Regalcare At Taunton
68 Dean Street - Rear, Taunton, MA 02780 · For profit - Corporation · 100 certified beds · (508) 824-1467 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- no federal fines or payment denials on record
- it has an abuse, neglect, or exploitation citation (F0600), cited May 2025
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has a citation for mishandling residents’ money or property (F0565)
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (36) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its independent health-inspection rating is low (1/5)
- its payroll-based staffing rating is low (2/5)
- its facility-reported quality-measure rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 2 to 1 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 20.0% | 16.4% | 15.4% | worse |
| Long-stay residents who lose too much weight | 5.7% | 5.1% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 0.4% | 0.8% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 1.9% | 1.8% | 2.0% | typical |
| Long-stay residents with depressive symptoms | 28.5% | 15.5% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 3.1% | 3.4% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 32.9% | 15.4% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 14.6% | 19.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 97.1% | 94.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.1% | 4.2% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 25.6% | 21.2% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 7.6% | 21.4% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.5% | 1.4% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 82.5% | 77.7% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 26.6% | 25.7% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 13.8% | 11.9% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.25 | 1.88 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.81 | 1.50 | 1.80 | typical |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
51.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 210 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 42.3% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 97 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 0.37 therapist hours per resident per day in 2026Q1 — more than 63% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 51% of this home’s weekday level — it runs therapy at close to weekday levels right through the weekend. 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 | 51.8%CMS range 45.4–59.4 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 12.4%CMS range 9.3–15.7 | 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 | 42.3% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 45.4% | 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 | 42.3% | 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 | 92.5% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 98.7% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.5% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.8% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.7%CMS range 4.9–10.3 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.99 | 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 100 beds and averages 83.7 residents a day — about 84% occupied, or roughly 16 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.31 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.72 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.86 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.80 hrs/resident/day on weekends vs 3.51 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.84 to 0.41 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 49% is about the same as the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
36 citations, most serious first. The 11 most serious are shown; the remaining 25 are one tap away and print in full.
- Immediate jeopardy · J2025-05-13 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
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 document review and interviews, the facility failed to ensure for one Resident (#40), out of a total sample of 18 residents, to ensure he/she was free from a significant medication error when the Resident's immunosuppressant medication was discontinued in error. As a result, Resident #40 missed 40 doses of tacrolimus (Prograf, an immunosuppressant medication used to prevent transplanted organ rejection) and required emergent hospitalization and medication adjustments during and after hospitalization. Findings include: Review of the facility's policy titled Reconciliation of Medications on Admission, revised 3/22, indicated, but was not limited to, the following: -Medication reconciliation is the process of comparing pre-discharge medications to post-discharge medications by creating an accurate list of both prescription and over the counter medications that includes the drug name, dosage, frequency, route, and indication for use for the purpose of preventing unintended changes or omissions at transition…
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 before2025-05-21 · 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
Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had severe cognitive impairment, the Facility failed to ensure he/she was free from abuse from a staff member, when on 03/30/25, Resident #1 became combative during care and in response to his/her behaviors, Certified Nurse Aide (CNA) #2, told Resident #1 if he/she hit her again, she would hit him/her back. CNA #2 hit Resident #1 on the top of his/her left hand twice. The incident was witnessed by another staff member who was assisting with Resident #1's care. A cognitively intact person would experience pain and mental anguish after being hit by a caregiver. Findings include: Review of the Facility's Policy titled Abuse Prohibition, dated as revised 3/2025, indicated the following: -each resident has the right to be free from verbal, sexual, physical and mental abuse, neglect, corporal punishment, involuntary seclusion, and misappropriation of their property; every resident in the facility will always be treated with respect and dignity -it is the goal of this facility to foster an…
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 before2025-05-21 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop 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 records reviewed and interviews, for one of three sampled residents (Resident #1), who had severe cognitive impairment, the Facility failed to ensure staff implemented and followed their Abuse Identification and Reporting Policy, when on 03/30/25 during the night shift, Certified Nurse Aide (CNA) #1 witnessed CNA #2 slap Resident #1's hand while providing care to him/her. CNA #1 did not immediately report the allegation of physical abuse to the nurse on duty as required and did not do so, until four hours after witnessing the incident. Findings include: Review of the Facility's Policy titled Abuse Identification and Reporting, dated as revised 3/ 2022, indicated the following: -identify any event that may be potential abuse, neglect, involuntary seclusion, or misappropriation of resident property -any suspected allegation of abuse shall be immediately reported to the administrator or his/her designee Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 03/30/25, indicated that on 03/30/25 Resident #1 was being combative…
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 before2025-05-13 · tag F0565 — failed to support the resident council — patternHonor the resident's right to organize and participate in resident/family groups in the facility.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on a resident group meeting, interviews, and record reviews, the facility failed to ensure concerns from the Resident Council were thoroughly documented to ensure the residents felt their concerns were acted upon timely and included the facility response to the group. Findings include: Review of the facility's policy titled Grievance, revised 3/22, indicated but was not limited to the following: The Resident Council is an additional forum within the facility for voicing complaints/grievances. Complaints/grievances received from this council will be acted upon by this procedure. Review of Resident Council minutes, dated 11/21/24 through 4/30/25, indicated residents voiced concerns with long call bell wait times at five out of six Resident Council meetings held. Review of the Resident Council resolution plan, dated 11/21/24, indicated audits were ongoing with no additional follow-up noted. The facility was unable to provide Resident Council resolution or follow-up for call light concerns identified in the January minutes and February minutes. During an interview on 5/5/25 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-05-13 · tag F0585 — failed to handle grievances — patternHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, observation, and document review, the facility failed to ensure residents had the right to voice and formulate grievances, have those grievances responded to promptly, and be provided a resolution to their grievance. Specifically, the facility failed to: 1. Investigate and address voiced grievances; and 2. Ensure residents had access to grievance/concern forms to submit grievances anonymously, should they choose not to alert a staff member to their concern. Findings include: Review of the facility's policy titled Grievance, last revised 3/2022, indicated but was not limited to: -The resident and/or resident representative will be made aware of the right to voice grievances orally, in writing, and anonymously. -If a resident, and/or health care representative, or another interested family member of a resident has a complaint, a staff member should encourage and assist the resident, or person acting on the resident's behalf, to file a written grievance with the facility using the Grievances/Complaint Report form. -Grievances and complaints may be submitted orally…
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 · E2025-05-13 · tag F0835 — failed to run the facility competently — patternAdminister the facility in a manner that enables it to use its resources effectively and efficiently.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on records reviewed and interviews, the facility failed to ensure it provided appropriate administrative oversight specific to clinical management when a Resident (#40) did not receive his/her tacrolimus (Prograf, an immunosuppressant medication used to prevent transplanted organ rejection) after readmission from the hospital in February 2025, resulting in abnormally low laboratory results and the Resident required emergent hospitalization and medication adjustments during and after hospitalization. Specifically, the facility administration failed to:1. Ensure effective systems were in place for education, and training for licensed staff to ensure competent, safe, and effective resident care related to medication reconciliation, laboratory result reporting and communication with consulting providers;2. Ensure an admission Medication Regimen Review (AMRR) was completed for Resident #40 upon return to the facility after a hospitalization, resulting in Resident #40 missing a total of 40 doses of tacrolimus; and3. Ensure a medication error was fully investigated and brought all…
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 · D2025-05-13 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to accurately complete a Level I Pre-admission Screening and Resident Review (PASARR) for one Resident (#35), out of a total sample of 18 residents, resulting in Resident #35 being admitted to the facility without the determination of whether he/she screened positive for intellectual disability (ID)/developmental disability (DD) or serious mental illness (SMI) requiring further evaluation. Findings include: Resident #35 was admitted to the facility in February 2025 with diagnoses including post-traumatic stress disorder (PTSD), major depressive disorder, and anxiety disorder. Review of Resident #35's Minimum Data Set (MDS) assessments indicated he/she scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident was cognitively intact. Further review of the assessments listed multiple other mental health diagnoses upon admission to the facility. Review of Resident #35's Level I PASARR indicated: -The Level I PASARR was submitted for review after admitting into the facility. -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 · D2025-05-13 · 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 observation, interview, and record review, the facility failed to implement the person-centered plan of care for two Residents (#20 and #69), out of 18 sampled residents. Specifically, the facility failed to:1. Implement the care plan for Resident #20 which indicated that the Resident required two staff for all care; and 2. Follow the plan of care for Resident #69 to wear eyeglasses.Findings include:1. Resident #20 was admitted to the facility in June 2023 with diagnoses including but not limited to cerebral infarction.Review of Resident #20's care plan indicated but was not limited to:Focus: Behavior problems, sexually inappropriate and accusatory, revised 8/1/23;Goal: Resident will have fewer episodes of accusations and sexually inappropriate statements, revised 5/24/24;Interventions: 2 people always, date initiated 8/1/23.On 5/5/25 at 9:23 A.M., the surveyor observed Resident #20 in their wheelchair being brought out of his/her room by Certified Nursing Assistant (CNA) #3.During an interview with observation on 5/5/25 at 9:23 A.M., CNA #3 said she completed the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-05-13 · tag F0710 — isolatedObtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and observation, the facility failed to ensure a physician and/or the physician assistant (PA) provided supervision and oversight for the care of one Resident (#40) with a known history of an organ transplant, out of a total sample of 18 residents, who required the daily use of tacrolimus (Prograf, an immunosuppressant medication used to prevent transplanted organ rejection). Specifically, the physician and PA failed to: 1. Identify that tacrolimus was discontinued after a recent hospitalization, resulting in a total of 40 missed doses; and 2. Address and intervene on abnormal tacrolimus level laboratory values, leading to the Resident's emergent hospitalization for organ transplant rejection surveillance and medication management. Findings include: Review of the facility's policy titled Labs and Diagnostics, revised 4/2022, indicated, but was not limited to, the following: -Assessment and Recognition 1. The physician will identify and order diagnostic and lab testing based on…
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 before2025-05-13 · tag F0712 — isolatedEnsure that the resident and his/her doctor meet face-to-face at all required visits.
What the surveyor found here — an excerpt from the official record, may be distressing
2. Resident #30 was admitted to the facility in November 2020 with diagnoses which included type 2 diabetes mellitus with diabetic neuropathy, dysarthria following cerebral infarct, hemiplegia and hemiparesis, pain, and major depressive disorder.Review of Physician progress notes and assessments indicated Resident #30 had not been seen by a Physician during the timeframe of 6/4/24 through 12/19/24, for a total of 199 days.During an interview on 5/7/25 at 9:00 A.M., the RDO reviewed Resident #30's Physician's notes and said the Physician must see residents every 60 days; visits can alternate between the Physician and NP/PA. The RDO said during the 199-day period from June to December 2024, Resident #30 was not visited by the Physician every 60 days and visits during that time did not alternate between the Physician and the NP/PA. The RDO said the Resident should have been seen more frequently by the Physician. Based on document review and interview, the facility failed to ensure residents were provided Physician/Nurse Practitioner (NP)/Physician's Assistant (PA) visits every 30 days…
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 · D2025-05-13 · 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 observation, record review, and interviews, the facility failed to ensure licensed nursing staff were competent in immunosuppressant drug therapy resulting in: a. failure to identify the adverse discontinuation of a necessary immunosuppressant medication (tacrolimus) for the prevention of organ rejection for one Resident (#40) in a sample of 18 residents; and b. failure to communicate with the practitioner about abnormally low tacrolimus level laboratory results for Resident #40, readmitted to the facility with a known history of heart transplant, resulting in emergent hospitalization in March 2025 for transplanted organ rejection surveillance and medication regimen adjustments. Findings include: Review of the Facility Assessment, updated 4/25/25 and reviewed by the QAPI Committee on 4/28/25, indicated: -Services and Care We Offer Based on our Residents' Needs Medications: Awareness of any limitations of administering medications Administration of medications that residents need Management of medical conditions: Assessment, early identification of problems/deterioration,…
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 25 citations
- Potential for harm · Dcited before2025-05-13 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interviews, the facility failed to ensure for one Resident (#40), out of a total sample of 18 residents, an admission Medication Regimen Review (AMRR) was completed by the Consultant Pharmacist upon readmission to the facility and an irregularity was identified. Specifically, the Consultant Pharmacist failed to identify the discontinuation of Resident #40's immunosuppressant medication and, as a result, Resident #40 (a heart transplant recipient) missed 40 doses of tacrolimus (Prograf, an immunosuppressant medication used to prevent transplanted organ rejection) and required emergent hospitalization and medication adjustments during and after hospitalization. Findings include: Review of the facility's policy titled Reconciliation of Medications on Admission, revised 3/22, indicated, but was not limited to, the following: -Medication reconciliation is the process of comparing pre-discharge medications to post-discharge medications by creating an accurate list of both prescription and over the counter medications that includes the drug name, dosage,…
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 · D2025-05-13 · tag F0867 — failed to act on quality-improvement findings — isolatedSet up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
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 document review and interview, the facility failed to ensure that the Quality Assurance Committee developed and implemented an effective Performance Improvement Plan (PIP), including a corrective action plan with effective monitoring for delayed laboratory result reporting, readmission medication reconciliation, and pharmacy admission Medication Regimen Review (AMRR) after admission/readmission. Findings include: Review of the facility's policy titled Quality Assurance Performance Improvement, revised 4/2022, indicated, but was not limited to, the following: -The facility has a Quality Assurance/Performance Improvement (QAPI) Program which systematically monitors, analyzes, and improves its performance to improve resident outcomes. -The QAPI committee will consist of the Administrator, Director of Nursing Services, a physician designated by the center and at least three other members of the facility staff. These additional members may include representation from nursing, dietary, housekeeping, laundry,…
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 before2024-10-31 · 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
Based on records reviewed and interviews for two of three sampled residents' (Resident #1 and #2) who were both assessed as requiring psychiatric interventions and evaluations, the Facility failed to ensure nursing staff provided care and services that met professional standards of quality, when recommendations made by psychiatric services for both residents, were not followed up on timely by nursing. Findings include: Review of the Facility Policy titled Physician Services and Discipline Recommendations, dated as revised 3/2022, indicated that the medical care of each resident is under the supervision of a licensed physician. The Policy indicated that the attending physician will determine the relevance of any recommended interventions form any discipline, however in not obligated to accept these recommendations if he/she has clinically valid reason for not doing so. 1) Resident #1 was admitted to the Facility in June 2024, diagnoses include Parkinson's Disease, metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), Urinary Tract Infection…
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 · Fcited before2024-06-03 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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, policy review, and interview, the facility failed to follow their policy and professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to: 1. Ensure the main kitchen was maintained in a sanitary condition; 2. Ensure food items were properly labeled and dated in the main kitchen refrigerators; 3. Ensure food items were properly stored in the main kitchen walk-in refrigerator; and 4. Ensure staff practiced proper hand hygiene to prevent cross contamination (transfer of pathogens from one surface to another) and to ensure appropriate hand drying provisions in one of two handwashing stations in the main kitchen. In addition, to ensure the use of gloves was limited to a single use task. Findings include: 1. Review of the 2022 Food Code by the Food and Drug Administration (FDA), revised 1/2023, indicated but was not limited to the following: 3-305.11 (A) Except as specified in paragraphs (B) and (C) of this section, food shall be protected…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-06-03 · tag F0565 — failed to support the resident council — patternHonor the resident's right to organize and participate in resident/family groups in the facility.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of the Resident Council meeting minutes, grievance book review, policy review, and interviews, the facility failed to ensure residents rights to: a. Participate in Resident Council was promoted and residents were not impeded or prevented from participating in Resident Council meetings; and b. Have grievances brought forward through Resident Council acted upon promptly and resolved to the residents' satisfaction within 3-5 working days of the grievance filing date, per the facility's policy. Findings include: During an interview on 5/29/24 at 12:56 P.M., the Activity Director (AD) said she coordinates monthly Resident Council meetings and documents the meeting minutes. The AD said she hoped that more residents would come to Resident Council meetings, but she was told by the previous AD that only alert and oriented residents are allowed to participate in Resident Council, and not everyone is invited. She said she invites residents she thinks would be good and sometimes nursing staff will tell her who would be appropriate to attend. The AD said she was not aware that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-06-03 · tag F0658 — failed to meet professional standards of care — patternEnsure 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 observations, interviews, and records reviewed, for three residents (Resident #216, #23, and #31) of 17 sampled residents, the facility failed to maintain professional standards of practice. Specifically, the facility failed: 1. For Resident #216, to document comprehensive weekly skin assessments; 2. For Resident #23, to ensure medication was administered as ordered by the Physician; and 3. For Resident #31, to ensure a physician's order for Trazodone (antidepressant) was complete and included the strength of the medication ordered. Findings include: Standard of Practice Reference: Pursuant to Massachusetts General Law (M.G.L.), chapter 112, individuals are given the designation of registered nurse and practical nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a Registered nurse and Practical nurse respectively. The regulations stipulate that both the registered nurse and practical nurse bear full responsibility 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 · Ecited before2024-06-03 · tag F0712 — patternEnsure that the resident and his/her doctor meet face-to-face at all required visits.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on records reviewed and interviews, for four Residents (#15, #17, #18, and #31), of 17 sampled residents, the facility failed to ensure the Resident was seen by the physician at least every 30 days for the first 90 days after admission and at least every 60 days thereafter, with alternate visits by a nurse practitioner as indicated. Findings include: Review of the facility's policy titled Physician Services and Discipline Recommendations, dated as revised 3/2022, indicated but was not limited to: -The physician will perform pertinent, timely medical assessments; prescribe an appropriate medical regimen; provide adequate, timely information about the resident's condition and medical needs; visit the resident at appropriate intervals; and ensure adequate alternative coverage. -Physician orders and progress notes shall be maintained in accordance with current OBRA regulations and facility policy. 1. Resident #17 was admitted to the facility in December 2019 and had diagnoses including dementia (group of symptoms that affect memory, thinking and interferes with daily life) 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 · E2024-06-03 · tag F0847 — patternInform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
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 Arbitration Agreement presented to residents as part of the admission packet was explained to the resident and his/her representative in a form and manner that he/she understands for six of six Arbitration Agreements reviewed. Findings include: During an interview on 5/28/24 at 1:35 P.M., Regional Staff #4 said they only have Arbitration Agreements signed from 2022 moving forward when the building was purchased from another company. During an interview on 5/28/24 at 2:00 P.M., the Director of Admissions (DOA) provided a bed board document that listed all residents that have signed the Arbitration Agreement. She said she has a few more residents that need to sign the agreement. Review of the document indicated 67 of 69 residents in the facility had signed the Arbitration Agreement. Review of six of six facility documents titled Arbitration Agreement indicated: -Resident #218 signed the agreement on 5/28/24 -Resident #3 signed the agreement on 4/11/24 -Resident #167 signed the agreement on 5/9/24 -Resident #118…
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 · E2024-06-03 · tag F0848 — patternProvide a neutral and fair arbitration process and agree to arbitrator and venue.
What the surveyor found here — the official record, unedited, may be distressing
Based on document review and interview, the facility failed to ensure their arbitration agreement specifically provides for the selection of a neutral arbitrator and neutral venue that is convenient to both parties. Findings include: Review of the Arbitration Agreement in use by the facility failed to indicate the residents or their representatives had the right to a neutral arbitrator and neutral venue agreed upon by both parties. During an interview on 5/31/24 at 1:01 P.M., the Director of Admissions reviewed the Arbitration agreement in use by the facility and said she could not find any language in the agreement that reflects the selection of a neutral arbitrator and neutral venue to be agreed upon by both parties. During an interview on 5/31/24 at 2:00 P.M., the Admissions Director provided the surveyor with an updated version of the Arbitration Agreement (updated May 2024) that went into effect 5/28/24, that provides for the selection of a neutral arbitrator and neutral venue that is convenient to both parties.
- Potential for harm · D2024-06-03 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interviews, the facility failed to notify the physician of a significant change in the resident's physical, mental, or psychosocial status, for one Resident (#14), out of 17 sampled residents. Specifically, for Resident #14, the facility failed to notify his/her physician of significant weight loss. Findings include: Review of the facility's policy titled Weight Management, dated as revised 4/22, indicated but was not limited to: -Weight change is defined as any unplanned weight gain or loss as follows: +/- 5% weight change in 1 month, +/- 7.5% weight change in 3 months, +/- 10% weight change in 6 months. -Reweighs should be done with a discrepancy of =/> [SIC] 5 pounds or at the recommendation of the dietitian or nursing. Reweighs should be done within 24 hours. -The MD and family/responsible party will be notified of any significant weight gain/loss and this notification will be documented in the nurses' notes. Review of the facility's policy titled Change of Condition in a Resident Status, dated 3/17, indicated but was not limited to: -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.
- Potential for harm · Dcited before2024-06-03 · 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
Based on observations, interviews, and record review, the facility failed to ensure residents were provided care and services to meet their care needs and were free from neglect for two Residents (#9 and #35) out of a total sample of 17 residents. Specifically, the facility failed to ensure staff responded to the Residents' call lights in a timely manner to provide assistance with care needs. Findings include: Review of the facility's policy titled Answering Call Lights, dated 3/2022, indicated but was not limited to: -The purpose of this procedure is to respond to the resident's requests and needs. -Answer the resident's call light as soon as possible. -Turn off the signal light. -Do what the resident asks of you, if permitted. If you are uncertain as to whether or not a request can be fulfilled or if you cannot fulfill the resident's request, ask the nurse supervisor for assistance. -If you have promised the resident you will return with an item or information, do so promptly. 1. Resident #9 was admitted to the facility in January 2024 and had diagnoses including Multiple…
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 · D2024-06-03 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews, the facility failed to ensure for one Resident (#18), out of a sample of 17 residents, that respiratory care was provided consistent with professional standards of practice. Findings include: Review of the facility's policy titled Oxygen Use, dated 4/2017, indicated but was not limited to: Preparation 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 2. Review the resident's care plan to assess for any special needs of the resident. 3. Assemble the equipment and supplies as needed. Equipment and Supplies The following equipment and supplies will be necessary when performing this procedure. -Humidifier bottle Documentation After completing the oxygen set up or adjustment, the following information should be recorded in the resident's medical record: 1. The date and time that the procedure was performed. 2. The name and title of the individual who performed the procedure.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-03 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review, and policy review, the facility failed to ensure staff implemented dialysis care and services consistent with professional standards of practice and comprehensive care plan for one of one Resident (#11) receiving dialysis, out of a total sample of 17 residents. Specifically, the facility failed to provide ongoing communication between the nursing facility and dialysis facility. Findings include: Review of the facility's policy titled Care of Resident with End-Stage Renal Disease, last revised April 2022, indicated but was not limited to: - Policy: Resident with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care. Resident #11 was admitted to the facility in November 2020 with diagnoses including diabetes mellitus and dependence on renal dialysis. Review of the Minimum Data Set (MDS) assessment, dated 5/5/24, indicated Resident #11 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Review of the May 2024 Physician's Orders indicated the following:…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-06-03 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure the consultant pharmacist identified and reported an incomplete medication order for Trazodone (antidepressant) during the monthly drug regimen review for one Resident (#31), out of a total sample of 17 residents. Findings include: Resident #31 was admitted to the facility in November 2021 and had diagnoses including anxiety and depression. Review of the Minimum Data Set assessment, dated 5/14/24, indicated Resident #31 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status score of 00 out of 15, and received psychotropic medication daily. Review of the medical record indicated the following Physician's Order: -Trazodone HCI, give 0.5 tablet by mouth one time a day related to depression, anxiety. Give 1/2 tab=25 milligrams (mg) once daily (8/25/22) Review of the medical record, including pharmacy consultant notes and reports, failed to indicate the pharmacist identified and reported to the physician the incomplete order for Trazodone. During a telephone interview on 6/3/24 at 10:47 A.M.,…
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 · Fcited before2023-01-27 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to: 1. Ensure food was stored, labeled, dated and maintained under sanitary conditions in the main kitchen walk-in refrigerator; 2. Maintain a clean and sanitary workstation during meal preparation; 3. Handle ready to eat food (food which does not require cooking or further preparation prior to consumption) utilizing proper hand hygiene to prevent cross contamination; and 4. Ensure the cleanliness of the main kitchen floor was maintained. Findings include: 1. On 1/24/23 at 8:30 A.M., during the initial tour of the main kitchen, the surveyor made the following observations in the walk-in refrigerator: - Large metal container which contained an open bag of cubed cheese, two packages of sliced pepperoni (one bag was not sealed), and a bag of open grapes. The inside bottom of the metal container was wet with a clear liquid. The contents…
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 before2023-01-27 · tag F0658 — failed to meet professional standards of care — patternEnsure 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 interview and record review, the facility failed to meet professional standards of practice for three Residents (#41, #12, and #68), out of a total sample of 19 residents. Specifically, the facility failed: 1. For Resident #41, to monitor the Resident's fluid input and output (I&O) to ensure the physician's order of 1,500 milliliters (ml) daily fluid restriction was being followed; 2. For Resident #12, to obtain urine culture sensitivity results from the hospital to ensure the Resident was receiving the appropriate antibiotic; and 3. For Resident #68, to ensure a physician's order was in place to ensure weekly skin assessments were conducted to monitor the Resident's skin integrity. Findings include: 1. Resident #41 was admitted to the facility in November 2022 with diagnoses which included hereditary motor and sensory neuropathy, lack of coordination, and endometrium cancer. Review of the Minimum Data Set (MDS) assessment, dated 12/23/22, indicated Resident #41 scored a 15 out of 15 on the Brief…
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 · E2023-01-27 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure 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 observations, interviews, and test tray results, the facility failed to ensure food was prepared by methods which conserved nutritional value, flavor, appearance, palatability, and appetizing temperatures for two of four meals served. Findings include: During a telephonic interview on 1/24/23 at 1:20 P.M., Family Member #1 said, Food is a concern, last night it was just lettuce with cottage cheese on top of peaches and another meal was scrambled eggs that looked like vomit. During an interview on 1/24/23 at 11:58 A.M., Resident #13 said he/she had concerns with the food being cold and not always tasty. During an interview on 1/24/23 at 12:10 P.M., Resident #35 said his/her only complaint was the food was not always tasty. During an interview on 1/24/23 at 12:14 P.M., Resident #50 said sometimes the food is not always hot. During an interview on 1/24/23 at 9:43 A.M., the Food Service Manager (FSM) said the plate warmer is broken, but the parts are ordered. She said the dietary staff are heating the plates in the oven to170 degrees Fahrenheit until the plate warmer is fixed.…
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 before2023-01-27 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, record review, and interview, the facility failed to ensure staff implemented the facility's abuse policy for two Residents (#31 and #27), out of a total sample of 19 residents. Specifically, the facility failed to: 1. For Resident #31, follow their policy and ensure an allegation of abuse was thoroughly investigated and was reported to the Department of Public Health (DPH) within two hours; and 2. For Resident #27, ensure the allegation of misappropriation was reported to the DPH within two hours. Findings include: Review of the facility's policy titled Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation, dated as revised December 2017, indicated but was not limited to the following: -Abuse, Neglect, Misappropriation of Patient Property and exploitation will not be tolerated by anyone, including staff, patients, consultants, volunteers, family members or legal guardians, friends, visitor or any other individual…
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 · D2023-01-27 · 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 interview and record review, the facility failed to provide one Resident (#41) with an effective bowel management program and dietary options to assist with ongoing constipation concerns, out of a total sample of 19 residents. Findings include: Resident #41 was admitted to the facility in November 2022 with diagnoses which included hereditary motor and sensory neuropathy, lack of coordination, and endometrium cancer. Review of the Minimum Data Set (MDS) assessment, dated 12/23/22, indicated Resident #41 scored a 15 out of 15 on the Brief Interview for Mental Status, indicating he/she was cognitively intact. During an interview on 1/24/23 at 12:00 P.M., Resident #41 said he/she was trying to get home so he/she could get better food to help fix his/her constipation problem. The Resident said since he/she was admitted to the facility, he/she had a constipation problem which had not been well managed by the doctor. Resident #41 said he/she continued to have weekly difficultly moving his/her bowels and at times it was painful. The Resident said the staff focus on giving him/her…
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 · D2023-01-27 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, policy review, and interview, the facility failed to ensure targeted behaviors and signs and symptoms of side effects were adequately monitored to evaluate the effectiveness of psychotropic medication to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being for one Resident (#28), out of a total sample of 19 residents. Findings include: Review of the facility's policy titled Psychotropic Medication Use, revised 7/22, indicated but was not limited to: -A psychotropic medication is any medication that affects brain activity associated with mental processes and behavior. -Residents, families and/or the representative are involved in the medication management process. Psychotropic medication management includes indications for use, dose (including duplicate therapy), duration, adequate monitoring for efficacy and adverse consequences, and preventing, identifying and responding to the adverse consequences. Resident #28 was admitted to the facility in December 2022 with diagnoses which included dementia, mood…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2025-05-13 · tag F0944 — widespreadConduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on documentation review and interview, the facility failed to provide training and education to all their staff to outline elements and goals of the facility's Quality Assurance Performance Improvement (QAPI) program. Findings include: Review of the facility's policy titled Quality Assurance Performance Improvement, revised 4/2022, indicated, but was not limited to, the following: -Small group education sessions on QAPI are provided to all caregivers working in the building. QAPI is also part of orientation for new staff members joining the team. -Administrator is responsible to ensure ongoing orientation, education and training on QAPI. In addition, as part of annual evaluations, staff members are expected to answer questions regarding performance improvement and how QAPI is used in operations of the facility. Review of five education records (including the electronic training system) for direct care staff, which included two nurses, a unit manager, a social worker, and the staff development coordinator, failed to indicate QAPI training had been completed for five out of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · B2025-05-13 · tag F0638 — patternAssure that each resident’s assessment is updated at least once every 3 months.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on Minimum Data Set (MDS) assessment review and staff interview, the facility failed to ensure staff completed the Quarterly MDS assessment within the required timeframe for five Residents (#49, #63, #1, #4, and #27), out of five residents reviewed for overdue assessments. Findings include: The MDS is part of the U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid-certified nursing homes. It is a core set of screening, clinical and functional status elements, including common definitions and coding categories, which forms the foundation of a comprehensive assessment. A Quarterly MDS assessment is considered timely if the Assessment Reference Date (ARD) of the Quarterly MDS is completed within 92 days of the most recent OBRA Assessment reference date (Admission, Annual, Quarterly, or a Significant Change in Status Assessment), and the completion date must be no later than 14 days after the ARD. 1. Resident #49 was admitted to the facility in April 2021. Review of Resident #49's quarterly MDS assessment, dated 3/19/25, indicated it…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · B2025-05-13 · tag F0732 — patternPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to ensure nurse staffing information which included the current date and actual hours worked per shift for licensed and unlicensed staff including Registered Nurses (RN), Licensed Practical Nurses (LPN), and Certified Nurse Aides (CNA) was posted daily as required. Findings include: On 5/4/25 at 7:46 A.M. and 10:23 A.M., the surveyor observed a nurse staffing document posted in the main lobby on top of the receptionist's desk. Review of the Nurse staffing document indicated it was dated 5/2/25. During an interview on 5/7/25 at 3:25 P.M., the Receptionist said the Scheduler leaves the completed nurse staff documents at the desk for the receptionist to change out each morning. The Receptionist said the Nurse staffing document should be updated every morning. During an interview on 5/7/25 at 3:39 P.M., the Scheduler said she was responsible for preparing the nurse staffing document and leaves the completed documents at the receptionist desk. The Scheduler said on Friday evenings she prepares the weekend sheets and leaves them 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.
- No harm found · B2024-06-03 · tag F0641 — patternEnsure 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 accurately complete the Minimum Data Set (MDS) assessment for one Resident (#11), out of 17 sampled residents and for one Resident (#65), out of 2 closed records. Specifically, the facility failed: 1. For Resident #11, to ensure dialysis was accurately coded on the MDS; and 2. For Resident #65, to ensure the discharge status was accurately reflected on the MDS. Findings include: Review of the facility's policy titled MDS (Minimum Data Set), last revised May 2017, indicated but was not limited to: - Policy: In compliance with federal and state regulations, each resident shall have a comprehensive assessment of his/her functional capacity recorded on a designated MDS form and electronically submitted to State Department of Health as per federal and state regulations and the Resident Assessment Instruments. 1. Resident #11 was admitted to the facility in November 2024 with diagnoses including diabetes mellitus (a disease in which the body does not control the amount of glucose (a type of sugar) in the blood) and dependence on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · B2023-01-27 · tag F0640 — patternEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
What the surveyor found here — the official record, unedited, may be distressing
Based on Minimum Data Set (MDS) assessment review and staff interview, the facility failed to encode and electronically transmit MDS data to the Centers for Medicare and Medicaid Service (CMS) processing system, for one Resident (#59), out of one resident assessment reviewed. Findings include: A discharge MDS is required any time a resident is discharged from the facility. Facilities are required to encode and transmit (submitted and accepted into the QIES ASAP system) the MDS electronically no later than 14 calendar days after the MDS completion date. Resident #59 was admitted to the facility in August 2022 with diagnoses which included congestive heart failure and hypertension and was discharged from the facility on 9/14/22. Review of the MDS assessments indicated a discharge MDS had not been transmitted to CMS. During an interview on 1/26/23 at 2:13 P.M., the MDS Coordinator said the facility recently changed over the electronic medical record system and the discharge MDS assessment had not been submitted as required.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to REGALCARE — 9 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 | 1 of 5 | 1.7 | -0.7 vs chain |
| Health inspection | 1 of 5 | 1.9 | -0.9 vs chain |
| Staffing | 2 of 5 | 3.0 | -1.0 vs chain |
| Quality measures | 2 of 5 | 2.2 | -0.2 vs chain |
The other 8 homes this chain runs (chain average 1.7★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| RC OPCO HOLDCO LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 09/01/2022 |
| MIRLIS, ELIYAHU | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; W-2 MANAGING EMPLOYEE; CORPORATE OFFICER | 99% | since 09/01/2022 |
CMS files one row per role, so the 4 rows in the source record cover these 2 parties — each is shown once here with every role it holds. Nothing is omitted.
1 organizational owner 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 $1.2M paid to related parties — landlords or management companies under common ownership — equal to about 11% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in MA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Massachusetts Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 225474. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-13, 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.