No sales calls · nothing personal collected unless you ask us to · no facility pays to be here
Text size
Contrast

Westford Nursing And Rehabilitation Center

3 Park Drive, Westford, MA 01886 · For profit - Limited Liability company · 123 certified beds · (978) 392-1144 Medicare & Medicaid certified

Call the home — (978) 392-1144 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0607) — cited Oct 20231 actual-harm citation
Insights

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

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (32) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing rating is low (2/5)
  • its facility-reported quality-measure rating is low (2/5)

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

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

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

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
238 Littleton Rd · (617) 286-2026 · Call to confirm hours
Pharmacy
4 Lan Dr · (978) 364-5060 · Call to confirm hours
Grocery
6 Cornerstone Sq · (978) 589-1108 · Call to confirm hours
Park
Concord Rd · Typically dawn to dusk
Place of worship
130 Littleton Rd · (978) 455-2634

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

Quality measures — how residents actually fare

Overall quality measures 2 of 5
Long-stay residentspeople who live here 2 of 5
Short-stay residentsrehab / post-hospital 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 4 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 rating4★
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 increased24.7%16.4%15.4%worse
Long-stay residents who lose too much weight2.6%5.1%5.4%better
Long-stay residents with a catheter left in their bladder0.2%0.8%0.9%better
Long-stay residents with a urinary tract infection0.3%1.8%2.0%better
Long-stay residents with depressive symptoms25.6%15.5%6.5%worse 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 injury4.0%3.4%3.3%worse
Long-stay residents whose ability to walk worsened21.7%15.4%16.1%worse
Long-stay residents on antianxiety or hypnotic medication17.4%19.5%18.9%typical
Long-stay residents given the seasonal flu vaccine73.8%94.8%95.3%worse
Long-stay residents with pressure ulcers3.6%4.2%4.7%better
Long-stay residents with worsening bladder/bowel control23.0%21.2%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table28.6%21.4%17.1%worse
Short-stay residents who newly got an antipsychotic medication2.6%1.4%1.4%worse
Short-stay residents given the seasonal flu vaccine55.6%77.7%79.4%worse
Short-stay residents rehospitalized after admission23.1%25.7%22.6%typical
Short-stay residents with an outpatient ER visit12.5%11.9%12.0%typical
Long-stay hospitalizations per 1,000 resident days2.791.881.67worse
Long-stay outpatient ER visits per 1,000 resident days1.491.501.80better

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.

49.1% 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 134 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

49.1%U.S. median 51.5%
Got home and stayed home
10.4%U.S. median 10.7%
Went back to hospital
39.1%U.S. median 56.6%
Met the expected recovery
0.31U.S. median 0.31
Therapy hours / resident / day
0.09hours / resident / day
Physical therapy
0.17hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 39.1% 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 46 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 0.31 therapist hours per resident per day in 2026Q1 — more than 49% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 26% 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 SNF49.1%CMS range 40.7–55.551.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.4%CMS range 7.5–14.910.7%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 discharge39.1%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 discharge43.5%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 discharge32.6%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 identified95.7%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — 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 worsened2.9%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 hospitalization5.0%CMS range 3.0–9.57.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.881.02Oct 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

0.26
RN hours/ resident / day
1.24
LPN hours/ resident / day
2.10
Aide hours/ resident / day
3.59
Total nurse hours/ resident / day
0.15
RN hoursweekends
52.5%
Total nursing turnover
66.7%
RN turnover

How full it usually is: this home is certified for 123 beds and averages 106.4 residents a day — about 87% occupied, or roughly 17 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 3.59 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.26 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.10 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 3.15 hrs/resident/day on weekends vs 3.77 on weekdays — 16% thinner on weekends. RN hours go from 0.30 to 0.15 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 52% 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

3
deficiencies at the latest standard inspection (2025-07-16)
8
at the previous standard inspection (2024-06-14)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

32 citations, most serious first. The 11 most serious are shown; the remaining 21 are one tap away and print in full.

  • Actual harm · G2023-02-07 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, record review, and interview, the facility failed to ensure its staff provided the appropriate care and services related to a pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) for one Resident (#151) out of three sampled closed records. Specifically, the facility failed to ensure its staff (1.) immediately implemented interventions to prevent further skin breakdown, (2.) implemented recommendations from the Wound Care Physician, (3.) revised the care plan to include goals and interventions related to the pressure ulcer and (4.) failed to obtain timely consent from the Resident's Representative for Physician recommended wound debridement (removal of dead tissue). Findings include: Review of the facility policy, Pressure Ulcers/Skin Breakdown, dated April 2018, indicated the following: -The nurse shall document/report a full assessment of the pressure ulcer including location, stage, length, width and depth, presence of exudates or necrotic…

    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 · D2025-07-16 · tag F0637 — isolated
    Assess the resident when there is a significant change in condition
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to identify and complete a Significant Change in Status (SCSA) Minimum Data Set assessment (MDS) for one Resident (#13), when he/she changed hospice providers and remained in the facility, out of a total sample of 22 residents.Findings include: Review of the MDS 3.0 Resident Assessment Instrument (RAI) Manual, dated October 2024, indicated a SCSA comprehensive assessment must be completed by the end of the 14th calendar day following determination that a significant change has occurred. The RAI Manual further indicated a SCSA is required to be performed when a terminally ill resident changes hospice providers and remains a resident at the nursing home. Resident #13 was admitted to the facility in April 2025 with diagnoses including malnutrition and chronic obstructive pulmonary disease (a lung disease that causes difficulty breathing). Review of Resident #13's readmission practitioner note, dated 5/14/25, indicated:- Patient has been readmitted to 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
  • Potential for harm · Dcited before2025-07-16 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and interview, the facility failed to ensure nursing implemented physician's orders and the recommendations made by therapy services for one Resident (#10) out of a total sample of 22 residents. Specifically, the facility failed to ensure Resident #10 was wearing a soft hand splint as ordered by the physician and as recommended by the therapy department.Findings include: Review of the facility policy titled Specialized Rehabilitation Services, dated and revised December 2009, indicated the following:- Policy Interpretation and Implementation: Once a resident has met his/her care plan goals, a licensed professional can either discontinue treatment or initiate a maintenance program which either nursing or restorative aides will implement to assure that the resident maintains his/her functional and physical status.Resident #10 was admitted to the facility in December 2024 with diagnoses including multiple sclerosis, hemiplegia and hemiparesis affecting right dominant side.Review of Resident #10's most recent Minimum Data Set 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-16 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    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 assistance with Activities of Daily Living (ADLs) for dependent residents for one Resident (#10) out of a total sample of 22 residents. Specifically, the facility failed to ensure Resident #10's fingernails were cut short in his/her right contracted hand.Findings include:Review of the facility policy titled Activities of Daily Living (ADL), Supporting, revised March 2018, indicated the following:- Residents who are unable to carry out activities of daily living independently will receive services necessary to maintain good nutrition, grooming, and personal and oral hygiene.- Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: hygiene (bathing, dressing, grooming, oral care)Resident #10 was admitted to the facility in December 2024 with diagnoses…

    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 · E2024-06-14 · tag F0693 — failed to provide proper feeding-tube care — pattern
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    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 appropriate care, services, and monitoring of a gastrostomy tube (G-tube- a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medication, also referred to as a feeding tube) for two Residents (#57 and #80), for two applicable residents, out of a total sample of 23 residents. Specifically, the facility staff failed to: 1. For Resident #57, provide appropriate care and services to facilitate restoring oral eating skills as possible for the Resident. 2. For Resident #80, verify proper placement of a G-tube every shift to identify and prevent potential complications associated with enteral (passing through the gastrointestinal [GI] tract) feeding. Findings include: 1. Resident #57 was admitted to the facility in March 2024, with diagnoses including Gastrostomy, Dementia (loss of memory, language, problem-solving and other thinking abilities) and Dysphagia…

    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 · D2024-06-14 · tag F0623 — isolated
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to notify the Office of the State Long-Term Care Ombudsman in writing, of a transfer or discharge for four Residents (#66, #43, #73, #51) out of a total sample of 23 residents. Specifically: 1. For Resident #66, the facility failed to notify the Office of the State Long-Term Care Ombudsman when the Resident was transferred out of the facility to the hospital on [DATE], 12/22/23, 3/11/24 and 5/15/24. 2. For Resident #43, the facility failed to notify the Office of the State Long-Term Care Ombudsman when the Resident was transferred to the hospital on 3/3/24. 3. For Resident #73, the facility failed to notify the Office of the State Long-Term Care Ombudsman when the Resident was transferred out of the facility to the hospital on [DATE], 2/4/24, and 2/15/24. 4. For Resident #51, the facility failed to notify the Office of the State Long-Term Care Ombudsman when the Resident was transferred out of the facility to the hospital on 3/3/24. Findings include: 1.…

    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 · D2024-06-14 · tag F0638 — isolated
    Assure that each resident’s assessment is updated at least once every 3 months.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to reassess one Resident (#99) out of a total sample of 23 residents, using the quarterly review instrument specified by the State and approved by Centers for Medicare and Medicaid Services (CMS) at least once every three months. Specifically, the facility staff failed to complete a Quarterly Minimum Data Set (MDS) Assessment for Resident #99 when the MDS Assessment was due, which increased the Resident's risk for an unidentified change in status between assessments. Findings include: Resident #99 was admitted to the facility in October 2023 with a diagnosis of Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory and loss of judgment). Review of Resident #99's clinical record indicated the following: -A Quarterly MDS Assessment, completed 1/30/24. -No evidence that any other Quarterly MDS Assessments had been completed after 1/30/24. During an interview on 6/13/24 at 2:19 P.M., the MDS Coordinator said the last MDS Assessment that had been completed for Resident #99 was…

    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 before2024-06-14 · tag F0641 — isolated
    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 complete assessments that accurately reflected the status of two Residents (#103 and #95) out of a total sample of 23 residents. Specifically, facility staff failed to complete: 1. an accurate assessment relative to wandering (aimless walking, getting lost, repetitive pacing) for Resident #103 2. an accurate assessment relative to cognition on the facility's Smoking Assessment for Resident #95. Findings include: 1. Resident #103 was admitted to the facility in February 2024 with diagnoses including Dementia (group of symptoms that affects memory, thinking and interferes with daily life) with Behavioral Disturbance. Review of Resident #103's Minimum Data Set (MDS) assessment dated [DATE], indicated the following: -The Resident was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of four out of 15 total points. -The Resident had exhibited wandering daily during the assessment period with 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
  • Potential for harm · D2024-06-14 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record and policy review, the facility failed to provide interdisciplinary team (IDT: professionals from various disciplines who work in collaboration to address a patient with multiple physical and psychological needs. An interdisciplinary team is not just a group of experts implementing separate treatments on a patient. They complement one another's expertise and actively coordinate to work toward shared treatment goals) review and revision of care plans after each Minimum Data Set (MDS) assessment for three Residents (#103, #55, and #61) out of a total sample of 23 residents. Specifically, the facility staff failed to provide IDT review and revision of: 1. Resident #103's care plan following an MDS Assessment completed for the Resident on 3/13/24. 2. Resident #55's care plan following MDS Assessments completed for the Resident on 8/10/23, 2/6/24, and 5/7/24. 3. Resident #61's care plan following MDS Assessments completed for the Resident on 1/12/24 and 4/10/24. Findings include: Review 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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-14 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and policy review, the facility failed to provide an environment that was as free of accidents and hazards as possible for two Residents (#95, #44), out of a total sample of 23 residents. Specifically, the facility staff failed to: 1. For Resident #95, secure a disposable lighter from the Resident after he/she returned from a smoking activity. 2. For Resident # 44, implement monitoring of the Resident during a smoking activity when the Resident had a diagnosis of Seizure Disorder (also known as Epilepsy, a brain condition that causes recurring seizures [sudden, uncontrolled burst of electrical activity in the brain that causes changes in behavior, movements, feelings and level of consciousness]) and was known to have seizures occur while smoking independently. Findings include: Review of the facility policy titled Smoking-Residents last revised July 2017 indicated the following: -The resident will be evaluated on admission to determine if he or she is a smoker or non-smoker. If a…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-06-14 · 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 observation, interview, and record review, the facility failed to provide care and services consistent with professional standards for one Resident (#101) out of one applicable resident, out of a total sample of 23 residents, who required dialysis (procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) treatment. Specifically, the facility staff failed to provide the delivery of meals in coordination with Resident #101's dialysis treatment schedule to ensure that the Resident received meals and/or snacks on dialysis treatment days. Findings include: According to the National Institute of Diabetes and Digestive and Kidney Disease, revised September 2016: (https://www.niddk.nih.gov/health-information/kidney-disease/kidney-failure/hemodialysis/eating-nutrition), a person's choices on nutrition and hydration while on hemodialysis can make a difference in how the person feels and can make the treatment work better. Resident #101 was admitted to the facility…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 21 citations
  • Potential for harm · Dcited before2024-05-07 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    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 diagnoses of paraplegia (paralysis of legs and lower body) and Stage IV (wound that has lost full thickness tissue, exposing bone, muscle, or tendon) pressure injury to sacral (lower back) region and required physical assistance from staff for Activities of Daily Living (ADL-bathing, dressing, grooming), the Facility failed to ensure they developed a baseline Care Plan which included minimal healthcare information related to the level of assistance he/she required to complete ADLs within forty-eight hours of admission as required, and per facility policy. Findings Include: The Facility Policy titled Care Plans-Baseline, with a revision dated of March 2022, indicated a baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission. The Policy indicated a baseline Care Plan included instructions needed to provide effective, person-centered care of the resident that meets professional standards 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 Assessment and Care Planning Deficiencies · Past Non-Compliance
  • Potential for harm · Dcited before2024-05-07 · 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 diagnoses of paraplegia (paralysis of the legs and lower body) and Stage IV (wound that has lost full thickness tissue, exposing bone, muscle, or tendon) pressure injury to sacral (lower back) region, and required physical assistance from staff for mobility and positioning, the Facility failed to ensure they maintained a complete and accurate medical record, related to Certified Nurse Aide (CNA) Activity of Daily Living (ADL) Flow Sheets and Positioning Sheets, when daily documentation by CNAs was not consistently completed. Findings include: Review of the Facility's policy titled Charting and Documentation, with a revision date of July 2017, indicated that all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. Resident #1 was admitted to the Facility in November 2023, diagnoses included Paraplegia (paralysis of the legs…

    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 · Past Non-Compliance
  • Potential for harm · Dcited before2023-12-05 · 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 policy review, interview, and record review, the facility failed to implement screening (assessing) for signs and symptoms of COVID-19 during a COVID-19 outbreak for one Resident (#3) out of a total sample of five residents. Specifically, for Resident #3, the facility failed to ensure that the Resident was being screened every shift for signs and symptoms of COVID-19 while the unit he/she resided on, was conducting outbreak testing. Findings include: Review of the facility policy titled Coronavirus Disease (COVID-19)-Testing Residents, revised 4/1/23, indicated the following: -During an outbreak, all residents on the unit with a positive COVID-19 individual are screened for COVID-19 signs and symptoms every shift to more rapidly detect those with new signs and symptoms. Resident #3 was admitted to the facility in September 2023. During the entrance conference on 12/5/23 at 7:55 A.M., the Director of Nurses (DON) said outbreak testing throughout the entire facility began on 11/16/23. During an interview on 12/5/23 at 11:17 A.M., Unit Manager (UM) #1 said the facility's…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-12-05 · 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 interview, record review, and policy review, the facility failed to offer the Pneumococcal Vaccination as required to one Resident (#4) out of a total sample of five residents. Specifically, for Resident #4, the facility failed to ensure the Resident was offered the Pneumococcal Vaccination at the time of admission or shortly thereafter, putting the Resident at risk for developing facility acquired Pneumonia. Findings include: Review of the facility policy titled Pneumococcal Vaccine, revised March 2023, indicated the following: -Assessments of Pneumococcal Vaccination status are conducted within thirty (30) days of the resident's admission if not conducted prior to admission. -Administration of the Pneumococcal Vaccines are made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of vaccination. Review of the CDC Pneumococcal Vaccine Timing for Adults Schedule, dated 3/15/23, indicated the following: -Adults aged 19 to 64 with chronic health…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-10-25 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    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 was admitted to the Facility with a wound that required treatment, the Facility failed to ensure a baseline Care Plan that included minimal healthcare information with instructions related to his/her wound care and treatment needs, was developed and implemented within forty-eight hours of admission as required, and per facility policy. Findings Include: The Facility Policy titled Comprehensive Person-Centered Care Plan, undated, indicated the Facility must develop and implement a baseline Care Plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The Policy indicated the baseline care plan must be developed within 48 hours of a resident's admission. The Policy indicated the baseline Care Plan must include the minimum healthcare information necessary to properly care for a resident that included but was not limited to initial goals based on admission orders. Resident #1 was…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-10-25 · 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 was admitted to the Facility with a wound and had orders for wound care treatments, the Facility failed to ensure they maintained complete and accurate medical records related to nursing documentation for Resident #1's wound care and dressing changes in his/her Treatment Administration Record (TAR), when nurses signed off as having completed dressing changes, but had not, there were wound treatments not signed off on with the TAR left blank and wound care dressing change documentation by nurses did not consistently include descriptions of his/her wound. Findings Include: The Facility Policy titled Charting and Documentation, dated as revised July 2017, indicated treatments and services performed were to be documented in the resident's medical record. The Policy indicated documentation of procedures and treatments would include care-specific details, including: -The date and time of the procedure/treatment was provided. -The name and title of the individual who provided the care. -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
  • Potential for harm · D2023-10-17 · tag F0607 — failed to have anti-abuse policies — isolated
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on records reviewed and interviews for two of three sampled Employee Personnel Records (Certified Nurse Aide #1 and Certified Nurse Aide #2), the Facility failed to ensure that Massachusetts Nurse Aide Registry (NAR)checks were conducted as part of the employees background check upon hire, in accordance with Facility Policy. Findings include: Review of the Facility's Abuse, Neglect, exploitation and Misappropriation Prevention Program, revised April 2023, indicated to conduct employee background checks and not knowingly employ or otherwise engage any individual who had a finding entered into the state nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property. Review of Certified Nurse Aide (CNA) #1's Personnel File indicated she was hired on 04/10/23 and there was no documentation to support that a Massachusetts NAR check was completed upon hire. Review of CNA #2's Personnel File indicated she was hired on 09/21/23 and there was no documentation to support that a Massachusetts NAR check was completed upon hire.…

    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 · Fcited before2023-02-07 · 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

    Based on observation, policy review, record review and interview the facility failed to ensure its staff implemented an infection prevention and control program to provide a sanitary environment and help prevent the development and transmission of communicable diseases. Specifically, the facility failed to ensure its staff (1a.) washed mops separately from linens, (b.) kept clean linen out of the soiled linen area and (c.) wore appropriate Personal Protective Equipment (PPE) when handling contaminated linen, to avoid the spread of infection and (2.) implement a surveillance plan to identify the potential presence of Legionella (a bacteria that can grow and multiply in moist areas of a building water system and cause lung infections) within the facility. Findings include: 1. The facility failed to ensure its staff: did not wash mops without any other linen, kept clean linen out of the soiled linen room and wore appropriate PPE when handling soiled linen. Review of the facility's policy, Laundry and Linen, dated January 2014, indicated the following: Purpose: To provide a process 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 · Ecited before2023-02-07 · tag F0656 — failed to write and follow a full care plan — pattern
    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 it's staff developed and/or implemented the plan of care for four Residents (#249, #73, #35 and #78) out of a total sample of 20 residents. Specifically, the facility staff failed to 1) develop a plan of care for the use of an arm sling for Resident #249, 2) implement the use of fall mats for Resident #73, 3) implement a powered air mattress as ordered for Resident #35, and 4) implement non skid socks for Resident #78 . Findings include: 1) Resident #249 was admitted to the facility in January of 2023 with a diagnosis including displaced fracture of the upper end of the left humerous (upper arm bone). Review of the Resident's admission assessment data indicated the Resident was cognitivelly intact as evidenced by a Brief Interview of Mental Status score of 15 out of a possible score of 15. During an observation on 2/5/23 at 9:41 A.M., the surveyor observed Resident #249 sitting in bed with a blue sling loosely applied to the left…

    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 · E2023-02-07 · tag F0730 — pattern
    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 record review, and interview, the facility failed to ensure that annual performance evaluations were completed (for Certified Nurse Aides- CNAs), and that regular in-service education was completed based on the outcome of those reviews. Specifically, the facility failed to ensure that two (CNAs) out of five sampled CNAs (#3 and #5) received an annual evaluation/performance review and regular in-service education based on the outcome of those reviews, as required. Findings include: 1. Review of CNA #3's personnel file indicated that there was no annual performance evaluation or in-service education was completed for 2022. 2. Review of CNA #4's personnel file indicated that there was no annual performance evaluation or in-service education completed for 2022. During an interview on 2/7/23 at 2:23 P.M., Additional Staff #3 said that she was unable to provide evidence that annual evaluations or regular in-service education for CNA's #3 and #4 had been done for 2022 as required.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-02-07 · tag F0756 — failed to review each resident's drug regimen — pattern
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview the facility failed to ensure that its staff provided pharmaceutical services for seven Residents (#40, #29, #3, #2, #38, #80, and #49) out of a total sample of 20 residents. Specifically, the facility staff failed to ensure that Residents #40, #29, #3, #2, #38, #80 and #49 had monthly pharmacy reviews completed by a licensed pharmacist as required. Findings include: 1.) Resident #40 was admitted to the facility in March of 2017. Review of the Resident's clinical record for 2022 and 2023 did not show any evidence of a monthly pharmaceutical review by a licensed pharmacist. 2.) Resident #29 was admitted to the facility in January of 2019. Review of the Resident's clinical record for 2022 and 2023 did not show any evidence of a monthly pharmaceutical review by a licensed pharmacist. 3.) Resident #3 was admitted to the facility in March 2016. Review of the Resident's clinical record for 2022 and 2023 did not show any evidence of a monthly pharmaceutical review by a licensed pharmacist. During an interview on 2/7/23 at 7:48 A.M., Unit Manager (UM) #2…

    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 · E2023-02-07 · tag F0868 — pattern
    Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility and its staff failed to ensure the required members were included in the Quality Assessment and Performance Improvement (QAPI) committee quarterly meetings. Specifically, there was no evidence that the Medical Director attended any of the quarterly QAPI meetings in 2022 as required. Findings include: Review of the attendance sheets for the quarterly QAPI meetings, provided by the facility, showed no evidence that the Medical Director attended the meetings. During an interview on 2/7/23 at 4:41 P.M., the Administrator said he could not provide any evidence that the Medical Director attended any QAPI meetings in 2022.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-02-07 · tag F0886 — failed to test for COVID-19 as required — pattern
    Perform COVID19 testing on residents and staff.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, record review and interview, the facility failed to ensure COVID-19 testing for staff was done in a timely manner, to prevent the spread of infection, during a COVID-19 facility outbreak. Specifically, the facility staff failed to conduct outbreak testing every 48 hours for two staff (Certified Nurse Aide (CNA) #2 and CNA #7) out of three sampled staff during a COVID-19 outbreak. Findings include: Review of the Massachusetts Department of Public Health memorandum dated October 13, 2022, Appendix B indicated the following: - If the facility identifies one new resident or staff case then the facility should take the following steps to mitigate any further transmission. -Testing exposed staff and residents on the affected units must take place as soon as possible. If the long-term care facility identifies that the resident or staff member's first exposure occurred less than 24 hours ago then they should wait to test until, but not earlier than, 24 hours after any exposure, if known. - Once…

    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 · E2023-02-07 · tag F0947 — failed to train nurse aides adequately — pattern
    Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to ensure that 12-hours of mandatory in-service education for Certified Nurses Assistants (CNAs) was completed as required annually. Specifically, the facility failed to ensure that 12 hours of mandatory in-service education was completed as required annually for two out of five sampled CNA's (#3 and #5). Findings include: Review of CNA #3's personnel file indicated that there was no 12-hour in-service education completed for 2022. Review of CNA #5's personnel file indicated that there was no 12-hour in-service education completed for 2022. During an interview on 2/7/23 at 2:23 P.M., the Staff Development Coordinator (SDC) said that she was unable to provide evidence that CNA #3 and #5 had received the 12-hour mandatory in-service education for 2022 as required.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-02-07 · tag F0641 — isolated
    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 review and interview the facility failed to ensure that its staff accurately completed Minimum Data Set (MDS) assessments for three Residents (#40, #43, and #3) out of a total sample of 20 residents. Specifically, the facility staff failed to accurately code for 1.) falls for Resident #40, 2.) current tobacco use for Resident #43, and 3.) the use of diuretic (causing increased passage of urine) medication for Resident #3. Findings include: 1.) Resident #40 was admitted to the facility in March of 2017 with diagnoses including a history of falling, difficulty in walking, and Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). Review of the Resident's clinical record indicated that the Resident sustained a fall on 11/11/22. Review of the MDS dated [DATE] did not indicate that the Resident had fallen. During an interview on 2/7/23 at 2:35 P.M., Additional Staff MDS nurse #4 said that the MDS dated [DATE] should have identified that the Resident fell…

    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 · D2023-02-07 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview the facility failed to ensure its staff provided treatment and care in accordance with professional standards of practice for one Resident (#97) out of three sampled closed records. Specifically, the facility failed to ensure its staff (1.) immediately obtained wound treatment orders once a wound was identified (2.) failed to implement a wound treatment as ordered, for several days and (3.) failed to update the care plan with wound goals and interventions. Findings include: Resident #97 was admitted to the facility in December 2022. Review of the admission Nursing Assessment, dated 12/13/22, indicated the Resident had a wound to the inner right leg. There were no wound measurements documented. Review of the Weekly Skin Check, dated 12/20/22, indicated the Resident had a wound on the right lower leg, no measurements were documented. The wound was described as open area, wound bed pink and moist, moderate amount of serous (thin watery fluid, produced by local inflammation) drainage noted, no odor. Review of the December 2022 Treatment…

    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 before2023-02-07 · 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 record review, interview and policy review, the facility failed to ensure its staff provided care and services consistent with professional standards for one Resident (#86), who required renal dialysis (a procedure to remove waste products and excess fluid from the body when the kidneys stop working properly) out of a total sample of 20 residents. Specifically, the facility staff failed to 1) obtain a complete physician order for dialysis treatments 2) document monitoring for the Resident's dialysis catheter (a soft plastic tube inserted into a large vein in the chest or neck used to carry blood from the body to the dialysis machine and from the dialysis machine back into the body) 3) maintain complete and accurate communication documentation with the dialysis facility. Findings include: Resident #86 was admitted to the facility in January of 2023 with a diagnosis of Endstage Renal Disease (the stage of renal impairment that appears irreversible and requires a regular course of dialysis) and dependence on renal dialysis. 1) Review of the January 2023 and February 2023…

    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 · D2023-02-07 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure its staff monitored for side effects and adverse reactions to medications for one Resident (#38) out of a total sample of 20 residents Specifically, the facility staff failed to monitor for side effects and adverse reactions related to the use of an anticoagulant (medication used to thin out the blood) for Resident #38. Findings include: 1) Resident #38 was admitted to the facility in October of 2022 with a diagnosis of displaced fracture of the head of the left femur (thigh bone), with delayed healing. Review of the January and February 2023 Physician orders indicated an order, initiated on 12/26/2022, for Lovenox Solution (an anticoagulant that helps reduce the formation of blood clots) prefilled Syringe 40 mg (milligrams) per 0.4 ml (milliliters), inject one syringe one time a day for Deep Vein Thrombosis (DVT) prophylaxis. Further review of the January and February 2023 Physician orders indicated no Physician order for the monitoring of side effects and/or adverse reactions to the Lovenox medication. Review 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-07 · 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

    Based on observation, policy review and interview the facility failed to ensure that its staff adhered to food safety requirements to prevent foodborne illness. Specifically, the facility staff failed store food in accordance with professional standards in the dry storage room. Findings include: Review of the facility policy for Food Receiving and Storage, revised October 2017, indicated: -dry foods that are store in bins will be removed from original packaging, labeled, and dated (use by date). Such foods will be rotated using a first in-first out system. -other opened containers must be dated and sealed or covered during storage On 2/5/23 at 8:14 A.M., during an inspection of the main kitchen's dry storage area the surveyor observed the following: -one opened bag of barley, unlabeled and undated. -one opened bag of penne pasta, unlabeled and undated. -one opened bag of elbow macaroni, unlabeled and undated. -one opened bag of rice, unlabeled and undated. -one opened package of spaghetti, unlabeled and undated. -one opened to bag of brown rice, exposed to air and undated. -one…

    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
  • No harm found · B2024-06-14 · tag F0755 — failed to provide safe pharmacy services — pattern
    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, record review and interview, the facility failed to ensure that nursing staff implemented and established systems to accurately reconcile controlled medications using acceptable standards of practice on two Units (Edgewood and [NAME]) of three units observed. Specifically, the facility failed to: 1. Maintain documentation of prescription numbers with the date of receipt of controlled substance medications and transfers. 2. Maintain professional standards of practice for discharging and transferring controlled medications within the narcotic book. Findings include: Review of the facility policy tiled Controlled Substances, revised April 2019, indicated the following: -The Nurse receiving the medication and the individual delivering the medication verify the name, dose and quantity of each medication. -Both individuals sign the controlled substance record of receipt. -An individual resident-controlled substance record contains: a) name of the resident b) name and strength of the medication c)…

    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
  • No harm found · B2023-02-07 · tag F0582 — pattern
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure its staff provided a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN- a notice to inform a resident or resident representative that skilled Medicare services will no longer be covered and to inform them of the cost they may be responsible to pay), for one Resident (#8) out of three applicable sampled residents. Findings include: Resident #8 was admitted to the facility in July 2021. Review of the record indicated skilled services for Resident #8 ended on 1/6/23. Review of the SNF ABN indicated that the box for the Resident/Resident Representative to indicate which of the following options they chose, was left blank: 1. Continue with services and bill Medicare for an official decision on payment and if they do not pay I can appeal to Medicare 2. Continue with services but do not bill Medicare. I understand I may be billed and am responsible for payment. I cannot appeal because Medicare will not be billed. 3. I do not want the services. I am not responsible for paying and I can not appeal…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to BEST CARE SERVICES — 10 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 4 of 52.3+1.7 vs chain
Health inspection 4 of 52.4+1.6 vs chain
Staffing 2 of 53.0-1.0 vs chain
Quality measures 2 of 52.4-0.4 vs chain
The other 9 homes this chain runs (chain average 2.3★, 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
PRESWEST HOLDING COMPANY LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 08/24/2022
CHAPLER, YAAKOVIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROLsince 02/01/2023
STEINBERG, MOSHEIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROLsince 02/01/2023
AL-MADI, SAMIIndividualOPERATIONAL/MANAGERIAL CONTROLsince 02/01/2023
KMON, LAURYNIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/29/2023
LEVITZ, MICHAELIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/11/2023

CMS files one row per role, so the 10 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.

$13.9M
Net patient revenuemost recent cost report
-3.8%
Operating marginrevenue minus expenses
$51K
Related-party expense0% of expenses
Who pays — share of resident-days
Medicaid 49%Medicare 8%Other / private 43%

This home reported $51K 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 2024. 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

$362per resident / day
operating cost
$10,996per month
≈ monthly operating cost
$348per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2024). 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 225586. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-07-16, 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.

What to do next