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Care One At Weymouth

64 Performance Drive, Weymouth, MA 02189 · For profit - Limited Liability company · 154 certified beds · (781) 443-4829 Medicare & Medicaid certified

Call the home — (781) 443-4829 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
No harm-level citations or fines — but 30 lower-level deficiencies on record (see below)
Insights

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

In its favor
  • no federal fines or payment denials on record
  • lower-than-typical staff turnover (34% vs 45% nationally) — better care continuity
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (2/5)
  • about 17% of its spending goes to commonly-owned related companies

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

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

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

Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
90 Libbey Industrial Pkwy · (781) 682-0600 · Call to confirm hours
Pharmacy
988 Middle St · (781) 340-1515 · Call to confirm hours
Grocery
700 Middle St · (781) 337-2782 · Call to confirm hours
Park
167 Lakehurst Ave · (781) 682-6124 · Typically dawn to dusk
Place of worship
222 Libbey Industrial Pkwy · (781) 331-3090

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 3 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 3 to 2 stars. From monthly CMS archive snapshots.

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

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased10.0%16.4%15.4%better
Long-stay residents who lose too much weight2.5%5.1%5.4%better
Long-stay residents with a catheter left in their bladder1.3%0.8%0.9%worse
Long-stay residents with a urinary tract infection1.8%1.8%2.0%typical
Long-stay residents with depressive symptoms0.7%15.5%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.3%0.1%0.1%worse
Long-stay residents with falls causing major injury2.6%3.4%3.3%better
Long-stay residents whose ability to walk worsened13.7%15.4%16.1%better
Long-stay residents on antianxiety or hypnotic medication12.6%19.5%18.9%better
Long-stay residents given the seasonal flu vaccine87.1%94.8%95.3%typical
Long-stay residents with pressure ulcers4.6%4.2%4.7%typical
Long-stay residents with worsening bladder/bowel control24.9%21.2%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table12.2%21.4%17.1%better
Short-stay residents who newly got an antipsychotic medication0.7%1.4%1.4%better
Short-stay residents given the seasonal flu vaccine45.1%77.7%79.4%worse
Short-stay residents rehospitalized after admission28.3%25.7%22.6%worse
Short-stay residents with an outpatient ER visit10.9%11.9%12.0%typical
Long-stay hospitalizations per 1,000 resident days1.541.881.67typical
Long-stay outpatient ER visits per 1,000 resident days0.711.501.80better

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.

59.4% 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 802 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

59.4%U.S. median 51.5%
Got home and stayed home
15.3%U.S. median 10.7%
Went back to hospital
48.5%U.S. median 56.6%
Met the expected recovery
0.51U.S. median 0.31
Therapy hours / resident / day
0.23hours / resident / day
Physical therapy
0.26hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 48.5% 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 332 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 0.51 therapist hours per resident per day in 2026Q1 — more than 82% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 12% 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 SNF59.4%CMS range 55.5–63.351.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF15.3%CMS range 13.2–17.110.7%Oct 2022–Sep 2024worse than U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge48.5%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 discharge52.1%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 discharge37.0%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 identified99.2%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 setting98.3%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 discharge96.7%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.4%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 worsened2.4%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 hospitalization6.9%CMS range 5.1–8.87.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.921.02Oct 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

0.69
RN hours/ resident / day
0.87
LPN hours/ resident / day
1.88
Aide hours/ resident / day
3.44
Total nurse hours/ resident / day
0.38
RN hoursweekends
33.6%
Total nursing turnover
63.0%
RN turnover

How full it usually is: this home is certified for 154 beds and averages 154.4 residents a day — about 100% occupied, or roughly -0 beds typically open. It runs essentially full — expect a waiting list. 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 3.44 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.69 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.88 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 3.02 hrs/resident/day on weekends vs 3.61 on weekdays — 16% thinner on weekends. RN hours go from 0.82 to 0.38 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 34% is below the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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

Inspection trend

7
deficiencies at the latest standard inspection (2026-01-13)
10
at the previous standard inspection (2024-10-11)

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.

30 citations, most serious first. The 10 most serious are shown; the remaining 20 are one tap away and print in full.

  • Potential for harm · D2026-02-26 · 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 records reviewed and interviews for one of three sampled residents (Resident #2), who was newly admitted related to his/her need for skilled nursing services, the Facility failed to ensure it provided treatment and care in accordance with professional standards of quality care, when during two separate Physician's visits, his/her provider indicated there were new treatment and/or medication orders for Resident #1, however they were not transcribed and entered as a Physicians order in a timely manner.Findings include:Based on the Facility Policy titled Medication and Treatment Orders, dated as last revised 07/2016, indicated orders for medications and treatments will be consistent with principles of safe and effective order writing.The Policy further indicated the following;-Medications shall be administered only upon the written order of a person duty licensed and authorized to prescribe such medication in this State;-Drugs and biological orders must be recorded on the Physician's Order sheet in the resident's chart; and-All drugs and biological orders shall be written,…

    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 before2026-02-26 · 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 #2), the Facility failed to ensure they maintained complete and accurate medical/treatment records when nursing documentation nursing on his/her Medication Administration Record (MAR) and/or Treatment Administration Record (TAR) were omitted, with some care areas left blank.Findings include:Review of the Facility Policy titled Charting and Documentation, dated as last revised July 2017, indicated that all services provided to the resident, progress towards the care plan goals, or any changes in the resident medical, physical, functional or psychosocial condition, shall be documented in the residents medical record, The Medical record should facilitate communication between the interdisciplinary team regarding the residents condition and response to care.The Facility indicated medication administration and treatments or services performed must be documented in the resident's medical record.Resident #2 was admitted to the Facility in 11/2025 diagnoses include a urinary tract infection, status post…

    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 · E2026-01-13 · tag F0757 — failed to avoid unnecessary drugs — pattern
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the drug regimen for one Resident (#56), from a total sample of 28 residents, was free of unnecessary drugs. Specifically, the facility failed to ensure two oral antibiotic medications (Doxycycline and Amoxicillin/Clavulanate) were not given in excessive duration resulting in the Resident receiving five unnecessary doses of oral antibiotics while on intravenous (IV) antibiotics. Findings include:Review of the facility's policy titled Adverse Consequences and Medication Errors, last revised June 2025, indicated but was not limited to:-A medication error is defined as the preparation or administration of drugs or biological which is not accordance with provider's orders, manufacturer's specifications, or accepted professional standards and principles of the professional(s) providing services.-Examples of medication errors include: -unauthorized drug- a drug administered without a provider's order. Resident #56 was admitted to the facility in…

    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 · Ecited before2026-01-13 · tag F0880 — failed to prevent and control infections — pattern
    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 observations and interviews, the facility failed to follow infection prevention and control practices. Specifically, the facility failed to:1. Ensure proper cleaning of resident shared equipment between resident use; and2. Ensure effective hand hygiene practices and appropriate personal protective equipment (PPE) were utilized when entering and exiting resident rooms, including residents on transmission-based precautions (implemented in addition to standard precautions in order to prevent or control infections.), to prevent the potential spread of infection. Findings include:1. Review of the facility's policy titled Cleaning and Disinfection of Resident-Care Items and Equipment, last revised September 2022, indicated but was not limited to:-Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC (Centers for Disease Control and Prevention) recommendations for disinfection and the OSHA (Occupational Safety and Health Administration) Bloodborne Pathogens Standard.-Reusable items are cleaned 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-01-13 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to notify the Resident's Physician or Nurse Practitioner about a medication error to re-evaluate the potential need to alter the treatment plan for one Resident (#56), from a total sample of 28 residents. Specifically, the facility failed to notify the Physician or Nurse Practitioner of Resident #56 receiving five doses of two antibiotics.Findings include:Review of the facility's policy titled Adverse Consequences and Medication Errors, last revised June 2025, indicated but was not limited to:-A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with provider's orders, manufacturer's specifications, or accepted professional standards and principles of the professional(s) providing services.-Examples of medication errors include:-unauthorized drug- a drug administered without a provider's order.-Promptly notify the provider of any significant error or adverse consequences. Resident #56 was admitted to the facility in December 2025 with diagnoses including acute…

    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 · D2026-01-13 · tag F0694 — isolated
    Provide for the safe, appropriate administration of IV fluids for a resident when needed.
    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 provide care and maintenance of a Peripherally Inserted Central Catheter (PICC-a flexible tube inserted through a vein in one's arm and passed through to larger veins near the heart, used to deliver medications intravenously (IV)), consistent with professional standards of practice for one Resident (#56), out of a total of 28 residents. Specifically, the facility failed to change the PICC dressing per professional standards. Findings include:Review of the facility's policy titled Central Venous Catheter Care and Dressing Changes, last revised June 2025, indicated but was not limited to the following:- The purpose of the procedure is to prevent complications associated with intravenous therapy, including catheter-related infections that are associated with contaminated, loosened, soiled, or well dressings.- Maintain sterile dressing (transparent semi-permeable membrane (TSM) dressing or sterile gauze) dressing for all central vascular access devices.- Change the dressing if it becomes damp, loosened or visibly…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-13 · tag F0745 — failed to provide medically-related social services — isolated
    Provide medically-related social services to help each resident achieve the highest possible quality of life.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews and record review, the facility failed to provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being for one Resident (#18), in a total sample of 28 residents. Specifically, the facility failed to assist Resident #18 in their request for discharge planning. Findings include:Review of the facility's policy titled Discharge Summary and Plan, revised in March 2025, indicated the following:-every resident has an individualized discharge plan, which begins at admission and is part of the comprehensive care plan-the discharge plan is based on the resident assessment, the goals for care, the desire for discharge and the resident's capacity for discharge-residents are periodically assessed for their interest in returning to the community-if the resident indicates an interest in returning to the community, the facility determines if appropriate and adequate support is in place-the facility makes referrals to local agencies, the local ombudsman, and support services that can assist in accommodating…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-13 · 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, interviews, and records reviewed, the facility failed to ensure residents were free from significant medication errors when one of two nurses observed during the medication pass failed to follow physician orders for an antiseizure medication. Specifically, for Resident #66, with a history of epilepsy (a brain disease that causes repeated seizures due to abnormal electrical signals in the brain), Nurse #1 failed to administer the correct dose of his/her anticonvulsant medication (drugs that control or prevent seizures by calming excessive electrical activity in the brain). Findings include:Review of the facility's policy titled Administering Medications, dated as revised April 2019, indicated but was not limited to:-Medications are administered in accordance with prescriber orders Review of Up To Date (an evidence-based clinical resource), Antiseizure medication maintenance therapy and drug monitoring, dated as revised 12/29/2025, indicated but was not limited to:-Studies have shown that those taking therapeutic doses of Levetiracetam have levels in the order 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 · Dcited before2026-01-13 · 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 record review and interviews, the facility failed to ensure staff maintained complete and accurate medical records for one Resident (#153), out of a total sample of 28 residents. Specifically, for Resident #153, the facility failed to ensure his/her medical record included his/her weight results.Review of the facility's policy titled Weight Assessment and Intervention, dated as revised March 2022, indicated but was not limited to:-Weights are recorded in each individual's medical record Resident #153 was admitted to the facility in December 2025 with diagnoses which included bacteremia (bacteria in the bloodstream) and sepsis (the body's reaction to extreme infection). Review of the Minimum Data Set (MDS) assessment, dated 12/23/25, indicated Resident #153 was 71 inches tall, weighed 155 pounds, and had no weight loss or gain. Review of Resident #153's Physician's Orders indicated but were not limited to:-weight every Monday for three weeks, start date 12/22/25 Review of Resident #153's December 2025 Treatment Administration Record (TAR) indicated but was not limited…

    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 · D2025-11-26 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    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 records reviewed and interviews for one of four sampled residents (Resident #4), the Facility failed to ensure they maintained Resident #4's right to privacy and confidentiality related to his/her Protected Health Information (PHI), when one of Resident #4's provider progress notes, which contained (PHI) was included in another resident's discharge paperwork and the Facility only became aware after the discharged residents' family member called and notified the Facility.Findings include: Review of the Facility Policy titled Use and Discloser of Health Information, dated as last revised 09/12/2013, indicated that the Center respects the importance of its residents' personal privacy, and understands the sensitive nature of its residents' health information. The Policy further indicated that the Center also recognizes that Federal and State laws require that individually identifiable health information must be safeguarded against improper use or disclosure. During a telephone interview on 11/25/25 at 10:08…

    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
Show the remaining 20 citations
  • Potential for harm · Dcited before2025-11-26 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records reviewed and interviews for two of three sampled residents (Resident #1 and #2), the Facility failed to ensure that upon admission, nursing developed and implemented baseline care plans with interventions, treatments, goals, and outcomes that addressed the residents' overall immediate care needs.Findings include:Review of the Facility Policy titled Baseline Care Plans, dated as last revised 3/2022, indicated that a baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within 48 hours of admission.The Policy further indicated the baseline care plan includes instructions needed to provide effective, person-centered care of the residents that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the residents.1) Resident #1 was admitted to the Facility in 9/2025, diagnoses include respiratory failure, pneumonia, chronic obstructive pulmonary disease and is oxygen…

    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 before2025-04-09 · 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 records reviewed and interviews for two of three sampled residents (Resident #1 and Resident #2) who had been assessed as requesting the use of bilateral side rails upon admission, the Facility failed to ensure nursing staff provided care and services that met professional standards of practice, when physician's orders were not obtained by nursing for the use of bilateral side rails. Findings include: Review of the Facility Form titled Informed Consent for Use of Bed Rail, undated, indicated under the section of Additional Comments, a blank box precedes the statement, Physician's Order has been obtained, including medical symptom/condition. 1) Resident #1 was admitted to the Facility in January 2025, diagnoses include metastatic colon cancer, history of falls, change in mental status, pulmonary emboli (blood clot in the lung), and ascites (abnormal buildup of fluid in the abdomen) with the need for a pleurx- drain (tunneled indwelling peritoneal catheter to manage small amounts of ascites). Review of Resident #1's Informed Consent for Use of Bed Rails, dated 01/12/25,…

    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 · E2024-10-11 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her 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 observation and interview, the facility failed to ensure residents in three of four dining areas had a dignified and homelike dining experience. Findings include: On 10/7/24 at 8:30 A.M., the surveyor made the following observations in the [NAME] Unit dining room: - Three residents were seated at tables in the dining area eating their breakfast meal on trays served at the table. - Covers for the plates were next to the residents filled with trash including milk cartons, coffee mug covers, and oatmeal bowl covers. - Three staff members were sitting in the back corner of the dining area, one of whom was on their phone. - A diathermy machine (a device used by physical and occupational therapy services to improve circulation, reduce swelling/inflammation, relax muscles/joints through electric currents to heat) was stored in the back of the dining area underneath the windows. On 10/8/24 at 8:11 A.M., the surveyor made the following observations in the [NAME] Unit dining room: - Three residents were seated at…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-10-11 · tag F0585 — failed to handle grievances — pattern
    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

    Based on interview and document review, the facility failed to ensure residents had the right to voice and formulate grievances, have those grievances responded to promptly, and be provided a resolution to their grievance. Specifically, the facility failed to: 1. Have voiced grievances investigated and addressed, for one Resident (#287), out of two residents investigated, who had repeatedly voiced concerns over call light answering times; 2. Provide one Resident (#238), out of a total sample of 25 residents, with a resolution to their grievance either in writing or by discussion once the grievance had been resolved; and 3. Ensure residents had access to grievance/concern forms so they could formulate grievances anonymously, should they choose not to alert a staff member to their concern. Findings include: Review of the facility's policy titled Grievances/Complaints, Filing, dated as revised April 2017, indicated but was not limited to the following: - Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff - 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 Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-10-11 · tag F0761 — failed to label and store drugs safely — pattern
    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 and interview, the facility failed to ensure all medications used in the facility were stored in accordance with currently accepted professional principles. Specifically, the facility failed to: 1. Dispose of oral medications that were no longer stored in their original dispensing systems in two of five medication carts reviewed; and 2. Provide a permanently affixed compartment for the storage of a schedule IV (potential for misuse and dependence) controlled substance in one of three medication room refrigerators reviewed. Findings include: Review of the facility's policy titled Medication Labeling and Storage, dated 2001, indicated but was not limited to the following: -Medications and biologicals are stored in the packaging, containers, or other dispensing systems in which they are received. -Controlled substances (listed as Schedule II-IV of the Comprehensive Drug Abuse Prevention and Control Act of 1976) and other drugs subject to abuse are separately locked in permanently affixed…

    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 · E2024-10-11 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential of foodborne illness to residents who are at high risk. Specifically, the facility failed to: 1. Handle ready-to-eat food (food which does not require cooking or further preparation prior to consumption) utilizing proper hand hygiene to prevent cross contamination (transfer of pathogens from one surface to another); and 2. Properly label and date food products and maintain safe and clean equipment in three of four nourishment kitchenettes. Findings include: Review of the facility's policy titled Food Preparation and Service, dated November 2022, indicated but was not limited to the following: - Cross-contamination can occur when harmful substances, i.e., chemical or disease-causing microorganisms are transferred to food by hands (including gloved hands), food contact surfaces, sponges, cloth towels, or utensils that are not adequately cleaned. - Food…

    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 · E2024-10-11 · tag F0847 — pattern
    Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and document review, the facility failed to explain binding arbitration agreements and provide the Residents the right to fully review the agreement for three Residents (#238, #239, and #237), out of three sampled residents. Findings include: Review of the facility's policy titled Binding Arbitration Agreements, dated November 2023, indicated but was not limited to the following: - Residents are informed of the nature and implications of any proposed binding arbitration agreements so as to make informed decisions on whether to enter into such agreements - Agreements are voluntary for the resident and are not required as a condition of admission or to receive care at the facility - Terms and conditions of the agreement are explained to the residents in a way that ensures his/her understanding to the agreement, including that the resident may be giving up their right to have a dispute resolved in a court proceeding (i.e., litigation) - The terms and conditions are explained in a manner that he/she can understand, taking into consideration the resident's primary…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-10-11 · tag F0883 — failed to offer flu and pneumonia vaccines — pattern
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, document review, policy review, and interview, the facility failed to implement policies and procedures to ensure residents were properly screened for eligibility to receive the recommended pneumococcal vaccine, residents/residents' representatives were educated on the benefits and potential side effects of the vaccine, and were offered and administered (if applicable) the vaccine in a timely manner for five Residents (#117, #25, #113, #388 and #1), out of a total sample size of five residents reviewed for immunizations. Findings include: Review of the Centers for Disease Control and Prevention (CDC) document titled Pneumococcal Vaccine Timing for Adults, dated March 2023, indicated the following: -Make sure your patients are up to date with pneumococcal vaccination. Adults >= [AGE] years old, Complete Pneumococcal Vaccine Schedules: -PCV13 (pneumococcal conjugate vaccine) only at any age - give PCV20 (pneumococcal 20-valent conjugate) or PPSV23 (pneumococcal polysaccharide vaccine) >= 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-10-11 · 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 document review and interview, the facility failed to ensure two Residents (#238 and #237) were provided a summary of their baseline care plan meeting, out of a total sample of 25 residents. Findings include: Review of the facility's policy titled Care Plans - Baseline, dated as revised March 2022, indicated but was not limited to the following: - a baseline care plan to meet the resident's immediate healthcare needs is developed for each resident within 48 hours of admission - the resident and/or their representative are provided a written summary of the baseline care plan that includes but is not limited to: the stated goals and objectives of the resident, a summary of medications and dietary instructions, and any services and treatments to be administered - provision of the summary to the resident and/or representative is documented in the medical record A. Resident #238 was admitted to the facility in September 2024 with diagnoses including: acidosis (a condition in which the body fluids become too acidic), fall, multiple sclerosis, and adjustment disorder with anxiety…

    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 before2024-10-11 · 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, interview, and document review, the facility failed to ensure professional standards of practice were met for one Resident (#388), out of a total sample of 25 residents. Specifically, the facility failed to address the wound physician's recommendations timely for care and treatment of a post-operative site infection. Findings include: Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised 4/11/18, indicated: Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescribers that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. Resident #388 was admitted to the facility in September 2024 with diagnoses including coronary bypass (a procedure that improves blood flow to…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-11 · tag F0908 — failed to keep essential equipment working — isolated
    Keep all essential equipment working safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interviews, the facility failed to ensure mechanical equipment located in the main kitchen, specifically the walk-in freezer, was maintained in safe operating condition. Findings include: On 10/7/24 at 8:00 A.M., the surveyor made the following observations of the walk-in freezer in the main kitchen: - The outside thermometer on the door of the walk-in freezer registered a temperature ranging between -36 to -48 Fahrenheit (F). - There was no thermometer inside the walk-in freezer to verify the temperature. - Frost/ice buildup on the cardboard box containing individual chocolate ice cream cups. Frost/ice buildup was also noted on the individual cups. - Frost/ice buildup was on a cardboard box containing individual vanilla ice cream cups. Frost/ice buildup was also noted to the individual cups. - Frost/ice buildup on the outside of a cardboard box containing individual cheese omelets. A plastic bag containing the cheese omelets was inside the cardboard box. The plastic bag was not secured shut and frost/ice was noted to individual cheese omelets towards 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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-07-21 · tag F0554 — pattern
    Allow residents to self-administer drugs if determined clinically appropriate.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, policy review, interview, and record review, the facility failed to ensure that one Resident (#29), from a total sample of 25 residents, was assessed to be clinically appropriate to self-administer medication. Findings include: Review of the facility's policy titled Self-Administration of Medications, revised December 2016, indicated but was not limited to the following: -Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. -In addition to general evaluation of decision-making capacity, the staff and practitioner will perform a more specific skill assessment, including (but not limited to) the resident's ability to read and understand medication labels; comprehend the purpose and proper dosage and administration time for his or her medications; ability to remove medications from a container and to ingest and swallow; and ability to recognize risks and major adverse consequences of his or her medications. -The staff and practitioner will ask…

    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 · E2023-07-21 · tag F0698 — failed to provide proper dialysis care — pattern
    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 and interview, the facility failed to ensure there was ongoing, accurate, and timely communication of information with the dialysis center in a manner that was consistent with professional standards of practice for one Resident (#55), of a total sample of 25 residents. Findings include: Resident #55 was admitted to the facility in June 2020 with diagnoses which included End Stage Renal Disease (ESRD), Type II diabetes mellitus (DM II), and hypertension. Record review indicated the Resident received hemodialysis (a procedure to remove waste products and excess fluid from the body to maintain life when the kidneys stop working properly) due to ESRD, at a local dialysis center every Tuesday, Thursday, and Saturday at approximately 7:00 A.M. Review of the Outpatient Dialysis Services Agreement between the facility and dialysis center, dated 10/18/21 indicated but was not limited to: Pages 1-2, A. Obligations of Nursing Facility and/or Owner 1. ESRD Residents Information. The nursing facility shall ensure that all appropriate medical and administrative information…

    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 before2023-07-21 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to notify the Physician when the Resident exceeded his/her prescribed daily fluid restriction of 1500 cubic centimeters (cc) and subsequently monitor the Resident accordingly for one Resident (#55), out of a total sample of 25 residents. Findings include: Review of the facility's policy titled: Fluid Restriction Management, dated 7/22/11 included but was not limited to the following: - The nurse will document the maintenance of prescribed fluid restriction each shift on the medication administration record (MAR). - The nurse will oversee documentation of the actual fluid intake on each shift and monitor to ensure that restriction is maintained. - A total of 24-hour intake is calculated. - If the fluid intake exceeds prescribed restriction, MD must be notified, and the Resident must be monitored for signs and symptoms of excess fluid. Resident #55 was admitted to the facility in June 2020 with diagnoses that included End Stage Renal Disease (ESRD) and hypertension. Review of the July 2023 Physician's Orders…

    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 · D2023-07-21 · 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 interview and record review, the facility failed to ensure one Resident (#111), out of a total sample of 25 residents, was referred for a Level II Preadmission Screening and Resident Review (PASRR) evaluation (an evaluation to determine if a resident needs specialized services to address his/her Serious Mental Illness (SMI)) once it was identified the Resident had a diagnosis of SMI. Findings include: Review of the MassHealth Nursing Facility Bulletin 169, dated October 2021 indicated the following: -Level I Screening - A preliminary screening of all nursing facility applicants, regardless of payer source, conducted prior to their admission to a nursing facility. A Level I Screening identifies whether an applicant for admission to a nursing facility has, or may have SMI (i.e. a positive Level I Screening). If the individual has a positive Level I Screening, the screener must refer the individual to the appropriate PASRR authority for a Level II Evaluation or Abbreviated Level II Evaluation, as…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-07-21 · 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, interview, policy review, and record review, the facility failed to follow standards of practice for three Residents (#115, #55, and #17), in a total sample of 25 residents. Specifically, the facility failed to: 1. For Resident #115, a. follow their skin care policy for a newly identified area to the Resident's right posterior knee secondary to an ace wrap bandage that was placed too tightly, and b. ensure staff did not leave morning medications with the Resident to self-administer without a physician's order to do so; 2. For Resident #55, ensure nursing staff observed the consumption of administered medication prior to leaving the room; and 3. For Resident #17, ensure nursing staff reviewed and communicated wound consultant recommendations with the facility provider timely. Findings include: 1a. Review of the facility's policy titled Skin Tears - Abrasions and Minor Breaks, Care of, revised September 2013, indicated but was not limited to the following: The purpose of this procedure is to guide the prevention and treatment of abrasions, skin tears, and minor…

    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 · D2023-07-21 · 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 observation, record review, and staff interview, the facility failed to ensure that medications were secure and not accessible to residents, for one Resident (#10), of a total sample of 25 residents. Specifically, the facility failed to ensure Resident #10 was assessed for mental and physical ability to safely self-administer medications and not share medications that were left with him/her at the bedside. Findings include: The Self-Administration of Medication policy dated 12/2016, was reviewed on 7/20/23, and indicated the following: -Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the residents to do so. -As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident. -Self-administered medications must be stored in a safe and secure place, which is not accessible by other residents. Resident #10 was admitted 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-21 · tag F0849 — isolated
    Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, hospice contract review, and staff interview, the facility failed to ensure for two Residents (#77 and #29), out of a total sample of 25 residents, that hospice services were provided in accordance with the agreement between the hospice and the facility. Specifically, the facility failed to provide ongoing documentation of hospice staff visits to ensure prompt and effective communication and continuity of care for the Resident, in accordance with the hospice agreement. Findings include: 1. On 7/20/23 at 11:30 A.M., review of the agreement between the hospice and the facility indicated: Each clinical record shall completely, promptly and accurately document all services provided to, and events concerning, each Hospice Patient, including evaluations, treatments, progress notes, authorizations to admission to Hospice and/or Facility, physician order entered pursuant to this Agreement and discharge summaries. Resident #77 was admitted to the facility in June 2022 and was admitted to hospice in December 2022. Admitting diagnoses included: history of…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-07-21 · 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 policy review, the facility failed to ensure staff maintained an infection control program designed to prevent the development and potential transmission of infections. Specifically, the facility failed: 1. To ensure proper infection control practices were followed while providing care for a resident who was on contact precautions for a methicillin-resistant staphylococcus aureus (MRSA) infection; and 2. To ensure staff properly transported linens so as to prevent the spread of infection. Findings include: 1. Review of Centers for Disease Control and Prevention (CDC) guidance titled Transmission-Based Precautions, revised January 2016, indicated but was not limited to the following: Contact Precautions: -Use personal protective equipment (PPE) appropriately, include gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning (to put on) PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens. On 7/18/23 at 10:38 A.M.,…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2024-10-11 · tag F0844 — pattern
    Follow rules about disclosure of ownership requirements and tell the state agency about changes in ownership and/or administrative personnel.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on interviews and review of the Health Care Facility Reporting System (HCFRS- State agency reporting system), the facility failed to provide written notice to the State Agency when a change in the facility's Administrator occurred. Findings include: Review of HCFRS indicated effective 8/30/24 the previous Administrator was no longer the Administrator of record at the facility. Further review of HCFRS failed to indicate the State Agency was notified of the current Administrator. During an interview on 10/8/24 at 5:22 P.M., the Administrator said he was unaware that when the previous Administrator went out on leave, they had submitted to the State Agency that they were not the Administrator of record. He said he was currently the Administrator and that he had not notified the State Agency of the effective date. On 10/9/24 at 3:54 P.M., the Administrator said the change in Administrator was effective 9/1/24 and was reported to the State Agency on 10/8/24.

    Administration 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 CAREONE — 37 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 2 of 53.4-1.4 vs chain
Health inspection 2 of 52.9-0.9 vs chain
Staffing 2 of 53.2-1.2 vs chain
Quality measures 4 of 54.4-0.4 vs chain
The other 36 homes this chain runs (chain average 3.4★, per CMS)
1 of 5Care One At MillburyMillbury, MA 1 of 5Care One At RandolphRandolph, MA 1 of 5Careone At OradellOradell, NJ 2 of 5Care One At BrooklineBrookline, MA 2 of 5Care One At NewtonNewton, MA 2 of 5Care One At RedstoneEast Longmeadow, MA 2 of 5CareOne At Hanover TownshipWhippany, NJ 2 of 5Careone At MiddletownAtlantic Highlands, NJ 2 of 5Rehab & Nursing Ctr Greater PittsburghGreensburg, PA 3 of 5Care One At LexingtonLexington, MA 3 of 5Care One At LowellLowell, MA 3 of 5Care One At New BedfordNew Bedford, MA 3 of 5CareOne At Madison AvenueMorristown, NJ 3 of 5CareOne At MoorestownMoorestown, NJ 3 of 5CareOne at New MilfordNew Milford, NJ 3 of 5Careone At East BrunswickEast Brunswick, NJ 3 of 5Careone At Ridgewood AvenueParamus, NJ 3 of 5Careone At WellingtonHackensack, NJ 4 of 5Care One At ConcordW Concord, MA 4 of 5Care One At Essex ParkBeverly, MA 4 of 5Care One At NorthamptonNorthampton, MA 4 of 5CareOne At TeaneckTeaneck, NJ 4 of 5CareOne at The HighlandsEdison, NJ 4 of 5Careone At CresskillCresskill, NJ 4 of 5Careone At EveshamMarlton, NJ 4 of 5Careone At LivingstonLivingston, NJ 4 of 5Careone At ParsippanyParsippany Troy Hill, NJ 4 of 5Careone At Somerset ValleyBound Brook, NJ 5 of 5Care One At HolyokeHolyoke, MA 5 of 5Care One At PeabodyPeabody, MA 5 of 5Care One At WilmingtonWilmington, MA 5 of 5CareOne At WallWall, NJ 5 of 5Careone At HolmdelHolmdel, NJ 5 of 5Careone At ValleyWestwood, NJ 5 of 5Careone At WayneWayne, NJ 5 of 5River Glen Health Care CenterSouthbury, CT

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
THCI OF MASSACHUSETTS, LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 07/01/2003
CARE REALTY, LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 04/30/2002
DES-I 2016 GRATOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 12/01/2021
STRAUS, DANIELIndividual5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 07/01/2003
BARUCH, DAVIDIndividualW-2 MANAGING EMPLOYEE; CORPORATE OFFICERsince 12/01/2021
HEALTHBRIDGE MANAGEMENT LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 07/01/2003

CMS files one row per role, so the 7 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

$20.7M
Net patient revenuemost recent cost report
-10.9%
Operating marginrevenue minus expenses
$3.9M
Related-party expense17% of expenses
Who pays — share of resident-days
Medicaid 58%Medicare 21%Other / private 22%

This home reported $3.9M paid to related parties — landlords or management companies under common ownership — equal to about 17% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

Cost & finances

$462per resident / day
operating cost
$14,039per month
≈ monthly operating cost
$416per 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 225634. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-13, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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