RegalCare at Wakefield

Location & what’s nearby

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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

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.

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.

30.3% 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 48 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 33.3% 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 24 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 0.18 therapist hours per resident per day in 2026Q1 — more than 18% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 1% of this home’s weekday level — it runs therapy on weekdays, with essentially none at 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.

Staffing

How full it usually is: this home is certified for 149 beds and averages 90.1 residents a day — about 60% occupied, or roughly 59 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 3.60 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.60 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.19 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 3.45 hrs/resident/day on weekends vs 3.66 on weekdays — 6% thinner on weekends. RN hours go from 0.64 to 0.52 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 30% is below the national median of 45%. 3 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

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

Inspection deficiencies

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

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

42 citations, most serious first. The 15 most serious are shown; the remaining 27 are one tap away and print in full.

• Immediate jeopardy · J2025-02-04 · 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 observations, interviews and record review, the facility failed to notify the physician of a significant change in status for one Resident (#72) out of a total sample of 26 residents. Specifically, the facility failed to notify the physician when Resident #72 verbalized Suicidal Ideation (SI) and acute psychological distress. Findings include: Review of the facility policy titled Change in a Resident's Condition of Status, dated as revised February 2021 indicated the following: -The nurse will notify the resident's attending physician or physician on call when there has been a significant change in the resident's physical/emotional/mental condition. -The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. Review of the facility policy titled Suicide Threats, undated, indicated the following: -Staff shall report any resident threats of suicide immediately to the nurse supervisor/charge nurse. -The nurse supervisor/charge nurse shall immediately assess the situation and shall notify Director…

  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
• Immediate jeopardy · J2025-02-04 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interview, the facility failed to protect two Residents (#72 and #17), from abuse and neglect, out of a total sample of 26 residents. Specifically: 1. For Resident #72 the facility neglected to provide psychosocial support including ongoing monitoring, intervention and notification of the physician timely in a Resident who has a known history of suicidal ideation (SI) and observed to be making statements of SI by multiple staff without intervention. 2. For Resident #17 the facility failed to prevent verbal abuse. Findings include: Review of the facility policy titled Abuse and Neglect-Clinical Protocol, dated revised 2018 indicated that abuse is defined as the deprivation of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being and it includes verbal abuse. Further review indicated that neglect is defined as the failure of the facility, its' employees or service providers to provide goods and services to a resident 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2025-02-04 · tag F0726 — failed to have competent, trained nursing staff — isolated
  Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, staff education review, and Facility Assessment review, the facility failed to ensure the nursing staff were trained and demonstrated the competencies and skill sets necessary to provide the level and types of care and services needed as outlined in the Facility Assessment. Specifically: The facility failed to ensure licensed nursing staff who were on the schedule on 1/28/25, 1/29/25 and 1/30/25, were trained and competent to identify, assess, and intervene when one Resident (#72), who was admitted with Suicidal Ideation's, made repeated statements of wanting to commit suicide. Findings include: According to the Board of Registration in Nursing, 244 CMR 9.00: Standards of Conduct, a competency is defined as the application of knowledge and the use of affective, cognitive, and psychomotor skills required for the role of a nurse licensed by the Board and for the delivery of safe nursing care in accordance with accepted standards of practice. Competency is a measurable pattern 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.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2025-02-04 · tag F0740 — failed to provide behavioral / mental-health care — isolated
  Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interview, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for two Residents (#72 and #80) with a history of suicidal ideation (SI) and depression, out of a total sample of 26 residents. Specifically: 1. For Resident #72 the facility failed to provide Resident #72 with appropriate behavioral health services following verbalizations of SI and psychosocial distress. 2. for Resident #80 the facility failed to indicate any behavioral health care plan or interventions were implemented after identifying Resident #80's history of attempted suicide or suicidal ideations. Findings include: Review of the facility policy titled Behavioral Assessment, Intervention and Monitoring, dated revised March 2019 indicated that the facility will provide and the residents will receive behavioral health services as needed to attain or maintain the highest practicable…

  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
• Actual harm · G2026-03-03 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, records reviewed and interviews, the facility failed to ensure one Resident (#77), out of a total sample of 23 residents, received the necessary care and treatment, consistent with professional standards of practice, to prevent the development of pressure ulcers. Specifically for Resident #77 who was assessed by nursing to be at high risk for skin breakdown and who experienced pain and limited mobility in his/her left lower extremity following a surgical repair, the facility failed to a. ensure nursing consistently implemented diabetic foot care, implemented weekly skin checks, and implemented interventions when the Physical Therapy Assistant (PTA) identified an area of red and non-blanchable skin on Resident #77's left heel, consistent with a stage one pressure injury (intact skin with non-blanchable redness of a localized area usually over a bony prominence) on 2/2/26, and the facility failed to provide a recommended prevalon boot for Resident #77's left heel wound, subsequently the left heel wound deteriorated to an unstageable pressure ulcer (known but 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-03-03 · tag F0552 — isolated
  Ensure that residents are fully informed and understand their health status, care and treatments.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure for one Resident (#4), out of a total sample 23 residents, that informed consent, including risk and benefits, was obtained from Resident #1's legal guardian prior to administering antipsychotic medication. Findings include: Review of the facility's policy titled, Subject: Psychotropic Medication, revised 2/2025, indicated: Guidelines 1. Obtain physician's order. Note: A physician's order and appropriate diagnosis is required for all psychoactive medications. Note: An informed consent from the resident (or legally authorized individual in the case of resident incompetence) is required for administration of psychoactive medication.Resident #4 was admitted to the facility in February 2026 with diagnoses including, but not limited to, aphasia (a language disorder) following cerebral infarction (stroke), major depressive disorder, recurrent and moderate, unspecified dementia with unspecified severity and with agitation, and history 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-03-03 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to ensure a homelike environment was maintained on one of three units. Specifically, on the [NAME] Unit, the facility failed to ensure that the unit refrigerator that was on the unit in a resident space was kept in a manner that was consistent of a reasonable homelike environment as evidenced by a brown, rusted color that was stained across the entire bottom part of the front of the refrigerator.Findings include:Review of the facility policy titled Resident Home, dated and revised April 2022, indicated the following: - Residents are provided with a safe, clean, comfortable and homelike environment.On 2/26/26 at 9:14 A.M., on the [NAME] Unit, the surveyor observed the unit refrigerator in the hallway which was a part of the Resident's shared space. The entire bottom part of the refrigerator was stained with a brown substance that resembled rust that did not rub off.Throughout the survey period, multiple residents would pass by the refrigerator as they…

  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 · D2026-03-03 · tag F0604 — failed to not use physical restraints improperly — isolated
  Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interview, the facility failed to assess the use of a potential restraint for one Resident (#34) out of a total sample of 23 Residents. Specifically, for Resident #34, the facility failed to assess the use of a scoop mattress as a potential restraint. Findings include:Review of the facility policy titled Use of Restraints, dated and revised April 2022, indicated the following:- Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. The assessment shall be used to determine possible underlying causes of the problematic medical symptom and to determine if there are less restrictive interventions that may improve the symptoms.- Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative.Resident #34 was admitted to the facility in June 2020 with diagnoses including paranoid schizophrenia and chronic kidney disease.…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-03-03 · tag F0644 — isolated
  Coordinate assessments with the pre-admission screening and resident review program; and referring for services as 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 (#1), out of a total sample of 23 residents, that recommended services were implemented in accordance with the Pre-admission Screening and Resident Review (PASRR) Level II Evaluation Determination Summary. Specifically, Resident #1 was screened to meet PASRR criteria for SMI (serious mental illness) with recommended behavioral health services, individual psychotherapy. Findings include: Review of the facility's policy subject; Preadmission Screening and Resident Review (PASARR), dated revised 5/2022 indicated: It is the policy of the facility to comply and state PASARR requirements to ensure that individuals with Serious Mental Illness (SMI), Intellectual Disability (ID), or Related conditions receive appropriate screening, placement, and specialized services prior to and during admission to the facility. Further, review of the policy indicated if Level 1 is positive a level II evaluation must be completed 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.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-03-03 · 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 observation, record review and interviews, the facility failed to ensure standards of professional nursing practice for one Resident (#1) out of a total sample of 23 residents. Specifically, the nursing staff documented in Resident #1's medical record that 1:1 supervision was being provided during meals when it was not provided in accordance with the physician's orders. Findings include: Findings include: Review of [NAME], Manual of Nursing Practice 11ed, 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 and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols,…

  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 · D2026-03-03 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility failed to ensure one Resident (#77) received treatment and care in accordance with professional standards of practice, out of total sample of 23 residents. Specifically for Resident #77 who had surgery on 1/22/26, the facility failed to send the Resident #77 to his/her orthopedic follow up appointment on 2/4/26 for suture removal and the sutures were not removed until 2/24/26, 35 days after surgery, potentially placing the resident at risk for complications. Findings include:Resident #77 admitted to the facility in January 2026 with diagnosis including diabetes, disorders of bone density, obesity, heart failure, and periprosthetic fracture around internal prosthetic left knee joint. Review of Resident #77's most recent Minimum Data Set assessment, dated 2/2/26, indicated the Resident had a moderate cognitive impairment as evidenced by a Brief interview of mental status score of 12 of 15. Resident #77 did not reject care, and he/she was coded as…

  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 before2026-03-03 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and observation the facility failed to ensure medications were secure on two of three resident units. Specifically, the facility failed to:Secure a narcotic medication in the Solerna Unit medication room.a.Secure medications which were left unsupervised at the [NAME] Unit nursing station and b. secure a treatment cart on the [NAME] Unit.Findings include:1.Review of the facility policy Medication Storage, dated as revised March 2022, indicated there was no reference to the securing of narcotics in the medication room refrigerator. On 3/3/26 at 9:15 A.M., the surveyor observed the Solana dementia unit medication storage room, accompanied by Nurse #9. Nurse #9 unlocked the medication room door. Inside the room was a small, unlocked refrigerator. The surveyor opened the refrigerator and observed one large, white box and one smaller black box. The white box was locked and affixed to the shelf by nylon cable ties. The black box locked but not affixed to the refrigerator. The surveyor lifted the box…

  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 · D2026-03-03 · tag F0776 — isolated
  Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on records review, and interviews, the facility failed to obtain diagnostic services as ordered by the provider for one Resident (#77), out of a total sample of 23 residents. Specifically for Resident #77 who experienced pain in the left lower extremity the facility failed to obtain a left lower extremity ultrasound (non-invasive imaging test used to detect blood clots, evaluate venous flow, and assess venous valve function in the leg). Findings include: Review of the facility policy titled, Labs and Diagnostics, dated as revised 5/2025, indicated:Assessment and Recognition 1. The physician will identify and order diagnostic and lab testing based on diagnostic and monitoring needs. 2. The staff will process test requirements and arrange for tests.3. The laboratory, diagnostic radiology provider, or other testing source will report test results to the facility. Resident #77 admitted to the facility in January 2026 with diagnosis including diabetes, disorders of bone density, obesity, heart failure, and periprosthetic fracture around internal prosthetic left knee joint. 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.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-02-04 · tag F0867 — failed to act on quality-improvement findings — widespread
  Set 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

  Based on observation, review of the Quality Assurance Performance Improvement (QAPI) plan, and interview, the facility failed to ensure that the Quality Assurance Committee developed and implemented an appropriate corrective action plan with effective monitoring for non-functioning call bell systems and Infection Control program related to COVID-19 vaccinations. Findings Include: During the survey period, multiple residents were identified as having signed consent to receive the COVID-19 vaccine however the facility failed to order the vaccine from the pharmacy or provide any monitoring of the vaccination status of Residents. During the survey period, two out of three nursing units were identified as having non-functioning call bell systems in place. Review of the QAPI program for the year 2024, failed to indicate that a QAPI was established and implemented for the ongoing non-functioning of the call bell system on two out of three units. Review of the QAPI program for the year 2024, failed to indicate that a QAPI was established and implemented for Infection Control program related…

  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 · F2025-02-04 · tag F0881 — failed to use antibiotics responsibly — widespread
  Implement a program that monitors antibiotic use.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review and interview, the facility failed to implement an antibiotic stewardship program to promote and monitor the appropriate use of antibiotics. Findings include: Review of the Centers for Disease Control and Prevention (CDC) guidance titled The Core Elements of Antibiotic Stewardship for Nursing Homes, undated, indicated but was not limited to the following: -The purpose of an antibiotic stewardship program is to improve the use of antibiotics in healthcare to protect patients and reduce the threat of antibiotic resistance. -Antibiotic stewardship refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. -The CDC recommends that all nursing homes take steps to improve antibiotic prescribing practices and reduce inappropriate use. -Any action taken to improve antibiotic use is expected to reduce adverse events, prevent emergence of resistance, and lead to better outcomes for residents in this setting. Review of the facility policy titled Antibiotic Stewardship,…

  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

“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.

Fines & penalties

$111,093 in federal fines across 2 penalties.

• $47,250 — penalty dated 2026-03-03
• $63,843 — penalty dated 2025-02-04

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 VANTAGE CARE — 10 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 →

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

CMS files one row per role, so the 9 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted.

2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

About 85% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.8M paid to related parties — landlords or management companies under common ownership — equal to about 14% 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