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Brookside Rehabilitation And Healthcare Center

11 Pontiac Avenue, Webster, MA 01570 · For profit - Limited Liability company · 81 certified beds · (508) 943-3889 Medicare & Medicaid certified

Call the home — (508) 943-3889 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0605) — cited Jul 2025Behavioral-health or dementia-care citation — no harm found (F0740)1 actual-harm citation
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure rating is low (1/5)

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

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

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

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
344 Thompson Rd · (508) 949-6880 · Call to confirm hours
Pharmacy
2 Worcester Rd · (508) 949-8804 · Call to confirm hours
Grocery
2 Worcester Rd · (508) 943-7232 · Call to confirm hours
Park
39 Davis St · Typically dawn to dusk
Place of worship
129 E Main St · (508) 213-8226

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

Quality measures — how residents actually fare

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

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 2 stars. From monthly CMS archive snapshots.

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

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased23.1%16.4%15.4%worse
Long-stay residents who lose too much weight3.5%5.1%5.4%better
Long-stay residents with a catheter left in their bladder1.0%0.8%0.9%typical
Long-stay residents with a urinary tract infection6.8%1.8%2.0%worse
Long-stay residents with depressive symptoms5.3%15.5%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury3.5%3.4%3.3%typical
Long-stay residents whose ability to walk worsened22.5%15.4%16.1%worse
Long-stay residents on antianxiety or hypnotic medication14.2%19.5%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%94.8%95.3%typical
Long-stay residents with pressure ulcers5.1%4.2%4.7%typical
Long-stay residents with worsening bladder/bowel control24.3%21.2%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table22.5%21.4%17.1%worse
Short-stay residents who newly got an antipsychotic medication6.8%1.4%1.4%worse
Short-stay residents given the seasonal flu vaccine82.8%77.7%79.4%typical
Short-stay residents rehospitalized after admission37.5%25.7%22.6%worse
Short-stay residents with an outpatient ER visit14.5%11.9%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.341.881.67worse
Long-stay outpatient ER visits per 1,000 resident days3.731.501.80worse

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.

52.3% 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 40 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

52.3%U.S. median 51.5%
Got home and stayed home
9.6%U.S. median 10.7%
Went back to hospital
0.23U.S. median 0.31
Therapy hours / resident / day
0.06hours / resident / day
Physical therapy
0.13hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.23 therapist hours per resident per day in 2026Q1 — more than 28% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 42% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF52.3%CMS range 40.0–65.251.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.6%CMS range 6.6–14.410.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identifiednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — 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 staynot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.961.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.61
RN hours/ resident / day
0.85
LPN hours/ resident / day
2.42
Aide hours/ resident / day
3.88
Total nurse hours/ resident / day
0.38
RN hoursweekends
41.8%
Total nursing turnover
54.5%
RN turnover

How full it usually is: this home is certified for 81 beds and averages 67.9 residents a day — about 84% occupied, or roughly 13 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 3.88 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.61 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.42 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 3.60 hrs/resident/day on weekends vs 4.00 on weekdays — 10% thinner on weekends. RN hours go from 0.71 to 0.38 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 42% is about the same as the national median of 45%.

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

Inspection trend

11
deficiencies at the latest standard inspection (2025-07-30)
10
at the previous standard inspection (2024-05-02)

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.

ABCDEFGHIJKL

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

30 citations, most serious first. The 11 most serious are shown; the remaining 19 are one tap away and print in full.

  • Actual harm · G2022-11-01 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, document review and interview, the facility failed to ensure its staff provided adequate assistance devices to prevent accidents for one Resident (#42), out of three discharged sampled Residents and failure to ensure the environment remained as free of accidents as possible. Specifically, 1) the facility failed to ensure that Resident #42's wheelchair foot pedals were functioning properly to help prevent major injuries from one of two falls the resident sustained, and 2) the staff failed to monitor the temperatures of foods that had been reheated in the microwave and provided to residents. Findings include: 1) Review of the facility's Falls Management Policy and Procedure, updated 10/6/22, indicated the following: -The facility will utilize all resident/patient related information made available upon admission and ongoing to determine resident/patient at-risk for fall status. -Fall Risk Factors: a) Environmental: improperly fitted or maintained wheelchairs. b) 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-14 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had an invoked Health Care Proxy (HCP) that had been affirmed by the Courts, the facility failed to ensure it maintained a complete and accurate medical record when there was no copy of the HCP readily available or accessible in his/her medical record.Findings include:Review of the facility policy titled Resident Representative, revised February 2021, indicated the Facility treats the decisions of the resident representative as the decisions of the resident to the extent delegated by the resident or to the extent required by the court, in accordance with applicable law. Documentation designating that the representative has been delegated the necessary authority to exercise the resident's rights for decision-making issues is obtained by the director of nursing or a designee.Resident #1 was admitted to the facility December 2025, diagnoses included unspecified severe dementia with mood disturbance, hypertension, and osteoarthritis of the knees.Review of Resident #1's Minimum Data Set (MDS)…

    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 · E2025-07-30 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    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 record review, interviews, and observations, the facility failed to maintain a clean and homelike environment for one Resident (#56) and 12 out of 15 rooms observed on two Units ([NAME] and [NAME]) out of two resident units. Specifically, the facility failed to ensure that room of the day deep-cleaning were completed relative to the room of the day cleaning schedule for:-Resident #56's bedroom.-rooms [ROOM NUMBER] on the [NAME] Unit.-Rooms 201, 202, 204, 206, 207, 208, 209, 221, and 224 on the [NAME] Unit. Findings include: Review of the facility policy titled Room of The Day, revised February 2021, included but was not limited to: -Residents are provided with safe, clean, comfortable and homelike environment. -The staff and management develop room of the day schedule for terminal cleaning of rooms to assure rooms are clean, sanitary, comfortable . -Strip bed and remove linen. -Clean all furniture. -Sweep/mop floors. -Remove curtains, clean above windowsills, light fixtures, fans, etcetera. Resident #56…

    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 · D2025-07-30 · tag F0605 — failed to not use drugs as a restraint — isolated
    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record reviews, and interviews, the facility failed to ensure that two Residents (#11 and #56) of five applicable residents, out of a total sample of 19 residents were free from unnecessary psychotropic medications. Specifically:For Resident #11, the facility failed to ensure a Physican order for PRN antipsychotic medications was limited to 14 days.For Resident #56, the facility failed to ensure a Gradual Dose Reduction (GDR) was attempted related to antidepressant medication use or provide supporting evidence that a GDR attempt was contraindicated. Findings include: 1. Review of the facility policy titled Antipsychotic Medication Use, revised July 2022, indicated the following: -PRN (as needed) orders for antipsychotic medications will not be renewed beyond 14 days unless the heath care practitioner has evaluated the resident for appropriateness of that medication and documented the rationale for continued use. -The duration of the PRN order will be indicated in the order. Resident #11 was admitted to the facility in March 2025, with diagnoses including Vascular Dementia…

    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 · D2025-07-30 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to provide appropriate treatment and services relative to an indwelling urinary catheter (a thin, flexible tube inserted into the bladder to drain urine outside the body) for one Resident (#56) out of a total sample of 19 residents.Specifically, for Resident #56, the facility staff failed to follow the Physician order's relative to the Foley (type of indwelling urinary catheter) catheter size, increasing the Resident's risk for indwelling urinary catheter complications. Findings include: Review of the facility policy titled Catheterization Foley, dated April 2018, indicated:-Indwelling urinary catheters are used only when there is valid medical justification.-the Foley catheter will be changed only when needed, unless otherwise specified by the Physician, Nurse Practitioner (NP) or Physician Assistant (PA).-Foley catheters should be changed when:>urinary tract infection is suspected>clogged or unable to irrigate>displaced (balloon [retention…

    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 · D2025-07-30 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, and interviews, the facility failed to provide adequate nutritional care and services for one Resident (#39), out of a total sample of 19 residents. Specifically, the facility failed to appropriately address a significant weight loss when Resident #39 was identified as having a greater than 5 percent (%) weight loss in one month and no re-weight was completed as required. Findings include: Review of the facility policy titled .Nursing Policy and Procedure Manual: Nutritional Services, last revised May 2024, indicated the following:-The facility will perform the following best practice guidelines to manage risk of unplanned weight change and ensure the nutritional needs are met for all residents.-Residents are weighed a minimum of monthly, by the 7th day of each month with more frequent weights obtained as ordered or deemed necessary.-Residents are weighed in a consistent manner, using the same scale, consistent time of day, and consistent clothing/devices at time of weight.-Weights are…

    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 before2025-07-30 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide respiratory care and services in accordance with professional standards of practice for one Resident (#29), out of a total sample of 19 residents. Specifically, for Resident #29, the facility failed to ensure that Physician orders for oxygen use were in place when the Resident was being administered oxygen. Findings include: Review of the facility policy titled Oxygen Administration - Reservoir or Pendant Style Nasal Cannula/Oxymizer, adopted November 2017, indicated:-Policy: To deliver low flow oxygen rates and concentration, per the Physician's order via oxygen conserving devices that serve to reduce oxygen usage and nasal irritation. Resident #29 was admitted to the facility in June 2025 with diagnoses including Chronic Kidney Disease (CKD), Obstructive Sleep Apnea (OSA), Acute and Chronic Respiratory Failure with Hypoxia, and Chronic Obstructive Pulmonary Disease (COPD). Review of the Minimum Data Set (MDS) assessment dated…

    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 before2025-07-30 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide 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 observations, interviews, and record reviews, the facility failed to provide care and services consistent with professional standards of practice for one Resident (#54), out of one applicable resident receiving dialysis (process that filters waste and fluids from the blood when the kidneys are unable to work adequately) services, out of a total sample of 19 residents.Specifically, for Resident #54, the facility failed to ensure:-Timely medication administration on the Resident's scheduled dialysis days (Tuesdays, Thursdays, and Saturdays), when scheduled morning medication administration was delayed until after the Resident's return to the facility in the early afternoon on dialysis days.-That Eliquis (medication to prevent and treat blood clots), ordered to be administered twice daily by the Physician, was being administered at appropriate intervals on dialysis days placing the Resident at risk for complications related to bleeding.-Accurately monitor daily fluid intake, as ordered by the Physician, when the Resident was dependent on renal dialysis, placing the Resident 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-30 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, and interviews, the facility failed to ensure proper sanitation and food storage practices to prevent the potential spread of foodborne illnesses on two kitchenettes ([NAME] Unit and [NAME] Unit) out of two kitchenettes observed. Specifically, the facility failed to ensure that the [NAME] Unit and [NAME] Unit kitchenette refrigerators: -had food items that were dated to ensure proper rotation by expiration dates.-were kept clean and sanitized on a scheduled basis.-had food/drink items that were not expired or past the perish dates. Findings include: Review of the Facility Policy titled Refrigerators and Freezers, revised December 2014, indicated: -All food shall be appropriately dated to ensure proper rotation by expiration dates. -Expiration dates on unopened food will be observed and use by dates indicated once food is opened. -Supervisors will be responsible for ensuring food items in pantry, refrigerators, and freezers are not expired or past perish dates. -Refrigerators and freezers…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-07-30 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to maintain clinical records in accordance with professional standards of practice relative to accurate documentation for two Residents (#45 and #56) out of a total sample of 19 residents.Specifically, the facility failed to: 1.For Resident #45, document the PRN (as needed) administration of Tramadol (opioid analgesic - controlled medication used to treat pain, having the potential for abuse and addiction), and its effectiveness, on the Resident's Medication Administration Record (MAR) when a PRN dose of Tramadol was administered to the Resident. 2. For Resident #56, the facility failed to complete accurate documentation relative to changing the Resident's Foley (type of indwelling urinary catheter) catheter size, increasing the Resident's risk for indwelling urinary catheter complications. Findings include: 1.Review of the facility's policy titled Medication Pass, dated April 2018, indicated the following: - Med (medical) record is…

    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 before2025-07-30 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record and policy review, the facility failed to implement an infection control program designed to help prevent the potential transmission of communicable diseases and infections within the facility for one Resident (#6) out of a total sample of 19 residents. Specifically, the facility staff failed to disinfect a multi-use Glucometer (machine used to test a resident's blood for blood sugar levels) after use on a resident, prior to placing the same equipment back into the medication cart. Findings include: Review of the facility policy titled Infection Control, revised October 2018, indicated but was not limited to:-The facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections.-The objectives of our infection control policies and procedures are to:>prevent, detect, investigate, and control infections in the facility.>provide guidelines for the safe cleaning and reprocessing of reusable resident-care…

    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
Show the remaining 19 citations
  • Potential for harm · D2025-07-30 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interview, the facility failed to assess the Pneumococcal Vaccine status, and/or administer Pneumococcal vaccinations as consented to by two Residents (#11 and #9), of five applicable residents, out of a total sample of 19 residents.Specifically, 1. For Resident #11, the facility failed to assess for Pneumococcal consent or declination for the Resident and to provide education relative to Pneumococcal vaccination at the time of admission. 2. For Resident #9, the facility failed to obtain a Physician's order and administer PCV 20 (Pneumococcal Conjugate Vaccine/ Prevnar 20: vaccine used to protect against 20 types of pneumococcal bacteria that commonly cause serious infections) at the time of admission when the Resident consented to PCV20 vaccination. Findings include: Review of the facility's policy titled Pneumococcal Vaccination dated April 2018, indicated but was not limited to the following: -It is the policy of the facility that Pneumococcal Vaccine will be offered to every new…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-05-02 · tag F0657 — failed to keep the care plan current — pattern
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to conduct interdisciplinary care plan meetings after Minimum Data Set (MDS) assessments were completed, and also failed to involve the Resident and/or Resident Representative in the care planning process for four Residents (#2, #67, #3, and #60) out of a total sample of 18 residents. Specifically, the facility failed to: 1. For Resident #2, provide evidence that the Resident and/or their invoked HCP had participated in the care planning process and that Interdisciplinary Team (IDT) care plan meetings were held for the Resident in 2024 following the MDS assessments completed on 1/9/24 and 4/9/24. 2. For Resident #67, provide evidence that the Resident and/or the Resident's Representative participated in the care planning process, or that a care plan meeting was held with the IDT following the MDS assessment completed on 1/24/24. 3. For Resident #3, provide evidence of care plan meetings being held, or that the Resident and/or Representative had…

    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 · D2024-05-02 · tag F0561 — failed to honor residents' choices — isolated
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure that a Resident's choices were honored when requested by his/her Resident Representative for one Resident (#14) out of a total sample of 18 residents. Specifically, the facility failed to evaluate whether the Resident Representatives' request for Resident #14 to receive double meal portions was appropriate for him/her, and implement the request if it was determined to be appropriate for the Resident indicated by family as always being hungry. Findings include: Resident #14 was admitted to the facility in June 2019, with a diagnosis of Dementia with Behavioral Disturbance (progressive disease with impairment in memory and functioning that includes symptoms such as depression, anxiety, psychosis, agitation, aggression, disinhibition, and sleep disturbances). During an interview on 4/30/24 at 12:01 P.M., Resident Representative #1 said he/she had requested double meal portions for Resident #14 on multiple occasions. Resident Representative #1 said when family visited with Resident #14, he/she was always hungry.…

    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 · D2024-05-02 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that care plans were developed and implemented accordingly for one Resident (#14) out of a total sample of 18 residents. Specifically, -For Resident #14 the facility failed to develop a care plan related to the Resident's behavior of eating nonfood items and topical medications. Findings include: Review of the facility policy titled Behavioral Assessment, Intervention, and Monitoring, revised March 2019, indicated the following: -The interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress, and potential safety risk to the resident, and develop a plan of care accordingly. Resident #14 was admitted to the facility in June 2019 with a diagnosis of Dementia with Behavioral Disturbance (progressive disease with impairment in memory and functioning that includes symptoms such as depression, anxiety, psychosis, agitation, aggression, disinhibition, and sleep disturbances). 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-02 · 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, interview, policy and record review, the facility failed to provide nutrition care and services that meet professional standards of practice in identifying and preventing a significant weight loss for one Resident (#65) recieving artificial nutrition via a Jejunostomy tube (J-Tube: a feeding tube that passes directly into the small intestine), out of a total sample of 18 Residents. Specifically, the facility staff failed to: -appropriately implement, monitor and evaluate weekly weights as ordered for the Resident, and reassess Resident refusal to be weighed. -assess tube feeds recommendations made by the Registered Dietitian (RD), and refer and/or offer alternative options when the Resident was unable to tolerate increased tube feeds and calorie goals. Findings Include: Review of the Professional Standards of Practice in the [NAME] NURSING PROCEDURES, 9th edition 2023, indicates the following relative to Enteral (method of feeding that uses the gastrointestinal (GI) tract to deliver…

    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 before2024-05-02 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, policy and record review, the facility failed to provide respiratory care and services consistent with professional standards of practice for two Residents (#272 and #3), out of 3 applicable residents, out a total sample of 18 residents. Specifically, the facility staff failed to: 1) For Resident #272, a) ensure that the aerosol compressor (a large volume nebulizer that is used in tracheostomy patients to deliver a high-volume mist that moisturizes/ humidifies the airway) was monitored and maintained for optimal humidification of the Resident's tracheostomy ( an opening surgically created through the neck into the trachea [windpipe] to allow direct access to the breathing tube) tube, b) ensure a Physician's order was obtained for oxygen use and increased liter flow, and c) that oxygen tubing equipment was changed as required to prevent contamination and the spread of infections. 2) For Resident #3, change oxygen tubing and nebulizer tubing and mask as ordered to ensure that the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-02 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, policy and record review, the facility failed to provide services consistent with professional stands of practice related to hemodialysis (a procedure to remove waste products and fluid from the blood by passing it through a special machine, necessary when the kidneys are unable to filter the blood) were provided for one Resident (#17), out of a total sample of 18 residents. Specifically, the facility failed to monitor Resident #17's AV (Arterio-Venous) Fistula (dialysis access site) for signs and symptoms of patency and infection. Findings include: Review of the facility policy titled Care of a Resident with End Stage Renal Disease (ESRD, the stage of renal impairment that appears irreversible and permanent, and requires a regular course of dialysis or kidney transplantation to maintain life), revised September 2010, indicated the following: -Staff caring for residents with ESRD, including residents receiving dialysis care outside the facility, shall be trained in the care and special needs…

    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 · D2024-05-02 · 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 record review, the facility failed to ensure that medications were stored safely and remained inaccessible to one Resident (#14) out of a total of 18 sampled residents. Specifically, the facility failed to: -ensure that [NAME] Lotion (an anti-itch topical [applied to the skin] medication) was safely stored, and locked up out of reach for Resident #14, resulting in him/her ingesting the medication and requiring hospitalization. -ensure that house barrier cream (a skin protectant cream) was safely stored and not easily accessible to Resident #14, resulting in him/her ingesting the medication and requiring monitoring for possible gastrointestinal upset. Findings include: Review of the facility policy titled Medication Storage in the Facility, revised 2019, indicated the following: -Medications and biologicals are stored safely, securely, and properly . -The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-02 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain complete and accurate medical records for one Resident (#14) out of 18 residents sampled. Specifically, for Resident #14, the facility staff failed to accurately update the Resident's Physician's orders to accurately match the Massachusetts Medical Order for Life-Sustaining Treatment (MOLST- form that indicates a person's medical wishes regarding life sustaining treatments). Findings include: Resident #14 was admitted to the facility in [DATE], with a diagnosis of Dementia with Behavioral Disturbance (progressive disease with impairment in memory and functioning that includes symptoms such as depression, anxiety, psychosis, agitation, aggression, disinhibition, and sleep disturbances). Review of the Resident's MOLST signed by the Resident Representative on [DATE], and by the Physician, Nurse Practitioner, or Physician's Assistant on [DATE], indicated the following request: -Do Not Resuscitate (do not perform cardiopulmonary resuscitation…

    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 before2024-05-02 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record and policy review, the facility failed to adhere to infection control standards for one Resident (#272) out of a total sample of 18 residents, putting the Resident at risk for contamination and the spread of infection. Specifically, the facility staff failed to: -identify the need for Enhanced Barrier Precautions (EBP) for Resident #272, when the Resident was indicated with indwelling medical devices of tracheostomy (an opening surgically created through the neck into the trachea [windpipe] to allow direct access to the breathing tube) and gastrostomy tube (G -Tube: a tube that is placed directly into the stomach through an abdominal wall incision for the enteral [passing through the gastrointestinal tract] administration of food, fluids, and medication). -provide appropriate signage and communication to staff relative to EBP and the appropriate PPE (personal protective equipment) usage. Findings include: Review of the Centers for Medicare and Medicaid Memo QSO-24-08-NH, dated 3/20/24, indicated the following: -Enhanced Barrier Precautions…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-11-01 · tag F0838 — failed to assess facility resources and resident needs — pattern
    Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on document review, and interview, the facility failed to ensure its staff reviewed and updated the Facility Assessment yearly (missing two years), to determine what resources are necessary to competently care for its residents during both day-to-day operations and emergencies. Finding include: On 10/28/22 at 8:57 A.M., the surveyor reviewed the Facility Assessment document. It was signed and dated 8/27/20. During an interview on 10/28/22 at 12:33 P.M., the Director of Nurses(DON) said the current Facility Assessment had not been updated and/or reviewed since 8/27/20. During an interview on 10/28/22 at 12:41 P.M., the Administrator said, after reviewing the Facility Assessment, that it had not been updated and/or reviewed yearly, as required.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-11-01 · tag F0687 — failed to care for feet properly — isolated
    Provide appropriate foot care.
    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 that its staff provided Podiatry care for one Resident (#20) out of 15 sampled residents. Specifically, lack of appropriate foot care leading to poor foot health and the development of a pressure ulcer on the Resident's left index toe. Findings include: Resident #20 admitted to the facility in August 2022 with diagnoses including Dementia (a group of symptoms that affects memory, thinking and interferes with daily life) and Hypertension (high blood pressure). Review of Resident #20's Minimum Data Set (MDS) Assessment, dated 8/18/22, indicated that the Resident was cognitively impaired as evidenced by completion of the staff assessment indicating both impaired short-term and long-term memory, as well as impaired decision makings skills. Further review of the MDS revealed that the Resident required extensive assistance for personal hygiene and was at risk for the development of pressure ulcers. Review of Resident #20's Activities of Daily Living (ADL) care plan, last revised 8/25/22, indicated 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-11-01 · tag F0730 — isolated
    Observe each nurse aide's job performance and give regular training.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on interview, the facility failed to ensure that all Certified Nurses Aides (CNA) were offered the 12 hours of in-service education training as required annually. Findings include: During an interview on 10/28/22 at 8:57 A.M., the Director of Nurses (DON) said that she and the new Staff Development Coordinator (SDC) were working on staff training. She said she was unsure if the facility had provided 12 hours of in-service education to the CNAs. During an interview on 10/28/22 at 2:05 P.M., the SDC said the facility provided an educational competency fair for the staff. The SDC said she was unsure if the facility had provided 12 hours of education for all CNAs. During an interview on 10/31/22 at 12:17 P.M., the DON said she was unable to provide evidence that 12 hours of training was provided by the facility to the CNA's as required.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-11-01 · 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 record review, and interview, the facility failed to ensure its staff provided care and services related to Substance Use Disorder (SUD- a mental disorder that affects a person's brain and behavior, leading to a person's inability to control their use of substances such as legal or illegal drugs, alcohol, or medications. Symptoms can range from moderate to severe, with addiction being the most severe form of SUDs) for one Resident (#18) out of 15 sampled residents. Findings include: Resident #18 was admitted to the facility in [DATE]. Review of the Health Care Facility Reporting System (HCFRS) indicated the facility reported that Resident #18 sustained a drug overdose in the facility on [DATE]. Review of a Progress Note, dated [DATE], indicated the Resident returned to the facility from the hospital. Further review of the Progress Note, dated [DATE], indicated the Resident had an unresponsive episode at the facility on [DATE] and Emergency Medical Technician's (EMTs) administered Narcan (medication used…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-11-01 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure its staff maintained a medication error rate less than 5%. Specifically, two out of three nurses observed failed to administer medications as ordered, for one Resident (#7). The medication error rate was calculated at 8% with 25 opportunities for error. Findings include: Resident #7 was admitted to the facility in June 2017 with a diagnosis of End Stage Renal Disease (ESRD- a disease that affects the kidneys and leads to loss of kidney function). During a medication administration observation on 10/27/22 at 7:44 A.M., the surveyor observed Nurse #1 pour and administer medications to Resident #7 including two 325 milligram (mg) tablets of Sodium Bicarbonate (given to people with ESRD to slow down the loss of kidney function) equaling a total dose of 650 mg of Sodium Bicarbonate. Review of the October 2022 Physician orders indicated an order initiated on 9/22/22, for Sodium Bicarbonate Tablet 650 mg, give 1300 mg by mouth in the morning related to acute kidney failure, unspecified. During an interview…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-11-01 · tag F0885 — failed to notify residents/families about COVID-19 — isolated
    Report COVID19 data to residents and families.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on document review and interview, the facility failed to ensure that its staff notified Residents, families, or Resident Representatives of COVID-19 positive staff cases in the facility by 5:00 P.M. the next calendar day during the month of October 2022, as required. Findings include: Review of the Centers for Medicare and Medicaid Services Interim Final Rule Updating Requirements for Notification of Confirmed or Suspected COVID-19 cases of Residents and staff in nursing homes, Reference: QSO-20-29-NH dated May 6, 2022, indicated: (3) Inform residents, their representatives, and families of those residing in facilities by 5 p.m. the next calendar day following the occurrence of either a single confirmed infection of COVID-19, or three or more residents or staff with new-onset of respiratory symptoms occurring within 72 hours of each other . During an interview on 10/26/22 at 11:02 A.M., the Infection Preventionist (IP) said that the last staff member in the facility to test positive for COVID occurred on 10/3/22. She also said that the Administrator was responsible 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-11-01 · tag F0887 — isolated
    Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
    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 that its staff maintained education regarding the potential benefits and risks of the COVID-19 vaccination for two Residents (#50 and #51) out of five sampled residents. Specifically, the facility failed to ensure that its staff provided evidence of offering the COVID-19 vaccination and that the Residents refused. Findings include: Review of the facility policy titled Infection Control-COVID VACCINATION, dated 5/15/21, indicated the resident's medical record includes documentation that indicates, at a minimum, the following: -that the resident or resident representative was provided education regarding the benefits and potential risks associated with COVID-19 vaccine; and -each dose of COVID-19 vaccine administered to the resident, or -if the resident did not receive the COVID-19 vaccine due to medical contraindications or refusal. 1. Resident #50 was admitted to the facility in September 2022. Review of the medical record failed to indicate that the Resident had been offered and/or was educated on the…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • No harm found · Bcited before2025-07-30 · tag F0641 — pattern
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, and interviews, the facility failed to complete Comprehensive Minimum Data Set (MDS) Assessments that accurately reflected the status of three Residents (#11, #45, and #54) out of a total sample of 19 residents, for care planning and care delivery. Specifically, 1. For Resident #11, the facility failed to accurately code diuretic medications when the Resident was prescribed and received diuretic medication. 2. For Resident #45, the facility failed to accurately code the MDS Assessment relative to the use of anticoagulant medication when anticoagulant medication had not been ordered and administered to the Resident.3. For Resident #11, the facility failed to accurately complete the MDS assessment relative to the use of tobacco products, when the Resident was an identified smoker.4. For Resident #54, the facility staff failed to accurately code for Therapeutic Diet when Resident #54 was prescribed and received Therapeutic Diet on two consecutive MDS assessments. Findings include: 1. 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.

    Resident Assessment and Care Planning Deficiencies · No revisit needed
  • No harm found · Bcited before2024-05-02 · tag F0641 — pattern
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that the Minimum Data Set (MDS) Assessments were accurately coded for two Residents (#22 and #29), out of a total sample of 18 residents. Specifically, the facility failed to: 1. For Resident #22, accurately code the MDS to reflect pressure ulcers as present on re-admission to the facility and not facility acquired. 2. For Resident #29, accurately code the MDS to reflect the use of IV (intravenous- within a vein) hydration. Findings include: 1. Resident #22 was admitted to the facility in December 2021, with diagnosis including Diabetes Mellitus with Autonomic Neuropathy (a condition that occurs when the body develops insulin resistance and no longer responds effectively to insulin and causes nerve damage because of high blood sugar levels). Review of the Nursing Progress Note dated 12/6/22 indicated Resident #22: -Had been on a medical leave of absence (MLOA) -Returned to the facility with a pressure area on the coccyx (the last…

    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

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to EPHRAM LAHASKY — 22 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 2 of 51.8+0.2 vs chain
Health inspection 3 of 51.9+1.1 vs chain
Staffing 4 of 52.1+1.9 vs chain
Quality measures 1 of 53.0-2.0 vs chain
The other 21 homes this chain runs (chain average 1.8★, 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 / managerTypeRoleShareSince
BNB HEALTH CARE FUNDS LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST7%since 05/16/2017
BIDERMAN, MICHAELIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL42%since 05/16/2017
BIDERMAN, YEHUDAIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST10%since 05/16/2017
MARTIN, BRADLEYIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST5%since 05/16/2017
PRESUTTI, MARKIndividualW-2 MANAGING EMPLOYEEsince 07/24/2017
LAHASKY, EPHRAMIndividualOPERATIONAL/MANAGERIAL CONTROLsince 05/16/2017

CMS files one row per role, so the 7 rows in the source record cover these 6 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.

$7.5M
Net patient revenuemost recent cost report
-7.7%
Operating marginrevenue minus expenses
$534K
Related-party expense7% of expenses
Who pays — share of resident-days
Medicaid 64%Medicare 9%Other / private 28%

This home reported $534K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

Cost & finances

$340per resident / day
operating cost
$10,321per month
≈ monthly operating cost
$315per day
avg. revenue, all payers

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

What families pay in MA

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 225483. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-07-30, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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