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Marian Manor Of Taunton

33 Summer Street, Taunton, MA 02780 · Non profit - Corporation · 116 certified beds · (508) 822-4885 Medicare & Medicaid certified

Call the home — (508) 822-4885 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0607, F0609, F0610) — most recent Sep 20231 actual-harm citation$8,788 in federal fines
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • a high payroll-based staffing rating (4/5)
  • lower-than-typical staff turnover (36% vs 45% nationally) — better care continuity
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609, F0610) — 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 (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $8,788 in federal fines (most recent 2025-08-19)
  • its facility-reported quality-measure rating is low (1/5)

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

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

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

Location & what’s nearby

Hospital
1/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1 Taunton Grn · (508) 823-6924 · Call to confirm hours
Pharmacy
7 Washington St · (508) 821-5605 · Call to confirm hours
Grocery
1 Washington St · (508) 822-4571 · Call to confirm hours
Park
Mill River Park · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

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

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 3 stars. From monthly CMS archive snapshots.

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

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased19.7%16.4%15.4%worse
Long-stay residents who lose too much weight8.7%5.1%5.4%worse
Long-stay residents with a catheter left in their bladder3.5%0.8%0.9%worse
Long-stay residents with a urinary tract infection6.9%1.8%2.0%worse
Long-stay residents with depressive symptoms6.8%15.5%6.5%typical
Long-stay residents who were physically restrained1.7%0.1%0.1%worse
Long-stay residents with falls causing major injury7.5%3.4%3.3%worse
Long-stay residents whose ability to walk worsened21.8%15.4%16.1%worse
Long-stay residents on antianxiety or hypnotic medication17.3%19.5%18.9%typical
Long-stay residents given the seasonal flu vaccine87.9%94.8%95.3%typical
Long-stay residents with pressure ulcers3.6%4.2%4.7%better
Long-stay residents with worsening bladder/bowel control13.7%21.2%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table22.6%21.4%17.1%worse
Short-stay residents who newly got an antipsychotic medication3.8%1.4%1.4%worse
Short-stay residents rehospitalized after admission22.4%25.7%22.6%typical
Short-stay residents with an outpatient ER visit11.3%11.9%12.0%typical
Long-stay hospitalizations per 1,000 resident days1.571.881.67typical
Long-stay outpatient ER visits per 1,000 resident days1.481.501.80better

§ 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.

36.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 31 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

36.0%U.S. median 51.5%
Got home and stayed home
11.3%U.S. median 10.7%
Went back to hospital
34.8%U.S. median 56.6%
Met the expected recovery
0.27U.S. median 0.31
Therapy hours / resident / day
0.09hours / resident / day
Physical therapy
0.17hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Met the expected recovery: 34.8% 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 23 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 0.27 therapist hours per resident per day in 2026Q1 — more than 40% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF36.0%CMS range 22.9–46.751.5%Oct 2022–Sep 2024worse than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.3%CMS range 7.0–16.510.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge34.8%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge34.8%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge39.1%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified91.3%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims for this measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.2%CMS range 4.2–13.27.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.931.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.90
RN hours/ resident / day
0.62
LPN hours/ resident / day
2.28
Aide hours/ resident / day
3.80
Total nurse hours/ resident / day
0.82
RN hoursweekends
35.5%
Total nursing turnover
40.0%
RN turnover

How full it usually is: this home is certified for 116 beds and averages 62.7 residents a day — about 54% occupied, or roughly 53 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.80 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.90 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.28 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 3.54 hrs/resident/day on weekends vs 3.90 on weekdays — 9% thinner on weekends. RN hours go from 0.93 to 0.82 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 36% is 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

4
deficiencies at the latest standard inspection (2025-03-10)
7
at the previous standard inspection (2024-01-18)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

28 citations, most serious first. The 11 most serious are shown; the remaining 17 are one tap away and print in full.

  • Actual harm · Gcited before2025-08-19 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records reviewed and interviews, for one of three sampled residents, (Resident #1), the facility failed to ensure his/her environment was free of accident hazards as possible, when on 06/28/25, while activity staff were assisting residents onto the elevator after an activity, they did not lock the elevator, which would have kept the door in the open position, as Resident #1 entered the elevator the door began to close and hit him/her causing him/her to fall into the elevator. Resident #1 complained of severe left leg pain and was transported to the Hospital Emergency Department (ED) for evaluation. Resident #1 was diagnosed with a left intertrochanteric fracture (break in the upper part of the thigh bone (femur), was admitted and underwent surgical intervention to repair the fracture.Findings include:Review of the Facility Policy titled, Fall Prevention Program, dated October 2024, indicated the following:-each resident will be assessed for risk factors and predisposition for falling using the Facility…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-01-15 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had an activated Health Care Proxy (HCP), the Facility failed to ensure nursing promptly notified his/her Health Care Agent (HCA), when nursing transcribed a physician's order to decrease the dosage of his/her antidepressant medication without notifying the HCA of the change, Resident #1 received the lower dosage of the medication for more than a month before the HCA was made aware.Findings include:Review of the Facility's Policy titled, Change in Resident Condition, dated as revised December 2025, indicated the following:-the resident's responsible party/next of kin are notified of a change in condition;-a licensed nurse in charge is responsible for timely notification of the responsible party/next of kin and notify with his or her consent the resident representative when there is: a need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment;-all changes and notifications should…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-10 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure staff notified the Physician of medication recommendations for one Resident (#15), out of a sample of 15 residents. Specifically, the facility failed to notify the Physician and/or Nurse Practitioner, in a timely manner, of the Psychiatric Nurse Practitioner (PNP)'s recommendations to increase Remeron (an antidepressant medication) dosage and implement a Gradual Dose Reduction (GDR) for Lexapro (an anti-anxiety medication), resulting in a 43-day delay in implementing the recommendations. Findings include: Resident #15 was admitted to the facility in June 2019 with diagnoses that included Alzheimer's disease, dementia, anxiety disorder, and major depressive disorder. Review of Resident #15's Psychiatric Nurse Practitioner (PNP) progress note/consult, dated 11/25/24, indicated but was not limited to the following: -Recommend GDR Lexapro (escitalopram). -Increase Remeron (mirtazapine) to decrease depression/enhance appetite. Review of Nurse Practitioner (NP) Encounter Notes, dated 12/11/24, 12/20/24, and 12/31/24,…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-10 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and records reviewed for two Residents (#19 and #48) of 15 sampled residents, the facility failed to ensure care was provided to residents in accordance with professional standards of practice. Specifically, the facility failed: 1. For Resident #19, to ensure a prescriber's order for Dycem (a thin, rubberlike material known for its non-slip material, used to reduce the likelihood of sliding or shifting) to wheelchair was implemented to prevent falls; and 2. For Resident #48, to follow the prescriber's orders for 1:1 (one to one) assistance and encouragement with meals. Findings include: Review of [NAME], Manual of Nursing Practice 11th edition, dated 2019, indicated the following: -The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated the following: -Nurse's Responsibility…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-10 · tag F0868 — isolated
    Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and document review, the facility failed to maintain a Quality Assurance and Performance Improvement (QAPI) Committee which included the required members at their meetings. Specifically, the facility Medical Director and Director of Nurses (DON) each failed to attend one of five Quarterly QAPI meetings reviewed. Findings include: Review of the facility's policy titled Quality Assurance on Performance Improvement (QAPI) Program, dated as revised 4/2024, indicated but was not limited to: -A facility must maintain a Quality Assessment and Assurance provision at 42 CFR, Part 483.75 (0) Quality Assessment and Assurance: 1. A facility must maintain a Quality Assessment and Assurance Committee consisting of: (i) the Director of Nursing Services; (ii) A physician designated by the facility; and (iii) At least 3 other members of facility's staff Review of the facility's QAPI Attendee sign-in sheets for January 2024 indicated the Medical Director was not in attendance. Review of the facility's QAPI Attendee sign-in sheets for July 2024 indicated the DON was not 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-01-18 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and policy review, the facility failed to ensure staff stored and properly labeled all drugs and biologicals in accordance with accepted professional standards of practice. Specifically, the facility failed to: 1. Ensure staff properly labeled all drugs and biologicals stored in 2 of 4 medication carts once opened; and 2. Ensure staff safely and securely stored all medications in 1 of 2 medication storage rooms and 2 of 4 medication carts. Findings include: Review of the facility's policy titled Medication Storage in the Facility, revised [DATE], indicated but was not limited to the following: -Medication rooms, carts, and medication supplies are locked when not in use or in direct view of persons with authorized access. -All medications dispensed by the pharmacy are stored in the container with the pharmacy label. -Certain medications or package types, such as multiple dose injectable vials, ophthalmics, once opened, require an expiration date shorter than the manufacturer's…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-01-18 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and test tray results, the facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature. Specifically, multiple residents voiced concerns regarding the quality and temperatures of the food provided by the facility. Findings include: During the initial tour of the 3rd floor unit on 1/11/24 at 10:30 A.M., multiple residents voiced complaints regarding the palatability of their meals as follows: -Resident #11 described the food as Iffy and not to his/her satisfaction. -Resident #50 said that the Food leaves little to be desired. -Resident #19 complained that the food is not always warm. -Resident #36 said the food's cold. -Resident #41 said The food is not always warm. That's my only complaint. During an interview on 1/10/24 at 4:42 P.M., the Ombudsman said that he frequently received complaints from residents regarding the temperatures and the quality of the food. During the Resident Group Meeting on 1/12/24 at 1:33 P.M., attended by 17 residents, many of the residents voiced complaints that the food was not…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-01-18 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and policy review, the facility failed to ensure staff maintained an infection control program designed to provide a safe and sanitary environment to help prevent the development and potential spread of infections. Specifically, the facility failed to: 1. Ensure staff properly performed hand washing during COVID-19 testing to prevent the potential spread of infection; and 2. Ensure staff prepared and administered medications in a safe and sanitary manner. Findings include: 1. Review of the facility's Anterior Nasal Swab Collection Competency Skills, undated, indicated but was not limited to the following: - Disinfect the surface where you will open the collection. Remove and lay out content of the kit. - Wash hands with soap and water. If soap and water are not available, use hand sanitizer. - Remove the swab from the package. Do not touch the soft end with your hands or anything else. - Insert the entire soft end of the swab into your nostril no more ¾ of an inch into your nose. - Slowly rotate the swab, gently pressing against the inside of your…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-18 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to ensure residents in one of four dining rooms experienced a comfortable and homelike dining experience. Findings include: During dining observations made on 1/11/24 and 1/12/24, the surveyors observed the following in the dining areas: On 1/11/24 at 8:41 A.M., the surveyor observed five residents seated in wheelchairs in the third-floor dining room. - Two residents were seated at a table facing the wall and a television, which was tuned into a news station. - Two residents were seated at a table on the opposite side of the room, facing the wall. - One resident was seated at a table in the middle of the room, facing out towards the window. - All residents were seated with their backs to each other. - All meals were served on trays to all the residents. - One staff member was observed to be checking their cell phone when the surveyor entered the dining room. On 1/11/24 at 12:05 P.M., the surveyor observed nine residents seated in wheelchairs in the third-floor dining room. - Two residents were seated at a table facing 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-01-18 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, policy review, and staff interview, the facility failed to develop a comprehensive person-centered care plan for two Residents (#22 and #55), out of a total sample of 19 residents. Specifically, the facility failed: 1. For Resident #22, to ensure staff developed a care plan for the Resident's use of an external catheter device (condom catheter) (urinary collection device with a tube that goes to a collection bag); and 2. For Resident #55, to ensure staff developed a care plan that addressed a cancerous lesion on the Resident's left forearm. Findings include: Review of the facility's policy titled Comprehensive Care Plan, revised July 2023, indicated but was not limited to the following: -All homes will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident right that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. -The comprehensive care plan must describe the services that are 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-09-27 · tag F0607 — failed to have anti-abuse policies — isolated
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews and records reviewed, for two of three sampled residents (Residents #1 and #2) the Facility failed to ensure staff consistently implemented the Facility Abuse Prohibition Policy when Nurse #2 observed a potentially sexually inappropriate interaction between the two residents, and did not immediately separated them. On 9/15/23, Nurse #2 saw Resident #1 in Resident #2's room, standing at Resident #2's bedside holding up Resident #2's leg. Resident #2 who was in bed, was not wearing an incontinence brief, and the lower half of his/her body was not covered by a sheet or a blanket, therefore leaving him/her exposed. Nurse #2 did not immediately separate Resident #1 and Resident #2, in accordance with Facility Policy, and did not attempt to remove Resident #1 from Resident #2's room at that time, but instead went to the nurses station and asked Nurse #1 for help, therefore leaving Resident #2 at risk for potential for abuse. Findings include: The Facility Abuse Prohibition Policy and Procedure, undated, indicated that residents would be immediately protected from…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
Show the remaining 17 citations
  • Potential for harm · Ecited before2022-02-23 · tag F0658 — failed to meet professional standards of care — pattern
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, and medical record review, the facility failed to ensure that staff met professional standards of practice for eight Residents (#47, #26, #39, #51, #15, #49, #52, and #34), out of a total sample of 15 residents. Specifically, the facility failed: 1.) For Resident #47, to ensure a physician's order was obtained prior to using a catheter to obtain a urine sample; 2.) For Resident #26, to follow a physician's order to apply pressure relieving booties, and failed to obtain a physician's order prior to implementing an alternating pressure relieving mattress to the Resident's bed; 3.) For Resident #39, to follow physician's orders to apply pressure relieving booties; 4.) For Resident #51, to ensure a bed alarm was applied to the Resident's bed as ordered by the physician, and failed to ensure that documentation was accurate on the Treatment Administration Record (TAR); 5.) For Resident #15, to ensure a physician's order was obtained prior to sending him/her out to the hospital for evaluation; 6.) For Resident #49, to follow physician's orders 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-02-23 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on policy review, observation, record review, and interview, the facility failed to ensure that respiratory equipment was managed in accordance with professional standards of practice for four Residents (#7, #33, #47, and #49), out of a total sample of 15 residents. Findings include: Review of the facility's policy titled Use of Oxygen Concentrators, last reviewed 10/20/21, included but was not limited to: -oxygen cannula [small, flexible tube that contains two open prongs intended to sit just inside your nostrils to deliver oxygen] or mask will be changed weekly and as needed -oxygen tubing will be dated and labeled 1. Resident #7 was admitted to the facility in November 2019 with diagnoses including congestive heart failure and shortness of breath. Review of the medical record indicated the following Physician's Orders: -Albuterol Sulfate solution for nebulization, 2.5 milligrams/ 3 milliliters inhalation four times a day (2/1/21) -Change nebulizer tubing every week on 11:00 P.M.-7:00 A.M. shift. *Must label tubing with the date (10/12/21) -Oxygen at 2 liters per minute…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-02-23 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and policy review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, including COVID-19. Specifically, the facility failed to: 1) Ensure that during a facility outbreak of COVID-19, the use of personal protective equipment (PPE), including eye protection, gowns, and gloves, were being used for high contact patient care per facility policy; and 2) Ensure that COVID-19 PCR (polymerase chain reaction) outbreak testing was conducted in a manner that is consistent with current standards of practice established by State and Federal agencies to maintain proper infection control and follow universal precautions for testing material. Findings include: Review of the facility's policy titled Policies & Procedures during the COVID-19 Outbreak, undated, indicated the following: -The facility follows the…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-02-23 · tag F0607 — failed to have anti-abuse policies — isolated
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on policy review, record review, and interview, the facility failed to ensure staff implemented the facility policy by not thoroughly investigating and reporting a bruise of unknown origin to the Department of Public Health (DPH) for one Resident (#11), out of a total sample of 15 residents. Findings include: Review of the facility's Abuse Prohibition Policy & Procedure, undated, and Incident Reporting Policy and Procedure, undated, included but were not limited to: It is the policy of the Diocesan Health Facilities that abuse prohibition is comprehensively enforced, as defined Freedom from Abuse, Neglect, and Exploitation (42 Code of Federal Regulations 483.12) - Report all alleged injuries of unknown source to all pertinent agencies as required and take all necessary corrective actions as defined in Freedom from Abuse, Neglect, and Exploitation. An injury should be classified as an injury of unknown source when the source of the injury was not observed by any person, or the source of the injury could not be explained by the resident; and the injury is suspicious because 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-02-23 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on policy review, record review, and interview, the facility failed to ensure staff reported a bruise of unknown origin within two hours to the Department of Public Health (DPH) for one Resident (#11), out of a total sample of 15 residents. Findings include: Review of the facility's Abuse Prohibition Policy & Procedure, undated, and Incident Reporting Policy and Procedure, undated, included but were not limited to: It is the policy of the Diocesan Health Facilities that abuse prohibition is comprehensively enforced, as defined Freedom from Abuse, Neglect, and Exploitation (42 Code of Federal Regulations 483.12) - Report all alleged injuries of unknown source to all pertinent agencies as required as defined in Freedom from Abuse, Neglect, and Exploitation. An injury should be classified as an injury of unknown source when the source of the injury was not observed by any person, or the source of the injury could not be explained by the resident; and the injury is suspicious because of the extent of the injury or the location of the injury (not generally vulnerable to trauma).…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-02-23 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on policy review, record review, and interview, the facility failed to ensure staff thoroughly investigated a bruise of unknown origin for one Resident (#11), out of a total sample of 15 residents. Findings include: Review of the facility's Abuse Prohibition Policy & Procedure, undated, and Incident Reporting Policy and Procedure, undated, included but was not limited to: It is the policy of the Diocesan Health Facilities that abuse prohibition is comprehensively enforced, as defined Freedom from Abuse, Neglect, and Exploitation (42 Code of Federal Regulations 483.12) -All Resident injuries of unknown origin must be investigated according to DPH policy. Resident #11 was admitted to the facility in August 2021 with diagnoses including Alzheimer's dementia. Review of the Minimum Data Set (MDS) assessment, dated 11/26/21, indicated Resident #11 has severe cognitive impairment as evidenced by a Brief Interview for Mental Status score of 1 out of 15. Review of a Resident Incident Report, dated 1/8/22, indicated a bruise to Resident #11's right eyelid was identified by a Certified…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-02-23 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure that staff developed and/ or implemented a comprehensive, person-centered care plan for two Residents (#47, #34), out of a total sample of 15 residents. Specifically, the facility failed 1.) For Resident #47, to develop a care plan to address the care and treatment of a urinary tract infection (UTI); and 2.) For Resident #34, to implement the care plan by failing to provide continuous supervision during all meals, per the physician's order. Findings include: 1.) Resident #47 was admitted to the facility in April 2021. The Resident was currently diagnosed as having a UTI. Review of the most recent Minimum Data Set (MDS) assessment, dated 1/21/22, indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 7 out of 15, indicating the Resident has severe cognitive impairment. Further review of the MDS indicated the Resident was frequently incontinent of urine. Review of the medical record indicated Resident #47 had a Physician's Order, dated 2/20/22, for Amoxicillin (antibiotic) 500…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-02-23 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews, the facility failed to ensure staff provided residents an environment free from accident hazards on one of two units, and for two Residents (#11 and #51), out of a total sample of 15 residents. Specifically, the facility 1. Failed to secure hazardous items left out in residents' rooms that were easily accessible to wandering residents on Unit 2; and failed to provide adequate supervision and implement new safety measures for hazardous items at the unit's nursing station after Resident #11 learned to bypass the locked screen; and 2. Failed to implement interventions identified in fall investigations to prevent future falls for Resident #51. Findings include: 1. Resident #11 was admitted to the facility in August 2021 with diagnoses including Alzheimer's dementia. Review of the Minimum Data Set (MDS) assessment, dated 11/26/21, indicated Resident #11 has severe cognitive impairment as evidenced by a Brief Interview for Mental Status score of 1 out of 15. Review…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-02-23 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, observation, and staff interviews, the facility a.) Failed to ensure a resident entering the facility with a urinary catheter had a clinical condition documenting that catheterization was necessary; and b.) Failed to provide care and services required to prevent urinary tract infections for one Resident (#49), out of a total of 15 sampled residents. Findings include: Resident #49 was admitted to the facility in May 2021 with diagnoses which included End Stage Renal Failure and diabetes. Review of the Minimum Data Set (MDS) assessment, dated 11/20/21, indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the Resident was cognitively intact. The MDS indicated the Resident was continent of bowel and had a urinary catheter. a.) Review of the Bowel and Bladder assessment, dated 5/16/21 and 5/20/21, indicated the urinary catheter was inserted during Resident #49's hospitalization and prior to his/her admission to the facility. The assessment indicated the catheter had been inserted for comfort. The Resident's bladder history…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-02-23 · tag F0742 — isolated
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and staff interview, the facility failed to ensure that for two Residents (#49 and #15), out of a sample of 15 residents, that care and treatment was provided in accordance with Professional Standards of Practice. Specifically, 1. For Resident #49, the facility failed to ensure the facility's psychiatric consultant, who provided one to one (1:1) psychotherapy, developed a treatment plan which identified individualized, person-centered, and measurable goals of treatment; and 2. For Resident #15, the facility failed to ensure the consultant Psychotherapist developed and implemented an appropriate treatment plan to address the Resident's needs, failed to integrate a psychosocial plan of care, and failed to ensure he/she was capable of participating in 1:1 psychotherapy. Findings include: 1. Resident #49 was admitted to the facility in May 2021 with diagnoses which included depression, anxiety, and insomnia. Review of the Minimum Data Set (MDS) assessment, dated 11/20/21, indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-02-23 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and staff interview, the facility failed to ensure that the licensed Pharmacist's medication regimen review recommendation was addressed timely for one Resident (#33), out of a total sample of 15 residents. Findings include: Resident #33 was admitted to the facility in June 2020 with diagnoses including adult failure to thrive. Review of the medical record indicated a Pharmacist Recommendation was completed for Resident #33 on 11/28/21 with the following recommendation: -Resident with current orders for Docusate Sodium (Colace-stool softener) 100 milligrams (mg) twice daily. In order to optimize medication administration times, consider changing Colace administration from twice daily, to 100 mg, 2 tablets (200 mg) at bedtime. The Pharmacy Recommendation was signed by the Nurse Practitioner, but it was not dated. Review of Physician's and Nurse Practitioner's Progress Notes, dated 12/1/21, 12/22/21, 12/28/21, and 1/10/22, failed to indicate that the 11/28/21 Pharmacy recommendation was reviewed. A 1/11/22 Nurse Practitioner's Progress Note indicated that the…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-02-23 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to ensure that antibiotics were not administered without adequate indication for their use for one Resident (#51), out of a total sample of 15 residents. Findings include: Review of [NAME] Pharmaceuticals website indicated that Rocephin (antibiotic) should be used only to treat or prevent infections that are proven or strongly suspected to be caused by bacteria. Precautions in prescribing Rocephin in the absence of a proven or strongly suspected bacterial infection or a prophylactic indication is unlikely to provide benefit to the patient and increases the risk of the development of drug-resistant bacteria. Resident #51 was admitted to the facility in January 2020 with diagnoses including dementia. Review of the Minimum Data Set (MDS) assessment, dated 1/12/22, indicated Resident #51 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status score of 3 out of 15, and was continent of bladder. Review of the medical record…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-02-23 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and facility policy review, the facility failed to ensure that all medications were properly labeled and stored to ensure the safe administration of medications. Specifically, the facility failed to ensure staff followed facility policy and acceptable standards of practice for pre-pouring and storing medications. Findings include: Review of the facility's policy titled Medication Administration - General Guidelines, dated 2/2019, indicated the following: - When medications are administered by mobile cart taken to the resident's location, medications are administered at the time they are prepared. Medications are not pre-poured either in advance of the med pass or for more than one resident at a time. During the Medication Administration observation on 2/17/22 at 8:34 A.M., the surveyor observed Nurse #4 preparing medications for a resident. The nurse separated the capsules into a separate clear plastic cup, which included Depakote (an anti-convulsant used to treat behaviors) and Gabapentin (an anti-convulsant used to treat neuropathic pain). At the…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-02-23 · tag F0773 — isolated
    Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure a physician was notified of a laboratory result that fell outside of the clinical reference range for one Resident (#26), out of a total sample of 15 residents. Findings include: Resident #26 was admitted to the facility in October 2010 with diagnoses that included heart failure and chronic kidney disease. Review of the Nurse Practitioner's (NP) Progress Note, dated 2/10/22, indicated labs would be drawn on the next scheduled lab day. Further review of the medical record did not indicate any current laboratory results. During an interview on 2/22/22 at 2:08 P.M., Nurse #5 said lab results are not always put in the medical record. She said that most times the lab results are put in a folder so the NP can review them. A lab result for Resident #26, dated 2/15/22, was located in the NP folder and was reviewed by the surveyor and Nurse #5. The lab results indicated a PRO-BNP (a blood test that helps with the diagnosis of Congestive Heart Failure) level of 2525.0, indicating an abnormal high level. A normal level for a…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2025-03-10 · tag F0641 — pattern
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) assessment was complete and accurate to reflect the status of one Resident (#27), out of a sample of 15 residents. Specifically, the facility failed: a. To ensure an MDS was accurately coded for a fall with major injury, and b. To ensure the use of a bed alarm was accurately coded on all MDS assessments. Findings include: The facility's policy titled Policy and Procedures within the Nursing Documentation Department for MDS, revised 12/2024, indicated but was not limited to the following: -The RAI (Resident Assessment Instrument) manual is our policy and procedure manual for MDS. Review of the Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated 10/2024, indicated but was not limited to the following: 1) J1800: Any Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA (Omnibus Budget Reconciliation Act) or Scheduled PPS (Prospective Payment System)), whichever is more recent -If this is not the first…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2024-01-18 · tag F0623 — pattern
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, policy review, and interview, the facility failed to ensure written notice for transfer and discharge was provided to the Resident and/or Resident Representative prior to hospital transfer for one Resident (#32), out of a total sample of 19 residents. Findings include: Review of the facility's policy titled 30 Day Notice of Intent to Transfer or Discharge Resident and Discharges, revised 07/15, indicated the following: -The transfer or discharge is necessary to meet the resident's welfare, and the resident's welfare cannot be met in the facility as documented by the resident's physician. Review of the medical record indicated Resident #32 was admitted to the facility in April 2023 with diagnoses which included anemia, cerebral infarction (stroke), type two diabetes mellitus, and chronic obstructive pulmonary disease. Review of the most recent Minimum Data Set (MDS) assessment, dated 1/17/24, indicated Resident #32 was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 6 out of 15. Review of the electronic medical…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2024-01-18 · tag F0625 — pattern
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on policy review, record review, and interview, the facility failed to provide written notification of the bed hold policy to the Resident and/or Resident Representative prior to transfer to the hospital for one Resident (#32), out of a total sample of 19 residents. Findings include: Review of the facility's policy titled Bed Hold and Notice, undated, indicated but was not limited to: - Residents on Medicaid are entitled when they are transferred to a hospital or for medical leave of absence. - During this period, the resident is permitted to return and resume residence in the facility. Resident #32 was admitted to the facility in April 2023 with diagnoses which included anemia, cerebral infarction, type two diabetes mellitus, and chronic obstructive pulmonary disease. Review of the electronic medical record census history indicated Resident #32 was transferred to the Hospital Emergency as followed: 6/27/23 change in condition displayed signs and symptoms of congested lung sounds, 11/24/23 medical leave of absence (MLOA) admitted to the hospital after planned paracentesis;…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

$8,788 in federal fines across 1 penalty.

  • $8,788 — penalty dated 2025-08-19

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 DIOCESAN HEALTH FACILITIES — 5 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 2 of 53.6-1.6 vs chain
Health inspection 3 of 53.2-0.2 vs chain
Staffing 4 of 54.6-0.6 vs chain
Quality measures 1 of 52.6-1.6 vs chain
The other 4 homes this chain runs (chain average 3.6★, per CMS)

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

Who owns this facility

Owner / managerTypeRoleSince
HOYE, JAMESIndividualCONTRACTED MANAGING EMPLOYEEsince 01/01/2024
MELCHERT, JO-ANNIndividualW-2 MANAGING EMPLOYEEsince 01/01/2022
ROQUE, JOANNEIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROLsince 07/01/2019
MITCHELL, LAURAIndividualOPERATIONAL/MANAGERIAL CONTROLsince 01/01/2020

CMS files one row per role, so the 5 rows in the source record cover these 4 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.

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.

$8.0M
Net patient revenuemost recent cost report
-13.4%
Operating marginrevenue minus expenses
$225K
Related-party expense2% of expenses
Who pays — share of resident-days
Medicaid 64%Medicare 6%Other / private 30%

This home reported $225K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$359per resident / day
operating cost
$10,916per month
≈ monthly operating cost
$317per day
avg. revenue, all payers

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

What families pay in MA

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 225477. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-03-10, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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