94 | 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 169 beds and averages 149.0 residents a day — about 88% occupied, or roughly 20 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.00 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.49 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.43 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 3.68 hrs/resident/day on weekends vs 4.13 on weekdays — 11% thinner on weekends. RN hours go from 0.55 to 0.33 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 37% 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 more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
27 citations, most serious first. The 11 most serious are shown; the remaining 16 are one tap away and print in full.
- Actual harm · G2023-12-14 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to follow the fall plan of care for 1 Resident (#124) out of a total of 36 sampled Residents. Subsequently, Resident #124 sustained a fall requiring hospitalization and was diagnosed with subdural hematoma, (bleeding that occurs within the skull but outside the actual brain tissue). Findings include: Review of the facility's Fall Prevention and Fall Committee Policy and Procedure, dated 6/7/22 indicated: *All residents who on admission, readmission or after an actual fall score at high risk for falls will have immediate interventions implemented for prevention of falls. *Any falls prevention interventions should minimize the resident's risk for falling and maintain functional independence and mobility. Various interventions should be used as appropriate for resident risk *Interventions may include but are not limited to: reinforcing use of the call bell, adjusting the bed to its lowest position, education of resident and family, use of chair…
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 before2026-01-15 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to provide quality of care in accordance with professional standards for four Residents (#154, #40, #118, and #58) out of a total sample of 31 residents. Specifically,1. For Resident #154, the facility failed to document and assess the alteration of the skin on his/her lower extremities to determine if the areas were healing or worsening and failed to report the condition of Resident 154's lower extremities to the medical provider. 2. For Resident #40, the facility failed to implement an order for a diuretic after a significant weight gain for Resident #40, who has congestive heart failure and edema.3. For Resident #118, the facility failed to label wound dressings after changing Resident #118's dressing.4. For Resident #58, the facility failed to complete weekly skin checks as ordered. Findings include:1.Resident #154 was admitted to the facility in December 2024 with diagnoses including multiple sclerosis, severe protein calorie…
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 · D2026-01-15 · 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 observation, record review and interview, the facility failed to identify and assess the use of a geri-chair (a high back chair on wheels with the ability to recline) as a potential restraint for one Resident (#118) out of a total of 31 sampled Residents. Findings include: Review of the facility's Use of Restraints policy, undated, indicated the following:Restraints shall only be used for the safety and well-being of the residents and only after other alternatives have been tried unsuccessfully.Restraints shall only be used to treat the residents' medical symptoms and never for discipline or staff convenience, or for the prevention of falls.When the use of restraints is indicated, the least restrictive alternative will be used for the least amount of time necessary, and the ongoing re-evaluation for the need for restraints will be documented.6. Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. The assessment shall be…
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 before2026-01-15 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to develop an activities care plan for one Resident (#40) out of a total sample of 31 residents. Findings include: Resident #40 was admitted in November 2025 with diagnoses including adjustment disorder with mixed anxiety and depressed mood. Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #40 scored a 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. During an interview on 1/13/26 at 8:58 A.M., Resident #40 said that he/she would like to attend some activities but has only been to one activity since he/she's been admitted . Resident #40 said that no one comes to get him/her for activities because he/she is at the end of the hall. During an observation on 1/13/26 at 4:02 P.M., Resident #40 was sitting in his/her wheelchair in his/her room. Resident #40 said that he/she hadn't done any activities that day. Resident #40 said that he/she loves music and entertainment but can't always…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-15 · 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 reviews and interviews, the facility failed to ensure for one Resident (#145), out of a total sample of 31 residents, that services were provided to maintain his/her hearing abilities. Specifically, for Resident #145 the facility failed to assist with providing his/her's left hearing aid and ensuring it was working to support the Resident's hearing. Findings include: Review of the facility's policy, titled Hearing Aid, Care of, dated as revised February 2022 indicted the purpose of this procedure is to maintain the resident's hearing at the highest attainable level. The following information should be recorded in the resident's medical record; 1. If the resident refused the procedure, the reason(s) why and the interventions taken, Reporting, Notify the supervisor if hearing aid is damaged, Notify the supervisor if the resident complains of problems related to hearing aid and/or the hearing aid or has a wax build up in the ear.Resident #145 was readmitted to the facility in September…
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 · D2026-01-15 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and observation, the facility failed to ensure physicians orders for the care of pressure ulcers were implemented for one Resident (#86) out of a total sample of 31 residents. Specifically, for Resident #86, the facility failed to ensure that the wound physician's recommendations for treatment to Resident #86's sacrum were followed. Findings include: Review of the facility policy titled Prevention of Pressure Ulcers, undated, indicated the following: It is the policy to prevent pressure ulcers unless clinically unavoidable and to provide care and services to promote the prevention of pressure ulcer development, the healing of pressure ulcers that are present (including of infection to the extent possible) and prevent development of additional pressure ulcers. Resident #86 was admitted to the facility in December 2025 with diagnoses including peripheral vascular disease, unstageable pressure ulcers of sacral region (base of the spine), left heel, left ankle and acquired absence…
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 before2026-01-15 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to accurately document in the electronic medical record for two Residents (#12 and #84), out of a total sample of 31 residents. Specifically, 1. For Resident #12, nursing staff documented a right arm sling as being provided when it was not. 2. For Resident #84, the facility failed to accurately record the Resident's oxygen saturation percentages in the medication administration record. Findings include: 1.Resident #12 was admitted to the facility in October 2025 with diagnoses that included but not limited to Alzheimer's Disease and a displaced fracture of the upper end of the right humerus. Review of the most recent Minimum Data Set assessment, dated 10/24/25, indicated Resident #12 scored 6 out of 15 on the Brief Interview for Mental Status exam, indicating he/she had severely impaired cognition, had an upper extremity impairment on one side, and was dependent on staff for upper and lower body dressing. On 1/13/26 at 8:30 A.M., Resident #12 was observed…
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 · E2024-12-19 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record review, and interviews, the facility failed to provide assistance with Activities of Daily Living (ADLs), for two Residents (#61 and #241) out of a total sample of 30 residents. specifically 1. For Resident #61 the facility failed to provide supervision with meals. 2. For Resident #241 the facility failed to provide incontinent care or hygiene care. Findings Include: Review of the facility policy titled Activities of Daily Living (ADL's), Supporting, undated, indicated the following: Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Policy Interpretation and Implementation 1(c). The refusal and information are documented in the resident's clinical record. 2. Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: d. Dining (meals and snacks). 1.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-12-19 · 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 accurately document in the clinical record for 4 Residents (#18, #43, #241 and #110) out of a total sample of 30 residents. Specifically: 1. for Resident #18 the facility failed to accurately document the changing of the oxygen tubing. 2. For Resident #43 the facility failed to accurately document the sex of the Resident. 3. For Resident #241 the facility failed to accurately document the Activities of Daily Living (ADL) care provided. 4. For Resident #110, the facility failed to ensure staff accurately documented the completion of wound treatments provided. Findings include: Review of the facility policy titled 'Charting and Documentation', dated revised July 2017 indicated that Documentation in the medical record will be objective (not opinionated or speculative), complete and accurate. 1. Resident #18 was admitted to the facility in January 2023 with diagnoses including chronic obstructive pulmonary disease, dementia and heart disease. Review of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-12-19 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to develop a plan of care for two Residents (#43 and #241) out of a total sample of 30 residents. Specifically; 1. For Resident #43 the facility failed to develop a plan of care for suicidal ideation's. 2. For Resident #241 the facility failed to ensure a call light was accessible. Findings include: Review of the facility policy titled Suicide Threats, dated December 2007 indicated that staff will monitor the resident's mood and behavior and update the care plans accordingly until a physician has determined that a risk of suicide does not appear to be present. 1. Resident #43 was admitted to the facility in June 2024 with diagnoses including suicidal ideation, depression with psychotic features, and dementia. Review of the Minimum Data Set assessment dated [DATE] indicated that Resident #43 is severely cognitively impaired and scored a 5 out of 15 on the Brief Interview for Mental Status exam. Further review indicated that Resident #43 requires…
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 before2024-12-19 · 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 interviews, the facility failed to provide respiratory care services in accordance with professional standards of practice for one Resident (#18) out of a total sample of 30 residents. Findings include: Review of the facility policy titled Oxygen therapy, not dated, indicated that humidifiers and nasal cannulas, mask and tubing are changed every 7 days. Resident #18 was admitted to the facility in January 2023 with diagnoses including chronic obstructive pulmonary disease, dementia and heart disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #18 scored a 7 out of 15 on the Brief Interview for Mental Status exam indicating severe cognitive impairment. Further review indicated that Resident #18 is dependent on staff for activities of daily living. Further review indicated that Resident #18 received oxygen therapy while a resident. On 12/17/24, at 8:35 A.M., and 11:59 A.M. 12/18/24 at approximately 11:00 A.M. the surveyor observed…
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 16 citations
- Potential for harm · Ecited before2023-12-14 · 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 observations, record reviews and interviews, the facility 1) failed to implement personalized care plans for 3 Residents (#128, #52, and #94) and 2) failed to develop a behavior care plan for 1 Resident (#81) out of a total sample of 36 residents. Findings include: 1a) Resident #128 was admitted to the facility in March 2023 with diagnoses including stroke and hemiplegia. Review of Resident #128's most recent Minimum Data Set (MDS) dated [DATE] indicated the Resident had a Brief Interview of Mental Status (BIMS) score of 0 out of a possible 10, which indicated he/she had severe cognitive impairment. The MDS also indicated Resident #128 required extensive assistance from staff for all bed mobility tasks. On 12/11/23 at 7:58 A.M., Resident #128 was observed lying in bed. A floor mat was standing upright, not flat on the floor on the left side of the bed. There was no floor mat on the right side of the bed and no other mat was visible in the room. On 12/14/23 at 7:05 A.M., Resident #128 was observed lying…
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 · E2023-12-14 · 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
Based on observations, policy review and interviews, the facility failed to 1. ensure medications with short expirations dates were dated when opened, expired medications were not available for administration, failed to ensure medication carts were kept clean and 2. failed to ensure medication and treatment carts were locked when unattended on three out of four units. Findings include: Review of the facility policy titled 'Storage of Medications', revised April 2019, indicated the following but not limited to: *The facility stores all drugs and biologicals in a safe, secure, and orderly manner. *The nursing staff is responsible for maintaining medication storage, and preparation area clean, safe, and sanitary manner. *Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. *Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. *Unlocked medication carts are not left unattended. *Medications requiring refrigeration…
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 · E2023-12-14 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure practices to prevent the spread of infection were implemented. Specifically, the facility failed to 1. ensure for two residents (#130 and #134) that staff implemented and adhered to enhanced infection precautions, 2. failed provide urinary catheter care in adherence to infection control standards for two residents (#130 and #102), 3. failed to handle clean linen to prevent possible contamination, 4. failed to ensure infection control practices were adhered to with multi-use medical equipment and 5. failed to ensure hand hygiene was preformed after glove use potentially contaminating the resident's environment and 6. failed to ensure a risk assessment was present as part of the overall water management program to prevent the risk of Legionella and other opportunistic pathogens. Findings include: 1. Review of the facility's policy, entitled Enhanced Barrier Precaution Policy, updated July 12, 2022, indicated the following: *Policy…
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 · D2023-12-14 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to alert the physician of changes in condition for 1 Resident (#94) and failed to notify the responsible party of a change in condition for 1 Resident (#40) out of a total of 36 sampled Residents. Specifically, the facility failed to: 1.) Alert the physician of a newly developed gangrenous wound for Resident #94 and, 2.) failed to notify the responsible party of a change in condition, resulting in the needs for medical attention. Review of the facility's policy entitled Change is Resident's Condition, undated, indicated the following: *The facility is required to notify a resident's physician when there is a significant change in the resident's health status. The facility is required to make any pertinent information available and provide it to the resident's physician upon request. *The facility is also required to notify resident's next of kin/responsible party with any and all changes in a resident's condition. 1. Resident #94 was admitted…
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 · D2023-12-14 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure that services provided met professional standards of quality, for three Residents (#48, #405 and #130) out of a total sample of 36 residents. Specifically, the facility 1. failed to follow physician's orders for maintaining and documenting fluid restriction for Resident #48 and #405 and 2. failed to provide fortified mashed potatoes in accordance with the medical orders. Findings include: Review of facility policy titled 'Fluid Restriction' revised September 2017, indicated the following but not limited to: *The nursing services will be responsible for tracking and documenting the total volume consumed in accordance with facility policy. 1. Resident #48 was admitted to the facility in November 2023 with diagnoses including renal insufficiency, hypo-osmolality, and hyponatremia. Review of Resident #48's Minimum Data Set Assessment (MDS) dated [DATE] indicated the Resident scored a 14 out of 15 on the Brief Interview for Mental…
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 before2023-12-14 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure staff provided treatment and care in accordance with professional standards of practice for two Residents (#94, #40) out of a total of 36 sampled Residents. Specifically the facility failed to: 1. Identify and address a newly developed gangrenous (dead tissue) skin injury for Resident #94. 2. Implement an antibiotic treatment for cellulitis and implement monitoring of the diagnosis for Resident #40. 1. Review of the facility's Prevention of Pressure Ulcer policy, undated, indicated: *Any resident who has a pressure or stasis ulcer (an skin ulcer related to poor circulation) as well as residents with weight loss/gain are reviewed weekly. *Residents will additionally be re-assessed minimally quarterly and with any chance in condition thereafter. *Resident's will receive necessary service to promote healing. *All direct care staff are educated on skin care prevention, identification and communication of issues and documentation of risk…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-12-14 · 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 observations, record reviews and interviews, the facility failed to provide respiratory care services in accordance with professional standards of practice. Specifically, the facility failed to 1. have physician orders to administer continuous oxygen for one Resident (#98), and 2. failed to ensure oxygen administration was in accordance with the medical plan of care for one resident (#134) out of a total sample of 36 residents. Findings include: Review of facility policy titled 'Oxygen Therapy' undated indicated the following but not limited to: *To administer oxygen in conditions in which insufficient oxygen is carried by the blood to the tissues. 1. Resident #98 was admitted to the facility in September 2023 with diagnoses including acute respiratory failure with hypoxia. Review of Resident #98's Minimum Data Set (MDS) dated [DATE] indicated the Resident scored a 14 out of a possible 15 on the Brief Interview for Mental Status (BIMS) score indicating he/she was cognitively intact. On 12/11/23 at 9:31…
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 · D2023-12-14 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure care and services for the provision for hemodialysis was in accordance with professional standards of practice for one out of one applicable resident (#134), out of a total sample of 36 residents. Specifically, the facility failed to 1.) ensure ongoing appropriate assessment of the resident's hemodialysis access site, and 2.) failed to provide equipment and supplies necessary to manage a medical emergency for those. Review of the facility's policy and procedure dated as revised 2/2019, titled Dialysis indicated the following: *Purpose: to ensure that residents receiving outpatient dialysis will have a comprehensive treatment plan. Policy: communication regarding treatment delivery or problems will be comprehensive and ongoing between the dialysis delivery company and the facility's nursing staff. *Procedure: 1. Each resident receiving dialysis must have an order on their physician order sheet for HD (hemodialysis). 2. Each 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 · D2023-12-14 · tag F0699 — isolatedProvide care or services that was trauma informed and/or culturally competent.
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 a plan of care was developed for Trauma-Informed Care for one Resident (#136), who was admitted with the diagnosis of Post-Traumatic Stress Disorder (PTSD), out of a total sample of 36 residents. Findings include: Review of facility policy titled 'Trauma-Informed Care' revised August 2022, indicated the following but not limited to: *To guide staff in providing care that is trauma-informed in accordance with professional standards of practice. *To address the needs of trauma survivors by minimizing triggers and/or re-traumatization. *Develop individualized care plans that address past trauma in collaboration with the resident and family, as appropriate. Resident #136 was admitted to the facility in November 2023 with diagnoses including post-traumatic stress disorder (PTSD). Review of Resident #136's most recent Minimum Data Set (MDS) dated [DATE] indicated the Resident scored a 15 out of possible 15 on the Brief Interview for Mental Status…
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 · D2023-12-14 · tag F0726 — failed to have competent, trained nursing staff — isolatedEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure licensed nursing staff possessed the appropriate competency and skills to care for one resident (#134) out of one applicable resident, requiring dialysis, out of a total sample of 36 residents. Specifically, 1. nursing staff did not provide appropriate assessment of the dialysis access site and did not know how to implement an emergency plan related to dialysis care and 2. facility staff failed to ensure newly hired licensed nursing staff had a complete orientation including medication pass competency. Findings include: Review of the Facility's Facility assessment dated reviewed 6/30/23 indicated at Part 1: Our Resident Profile, Category: Genitourinary System Common diagnoses: renal failure, ends stage renal disease. Example 2 Special Treatments and Conditions, other: dialysis. Resident #134 was admitted in November 2023 with diagnoses that include but not limited to chronic kidney disease. Review of the Minimum Data Set assessment…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-14 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and staff interview, the facility failed to ensure pharmaceutical services met the needs of each resident. Specifically, the facility failed to ensure an antibiotic kit, an emergency kit and an insulin kit were replaced by the pharmacy after being opened. Findings include: On 12/12/23 at 12:38 P.M., during an inspection of the medication room on Birch hill unit, the following was observed: -An emergency kit and an antibiotic kit opened with several items missing, the surveyor was unable to determine when the kits were opened and if they were reordered from the pharmacy. During an interview on 12/12/23 at 12:44 P.M., Nurse #2 said she did not know when the kits were opened and there should be a manifest in the kit indicating when items were removed and when they were reordered. On 12/12/23 at 1:09 P.M., during an inspection of the medication room on Cherry hill unit, the following was observed: -In the refrigerator an insulin kit that was opened, the manifest inside the kit did not indicate if the kit had been reordered. During an interview on 12/12/23 at 1:19…
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 · D2023-12-14 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record reviews and interviews, the facility failed to ensure it was free from medication error rate of greater than 5 percent. Two out of three nurses observed made two errors out of 27 opportunities on two of two units resulting in a medication error rate of 7.41%. These errors impacted two Residents (#72 and #38), out of four residents observed. Findings include: Review of the facility policy titled 'Medication Administration - General Guidelines', dated 2017 indicated the following but not limited to: *Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the facilities medication distribution system procurement storage handling and administration. The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions. *Five rights right resident, right drag right dose right route 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 · D2023-12-14 · 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 ensure for one resident (#130), out of five applicable residents, was assessed for the eligibility, received, or declined the pneumonia vaccine, and was provided education of the risk benefits of the pneumonia vaccine timely. Findings include: Review of the facility's Pneumococcal Vaccine Policy, dated as revised March 2022 indicated the following: All residents are offered the Pneumococcal vaccines to aid in preventing pneumonia/Pneumococcal infections. Policy Interpretation and Implementation: 1. Prior to or upon admission residents are assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, are off ere the vaccine within 30 days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. 2. Assessments of pneumococcal vaccination status are conducted within 5 working days of the resident's admission if not conducted prior to admission. 3. Before receiving a pneumococcal…
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 · B2026-01-15 · tag F0582 — patternGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and interviews, the facility failed to issue a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) (a form issued by SNFs to notify Medicare beneficiaries of potential financial liability for certain services) for 2 applicable residents, out of a sample of 3 residents. Specifically, the facility failed to issue SNF ABN notices after skilled services ended. Findings include: A review of two Notices of Medicare Non-coverage issued for the two residents who remained in the facility after skilled services ended on 11/28/25 and 1/9/26 respectively, failed to indicate that SNF ABN notices were issued. During an interview on 1/14/26 at 10:04 A.M., Social Worker #1 said that the expectation for residents who remain in the facility after skilled services ending is to get a SNF ABN notice informing them of potential financial liability for certain services.
- No harm found · C2023-12-14 · tag F0623 — widespreadProvide 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 reviews and interviews, the facility failed to provide a written notice of intent to discharge prior to transferring 3 Residents (#37, #98 and #127) to the hospital, out of a total sample of 36 residents. Findings include: Review of facility policy titled Discharge Policy and Procedure, revised 2/6/08 indicated the following but not limited to: *Social services will complete the Discharge/Transfer form for each resident who has a planned discharge. The social service department will ensure a copy of the discharge/transfer form is given to the resident upon discharge; a copy sent to state ombudsman; and the original document placed on the residence chart for the permanent record. * Nursing staff will be responsible for the completion of any discharge/transfer form for residents who leave the facility on an emergency discharge to the hospital. 1. Resident #37 was admitted to the facility in October 2023 with diagnoses including acute respiratory failure with hypoxia and the infarction of spleen.…
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 · C2023-12-14 · tag F0625 — widespreadNotify 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 reviews and interviews, the facility failed to provide a bed-hold notice upon transferring three Residents (#12, #37, and #98) to the hospital, out of a total sample of 36 residents. Findings include: Review of facility policy titled 'Bed Hold Policy And Procedure' undated, indicated the following but not limited to: *At the time of transfer of a resident for hospitalization, Bear Hill must provide a written notice of the bed hold policy to the resident and his/her legal representative. * Off hour transfers 5:00 PM to 8:30 AM the licensed nurse is responsible to give the resident the notice and call the family. Social services will follow up with the family by sending written notice of bed hold by certified return receipt mail. In case of emergency transfer or the resident is unable to understand his/ her rights a copy of the notice must be sent with the resident. * Social service and nursing must document that the procedure was followed in their progress notes. During the off shifts, 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.
“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
$16,146 in federal fines across 1 penalty.
- $16,146 — penalty dated 2023-12-14
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 COLEV GESTETNER — 7 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 5 of 5 | 4.6 | +0.4 vs chain |
| Health inspection | 4 of 5 | 3.9 | +0.1 vs chain |
| Staffing | 3 of 5 | 3.3 | -0.3 vs chain |
| Quality measures | 5 of 5 | 4.4 | +0.6 vs chain |
The other 6 homes this chain runs (chain average 4.6★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| GESTETNER, COLEV | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 50% | since 01/01/2020 |
| MOSKOWITZ, YISROEL | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 50% | since 01/01/2020 |
| CITRONI, SUSAN | Individual | W-2 MANAGING EMPLOYEE | — | since 06/08/2022 |
| STERN, NATHAN | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 01/01/2020 |
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $4.0M paid to related parties — landlords or management companies under common ownership — equal to about 17% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in MA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Massachusetts Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 225272. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-15, 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 →
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