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Blackstone Valley Health And Rehabilitation

447 Hill Street, Whitinsville, MA 01588 · For profit - Individual · 123 certified beds · (508) 570-4908 Medicare & Medicaid certified

Call the home — (508) 570-4908 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
No harm-level citations or fines — but 28 lower-level deficiencies on record (see below)
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
Worth asking about
  • a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure rating is low (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.

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

Location & what’s nearby

Urgent care / clinic
100 Commerce Dr · (508) 372-3510 · Call to confirm hours
Pharmacy
1163 Providence Rd · (800) 746-7287 · Call to confirm hours
Grocery
100 Main St
Park
Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 2 of 5
Long-stay residentspeople who live here 1 of 5
Short-stay residentsrehab / post-hospital 2 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 4 to 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 increased31.5%16.4%15.4%worse
Long-stay residents who lose too much weight3.0%5.1%5.4%better
Long-stay residents with a catheter left in their bladder2.1%0.8%0.9%worse
Long-stay residents with a urinary tract infection2.2%1.8%2.0%worse
Long-stay residents with depressive symptoms1.2%15.5%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury3.9%3.4%3.3%worse
Long-stay residents whose ability to walk worsened24.9%15.4%16.1%worse
Long-stay residents on antianxiety or hypnotic medication20.7%19.5%18.9%typical
Long-stay residents given the seasonal flu vaccine97.1%94.8%95.3%typical
Long-stay residents with pressure ulcers2.6%4.2%4.7%better
Long-stay residents with worsening bladder/bowel control28.7%21.2%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table24.1%21.4%17.1%worse
Short-stay residents who newly got an antipsychotic medication1.5%1.4%1.4%typical
Short-stay residents given the seasonal flu vaccine98.6%77.7%79.4%better
Short-stay residents rehospitalized after admission25.4%25.7%22.6%worse
Short-stay residents with an outpatient ER visit7.9%11.9%12.0%better
Long-stay hospitalizations per 1,000 resident days1.941.881.67worse
Long-stay outpatient ER visits per 1,000 resident days2.281.501.80worse

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

51.6% 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 142 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

51.6%U.S. median 51.5%
Got home and stayed home
11.5%U.S. median 10.7%
Went back to hospital
32.6%U.S. median 56.6%
Met the expected recovery
0.37U.S. median 0.31
Therapy hours / resident / day
0.15hours / resident / day
Physical therapy
0.17hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 32.6% 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 43 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 0.37 therapist hours per resident per day in 2026Q1 — more than 64% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 16% 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 SNF51.6%CMS range 41.7–62.451.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.5%CMS range 8.8–15.110.7%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 discharge32.6%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 discharge34.9%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 discharge41.9%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care 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 discharge100.0%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 stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened1.8%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 hospitalization7.0%CMS range 3.9–11.67.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.911.02Oct 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

0.38
RN hours/ resident / day
1.03
LPN hours/ resident / day
1.80
Aide hours/ resident / day
3.22
Total nurse hours/ resident / day
0.25
RN hoursweekends
41.7%
Total nursing turnover
30.0%
RN turnover

How full it usually is: this home is certified for 123 beds and averages 115.3 residents a day — about 94% occupied, or roughly 8 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.22 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.38 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.80 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 2.87 hrs/resident/day on weekends vs 3.36 on weekdays — 15% thinner on weekends. RN hours go from 0.44 to 0.25 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 42% is about the same as the national median of 45%. 1 administrator has left in the past year.

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

Inspection trend

11
deficiencies at the latest standard inspection (2025-04-29)
5
at the previous standard inspection (2024-02-02)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

28 citations, most serious first. The 10 most serious are shown; the remaining 18 are one tap away and print in full.

  • Potential for harm · D2025-04-29 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interview, the facility failed to ensure that a Level II [comprehensive evaluation that identifies the specialized services required] Preadmission Screening and Resident Review (PASARR- evaluation done if it was determined by the Level I [initial pre-screening] screen that a resident had an intellectual or developmental disability and/or serious mental illness [SMI] and if a resident was in need of additional support services at the facility) screen was submitted for two Residents (#93) and (#74), out of a total sample of 25 residents. Specifically, for Resident's #93 and #74, the facility failed to request a Level II PASARR evaluation when both Residents demonstrated a change in psychosocial condition requiring emergency mental health intervention. Findings include: 1. Resident #93 was admitted to the facility in May 2024 with diagnoses including Anxiety Disorder, Depression, and Post Traumatic Stress Disorder (PTSD). Review of Resident #93's PASARR Level I screen dated 5/17/24,…

    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 before2025-04-29 · 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, and record review, the facility failed to ensure that the Resident and/or Resident Representative was provided the right to participate in the care plan process for one Resident (#46), out of a total sample of 25 residents. Specifically, the facility failed to ensure that quarterly care plan meetings were conducted as required for Resident #46. Findings include: Review of the facility policy titled Resident Assessment and Care Planning Policies and Procedures, last revised February 2022, included the following: -Residents and their families .are invited to attend and participate in the resident's assessment and care planning conferences (admission, quarterly, annual, and significant change in status). -A timely advance notice of the care planning conference is provided to the resident and interested family members. -Social services maintain a record of such notices. -Attendance will be taken and kept in the resident's record. -All care plans will be reviewed with the attendees for further…

    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 before2025-04-29 · 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 record reviews, and interviews, the facility failed to ensure two Residents (#32 and #113) out of a total sample of 25 residents, remained free from accidents and hazards. Specifically, 1. For Resident #32, the facility failed to secure smoking materials at the nurses station after the Resident participated in smoking activities, ensure the Resident disposed of smoking materials safely, and perform one out of three quarterly Safe Smoking Assessments. 2. For Resident #113, the facility failed to include the Resident's name and photograph as part of the Wandering Resident Red Binder located at the facility front desk and unit nurses' stations, when the Resident was evaluated as being at risk for elopement. Findings include: 1. Review of the facility policy titled: Facility Smoking, effective date January 2025, indicated the following: -The purpose of this policy is to protect residents' rights while ensuring the highest level of safety for both residents and staff from the serious consequences that may…

    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 · D2025-04-29 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility staff failed to ensure appropriate care and services were provided for one Resident (#45) out of a total sample of 25 residents, when the Resident was identified as being at risk for altered nutrition status. Specifically, for Resident #45, the facility failed to perform a nutritional assessment when the Resident was admitted to the facility and implement interventions thereafter when the Resident was identified as having experienced a significant weight loss. Findings include: Review of the facility policy titled: Nutrition/Weight Policy, effective 12/1/24, indicated the following: -When weights demonstrate undesired trends, or progressive insidious weight change, or significant weight change (gains or losses) the licensed nurse will document the weight change in the EMR (Electronic Medical Record). -The threshold for significant unplanned and undesired weight change (loss/gain) will be based on the following criteria: a. 1 month -5% weight…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-29 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to provide respiratory care and services consistent with professional standards of practice for two Residents (#36 and #93) out of a total sample of 25 residents. Specifically, 1. for Resident #36, the facility failed to ensure a clean and sanitary oxygen concentrator (device used to deliver supplemental oxygen) filters in accordance with the manufacturers' guidelines when the air intake gross particle filter was observed with a thick coating of dust, placing the Resident at risk of equipment malfunction and inhaling dust particulate matter. 2. for Resident #93, the facility failed to maintain the Resident's oxygen concentrator filter as required, placing the Resident at risk for impaired oxygen supply delivery and inhaling contaminated oxygen. Findings include: Review of the Invacare Platinum XL II user manual dated, 8/9/06, indicated: -Remove each filter and clean at least once a week depending on environmental conditions. Note:…

    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 · D2025-04-29 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, and record review, the facility failed to ensure Medication Regimen Reviews (MRRs) were responded to and/or implemented timely for one Resident (#34), out of five applicable residents reviewed for unnecessary medications, out of a total sample of 25 residents. Specifically, for Resident #34, the facility failed to ensure that duplicate recommendations from the Consultant Pharmacist were reviewed and responded to by the Provider and/or nursing staff, and that orders were implemented timely relative to: -obtaining a Vitamin D level made on 5/3/24, 6/2/24, and 7/2/24. -discontinuation of Loratadine (antihistamine medication) made on 10/2/24, 11/4/24, 12/6/24, and 1/2/25. Findings include: Review of the facility policy titled Drug Regimen Review, dated 4/2022, indicated the following: -Consultant Pharmacist reviews the medication regimen of each active resident at least monthly -Findings and recommendations are reported to the Director of Nurses (DON) and the Medical Director. -The Consultant Pharmacist documents the date each medication regimen review is completed…

    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 · D2025-04-29 · 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 interview and record review, the facility failed to ensure one Resident (#34) was not administered unnecessary medications, of five applicable residents reviewed for unnecessary medications, out of a total sample of 25 residents. Specifically, the facility failed to ensure the Consultant Pharmacist Recommendation to discontinue scheduled Loratadine (antihistamine medication), that was approved by the Provider on 10/8/24, was discontinued and Resident #34 continued to receive the scheduled doses of the medication until it was discontinued on 2/4/25 (over three months later). Findings include: Resident #34 was admitted to the facility in May 2024 with diagnoses including Dementia and Chronic Kidney Disease (CKD). Review of the Consultant Pharmacist Progress Notes indicated the following repeated recommendations: -10/2/24: to the Medial Doctor (MD) - Recommend continued need for Loratadine medication -11/4/24: to Nursing - Recommend follow through with Consultant Pharmacist's Recommendation to discontinue Loratadine. -12/6/24: to Nursing - Recommend follow through with…

    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 · D2025-04-29 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to maintain a medication pass error rate of less than five percent (%) for two Residents (#11 and #47), out of five applicable residents, out of 29 medication pass opportunities. The medication error rate was observed to be 6.9%. Specifically, 1. For Resident #11, the Resident was administered the wrong medication dosage form when a Ferrous Sulfate tablet was administered and Ferrous Sulfate Oral Solution was ordered. 2. For Resident #47, the Resident was administered the incorrect dosage of Fish Oil when 2000 mg (milligrams) of Fish Oil was administered and 1000 mg of Fish Oil was ordered. Findings include: Review of the facility policy titled Medication and Treatment Orders, effective June 2022, indicated the following: -Policy: Orders for medications and treatments will be consistent with principles of safe and effective order writing. -Medications shall be administered only upon the written order of physician/NP/PA licensed in MA. Review of the facility policy titled Specific Medication Administration…

    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 · D2025-04-29 · 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, and interview, the facility failed to follow professional standards of practice for food safety and sanitation in the facility's main kitchen to prevent contamination and the potential spread of foodborne illnesses. Specifically, the facility failed to ensure that food items stored in the walk-in refrigerator in the facility main kitchen area were properly labeled and dated as required. Findings include: Review of the 2022 Food Code by the U.S. Food and Drug Administration (FDA) indicated but was not limited to: -501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when Packaging Food using a Reduced Oxygen Packaging method as specified under §3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours: > shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the premises, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum…

    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 · D2025-04-29 · tag F0825 — isolated
    Provide or get specialized rehabilitative services as required for a resident.
    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 specialized rehabilitation services were provided to assist in maintaining the highest practicable level functioning for one Resident (#74) out of a total sample size of 25 residents. Specifically, for Resident #74, the facility failed to ensure that Physical Therapy (PT) Evaluations were completed timely as ordered by the Physician for symptoms of bilateral knee pain and stiffness. Findings include: Resident #74 was admitted to the facility in June 2024 with diagnoses including bilateral primary Osteoarthritis of the knees. Review of the Facility Policy titled Scope of Services, Rehabilitation, revised February 2022 indicated: -Residents are screened and/or evaluated by Physical, Occupational and Speech Therapy according to demonstrated need in a specific area -Such therapy encompasses examination and analysis of patients to maximize functional independence: >A therapy screen to assess the need for skilled service >An initial evaluation and assessment of the patient prior to provision of services >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
Show the remaining 18 citations
  • Potential for harm · Dcited before2025-04-29 · 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, and interview, the facility failed to adhere to infection prevention and control standards of multi-resident use medical equipment to prevent the development and transmission of communicable diseases and infections for one Resident (#108), out of a total sample of 25 residents. Specifically, the facility staff failed to clean and disinfect a blood glucose monitor (BGM- device used to measure the amount of glucose [sugar] in a person's blood) after using the BGM to obtain a blood glucose level for Resident #108 and before storing in the medication cart with clean equipment. Findings Include: Review of the facility policy titled: Disinfecting Shared Resident Equipment indicated the following: -It is the policy of the facility to clean/disinfect shared equipment in order to decrease the risk of infection. -Disinfecting all resident shared equipment with the method recommended depending on the object's intended use and type of contamination will be done routinely. On 4/24/25 at 9:41 A.M., during a medication administration observation, the surveyor observed Nurse…

    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 before2024-02-02 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — pattern
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to provide treatment consistent with professional standards of practice, to promote healing and reduce risk for infection, for one Resident (#75) out of a total sample of 24 residents, with a Stage Three (full-thickness loss of skin) pressure ulcer (localized damage to the skin and/or underlying soft tissue usually over a bony prominence) on the sacrum (large flat bone in the lower part of the spine). Specifically, the facility staff failed to implement recommendations from the Wound Consultant, made over four consecutive weekly wound consults, with recommendations reviewed and approved by the Physician to apply Skin Prep (water-proof liquid that forms a transparent film over the skin for protection) to the periwound (tissue surrounding a wound) of Resident #75's sacral wound. Findings include: Resident #75 was admitted to the facility in December 2023 with Venous Insufficiency (a condition in which veins fail to return blood efficiently to the heart), Adult Failure to Thrive (a syndrome of global decline 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-02 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide Foley catheter (also known as a urinary catheter - a flexible tube inserted into the bladder to drain urine outside of the body) care related to infection control prevention for one Resident (#64) out of a total sample of 24 residents. Specifically, the facility staff failed to change Resident #64's Foley catheter drainage bag when the Physician ordered weekly catheter drainage bag changes, and the Resident was on Contact Precautions (intended to prevent transmission of infectious agents) for Vancomycin Resistant Enterococcus (VRE- bacterial infection resistant to the Vancomycin antibiotic) in the urine. Findings include: Review of the facility's policy titled Indwelling Urinary Catheter, dated 2/2022, indicated: -Change catheters and drainage bags based on clinical indications such as infection. Resident #64 was admitted to the facility in October 2023 with diagnoses including Retention of Urine (inability to completely empty 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 · D2024-02-02 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record and policy review, and interviews, the facility failed to provide care and services consistent with professional standards for one Resident (#73) out of a total sample of 24 residents, who required renal dialysis (also known as hemodialysis: a life-saving treatment that filters waste products and excess fluid when the kidneys stop working). Specifically, the facility staff failed to ensure accurate and complete communication with the dialysis facility for Resident #73's dialysis appointments as required. Findings include: Review of the facility policy for Caring for a Hemodialysis Resident, effective January 2023, indicated: -It is the policy of the facility that hemodialysis residents are monitored and assessed following the current professional practices that supports the resident's safety and care unless otherwise ordered by the Physician. -Vital signs should be taken and documented on the dialysis form (and in the resident's record) before the resident goes to dialysis at the floor's regular…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-02 · tag F0742 — isolated
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
    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 and policy review, and interview, the facility failed to provide mental health services for one Resident (#48) out of a total sample of 24 residents, with a documented history of Depression and Anxiety. Specifically, the facility staff failed to: 1. provide timely Behavioral Health Services for Resident #48 who was expressing psychosocial distress following the death of their roommate. 2. follow the facility suicidal ideation (thinking about or planning suicide) policy when Resident #48 had expressed suicidal ideation to staff members. Findings include: 1. Review of the facility policy for Behavioral Services, effective October 2023, indicated that any resident who identified as exhibiting any behavior or has an order for psychoactive (medication that affects how the brain works) medications is .referred to the facility contracted Behavioral Services vendor for follow-up. Resident #48 was admitted to the facility in June 2013, with diagnoses including Depression (a mental health disorder…

    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 · D2024-02-02 · tag F0868 — isolated
    Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure that all required members of the QAPI Committee participated in quarterly QAPI meetings. Specifically, the facility failed to ensure that the facility Infection Preventionist (IP) attended and participated in two out of four quarterly QAPI meetings reviewed. Findings include: Review of the Quarterly QAPI Meeting Attendance Sheet provided by the facility, dated 10/19/23, included no evidence that the IP attended the quarterly meeting. Review of the Quarterly QAPI Meeting Attendance Sheet provided by the facility, dated 1/18/24, included no evidence that the IP attended the quarterly meeting. During an interview on 2/2/24 at 1:50 P.M., the Administrator said the IP was a required QAPI Committee member. The surveyor and the Administrator reviewed the QAPI Meeting Attendance Sheets and the Administrator said the facility did not have an IP in October 2023, so no IP was present for the Quarterly QAPI Meeting held on 10/19/23. The Administrator also said the facility currently had an IP, and that he/she provided a report…

    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 · D2022-07-26 · tag F0550 — failed to protect resident dignity and rights — isolated
    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

    Based on observations and interviews, the facility failed to ensure its staff provided one Resident (#53) with a dignified experience, out of a total sample of 22 residents. Specifically, the facility failed to ensure its staff provided: 1) A clean wheelchair for Resident #53 to use when he/she was out of bed, and 2) When he/she was seated in a common area, where other residents and staff were present. Findings include: On 7/20/22 at 10:47 A.M., the surveyor observed a wheelchair in Resident #53's room, positioned at the foot of the Resident's bed, labeled with the Resident's name. Resident #53 was in bed. The right side of the wheelchair, right wheel, and top of the wheelchair cushion all contained dried, white, spattered, and smeared debris. Underneath the cushion, there was dried food debris and wet milk on the wheelchair seat. The bottom of the cushion had dried food debris adhered to it. On 7/25/22 at 9:33 A.M., the surveyor observed Resident #53 in bed in his/her room and the Resident's wheelchair was positioned at the foot of the bed. The right side of the wheelchair, right…

    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 · D2022-07-26 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure its staff accurately identified advance directives relative to life sustaining treatment for one Resident (#97) out of a total sample of 22 residents. Specifically, the facility failed to ensure its staff accurately identified the wishes of the Resident and/or his/her invoked health care proxy (HCP- advanced medical directive in the form of a legal document designating another person to make health care decisions when a person is deemed incapable of making their own decisions) relative to whether or not the Resident wished to be a full code (resuscitated - action taken to revive someone from death, and/or intubated/ventilated - action taken to cause air to enter into one's body when they cannot breathe on their own) in the event that his/her heart stopped and/or he/she was in respiratory distress. Findings include: Review of the facility's policy titled, HCP and Medical Orders for Life Sustaining Treatment (MOLST) Forms, dated February 2022…

    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 · D2022-07-26 · 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 ensure its staff notified the Physician/non Physician Practitioner and health care proxy (HCP) about a non-pressure related change in skin condition for one Resident (#97) out of 22 total sampled residents. Specifically, the facility failed to ensure its staff notified the Physician/non Physician Practitioner and HCP when Resident #97 developed a non-pressure related opening in his/her skin, on the right knee. Findings include: Review of the facility's policy titled, Change in a Resident's Condition or Status and Notification, dated April 2022, included the following: - The facility would promptly notify the resident, his/her attending physician, and resident representative (consistent with their authority) of changes in the residents medical .condition and/or status . - The nurse supervisor/charge nurse shall be notified of a change in the resident's condition .that may serve as an early warning sign of clincal events .including but not limited to .deterioration in the resident's physical .condition . and…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-07-26 · 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 its that staff implemented the plan of care for two Residents (#44 and #97) out of a total sample of 22 residents. Specifically ensuring facility staff implemented: 1) Physician's orders for Resident #44 to be out of bed (OOB) for all meals, and 2) The Physician order of no added salt with meals for Resident #97. Findings include: 1. For Resident #44 the facility staff failed to implement the plan of care to ensure that the Resident was out of bed for all meals as ordered by the Physician. Resident #44 was admitted to the facility in August 2018 with diagnoses including: muscle weakness, cerebral infarction (disrupted blood flow to the brain which causes brain damage), and dysphagia - oropharyngeal phase (difficulty swallowing foods or liquids occurring in the mouth and/or throat). Review of the Resident's clinical record nursing note indicated that on 10/25/21 at approximately 9:45 A.M., the Resident was observed choking on his/her breakfast and staff intervened to clear the Resident's throat. Review…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-07-26 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record reviews and interviews, the facility failed to ensure its staff developed care plans within seven days of the completion of comprehensive Minimum Data Set (MDS) assessments for one Resident (#80) out of 22 active resident records reviewed, and for one discharged Resident (#74) out of three discharged Resident records reviewed. Specifically, the facility failed to ensure its staff: 1) Developed a care plan relative to falls for Resident #80, when these areas were triggered on the Residents' comprehensive MDS assessments and the plan was indicated to proceed with developing care plans, and 2) Developed care plans relative to urinary incontinence and cognitive loss/dementia for Resident #74. Findings include: Review of the facility's policy titled, Resident Assessment (MDS) and Care Planning Policies and Procedures, undated, included the following: - The care plan/interdisciplinary team would develop comprehensive .care plans for each resident. - Comprehensive care plans would include measurable objectives and timetables to meet the medical, nursing, and psychological…

    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 · D2022-07-26 · 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 observations, interviews, and record review, the facility failed to ensure its staff provided quality of care relative to a non-pressure related change in skin for one Resident (#97) out of a total sample of 22 residents. Specifically, the facility failed to ensure its staff: a) Assessed the Resident's non-pressure related skin change, and b) Obtained treatment orders, when the non-pressure related skin alteration was identified on the Resident's right lower extremity. Findings include: Review of the facility's Skin Care Program and Protocols, dated April 2022, included the following: - The purpose of skin assessment and surveillance included supporting early detection and interventions for all skin problems. - Wound treatment protocols were established to facilitate wound healing and to prevent infection. - All treatments required a physician order as well as appropriate documentation. - For venous ulcers, staff were to 1) notify the physician and report the location and size of the wound, characteristics of the wound and surrounding tissue, and odor, drainage, callus…

    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 before2022-07-26 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure its staff provided appropriate care and services relative to a pressure wound for one Resident (#262) out of a total sample of 22 residents. Specifically, the facility failed to ensure its staff obtained a Physician order for the treatment of a pressure wound on the Resident's left buttock. Findings include: Resident #262 was admitted to the facility in July 2022 with a diagnosis of left hip fracture with surgical repair. During an interview on 7/20/22 at 9:05 A.M. with Resident #262, the Resident said I have a sore on my bottom Review of a facility Skin Observation Tool dated 7/17/2022 indicated the Resident had a left buttock pressure wound that measured 0.5 cm (centimeters) in length, 1.0 cm in width, and 0.25 cm in depth. Review of the Resident's record did not indicate there was a treatment order in place for the left buttock pressure wound identified on the facility Skin Observation Tool. During an interview on 7/25/22 at 1:33 P.M., Nurse #4 said that the Resident had a pressure wound on his/her left buttock.…

    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 before2022-07-26 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure its staff provided one Resident (#80) with an environment as free of accident hazards as possible, out of 22 total sampled residents. Specifically, the facility failed to ensure its staff: a) Assessed the Resident's risk for entrapment relative to the use of bed rails, and b) Identified the Resident's risk for entrapment/injury and assessed the Resident for adequate assistive devices while positoned in bed, when facility staff placed a bedside night stand against the bed at the base of the bed rail, as an assistive device for security and to prevent falls. Findings include: Review of the facility's policy titled, Bed Safety/Entrapment Prevention, dated February 2022, included the following: - It was the policy of the facility that the highest level of safety would be maintained at all times. - Potential entrapment zones included: within the rail, under the rail between rail supports or next to a single rail support, between the rail and mattress, under the rail at the ends of the rail, .between the end…

    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 before2022-07-26 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interview, the facility failed to ensure that its staff provided care consistent with professional standards related to the changing of oxygen tubing, for one Resident (#105) out of a total sample of 22 residents. Findings include: Review of the facility policy titled Equipment Change/Disinfection, dated 4/2022, indicated to date oxygen concentrator equipment when changed or cleaned. Resident #105 was admitted to the facility in March of 2022 with diagnoses including: Schizophrenia (a serious mental illness), panic disorder and Chronic Obstructive Pulmonary Disease (COPD - a chronic lung disease). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident had shortness of breath and required assistance with his/her activities of daily living (ADLS). Review of the physician's orders for July of 2022 indicated that Resident #105 was prescribed Oxygen at 2-3 liters per minute (LPM) via nasal cannula to maintain a blood oxygen saturation level of 88…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-07-26 · 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 observation, record review, and interview the facility failed to ensure that its staff accurately documented when the Resident was out of bed (OOB) for meals on the Medication Administration Record (MAR) for one Resident (#44) out of a total sample of 22 residents. Findings include: Resident #44 was admitted to the facility in August 2018 with diagnoses including: muscle weakness, cerebral infarction (disrupted blood flow to the brain which causes brain damage), and dysphagia - oropharyngeal phase (difficulty swallowing foods or liquids occurring in the mouth and/or throat). Review of the Resident's Physician's orders for December 2021 indicated: -OOB for all meals before meals for aspiration, order date 10/25/2021. Review of the MAR for December 2021 indicated that on 12/10/21, the Resident was OOB at 11:00 A.M. before meals. Review of the Resident's Nurse's note dated 12/10/21 indicated that the Resident was observed eating lunch in bed. Review of the Resident's Physician's orders dated 7/25/2022 indicated: -OOB for all meals, before meals for aspiration, order date…

    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 before2022-07-26 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure that its staff wore personal protective equipment (PPE), specifically a gown, as required to prevent the spread of infection for one Resident (#54) out of a total sample of 22 residents. Findings include: Review of Facility Policy titled Isolation and Infection Precautions Contact Precautions, dated 2/2022, indicated to use contact precautions for specific residents known or suspected to be infected or colonized with epidemiologically important microorganisms that can be transmitted by direct contact with resident, or indirect contact with environmental surfaces or resident-care items in the resident's environment. Further review of the policy indicated to wear a gown when entering the room if you anticipate that your clothing will have substantial contact with the resident, environmental surfaces, or items in the resident's room. Resident #54 was admitted to the facility in December 2021 with diagnoses including: Atrial Fibrillation…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-07-26 · tag F0886 — failed to test for COVID-19 as required — isolated
    Perform COVID19 testing on residents and staff.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility staff failed to perform weekly polymerase chain reaction testing (PCR- a type of COVID-19 test) or BinaxNOW ag card testing (rapid testing) per the facility protocol for 2 staff members (#1 and #4) out of 4 sampled staff members. Findings include: Review of the Massachusetts Department of Public Health Memo, titled Updates to Caring for Long Term Care Residents During the COVID-19 Response, dated 6/10/2022, indicate that Long Term Care (LTC) facility personnel must be screened at the beginning of every shift. Review of the facility's policy for COVID-19 Prevention and Control, revised 3/30/22, indicated that the facility will conduct weekly surveillance testing of all staff regardless of their vaccination status. Further review indicates that the facility will perform BinaxNOW test kits for individuals entering the facility who are not regularly reporting staff. Review of the timecard for staff # 1 indicated that she worked in the facility on: -7/11/22 from 7 A.M. to 7 P.M. -7/12/22 from 7 A.M. to 7 P.M. -7/13/22 from 7 A.M. to 7…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction

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

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.

Who owns this facility

Owner / managerTypeRoleShareSince
BLUPOINT MANAGEMENT II LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 11/13/2020
CUZZUPOLI, JOSEPHIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; CONTRACTED MANAGING EMPLOYEENO PERCENTAGE PROVIDEDsince 11/13/2020

CMS files one row per role, so the 3 rows in the source record cover these 2 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.

$15.3M
Net patient revenuemost recent cost report
-3.3%
Operating marginrevenue minus expenses
$1.0M
Related-party expense6% of expenses
Who pays — share of resident-days
Medicaid 59%Medicare 7%Other / private 34%

This home reported $1.0M paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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

Cost & finances

$377per resident / day
operating cost
$11,454per month
≈ monthly operating cost
$365per 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 225312. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-29, 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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