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Beaumont Rehab & Skilled Nursing Ctr - Westboro

3 Lyman Street, Westborough, MA 01581 · For profit - Corporation · 152 certified beds · (508) 898-3490 Medicare & Medicaid certified

Call the home — (508) 898-3490 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0604) — cited Dec 2024Behavioral-health or dementia-care citation — no harm found (F0740)1 actual-harm citation CMS recorded as corrected before the inspection ended (past non-compliance)$12,735 in federal fines
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • a middle-of-the-pack inspection score (3/5)
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $12,735 in federal fines (most recent 2026-02-26)

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.

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

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
24 Lyman St Ste 130 · (508) 836-8733 · Call to confirm hours
Pharmacy
74 E Main St · (508) 366-0670 · Call to confirm hours
Grocery
18 Lyman Street · (508) 366-7037 · Call to confirm hours
Park
600 Union St · (508) 898-0104 · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 4 of 5
Short-stay residentsrehab / post-hospital 5 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 4 to 3 stars. From monthly CMS archive snapshots.

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

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased13.9%16.4%15.4%better
Long-stay residents who lose too much weight4.2%5.1%5.4%better
Long-stay residents with a catheter left in their bladder2.0%0.8%0.9%worse
Long-stay residents with a urinary tract infection0.6%1.8%2.0%better
Long-stay residents with depressive symptoms4.5%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 injury5.9%3.4%3.3%worse
Long-stay residents whose ability to walk worsened10.8%15.4%16.1%better
Long-stay residents on antianxiety or hypnotic medication12.0%19.5%18.9%better
Long-stay residents given the seasonal flu vaccine99.1%94.8%95.3%typical
Long-stay residents with pressure ulcers3.2%4.2%4.7%better
Long-stay residents with worsening bladder/bowel control17.2%21.2%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table19.0%21.4%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.9%1.4%1.4%better
Short-stay residents given the seasonal flu vaccine90.3%77.7%79.4%better
Short-stay residents rehospitalized after admission32.7%25.7%22.6%worse
Short-stay residents with an outpatient ER visit6.8%11.9%12.0%better
Long-stay hospitalizations per 1,000 resident days1.871.881.67worse
Long-stay outpatient ER visits per 1,000 resident days1.251.501.80better

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.

67.3% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 252 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

67.3%U.S. median 51.5%
Got home and stayed home
10.3%U.S. median 10.7%
Went back to hospital
55.1%U.S. median 56.6%
Met the expected recovery
0.18U.S. median 0.31
Therapy hours / resident / day
0.08hours / resident / day
Physical therapy
0.07hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 55.1% 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 147 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 15% 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 SNF67.3%CMS range 60.2–73.151.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.3%CMS range 7.8–13.410.7%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 discharge55.1%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge46.3%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge59.9%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final 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 stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened1.9%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization5.8%CMS range 3.8–8.97.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.721.02Oct 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

0.48
RN hours/ resident / day
1.22
LPN hours/ resident / day
1.85
Aide hours/ resident / day
3.55
Total nurse hours/ resident / day
0.32
RN hoursweekends
40.2%
Total nursing turnover
50.0%
RN turnover

How full it usually is: this home is certified for 152 beds and averages 143.9 residents a day — about 95% occupied, or roughly 8 beds typically open. It runs fairly full. 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 3.55 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.48 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.85 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 3.18 hrs/resident/day on weekends vs 3.70 on weekdays — 14% thinner on weekends. RN hours go from 0.55 to 0.32 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 40% 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

7
deficiencies at the latest standard inspection (2026-03-18)
5
at the previous standard inspection (2024-12-10)

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.

25 citations, most serious first. The 11 most serious are shown; the remaining 14 are one tap away and print in full.

  • Actual harm · G2026-02-26 · 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

    Based on records reviewed and interviews for one of three sampled residents (Resident #1), who required set up assistance with meals and beverages, the Facility failed to ensure his/her environment was free from accidents resulting in serious injury, when on 1/16/26, a staff member served Resident #1 a hot cup of coffee that had been reheated in the microwave, however the staff member did not check the temperature of the coffee, in accordance with facility policy, before serving it to him/her. The hot coffee was spilled onto Resident #1, and he/she sustained second degree burns (partial thickness, involves both the first and second layer of skin and appears red, blistered, and maybe swollen or painful) to his/her bilateral upper thighs, which required daily treatment and monitoring by nursing.Findings include:Review of the Facility's protocol titled Microwave Safety for Hot Liquids dated 05/08/2011, indicated any liquids heated in the microwave will have temperature checked and the acceptable serving temperature is between 135-155 degrees Fahrenheit.Review of the American Burn…

    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 · Past Non-Compliance
  • Potential for harm · Ecited before2026-03-18 · tag F0760 — failed to prevent significant medication errors — pattern
    Ensure that residents are free from significant medication errors.
    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 two Residents (#11 and #6), out of a total sample of 30 residents, were free from significant medication errors. Specifically, the staff failed to: 1. For Resident #11, ensure that Seroquel (a medication used to help regulate mood, behaviors and thoughts) was accurately transcribed onto the Medication Administration Record (MAR), resulting in the Resident missing 19 doses of the prescribed medication, and increasing the risk for worsening mood and behavior patterns. 2. For Resident #6, ensure Metoprolol Tartrate (medication used to treat high blood pressure) and Midodrine (medication used to treat low blood pressure) were administered to the Resident in accordance with physician ordered parameters, increasing the Resident's risk for adverse medication reactions. Findings include: 1. Resident #11 was admitted to the facility in November 2023 with diagnoses including Dementia, Parkinson's Disease, and Adjustment disorder with depressed mood. Review of the Resident's written Physician's Order, dated 2/24/26,…

    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 · E2026-03-18 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and records reviewed, the facility failed to provide food at safe and appetizing temperatures to residents from two out of three lunch meal carts on two Units ([NAME] Unit and [NAME] Unit) out of three total resident units.Specifically, the facility failed to provide food at safe and appetizing temperatures for the lunch meal for Residents eating lunch on the [NAME] Unit and [NAME] Unit, increasing residents' risks for reduced food/fluid intake. Findings include:Review of the facility's policy titled Food: Quality and Palatability, revised February 2023, included but was not limited to: -Food will be prepared by methods that conserve nutritive value, flavor and appearance. -Food will be palatable, attractive and served at a safe and appetizing temperature.-Food and liquids are prepared and served in a manner, form and texture to meet resident's needs.-Food should be at the appropriate temperature as determined by the type of food to ensure residents' satisfaction. Review of the…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-18 · tag F0585 — failed to handle grievances — isolated
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to make prompt efforts to adequately resolve grievances for two Residents (#82 and #7) out of a total sample of 30 residents.Specifically, the facility failed to:1. For Resident #82, -identify steps taken to investigate the Resident's grievance with respect to care not being provided.-summarize pertinent findings or conclusions regarding the Resident's concern with respect to care not being provided.-state whether the Resident's grievance with respect to care not being provided was confirmed or not confirmed.2. For Resident #7, the facility failed to adequately resolve the Resident's grievance for missing dentures in a timely manner when the Resident's lower dentures were missing. Findings include: Review of the facility's Grievance and Complaint Policy, dated October 1998 and revised 7/31/12, indicated the facility has a process that provides residents and families with a means to assure complaints or grievances regarding care or lack 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 · D2026-03-18 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews, and record review, the facility failed to implement the person-centered care plan relative to transfers for one Resident (#70) out of a total sample of 30 residents. Specifically, for Resident #70, the facility failed to ensure that two staff assists were utilized per his/her plan of care when transferring the Resident with the use of a mechanical lift, putting the Resident at risk for injury or falls. Findings include: Review of the facility policy titled, Care Planning, undated with revision date 11/28/18, indicated the following: -Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. -The care plan is based on the resident's comprehensive assessment and developed by a Care Planning/Interdisciplinary team . Review of the facility policy titled Safe Lifting and Movement, dated 3/30/11 with revision date 8/1/18, indicated the following: -This policy describes ways to ensure that employees use safe methods for lifting and moving elders in the nursing facility in order…

    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 · D2026-03-18 · tag F0657 — failed to keep the care plan current — isolated
    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

    Based on interviews, and record review, the facility failed to ensure that three Residents (#3, #11, and #15), out of a total sample of 30 residents was provided the right to participate in their care plan process.Specifically, for Residents (#3, #11, and #15), the facility failed to ensure that each Resident was invited to participate in their individual care plan meeting process and the facility also failed to provide rationale as to why the participation of the three Residents was determined not practicable for the development of the care plan.Findings include:Review of the facility policy titled Resident's Rights, dated 11/28/17 and revised 9/5/25, included the following:-The Federal and State laws guarantee basic rights to all residents of this facility:>be informed of, and participate in, his/her care planning and treatment. Review of the facility Patient and Resident Guide, dated 1/4/22, included the following:>We encourage you to participate in the development of your plan of care with our interdisciplinary team. Together we will develop goals based on your needs .>Regular…

    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 · D2026-03-18 · 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 observations, interviews, and record reviews, the facility failed to provide treatment and services related to an indwelling urinary catheter (thin, flexible tube inserted into the bladder to drain urine outside the body) for two Residents (#93 and #51), out of a total sample of 30 residents.Specifically, the facility failed:1. For Resident #93, to implement the physician's orders relative to the correct indwelling urinary catheter size as ordered by the Physician, increasing the Resident's risk for indwelling urinary catheter complications.2. For Resident #51, to ensure that the urinary catheter drainage bag was not placed directly on the floor, placing the Resident at risk for contamination and infection. Findings include: Review of the facility's policy titled, Reception and Transcription of Physician Orders, revised, 5/16/24, included but limited to:*Is to provide guidelines for the safe and effective means to receive, transcribe and implement physician's orders. -Attending physician (MD-medical…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-03-18 · 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, and record review, the facility failed to adhere to infection control standards of practice for one Resident (#93), out of a total sample of 30 residents. Specifically, for Resident #93, the facility failed to ensure that Enhanced Barrier Precautions (EBPs - the use of protective gowns and gloves during high contact care activities that may provide opportunity for transmission of medication resistant organisms through staff hands and/or clothing), were appropriately utilized when providing high contact care for the Resident, to mitigate the risk of organism transmission and the spread of infection to the Resident and other residents within the facility. Findings include:Review of the facility's policy titled Enhanced Barrier Precautions, dated 4/6/2023, included but was not limited to:*Enhanced Barrier Precautions expand the use of personal protective equipment (PPE: items such as gowns and gloves worn to prevent the spread of infection) and refer to the use of gown and gloves during high contact resident care activities that provide opportunities…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-10 · 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

    Based on observation, interview, and record review, the facility failed to ensure that a device utilized for one Resident (#38), was assessed when used as a physical restraint, for one applicable Resident who had nephrostomy tubes (tubes that drain urine from the kidneys into drainage bags), out of a total sample of 27 residents. Specifically, the facility failed to assess Resident #38 for the need of an abdominal binder (wide compression belt that encircles the abdomen) to cover Resident #38's nephrostomy sites to prevent him/her from pulling on the nephrostomy tubes. Findings include: Review of the facility's policy titled Physical Restraints, last revised 10/28/15, indicated: -it is the policy of this facility to use a physical restraint on a resident when alternatives have failed, and it is required by a medical symptom. Every effort will be made to use the least restrictive device with the goal of reducing or eliminating the restraint as soon as possible. -a physical restraint is defined as any manual method or physical or mechanical device, material, or equipment attached or…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-10 · 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 record review, and interview, the facility failed to ensure that a Level II [comprehensive evaluation that identifies the specialized services required] Preadmission Screening and Resident Review (PASARR- evaluation done if it was determined by the Level I [initial pre-screening] screen that a resident had an intellectual or developmental disability and/or serious mental illness [SMI] and if a resident was in need of additional support services at the facility) screen was submitted for one Resident (#36), out of a total sample of 27 residents. Specifically, for Resident #36, the facility staff failed to request a Level II PASARR evaluation when the Resident demonstrated an increase in behavioral, psychiatric, and mood-related symptoms resulting in a change to the Resident's plan of care. Findings include: Resident #36 was admitted to the facility in September 2023 with diagnoses including Bipolar Disorder (chronic mood disorder characterized by manic, hypomanic and depressive episodes, Depression 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 · D2024-12-10 · tag F0699 — isolated
    Provide care or services that was trauma informed and/or culturally competent.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to develop a comprehensive Trauma Informed Care Plan for one Resident (#36), out of a total sample of 27 residents. Specifically, for Resident #36, the facility failed to complete an assessment and ensure that a comprehensive Trauma Informed Care Plan was developed relative to the Resident's history of Post-Traumatic Stress Disorder (PTSD). Findings include: Review of the facility's policy for Trauma Informed Care, last revised 5/2020, indicated: -acknowledging that trauma is widespread and can affect anyone, and understanding how it can manifest in behaviors and presentations. -care plan will be developed to communicate this history and how it impacts the individualized care of the resident. -all staff members receive comprehensive training in trauma informed care principles and practices. -regularly monitoring the effectiveness of trauma-informed practices and making necessary adjustments. Resident #36 was admitted to the facility in September 2023 with diagnoses including Bipolar Disorder and depressive episodes,…

    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
Show the remaining 14 citations
  • Potential for harm · D2024-12-10 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    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 and interview, the facility failed to accurately and safely provide pharmaceutical services pertaining to the administration of routine medications for one Resident (#40), out of a total of five resident medication administration observations. Specifically, the facility failed to ensure that Resident #40's Furosemide (medication used to treat high blood pressure, heart failure and build-up of fluid in the body) medication: -was dispensed from the pharmacy. -was administered in the correct dose to the Resident when the facility staff used a higher dose medication tablet and broke the higher dose tablet to obtain the ordered dose. Findings include: Review of the facility's policy titled, General Guidelines for Medication Administration, revised August 2020, indicated: -At a minimum, the 5 Rights - right resident, right drug, right dose, right route and the right time should be applied to all medication administration and reviewed at three steps in the process of preparation. -Select the…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2023-09-28 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, policy and record review and interview, the facility failed to adhere to infection control guidelines to prevent contamination and the spread of infection. Specifically, the facility staff failed to: 1.a) don (put on) gloves when handling medications. b) ensure a medical supply bag was placed in a clean area. c) ensure handwashing occurred after doffing (remove) gloves. d) ensure proper COVID-19 (an infectious respiratory illness) staff testing procedure. 2. to perform COVID-19 testing for staff and residents in a manner consistent with infection control standards and perform COVID-19 testing for staff timely as required. Findings include: 1. Review of the facility policy titled, Hand Hygiene, dated 11/28/19, included, but not limited to: -The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. a) On 9/27/23 at 7:25 A.M., during a medication administration pass, the surveyor observed…

    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 · D2023-09-28 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to notify the Physician when medications were not administered for one Resident (#283) out of a total sample of 30 residents. Specifically, the facility staff failed to notify the Physician when medications were not administered as ordered upon the Resident's admission to the facility, and prior to Renal Dialysis treatments. Findings include: Review of the facility policy titled Medication Administration-General Guidelines effective February 2019 indicated the following: -Medications are administered in accordance with written orders of the prescriber. -If a dose of regularly scheduled medication is withheld, refused, not available, or given at a time other than the scheduled time, the space provided on the front of the Medication Administration Record (MAR) for that dosage administration is initialed and circled. -If an electronic MAR is used, documentation of the unadministered dose is done as instructed by procedures for use of the eMAR system. An…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-28 · 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

    Based on observation, policy review and interview, the facility failed to ensure professional standards of quality were maintained during observation of a medication pass for one Resident (#45), out of eight applicable residents, in a total sample of 30 residents. Specifically, -for Resident #45, the facility staff failed to follow professional standards related to crushing enteric coated (EC-special coating that prevent dissolving by stomach acids but allows release of the medication in the intestine) medications prior to administration. Findings include: Review of the facility policy titled, Medication Administration-General Guidelines dated 2/2019, included, but not limited to: -Tablet Crushing/Capsule Opening: Crushing tablets may require a Physician's order, per facility policy. -The Physician order for crushing medications should be included in the Medication Administration Record (MAR) so that all personnel administering medications are aware of this need Review of the Long-Term AdviseERR (Journal for The Institute for Safe Medication Practices), April 2017, Volume 5 Issue 4,…

    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 · D2023-09-28 · tag F0676 — failed to keep up residents' daily-living abilities — isolated
    Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to provide treatment, care, and services as required for one Resident's (#77), out of a total sample of 30 residents. Specifically, the facility staff failed to respond timely to Resident #77's request to use the bathroom, when the Resident required assistance from staff with activities of daily living (ADLs). Findings include: Resident #77 was admitted to the facility in September 2023 with the following diagnoses: nondisplaced left hip fracture (when broken bones do not separate), subsequent encounter for closed fracture (broken bone with the skin still intact) with routine healing, difficulty walking, unspecified fracture of the lower end of left radius (one of the two bones in the forearm) and unspecified falls. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE], indicated: -Resident #77 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. -required assistance…

    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 · D2023-09-28 · tag F0679 — failed to provide activities — isolated
    Provide activities to meet all resident's needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review, and interview the facility failed to assess, provide, and implement activities of the Resident's choice for one Resident (# 77) out of a total sample of 30 residents. Specifically, the facility staff failed to assess Resident #77 for activities preferences, provide meaningful activities designed to meet his/her interests and support his/her physical, mental, and psychosocial well-being. Findings include: Resident #77 was admitted to the facility in September 2023 with the following diagnoses: nondisplaced intertrochanteric fracture of the left femur, subsequent encounter for closed fracture with routine healing, difficulty walking, unspecified fracture of the lower end of left radius, unspecified falls. Review of the most recent Minimum Data Set (MDS) assessment, dated 9/12/23, indicated that Resident #77 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15 and required assistance with activities of daily living (ADLs). Further reviewof the medical record indicated that the Resident was not…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-28 · 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 interviews, the facility failed to provide Behavioral Health Services for one Resident (#91) out of a total sample of 30 residents. Specifically, 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 a resident identified with a history of suicidal ideation, and a documented suicide attempt while in the facility resulting in hospitalization. Findings Include: Review of the Facility Policy titled Behavior Management Program, last revised 11/1/2010, indicated the following: -Resident's with behaviors that are problematic and/or dangerous for themselves or others will be identified. -Staff should look for triggers of previous circumstances that lead up to the problematic behavior. -The Interdisciplinary Team can develop a Care Plan for the behavior. The team should review the Minimum Data Set Assessment and psychotropic medications, and use all possible…

    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 · D2023-09-28 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, policy review and interview, the facility failed to implement a Consultant Pharmacist recommendation for one Resident (#86) out of 5 residents reviewed, out of a total sample of 30 residents. Specifically, the facility staff failed to implement a Consultant Pharmacist recommendation, agreed upon by the attending Physician for uric acid serum levels to monitor the results of medication therapy for Resident #86. Findings include: Review of the facility policy titled, Consultant Pharmacists Reports dated February 2019, indicated: - all non-urgent recommendations must be addressed/reviewed within 30 days of the Consultant's monthly visit. Resident #86 was admitted to the facility in July 2022 with diagnoses including: Acute Kidney Failure (when the kidneys suddenly become unable to filter waste from the blood, indicated by increased serum levels of urea and creatinine) and Gout (when urate [normal body waste broken down from uric acid] builds up in the joints, causing pain and swelling). Review of a document titled, Note to Attending Physician/Prescriber 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-09-28 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and interview, the facility failed to ensure a significant medication error did not occur for one Resident (#37), out of a total sample of 30 residents. Specifically, the facility failed to ensure Paxlovid (an oral antiviral pill) used to treat Covid-19 (an infectious respiratory illness) was available for administration. Findings include: Review of the eight rights of medication administration, Nursing 2022 Drug Handbook, Wolters Kluwer, page 17, included, but is not limited to: -the right drug -the right patient -the right dose -the right time -the right route -the right reason -the right response -the right documentation Resident #37 was admitted to the facility in September 2023 with diagnoses including Pneumothorax (an accumulation of blood in the space that surrounds each lung) and Diabetes Mellitus (a group of diseases that result in too much sugar in the blood) Review of the Minimum Data Set (MDS) assessment indicated that Resident #37 was cognitively intact as evidenced by a score of 15 out of 15 on the Brief Interview for Mental Status…

    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 · D2023-09-28 · 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 observation, record review and interview, the facility failed to ensure the appropriate storage and safety of medications per professional standards. Specifically, the facility staff failed to ensure: 1. drugs and biologicals were ordered and safely stored for one out of two Medication Storage Rooms. 2. medication was safely stored for one Resident (#86), out of a total sample of 30 residents. Findings include: Review of the facility policy, titled, Storage of Medications, dated 2/2019, included, but not limited to: -Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. -The medication supply is accessible only to licensed personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. -Medications requiring refrigeration are kept in a refrigerator at temperatures between 35 and 46 degrees F with a thermometer to allow temperature monitoring. Review of the facility policy, titled, Emergency…

    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 · D2023-09-28 · 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 observations, record reviews, and interviews, the facility failed to maintain complete, accurate, and readily accessible medical records for three Residents (#39, #122, and #37), out of a total sample of 30 residents. Specifically, the facility staff failed to: 1. ensure for Resident #39, accurate and complete documentation of the interdisciplinary care plan meetings. 2. ensure for Resident #122, an accurate Physician medication order for Paxlovid ([an oral antiviral pill] used to treat Covid-19 [an infectious respiratory illness]) was prescribed. 3. ensure for Resident #37, a Physician order for Paxlovid was transcribed correctly in the Medication Administration Record (MAR). Findings include: 1. Resident #39 was admitted to the facility in October 2019 with diagnoses that included: Dementia due to Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) and widespread lytic bony lesions (areas of bone destruction that result in holes). Review of the facility policy titled, Care Planning, effective 11/28/18, indicated 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • No harm found · Bcited before2024-12-10 · tag F0640 — pattern
    Encode each resident’s assessment data and transmit these data to the State within 7 days of 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 review, and interview, the facility failed to ensure that a Minimum Data Set (MDS) assessment was transmitted within the required timeframe after the completion date for one Resident (#46), out of one applicable resident, out of a total sample of 27 residents. Specifically, for Resident #46, a discharge MDS assessment was not transmitted within 14 days of the MDS assessment completion date as required. Findings include: Review of the Centers for Medicare and Medicaid (CMS) MDS 3.0 Resident Assessment Instrument (RAI) Manual, dated [DATE], indicated: -Non-comprehensive MDS assessments (OBRA- required non comprehensive MDS assessments include a select number of MDS items, but not completion of the CAA process [Care Area Assessments- items coded on the MDS to identify problems, needs or strengths] and care planning) must be transmitted to IQIES (Internet Quality Improvement and Evaluation- web based system that is used to transmit data to CMS) no later than 14 calendar days after the MDS completion…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2023-09-28 · tag F0636 — pattern
    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to ensure that two Comprehensive Minimum Data Set (MDS) Assessments were completed timely as required for one Resident (#25) out of a total sample of 30 residents. Findings include: Review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) version 3.0 Manual dated 9/8/23, https://www.cms.gov/medicare/quality/nursing-home-improvement/resident-assessment-instrument-manual indicated that the MDS assessment must be completed no later than 14 days after the Assessment Reference Date (ARD). Review of Resident #25's clinical record indicated: -The MDS with an ARD of 2/22/23, had not been completed until 3/20/23 (greater than 14 days). -The MDS with an ARD of 8/15/23, had not been completed until 8/31/23 (greater than 14 days). During an interview on 9/28/23 at 11:53 A.M., the MDS Nurse said that the MDS's were completed late and not within the required timeframes.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • No harm found · Bcited before2023-09-28 · tag F0640 — pattern
    Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview the facility failed to transmit a significant change Minimum Data Set (MDS) Assessment timely as required for one Resident (#25) out of a total sample of 30 residents. Findings include: Review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) version 3.0 Manual dated 9/8/23, https://www.cms.gov/medicare/quality/nursing-home-improvement/resident-assessment-instrument-manual indicated that the MDS assessment must be transmitted no later than 14 days after the completion date to CMS. Review of Resident #25's clinical record indicated that Resident #25 had a significant change MDS completed on 8/31/23. Further review of the clinical record indicated that that the MDS completed on 8/31/23 had not been transmitted to CMS within the 14 days as required. During an interview on 9/28/23 at 11:53 A.M., the MDS Nurse said that the MDS completed on 8/31/23 had not been transmitted as required until the surveyor brought it to the facility's attention on 9/28/23.

    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

$12,735 in federal fines across 1 penalty.

  • $12,735 — penalty dated 2026-02-26

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.

Who owns this facility

Owner / managerTypeRoleShareSince
SALMON, DANIELIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST55%since 12/01/1983
SALMON, DOROTHYIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST30%since 12/01/1983
TUFFY, ROBERTIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST15%since 12/01/1983
SACON, GARYIndividualW-2 MANAGING EMPLOYEE; CORPORATE OFFICERsince 11/03/1997
SALMON, MATTHEWIndividualW-2 MANAGING EMPLOYEE; CORPORATE OFFICERsince 07/21/1995
CONTINUING CARE MANAGEMENT LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 01/25/2012
COPPOLA, LISAIndividualOPERATIONAL/MANAGERIAL CONTROLsince 08/24/2020

CMS files one row per role, so the 9 rows in the source record cover these 7 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.

$19.1M
Net patient revenuemost recent cost report
+2.7%
Operating marginrevenue minus expenses
$1.7M
Related-party expense9% of expenses
Who pays — share of resident-days
Medicaid 56%Medicare 7%Other / private 37%

This home reported $1.7M paid to related parties (affiliated landlords or management companies) in its most recent cost report.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 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

$371per resident / day
operating cost
$11,268per month
≈ monthly operating cost
$381per 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 225275. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-18, 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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