Life Care Center Of Stoneham
25 Woodland Road, Stoneham, MA 02180 · For profit - Limited Liability company · 94 certified beds · (781) 662-2545 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- a high payroll-based staffing rating (4/5)
- lower-than-typical staff turnover (32% vs 45% nationally) — better care continuity
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0600), cited Mar 2025
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 2 actual-harm citations
- inspectors recorded 3 serious findings as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- 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
- the CMS record shows $39,559 in federal fines (most recent 2025-03-19)
- its facility-reported quality-measure score sits well above its independent inspection score
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) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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 | 4 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 held steady at 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 11.9% | 16.4% | 15.4% | better |
| Long-stay residents who lose too much weight | 8.5% | 5.1% | 5.4% | worse |
| 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 | 0.9% | 1.8% | 2.0% | better |
| Long-stay residents with depressive symptoms | 5.9% | 15.5% | 6.5% | typical |
| Long-stay residents who were physically restrained | 3.1% | 0.1% | 0.1% | worse |
| Long-stay residents with falls causing major injury | 2.2% | 3.4% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 12.1% | 15.4% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 20.4% | 19.5% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 94.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.6% | 4.2% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 14.2% | 21.2% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 27.3% | 21.4% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 1.4% | 1.4% | 1.4% | typical |
| Short-stay residents given the seasonal flu vaccine | 97.7% | 77.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 30.2% | 25.7% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 8.9% | 11.9% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.89 | 1.88 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 0.51 | 1.50 | 1.80 | better |
§ 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.
63.4% 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 357 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 82.5% 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 183 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 0.52 therapist hours per resident per day in 2026Q1 — more than 82% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 27% 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 | 63.4%CMS range 58.4–67.9 | 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 | 10.9%CMS range 8.1–14.1 | 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 | 82.5% | 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 | 80.3% | 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 | 78.1% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 99.6% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.9% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 1.1% | 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 | 4.9%CMS range 3.0–7.7 | 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 94 beds and averages 78.8 residents a day — about 84% occupied, or roughly 15 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.00 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.83 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.36 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 3.59 hrs/resident/day on weekends vs 4.16 on weekdays — 14% thinner on weekends. RN hours go from 0.94 to 0.55 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 32% is below the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
31 citations, most serious first. The 15 most serious are shown; the remaining 16 are one tap away and print in full.
- Actual harm · G2025-03-19 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records reviewed and interviews for one of three sampled residents (Resident #1) who during the overnight shift (11:00 P.M. to 7:00 A.M.) on 1/30/25 into 1/31/25, had an unwitnessed fall and was found on the floor by staff, the facility failed to ensure he/she was free from neglect, when although Resident #1 told staff he/she was hurt and was screaming I'm in pain, without assessing him/her for the potential for injuries, Nurse #1 picked Resident #1 up off the floor put him/her in a wheelchair, picked him/her up again, transferred him/her back into bed and left the room. Despite Certified Nurse Aide (CNA) #1 reporting to Nurse #1 that Resident #1 was still complaining of and was in obvious pain, Nurse #1 did not go check on Resident #1 and still did not assess him/her for injuries. Nurse #1 finished his shift, left the facility and never reported the incident to anyone. Day shift nursing staff, who were totally unaware that Resident #1 had an unwitnessed fall on the previous shift, were unable 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.
- Actual harm · Gcited before2025-03-19 · 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 records reviewed and interviews, for one of three sampled residents (Resident #1) who during the overnight shift (11:00 P.M. to 7:00 A.M.) on 1/30/25 into 1/31/25, had an unwitnessed fall, was found on the floor by staff complaining of pain, the facility failed to ensure he/she was provided care and services that met professional standards of nursing practice, when although Resident #1 was crying out in pain, without completing any type of assessment, Nurse #1 picked Resident #1 up off the floor, initially put him/her in a wheelchair, then transferred him/her again by picking him/her up out of the wheelchair, put him/her in bed, and left the room. Nurse #1 did not complete any type of assessments, did not document the fall in a progress note that night, did not complete an incident report, and did not inform oncoming nursing staff during change of shift report that Resident #1 had been found on the floor after an unwitnessed fall and had been complaining of pain since the fall. Resident #1 was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · G2025-03-19 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management 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 records reviewed and interviews, for one of three sampled residents (Resident #1) who during the overnight shift (11:00 P.M. to 7:00 A.M.) on 1/30/25 into 1/31/25, had an unwitnessed fall, was found on the floor by staff and was crying out in pain, the facility failed to ensure he/she was provided with care and treatment consistent with professional standards of practice related to pain management. Certified Nurse Aide (CNA) #1 said she found Resident #1 on the floor in his/her room, he/she was crying out in pain and immediately called Nurse #1 for help. CNA #1 said she asked Nurse #1 more than once to check on Resident #1 that night, because he/she kept crying out in pain. Nurse #1 did not complete a pain assessment on Resident #1, there was no documentation to support Nurse #1 medicated or did anything to treat or manage Resident #1's pain including not notifying the Physician. Day Shift nursing staff were unable to provide care, as Resident #1 screamed whenever staff tried to touch him/her, he/she…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2023-09-14 · 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 record review, and interview, the facility failed to meet professional standards of care for one Resident (#5), out of a total sample of 21 residents. Specifically: 1. For Resident #5 the facility failed to ensure an occupational therapy assistant provided services within her scope of practice resulting in an injury. Findings include: Review of 259 CMR Board of Allied Health Professionals: 3.00 OCCUPATIONAL THERAPISTS, indicated the following: 1. Evaluation is the process of obtaining and interpreting data necessary for an intervention, including planning for and documenting the evaluation process and results. 2. Occupational Therapy Assistants (OTA) may not initiate or alter an intervention plan without prior evaluation by and approval of, the supervising Occupational Therapist (OT). 3. The OT must be directly involved in the delivery of services during evaluation and re-evaluation. Resident #5 was admitted to the facility in September 2020 with diagnoses including diabetes, Charcot's joint of the left…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2023-09-14 · 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 nursing staff implemented orders for one Resident (#5) out of a total sample of 21 residents. Staff failed to remove a leg brace as recommended by the orthopedic surgeon resulting in the worsening of a surgical wound. Subsequently, Resident #5 was hospitalized requiring debridement (a surgical procedure to remove dead tissue) of the wound and sepsis (an infection of the blood stream) with associated Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia requiring a PICC line (a long, thin tube that's inserted through a vein in the arm and passed through to the larger veins near the heart) for IV antibiotics. Findings include: Review of the Treatment of Wounds policy, dated 3/31/23, indicated: It is the intent of this center that a resident having a wound receives necessary medical treatment to prevent infection, deterioration or development of wounds in keeping with the resident's medical condition. Resident #5 was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-09-17 · 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
Based on observation and interview, the facility failed to maintain a homelike setting in resident rooms on the first and second floor nursing units. Findings include:On 9/18/25 at 11:50 A.M., the following was observed on the 1st floor unit. 102: Chipped paint on walls, and a nightstand with peeling laminate. 103: Peeling laminate on the nightstand by A bed. 104: Peeling paint/laminate on nightstand A bed 106: Laminate on B bed bureau was bubbled and peeling laminate on the nightstand. The walls in the bathroom were scuffed and there was a stained ceiling tile. 111: Scuffed/gauged walls by bathroom 112: Missing handle on 2nd drawer of A bed's nightstand and peeling laminate. Large gauges/scrapes behind bed. 115: Rubber baseboard under air conditioner pulling away from the wall. The nightstand by B bed had peeling laminate and A bed's nightstand had a broken handle. There was peeling paint in the bathroom. 116: Scuff marks by window, and baseboard pulling away from the window, with stained ceiling tile. The top drawer of A bed's nightstand was missing. 117: Deep gouges on the wall…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-09-17 · 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 observation and interview the facility failed to ensure that drugs and biologicals used in the facility were 1. labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, including the expiration date in two of two medication carts and in one vital sign cart observed. 2. were stored in a locked area not accessible to residents and or visitors. Findings include:Review of the facility policy titled Storage and Expiration Dating of Medications and Biologicals, dated revised 6/30/25, indicated that the facility should ensure all medications and biologicals .are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. Further review indicated that the facility should ensure medications and biologicals have an expiration date on the label. On 9/17/25 at 8:59 A.M. the surveyor observed a mobile vital sign cart in the WN unit hallway, to contain one Arnuity Ellipta inhaler and one Anoro Ellipta inhaler (both used to treat asthma) in the basket 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 · Dcited before2025-09-17 · 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 an interview, the facility failed to implement appropriate monitoring for a pacemaker for one Resident (#25), out of a total of 19 sampled residents. Findings include:Review of the American Heart Association's article, dated 10/29/24 titled Living with your Pacemaker, indicated: Make sure you understand your pacemaker's programmed lower and upper heart rate. Talk to your health care professional about the maximum acceptable heart rate above your pacemaker rate. Your pacemaker should be checked periodically to assess the battery and find out how the wires are working. Be sure to keep your pacemaker checkup appointments. It's usually every six months or one yearOn 9/17/25 the surveyor was provided with a copy of the facility's Pacemaker Policy, dated as revised 9/17/25. The surveyor requested a copy of the policy previous to 9/17/25 and the facility was unable to provide one.Resident #25 was admitted to the facility in July 2024 with diagnoses including cognitive communication deficit 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 · E2024-09-19 · tag F0839 — patternEmploy staff that are licensed, certified, or registered in accordance with state laws.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure professional staff are licensed, certified, or registered in accordance with applicable State laws. Specifically, when the facility indicated they had one nurse employed under a nursing waiver, they failed to ensure that the nurse had graduated from a board approved nursing program. Findings Include: Review of The Department of Public Health (DPH) Circular Letter, issued on June 3, 2024, regarding Guidance for Nursing Practice by Graduates and Students in Their Last Semester of Nursing Education Programs, indicated, but was not limited to: -An individual who graduated from a registered nursing or practical nursing program approved by the board or who is a senior nursing student attending the last semester of a registered nursing or practical nursing program approved by the board may practice nursing; provided that: -(iii) the employing licensed health care facility or licensed health care provider has verified that the individual is a graduate…
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 before2024-09-19 · 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 — the official record, unedited, may be distressing
Based on observations and interviews the facility failed to ensure a dignified existence was maintained for residents who require assistance with meals. Findings Include: Review of facility policy titled Dignity, dated as reviewed 9/25/23, indicated the following: -Each resident has the right to be treated with dignity and respect. -Examples of treating residents with dignity and respect include, but are not limited to: -e. Addressing residents by the name or pronoun of the resident's choice, avoiding the use of labels for residents such as feeders or walkers. On 9/19/24 at 8:03 A.M., the surveyor overheard a staff member in a resident's room yell out into the hallway to another staff member to go downstairs and help with breakfast because they have more feeders on that unit. The Staff member yelling into the hallway was sitting in a resident room, assisting a resident with his/her meal. During an interview on 9/19/24 at 10:32 A.M., the Director of Nurses (DON) said staff should not refer to residents as feeders as it is not dignified to refer to someone that way.
- Potential for harm · Dcited before2024-09-19 · 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
Based on observations, record review and interviews, the facility failed to develop and implement a comprehensive person centered care plan for three Residents (#43, #31 and #16) out of a total sample of 20 residents. Specifically, 1. For Resident #43, the facility failed to develop a care plan regarding a new skin tear and treatment applied. 2. For Resident #31, the facility failed to develop a care plan for Resident #31's resident specific Activities of Daily Living needs. 3. For Resident #16, the facility failed to implement the plan of care for completing weekly skin checks. Findings include: 1. Resident #43 was admitted to the facility in September 2019 and has diagnoses that include dementia, anxiety disorder and history of falling. Review of the most recent Minimum Data Set (MDS) assessment, dated 6/20/24, indicated that on the Brief Interview for Mental Status exam Resident #43 scored a 2 out of a possible 15, indicating severe cognitive impairment. The MDS further indicated Resident #43 was dependent on staff for activities of daily living. On 9/17/24 at 8:34 A.M., Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-09-19 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide 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 ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good grooming and hygiene. Specifically, the facility failed to provide nail care for one Resident (#54) out of a total sample of 20 residents. Findings Include: Review of facility policy titled Nail Care. dated as reviewed 9/10/24, indicated but was not limited to the following: - For general fingernail care for most residents, the following procedure will be followed: - 1. Ensure fingernails are clean and trimmed to avoid injury and infection. Resident #54 was admitted to the facility in August 2024 with diagnoses that included fracture of the right femur and muscle weakness. Review of Resident #54's most recent Minimum Data Set (MDS) assessment, dated 9/2/24, indicated a Brief Interview for Mental Status score of 14 out of 15, indicating that the Resident is cognitively intact. The MDS further indicated that the Resident is dependent on staff for activities of daily living (ADLs). Further…
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 before2024-09-19 · 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
Based on observation, record review and interview the facility failed to ensure standards of quality care were implemented for one Resident (#43) out of a total sample of 20 residents. Specifically, the facility failed to a.) notify the physician or responsible party of a new skin tear, b.) failed to obtain an order for a treatment applied to a new skin tear and c.) failed to document an assessment of the new skin tear. Findings include: The facility policy titled area of Focus: Basic Skin Management, dated 11/29/23, indicated the following: -All residents have a head-to-toe inspection upon admission/readmission, then completed weekly, and as needed by nursing. It is documented in PCC: NRSG: Weekly Skin. -If any new skin alteration/wound is identified, it is the responsibility of the nurse to perform and document an assessment/observation, obtain treatment orders, and notify the MD and responsible party. -Orders are required for skin and wound care. There are wound care protocol orders in PCC under Orders-TX (treatment) Template. Resident #43 was admitted to the facility 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 · D2024-09-19 · 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
Based on observation, record review and interview, the facility failed to ensure a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent new ulcers from developing for one Resident (#31) out of a total sample of 20 residents. Specifically, the facility failed to ensure Resident #31 wore Prevalon boots while in bed, as ordered by the Physician. Findings include: The facility policy titled Skin Integrity & Pressure Ulcer/Injury Prevention and Management, dated as revised 7/9/24, indicated the following: 5. Measures to protect the resident against the adverse effects of external mechanical forces, such as pressure, friction and shear are implemented in the plan of care: d. heel protection/suspension if indicated. Resident #31 was admitted to the facility in July 2024 and has diagnoses that include an unstageable pressure ulcer of the right heel and Type II Diabetes. Review of the most recent Minimum Data Set (MDS) assessment, dated 7/22/24, indicated that on the Brief Interview for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-09-19 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and interview the facility failed to ensure professional standards of practice for food service safety by failing to perform proper hand hygiene. Findings include: Review of the facility's policy, titled Chapter 1: Food Safety and Infection Control, Washing Hands Properly, not dated, indicated the following: -Training objective: Participants will know when they should wash their hands and will demonstrate the proper way to do so. Discussion, as food service workers, our hands come into contact with many unsanitary things during the day. Some of these contacts are part of our job tasks and some are not. Harmful bacteria can pass from an infected person to a well person from objects such as food, dishes, eating, utensils, glasses etc. These bacteria, in turn can make a person very ill. We can reduce the risk of becoming contaminated by washing out hands properly. When you should wash your hands: included but not limited to: -When they become soiled, -After completing a task and before beginning a new one. -Before handling food, clean dishes, or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 16 citations
- Potential for harm · Dcited before2024-09-19 · 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 an accurate medical record for two Residents (#31 and #43) out of a total sample of 20 residents. Specifically, 1. Nurses documented in the Treatment Administration Record (TAR) that Resident #31 wore Prevalon boots while in bed, contrary to direct observation of the boots not being worn. 2. A nurse inaccurately documented on a Skin Assessment that Resident #43 did not have a skin tear, when he/she had a skin tear to the left hand. Findings include: The facility policy titled Nursing Documentation, dated as reviewed 9/5/24, indicated the following: -The medical record must contain an accurate representation of the actual experience of the resident and include enough information to provide a picture of the resident's progress, including his/her response to treatment and /or services, and changes in his/her condition, plan of care goals, objectives and/or interventions. 1. Resident #31 was admitted to the facility in July 2024 and has diagnoses that include an unstageable pressure ulcer of the right heel…
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 before2024-08-29 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records and interviews, for one of three sampled residents (Resident #1) whose Physicians Orders included the administration of multiple bowel medications for the management of constipation and frequently complained of abdominal pain, the Facility failed to ensure they developed and implemented a Comprehensive Plan of Care that identified goals, outcomes and interventions related to constipation and abdominal pain, so identified care needs would be met by Nursing. Findings include: Review of the Facility's Policy, titled Person-Centered Care Planning, dated as reviewed 08/22/23, indicated each resident will have a person-centered comprehensive care plan developed and implemented to meet his or her preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs. Review of the Facility's Policy, titled Comprehensive Care Plans and Revisions, dated as reviewed 08/22/23, indicated the Facility will ensure the timeliness of each resident's person-centered, comprehensive…
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 · D2024-08-29 · tag F0726 — failed to have competent, trained nursing staff — isolatedEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on records reviewed and interviews for one of three sampled residents (Resident #1), who had a history of constipation, and had Physician's Order on 07/19/24 and 07/25/24, for Nursing to insert an 18 French Foley Catheter (due to unavailability of a Rectal Tube) into his/her rectum to treat abdominal distention and pain, the Facility failed to ensure nursing staff were competent in the process, which included being aware of Facility Policy and Procedures and documenation requirements. Findings include: Review of the Facility's Policy titled, Nursing Documentation, dated as reviewed 08/10/23, indicated the facility will ensure nursing documentation is consistent with professional standards of practice, the state nurse practice act, and any state laws governing the scope of nursing practice. The Policy indicated the Facility must ensure that Licensed Nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. Review of the Facility Policy titled, Rectal Tube Insertion…
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 · E2023-09-14 · tag F0759 — failed to keep medication error rate low — patternEnsure 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 observation, record review and interview the facility failed to ensure that it is free from medication rates of 5% or greater. Findings include: Review of the facility policy titled Administration of Medications dated reviewed 8/24/23, indicated the facility will ensure medications are administered safely and appropriately per physician order to address resident's diagnoses and signs and symptoms. 1. Resident #25 was admitted to the facility in March 2023 with diagnoses Parkinson's disease, psychotic disorder and generalized weakness. Review of the doctor's orders dated September 2023 indicated a doctor's order for Acetaminophen oral tablet 500 mg (milligrams) give 2 tablets by mouth three times a day for pain. Further review indicated the following orders: 1. Lidocaine external patch 4% apply to mid upper back topically one time a day for pain and remove per schedule. 2. Miralax oral packet 17 GM (grams) give one packet by mouth in the morning for constipation. On 9/13/23, at 8:30 A.M., the surveyor observed Nurse #4 administer medications to Resident #25. The surveyor…
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 before2023-09-14 · 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 observation, interview, and policy review, the facility failed to ensure medications 1. were stored properly and labeled 2. once opened were dated as required and 3. topical and treatment items were not stored with oral medications. Findings include: Review of the facility policy titled Storage and Expiration Dating of Medications, Biologicals, dated last revised 7/21/22, indicated the following: 1. Facility should ensure that external use medications and biologicals are stored separately from internal use medications and biologicals. 2. Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. 3. Once any medication or biological package is opened, the facility should follow manufacturer's guidelines with respect to expiration dates for opened medications. 4. If a multi-dose vial of an injectable medication has been opened or accessed the vial should be dated and discarded within 28 days unless the manufacturer specifies a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-09-14 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview the facility failed to store food in accordance with professional standards for food service safety. Findings include: Review of the facility policy titled Food Safety, revised 04/26/23, indicated the following: -Food in a walk-in cooler/freezer is stored six inches off the floor -Leftovers are dated properly and discarded after 72 hours unless otherwise indicated. On 9/12/23 at 7:04 A.M., the following observations were made during the initial walkthrough of the kitchen: -Asparagus, lemons, and apples with significant signs of decomposition including the growth of a white wispy substance in the walk-in refrigerator. -Red Onions and sweet potatoes with significant signs of decomposition including the growth of a blue-white wispy substance in the main kitchen. -Multiple Jars of dressing coated on the outside with a black wispy substance in the walk-in refrigerator, the substance was observed on the inside of the lid of one dressing container. -A nearly empty container of garlic aioli (a mayonnaise-based sauce) in the walk-in refrigerator, dated 5/16…
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 before2023-09-14 · 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
Based on observations, policy review and interviews, the facility failed to provide a dignified dining experience for the residents on the first floor unit. Findings include: Review of the facility policy titled, Dignity, dated 9/30/22, indicated the following: *Each resident has the right to be treated with dignity and respect. Interactions and activities with residents by staff, temporary agency staff, or volunteers must focus on maintaining and enhancing the resident's self-esteem, self-worth, and incorporating the resident's goals, preferences, and choices. On 9/12/23 at 8:15 A.M., the following was observed in the first floor dining room: *Two residents were seated at a table. One resident was served his/her meal at 8:21 A.M. The second resident asked for his/her meal. He/She was not given his/her meal until 8:38 A.M., 17 minutes later. *A resident who is assist for meals was provided his/her meal at 8:40 A.M. The Certified Nursing Assistant (CNA) put the resident's tray on the bedside table. She did not return to assist the resident with his/her meal until 9:03 A.M., 23…
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 · D2023-09-14 · tag F0552 — isolatedEnsure that residents are fully informed and understand their health status, care and treatments.
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 honor 1 Resident's (#174) right to refuse treatment out of a total of 21 sampled Residents. Findings include: Review of the facility's Resident Rights policy, dated 10/6/22, indicated: *The resident has the right to be free of interference, coercion, discrimination and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart. *The resident has the right to request, refuse, and/or discontinue treatment to participate in or refuse to participate in experimental research and to formulate an advance directive. Resident #174 was admitted to the facility in June 2023 with diagnoses including metabolic encephalopathy and chronic obstructive pulmonary disease. Review of the Minimum Data Set assessment dated [DATE] indicated Resident #174 scored 14 out of 15 in the Brief Interview for Mental Status Exam (BIMS) indicating intact cognition. The MDS also…
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 · D2023-09-14 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and interviews, the facility failed to ensure resident Protected Health Information (PHI) was secure and not visible to others on one of two nursing units. Findings include: Review of the facility policy titled Safeguarding and Storage of Medical Records dated reviewed 3/16/23, indicated do not leave medical records unattended in public areas. On 9/12/23, at 8:31 A.M., during a medication pass, Nurse #4 had an Electronic Health Record (EHR) located on a medication cart on the first floor hallway. The screen was open, unattended and the screen of a residents' Protected Health Information (PHI) was visible to anyone who passed by. The surveyor also observed that there were several residents and unauthorized staff in the area at the time. On 9/14/23, at 10:20 A.M., the surveyor observed an Electronic Health Record (EHR) located on a medication cart on the first floor hallway. The screen was open, unattended and the screen of a residents' Protected Health Information (PHI) was visible to anyone who passed by. The surveyor also observed that there were several…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-14 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and policy review, the facility failed to report an allegation of abuse and/or neglect within 2 hours as required for 1 Resident (#324) out of a total sample of 21 residents. Findings include: Facility policy titled Incident and Reportable Event Management, revised October 15, 2023, indicated the following: -Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made. Resident #324 was admitted to the facility in September 2023 with diagnoses including hemiplegia and hemiparesis following other cerebrovascular disease affecting right dominant side, muscle weakness, and cancer. Review of the most recent Minimum Data Set (MDS) assessment, dated 9/7/23, indicated that Resident #324 scored a 14 out of 15 on the Brief Interview for Mental Status (BIMS) which indicates the Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-14 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
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, policy review and interviews, the facility failed to 1) investigate an allegation of neglect for 1 Resident (#13) and 2) failed to investigate a bruise of unknown origin for 2 Residents (#6 and #51) out of a total sample of 21 residents. Findings include: 1. Review of the facility policy titled, Event and Reportable Event Management, dated 5/4/23, indicated the following: *Ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made. * Immediately means as soon as possible comma in the absence of a shorter state time frame requirement comma but no later than 2 hours after the allegation is made comma if the events that caused the allegation involve abuse or result in serious bodily injury comma or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-09-14 · 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 observations, record reviews and interviews, the facility failed to implement a skin integrity care plan for 1 Resident (#69) out of a total sample of 21 residents. Findings include: Resident #69 was admitted to the facility in June 2023 with diagnoses including hypertension. Review of Resident #69's most recent Minimum Data Set (MDS) dated [DATE] indicated he/she had a Brief Interview for Mental Status (BIMS) score of 11 out of a possible 15 which indicted the Resident had moderate cognitive impairment. The MDS also indicated Resident #69 required extensive assistance from staff for bed mobility tasks. On 9/12/23 at 8:08 A.M., and 12:33 P.M., Resident #69 was observed lying in bed with both feet directly on the bed and legs not elevated. On 9/13/23 at 6:37 A.M., 9:05 A.M. and 11:00 A.M., Resident #69 was observed lying in bed with both feet directly on a pillow and legs not elevated. Review of Resident #69's physician orders indicated the following active orders: *Ensure heels are FREE FLOATING when 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 · Dcited before2023-09-14 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and interviews, the facility failed to provide assistance with meals as needed for 2 Residents (#6 and #56) out of a total sample of 21 residents. Findings include: 1. Resident #6 was admitted to the facility in February 2023 with diagnoses including dementia. Review of Resident #6's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status score of 8 out of a possible 15 which indicated he/she had moderate cognitive impairment. The MDS also indicated the Resident requires physical assistance from staff for functional daily tasks. On 9/12/23 at 8:39 A.M., Resident #6 was observed eating breakfast while lying in bed. There were no staff present to supervise or assist if needed and he/she was not visible from the hallway. The Resident's tray was not completely set up with his/her hot cereal still covered and his/her utensils not unwrapped. The Resident had pieces of egg on his/her chest. On 9/12/23 at 12:30 P.M., Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-14 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
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 the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one Resident (#51), out of a total sample of 21 residents. The facility failed to ensure Resident #51 was wearing prosthetic device and hand splints. Findings include: Resident #51 was admitted to the facility in November of 2019 with diagnosis including stroke, diabetes, orthopedic conditions, muscle weakness, contracture right hand, contracture left hand, traumatic spinal cord dysfunction, and traumatic brain dysfunction. Review of Resident #51 most recent Minimum Data Set (MDS) dated , 6/29/23, indicates the Resident has a Brief Interview for Mental Status (BIMS) score of 9 out of a possible 15, indicating he/she is cognitively intact. The MDS also indicates Resident #23 requires total dependence with all functional tasks. On 9/12/23 at 7:49 A.M., Resident #51 was observed lying in bed. His/her left 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 before2023-09-14 · 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 ensure medical records were accurate for 1 Resident (#25) out of a total sample of 21 residents. Findings include: 1. Resident #25 was admitted to the facility in March 2023 with diagnoses of Parkinson's disease, psychotic disorder and generalized weakness. Review of the doctor's orders dated September 2023 indicated a doctor's order for Acetaminophen oral tablet 500 mg (milligrams) give 2 tablets by mouth three times a day for pain. Further review indicated the following orders: 1. Lidocaine external patch 4% apply to mid upper back topically one time a day for pain and remove per schedule. 2. Miralax oral packet 17 GM (grams) give one packet by mouth in the morning for constipation. On 9/13/23, at 8:30 A.M., the surveyor observed Nurse #4 administer medications to Resident #25. The surveyor observed Nurse #4 give Resident #25 2 tablets of Acetaminophen 650 mg. The surveyor did not observe Nurse #4 administer the Lidocaine patch or the Miralax. Review of the medication administration record (MAR) indicated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-14 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, record review and interview the facility failed to ensure that infection control measures were maintained during medication pass. Findings include: 1. Resident #25 was admitted to the facility in March 2023 with diagnoses Parkinson's disease, psychotic disorder and generalized weakness. On 9/13/23, at 8:30 A.M., the surveyor observed Nurse #4 to prepare to administer medications to Resident #25. The surveyor observed Nurse #4 to remove the vital signs stand from the hallway, enter the Resident's room and take the Resident's blood pressure and oxygen level without cleaning the blood pressure cuff or the oximeter. During an interview on 9/13/23, at 8:43 A.M., Nurse #4 said that she should have cleaned the blood pressure cuff and oximeter before applying them to Resident #25.
“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
$39,559 in federal fines across 2 penalties.
- $9,620 — penalty dated 2025-03-19
- $29,939 — penalty dated 2023-09-14
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 LIFE CARE CENTERS OF AMERICA — 194 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 3.4 | +0.6 vs chain |
| Health inspection | 3 of 5 | 2.8 | +0.2 vs chain |
| Staffing | 4 of 5 | 3.3 | +0.7 vs chain |
| Quality measures | 5 of 5 | 4.5 | +0.5 vs chain |
The other 193 homes this chain runs (chain average 3.4★, per CMS)
Showing 40 of 193; lowest-rated first.
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 | Since |
|---|---|---|---|
| DEVELOPERS INVESTMENT COMPANY INC | Organization | DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | since 01/28/2020 |
| PRESTON, FORREST | Individual | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 08/28/1987 |
| COTE, KIMBERLY | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | since 09/06/2023 |
| LONG, ZOFIA | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | since 03/15/2004 |
| NGUYEN, DENNIS | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/18/2025 |
| LAY, LISA | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | since 02/09/2018 |
| SWANKER, RICHARD | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | since 01/01/2022 |
| CROSS, CINDY | Individual | CORPORATE OFFICER; INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 03/25/1996 |
| HENRY, TERRY | Individual | CORPORATE OFFICER | since 08/16/1999 |
| THURMOND, JOAN | Individual | CORPORATE OFFICER | since 09/22/2000 |
| LIFE CARE CENTERS OF AMERICA, INC. | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/25/1996 |
| STONEHAM OPERATIONS LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/21/1997 |
| BERDZENISHVILI, MAYA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/01/2024 |
| FLETCHER, TODD | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 12/13/2024 |
| PRESTON, AUBREY | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 12/13/2024 |
| ZIEGLER, JAMES | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 12/13/2024 |
CMS files one row per role, so the 28 rows in the source record cover these 16 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
3 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $621K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. 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, FY2024). 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 225732. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-17, 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.