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Hampden Post Acute

9 Maple Street, Wilbraham, MA 01095 · For profit - Limited Liability company · 135 certified beds · (413) 596-2411 Medicare & Medicaid certified

Call the home — (413) 596-2411 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Behavioral-health or dementia-care citation — no harm found (F0758)1 actual-harm citation
Insights

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

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
Worth asking about
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing rating is low (1/5)
  • nursing-staff turnover (64%) runs well above the national median (45%)

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 4 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 3 of 5

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
35 Office Park · (413) 525-1870 · Call to confirm hours
Pharmacy
2035 Boston Rd · (413) 543-9912 · Call to confirm hours
Grocery
2341 Boston Rd · (413) 519-5140 · Call to confirm hours
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 3 of 5
Long-stay residentspeople who live here 5 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 improved from 1 to 3 stars. From monthly CMS archive snapshots.

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

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased7.0%16.4%15.4%better
Long-stay residents who lose too much weight7.6%5.1%5.4%worse
Long-stay residents with a catheter left in their bladder1.2%0.8%0.9%worse
Long-stay residents with a urinary tract infection1.1%1.8%2.0%better
Long-stay residents with depressive symptoms55.2%15.5%6.5%worse than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury2.4%3.4%3.3%better
Long-stay residents whose ability to walk worsened8.8%15.4%16.1%better
Long-stay residents on antianxiety or hypnotic medication21.8%19.5%18.9%worse
Long-stay residents given the seasonal flu vaccine95.9%94.8%95.3%typical
Long-stay residents with pressure ulcers5.8%4.2%4.7%worse
Long-stay residents with worsening bladder/bowel control29.1%21.2%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table22.6%21.4%17.1%worse
Short-stay residents who newly got an antipsychotic medication1.9%1.4%1.4%worse
Short-stay residents given the seasonal flu vaccine79.7%77.7%79.4%typical
Short-stay residents rehospitalized after admission27.2%25.7%22.6%worse
Short-stay residents with an outpatient ER visit10.2%11.9%12.0%better
Long-stay hospitalizations per 1,000 resident days1.231.881.67better
Long-stay outpatient ER visits per 1,000 resident days1.391.501.80better

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.

52.3% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 70 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

52.3%U.S. median 51.5%
Got home and stayed home
12.6%U.S. median 10.7%
Went back to hospital
46.3%U.S. median 56.6%
Met the expected recovery
0.21U.S. median 0.31
Therapy hours / resident / day
0.08hours / resident / day
Physical therapy
0.12hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Met the expected recovery: 46.3% 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 54 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 0.21 therapist hours per resident per day in 2026Q1 — more than 23% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 60% of this home’s weekday level — it runs therapy at close to weekday levels right through the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF52.3%CMS range 39.4–63.051.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF12.6%CMS range 9.4–17.910.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge46.3%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 discharge44.4%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 discharge40.7%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final 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 worsened3.2%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization5.3%CMS range 2.8–9.47.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.931.02Oct 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

0.33
RN hours/ resident / day
1.14
LPN hours/ resident / day
2.17
Aide hours/ resident / day
3.63
Total nurse hours/ resident / day
0.21
RN hoursweekends
63.9%
Total nursing turnover
87.5%
RN turnover

How full it usually is: this home is certified for 135 beds and averages 122.6 residents a day — about 91% occupied, or roughly 12 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 3.63 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.33 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.17 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 3.27 hrs/resident/day on weekends vs 3.78 on weekdays — 13% thinner on weekends. RN hours go from 0.37 to 0.21 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 64% is well above 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

5
deficiencies at the latest standard inspection (2026-01-23)
6
at the previous standard inspection (2024-09-16)

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.

23 citations, most serious first. The 11 most serious are shown; the remaining 12 are one tap away and print in full.

  • Actual harm · G2023-06-27 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to provide care consistent with professional standards of practice to prevent a facility-acquired pressure injury (localized damage to the skin and/or underlying tissue usually over a bony prominence which will often present as an open ulcer because of intense and/or prolonged pressure. Soft tissue damage related to pressure may also be affected by skin temperature and moisture) for one Resident (#65) out five applicable residents, in a total sample of 22 residents. Specifically, the facility staff failed to assess the Resident's skin based on facility policy and professional standards, resulting in the development of a Stage 3 pressure injury (Full-thickness skin and tissue loss in which subcutaneous (beneath the skin) fat may be visible in the ulcer and granulation tissue (new connective tissue) and epibole (rolled edges) are often present), and subsequent wound infections, requiring multiple hospitalizations and surgical interventions.…

    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 · Ecited before2026-01-23 · 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, interviews, and records reviewed, the facility failed to adhere to infection control standards of practice to prevent contamination and the potential spread of infections on two units (Unit B1 and Unit A2) out of three units and five Residents (#60, #121, #122, #15, and #5) out of a total sample of 24 residents. Specifically, the facility failed to ensure:On Unit B1, that facility staff adhered to the appropriate Personal Protective Equipment (PPE) protocols for removal of PPE for two Residents (#60 and #121) who were on Transmission-Based Precautions (TBP) for COVID/Influenza infections.On Unit A2, that facility staff:-adhered to the appropriate PPE protocols for three Residents (#122, #15, and #5) when posted signage indicated Droplet Precautions.-ensured the correct signage was posted for Resident #122 and Resident #5, who were also on Contact Precautions, in addition to Droplet Precautions.-performed hand hygiene as required, to prevent contamination and the potential spread of infection. Findings include:Review of the facility's policy titled Isolation -…

    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 before2026-01-23 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interview, the facility failed to provide care and services that met professional standards of quality related to implementing Physician orders for medications and conducting assessments for one Resident's (#1) closed record out of three total closed resident records reviewed. Specifically, for Resident #1, the facility failed to ensure that:-Nurse #2 administered Physician ordered medications and completed vital signs and pain assessments as ordered when Nurse #2 held (not administered and not completed) Resident #1's medications and assessments on two shifts for two days with the Resident's consent not signed documented as the reason for holding care and services. -Nurse #2 reviewed and implemented Resident #1's admission agreement that included consent to admission and treatment, placing the Resident at risk for medical complications. Findings include:Review of the facility's Admissions Policy, dated 2001 and revised December 2006, indicated the following:-The primary purpose of…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-01-23 · 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 observations, interviews, and records reviewed, the facility failed to maintain a medication administration error rate of less than five percent (%) when three medication errors were made out a total of 41 opportunities, resulting in a medication error rate of 7.32%. Specifically, for Resident #121, Nurse #4 failed to:1. ensure the correct medication dose was administered to the Resident, when Calcium 600 mg/ Vitamin D 200 units was ordered by the Physician and Calcium 600 milligrams (mg)/ Vitamin D [10 micrograms (mcg) = 400 units] was administered.2. ensure that the correct medication dose was administered when Vitamin B12 100 mcg was ordered by the Physician and Vitamin B12 500 mcg was administered.3. ensure that the correct medication solution was administered when Cefazolin 2 gm in Sodium Chloride 0.9 gm per 100 milliliters (ml) intravenous (IV) solution was ordered by the Physician and Cefazolin (antibiotic) 2 grams (gm) in Dextrose 100 ml IV solution was administered. Findings include:Review of the facility policy titled Administering Medications, revised April 2019,…

    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 · D2026-01-23 · tag F0791 — failed to provide routine dental services — isolated
    Provide or obtain dental services for each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and records reviewed, the facility failed to ensure that one Resident (#69) of one applicable resident reviewed for dental services, out of a total sample of 24 residents, received routine dental services. Specifically for Resident #69, the facility failed to ensure that routine dental services were provided when dental consent for treatment was obtained and requested by the Resident and Resident Representative (RR) in June 2023, resulting in the Resident experiencing dental pain and discomfort. Findings include: Review of the facility policy titled Dental Service, dated December 2016, indicated routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessments and plan of care. The policy also included the following: -routine and 24-hour emergency dental services are provided to our residents through: >a contract agreement with a licensed dentist that comes to the facility monthly >a referral to the resident's personal dentist >referral to community dentists>referral 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-16 · 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

    Based on interview, record and policy review, the facility failed to accurately execute Advance Directives (legal documents that provide instructions for medical care and only go into effect if you are unable to communicate your own wishes) for one Resident (#73) out of a total sample of 20 residents. Specifically, for Resident #73, the facility failed to ensure that the MOLST (Massachusetts Medical Order for Life-Sustaining Treatment) form was valid and reflected the signature of Resident #73's invoked (made active by a Physician) Health Care Proxy (HCP- the person chosen as the healthcare decision maker when the individual is unable to do so for themself). Findings include: Resident #73 was admitted to the facility in May 2021, with diagnoses including Cerebral Infarction (stroke: damage to tissues in the brain caused by blood clots, disrupted blood supply and restricted oxygen supply to the specific area) and Hemiplegia (paralysis of one side of the body). Review of the facility policy for Advance Directives, last revised May 2022, indicated: -prior to or upon admission of 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-16 · tag F0679 — failed to provide activities — isolated
    Provide activities to meet all resident's needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record and policy review, the facility failed to implement a resident-centered, meaningful, and engaging activity program for one Resident (#72) out of a total sample of 20 residents. Specifically, the facility failed to ensure that staff offered and encouraged engagement in activities identified as being preferences for Resident #72. Findings include: Review of the facility policy titled Activities and Social Services, dated 2001 revised 2024, indicated that: -the facility will provide, based on the comprehensive assessment and care plan and the preferences of each resident, -an ongoing program to support residents in their choice of activities, -both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community. Resident #72 was admitted to the facility in May 2022, with diagnoses…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-09-16 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record and policy review, and interview, the facility failed to ensure an environment that was free from accidental hazards for one Resident (#16), out of a total sample of 20 residents. Specifically, the facility failed to provide a smoking apron for use during smoking activities for Resident #16 when the safety intervention was indicated in the Resident's comprehensive smoking assessment and care plans to ensure the Resident's safety related to smoking. Findings include: Review of the facility's policy titled Smoking Policy and Procedure - Smoking Facility, undated, indicated but was not limited to the following: -Licensed staff will conduct a smoking assessment upon admission prior to being allowed to participate in smoking times or with an observed change in the ability of the resident to smoke safely. -the use of appropriate safety precautions such as smoking aprons, fire retardant blankets, etc., will be determined based on this assessment. -these assessments are typically conducted…

    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 · D2024-09-16 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record and policy review, and interview, the facility failed to ensure that a gastrostomy tube (g-tube, a feeding tube that is placed directly into the stomach through an abdominal wall incision for the enteral [passing through the gastrointestinal tract] administration of food, fluids, and medication) care and management was provided in accordance with professional standards of practice for one Resident (#19) out of a total sample of 20 residents. Specifically, for Resident #19, the facility failed to: 1) obtain a Physician's order or care plan for g-tube replacement should it become dislodged. 2) replace the Resident's g-tube with a new g-tube after it was dislodged during a shower, to decrease the risk of contamination and infection to the Resident. Findings include: Resident #19 was admitted to the facility in October 2015, with diagnoses including Gastrostomy (surgical procedure to insert a g-tube) and Cerebral Infarction (stroke: damage to tissues in the brain caused by blood clots, disrupted…

    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 · D2024-09-16 · tag F0726 — failed to have competent, trained nursing staff — isolated
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    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, facility assessment, record and policy review, the facility failed to ensure that the licensed nurses working in the facility had the specific competencies (measurable patterns of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully) required to provide the care needed by the resident population for five Nurses (#1, #3, #4, #5 and #6) out of five applicable Nurses. Specifically, the facility failed to: 1. ensure that Nurse #1 had completed a competency for care and management of a gastrostomy tube (g-tube: a tube that is placed directly into the stomach through an abdominal wall incision for the enteral [passing through the gastrointestinal tract] administration of food, fluids, and medication) prior to providing care for Resident #19 who had a g-tube in place, which was dislodged during shower care, fell on the floor, and Nurse #1 re-inserted the same g-tube that was dislodged 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-16 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, record and policy review, the facility failed to offer the Influenza Vaccination as recommended for one Resident (#15) out of five applicable Residents, in a total sample of 20 Residents, putting the Resident at risk for developing infections. Specifically, the facility failed to ensure that Resident #15 was offered, received or declined the seasonal Influenza Vaccine during the 2023 through 2024 flu season. Findings include: Review of the facility policy titled Influenza Vaccine, dated October 2022, indicated the following: -Between October 1st and March 31st each year, the Influenza Vaccine shall be offered to residents and employees. -A resident's refusal of the vaccine shall be documented on the Informed Consent for Influenza Vaccine and placed in the resident's medical record. Resident #15 was admitted to the facility in October 2018, with diagnoses including Chronic Obstructive Pulmonary Disease (lung disease that causes obstructed air flow and breathing problems) and Tracheostomy Status (a medical procedure that involves creating an opening in the neck 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
Show the remaining 12 citations
  • Potential for harm · F2023-06-27 · tag F0761 — failed to label and store drugs safely — widespread
    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 maintain the storage of medications and biologicals according to professional standards in two of three medication storage rooms, and three of six medication carts. Findings include: Review of the facility policy titled, Storage of Medications, revised [DATE] included, but not limited to: - The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. - Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing. - The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. - Drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. -Each resident's medications shall be assigned to an individual cubicle, drawer, or other holding area to prevent the…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-06-27 · tag F0842 — failed to keep accurate, complete medical records — pattern
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to maintain complete and accurate medical records related to Physician's orders for three Residents (#23, #14, and #83) out of a total sample of 22 residents, and for three Residents (#89, #86, and #104) out of a sample of five residents for immunization review. Specifically, the facility failed to: 1. Ensure Physician's orders reflected the Residents' wishes related to Advanced Directives for three Residents (#23, #14, and #83). 2. Ensure a medication listed in the electronic medical record (EMR) accurately reflected the medication being administered to one Resident (#83). 3. Ensure the accuracy and completeness of immunization consents for three Residents (#89, #86, and #104). Findings include: 1a. Resident #23 was admitted to the facility in [DATE], and readmitted in [DATE]. Review of the EMR indicated the following Physician's orders initiated [DATE]: -Do Not Resuscitate (DNR - not to do cardiopulmonary resuscitation (CPR) in an emergency). -Do Not…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-06-27 · 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, record review and interview, the facility failed to follow professional standards relative to checking the placement of a gastrostomy tube (GTube/GT - a surgically placed device used to give direct access to the stomach for supplemental feeding, hydration or medicine) for one Resident (#86), out of two applicable residents, in a total sample of 22 residents. Specifically, the facility staff did not check the GT for placement as required, prior to administering Resident #86's medications. Findings include: Review of the Enteral Feedings-Safety Precaution Policy, revised May 2022, included, but not limited to: -Check enteral tube placement prior to each feeding and administration of medication. Review of the Lippincott Nursing Procedures-9th Edition for Enteral (passing through the intestine) Gastrostomy and Jejunostomy (an opening into the small intestine) Tube Feeding and Care, included, but not limited to: -Verify tube placement by using at least two of the following methods: *Observe for a change in the external length or incremental marking on the tube 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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-06-27 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to secure unattended medications on one out of three units. Specifically, unattended medications were left on the windowsill in a resident's room, to be accidentally ingested by another resident(s). Finding include: Review of the facility policy titled, Storage of Medications, dated 5/2022, indicated the following: -Compartments (including, but not limited to drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. On 6/22/23 at 7:15 A.M., the surveyor observed on the windowsill in room [ROOM NUMBER], a medication cup containing 7 tablets and another medication cup containing 10 milliliters (mls) of red liquid that was left unattended. During an interview and observation on 6/22/23 at 7:21 A.M., Nurse #2 said the medication should not be left on…

    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 · D2023-06-27 · 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

    Based on observation, interview, and record review, the facility failed to follow professional standards of care regarding respiratory equipment for two Residents (#55 and #362), out of a total sample of 22 Residents. Specifically, the facility staff failed to store respiratory equipment per policy to prevent contamination and infection. Findings include: Review of the facility policy titled, Respiratory-Prevention of Infection, dated 11/2022, indicated the following: Infection Control Considerations Related to Medication Nebulizer/Continuous Aerosol: -store the circuit (a device used to change liquid medication into a fine mist to be breathed directly into the lungs) in a plastic bag, mark with date and Resident's name, between uses. -discard the administration set-up every seven days. 1. Resident #55 was admitted to the facility in January 2023 with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe). Review of the Physician's orders dated 6/22/2023 indicated the Resident had an order for…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-06-27 · tag F0727 — failed to provide required RN coverage — isolated
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation, interview and record review, the facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week. Findings include: Review of the facility's weekly nursing schedule, dated 6/21/23 through 6/27/23 indicated an RN was not scheduled to work for eight consecutive hours on Saturday, 6/24/23. During an interview on 6/27/23 at 11:01 A.M., the Staffing Coordinator said that she struggles with getting an RN on the schedule every day. During an interview on 6/27/23 at 1:59 P.M., the Staffing Coordinator said there was not an RN scheduled to work in the building on 6/24/23. During an interview on 6/27/23 at 2:07 P.M. the Director of Nurses (DON) said the facility did not have an RN scheduled to work every other Saturday and that there was not an RN scheduled to work in the facility on 6/24/23 as required.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-06-27 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to provide an as needed (PRN), pain medication upon request resulting in increased pain and discomfort for one Resident (#312), out of a total sample of 22 residents. Findings include: Review of the Unavailable Medications Policy, revised April 2022, included, but not limited to: -When a medication is ordered for a resident, the facility must ensure that the medication is always available for the resident . -If medication is not available for a resident, the Licensed Nurse must update the Physician and the pharmacy promptly. -The medication must be ordered STAT (immediately) and sent by the pharmacy or per Physician's orders. Resident #312 was admitted to the facility in June 2023 with a diagnosis of Intraspinal Abscess (an infection that forms in the space between the skull bones and brain lining) and Granuloma (a tiny cluster of white blood cells and other tissue that can be found in the body). Review of the Minimum Data Set (MDS) Assessment, dated 6/22/23, indicated the Resident had occasional pain and the…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-06-27 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to provide monitoring for adverse side effects of psychotropic medication (medication which affects mood and behavior) use and behaviors for two Residents (#22 and #90), out of a total sample of 22 residents. Findings include: Review of the facility policy titled Psychoactive Medication Use, revised December 2022, indicated the following: -Residents receiving psychotropic medications are monitored for adverse consequences. Review of the facility policy titled Behavioral Assessment, Intervention, and Monitoring, revised March 2022, indicated the following: -If the resident is being treated for altered behavior or mood, the interdisciplinary team (IDT) will seek and document any improvements or worsening in the individual's behavior, mood, and function. -The IDT will monitor for side effects and complications related to psychoactive medications . 1. Resident #22 was admitted to the facility in July 2021 with diagnoses including Schizoaffective Disorder and Major Depressive Disorder. Review of the June 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-06-27 · 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 error rate of less than five percent during a medication administration pass. Two medication errors occurred for two Residents (#83 and #87), out of six Residents observed, in a total of 26 opportunities, resulting in a medication error rate of 7.69%. Findings include: Review of the 2022 Nursing Drug Handbook included, but not limited to: -The five rights of medication administration are: -the right drug, -the right patient, -the right dose, -the right time -and the right route. 1. During an observation of a medication administration on 6/22/23 at 8:05 A.M., Nurse #3 administered Artificial Tears, one eye drop into Resident #83's right eye. Review of the June 2023 Physician's orders indicated an order for Artificial Tears 1%, instill one drop into the left eye, two times a day for redness. During an interview on 6/22/23 at 12:00 P.M., Nurse #3 nodded his head up and down, indicating a medication error when asked by the surveyor if he instilled the Artificial Tears into the right eye…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-06-27 · 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 and interview, the facility failed to provide communication of Hospice services for one Resident (#99) out of a total sample of 22 residents. Specifically, the facility failed to ensure that its staff: -Designated an interdisciplinary team member to be responsible for collaborating with the Hospice Representative(s). -Maintained a record that contained the plan of care that included what individualized services the Hospice Agency would provide for the Resident. Findings include: Resident #99 was admitted to the facility in December 2022. Review of the medical record indicated a Physician's order to admit Resident #99 to Hospice services, dated 5/1/23. During a record review and interview on 6/22/23 at 9:08 A.M., one document located in the chart, dated 4/1/23, indicated a referral for Resident #99 to Hospice services. Unit Manager (UM) #2 said that the Resident had received Hospice services for a few months. She said that it was difficult to identify what level of care the Resident was provided by the Hospice Agency as it was not a part of the medical record.…

    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 before2023-06-27 · 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 staff failed to utilize infection control practices during the medication pass process for two out of six residents observed. Findings include: Review of the facility policy titled, Administering Medications Policy, revised April 2022, included but not limited to: -Staff follows established facility infection control procedures (example: handwashing, antiseptic technique, gloves, isolation precautions, etcetera) for the administration of medications, as applicable. 1. During an observation of a medication administration pass on 6/22/23 at 8:05 A.M., Nurse #3 popped medication tablets into his bare hands from three different blister packs and then placed the tablets into a medication cup for administration to a resident. During an interview on 6/22/23 at 8:15 A.M., Nurse #3 said he removes tablets from the blister packs with his bare hands because he sanitizes his hands prior to beginning the medication administration pass process. During an interview on 6/22/23 at 10:10 A.M., the Director of Nurses (DON) said gloves must be worn when…

    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 · C2026-01-23 · tag F0732 — widespread
    Post nurse staffing information every day.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, and interviews, the facility failed to post nursing staff data daily, at the beginning of each shift, relative to licensed and unlicensed nursing staff directly responsible for resident care per shift as required. Specifically, the facility failed to post nursing staff data that included the actual hours worked for Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Certified Nurse's Aides (CNAs). Findings include:Review of the facility policy titled Posting Direct Care Daily Staffing Numbers, revised August 2022 indicated the following in part:-The facility will post on a daily basis for each shift nurse staffing data, including the number of nursing personnel responsible for providing direct care to residents. -Daily, the number of licensed nurses (Registered Nurses, Licensed Practical Nurses and Licensed Vocational Nurses) and the number of unlicensed nursing personnel (Certified Nurses' Aides and Nurses' Aides) directly responsible for resident care is posted in a prominent location (accessible to residents and visitors) and in a clear 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.

    Nursing and Physician Services Deficiencies · No revisit needed

“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 MARQUIS HEALTH SERVICES — 87 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 3 of 53.0≈ chain avg
Health inspection 4 of 52.6+1.4 vs chain
Staffing 1 of 52.3-1.3 vs chain
Quality measures 3 of 54.3-1.3 vs chain
The other 86 homes this chain runs (chain average 3.0★, per CMS)
1 of 5Avalon Rehabilitation And Healthcare CenterHamilton, NJ 1 of 5Bay Harbor Post Acute Healthcare CenterSalisbury, MD 1 of 5Blueberry Hill Rehabilitation And Healthcare CtrBeverly, MA 1 of 5Canterbury Rehabilitation And Healthcare CenterRichmond, VA 1 of 5Cape Cod Post Acute CareBrewster, MA 1 of 5Crest Pointe Rehabilitation And Healthcare CenterPt Pleasant, NJ 1 of 5Highland Park Rehabilitation And Healthcare CenterChelsea, MA 1 of 5Mount Holly Rehabilitation & Healthcare CenterLumberton, NJ 1 of 5Nashua Post Acute CareNashua, NH 2 of 5Arbor Ridge Rehabilitation And Healthcare CenterWayne, NJ 2 of 5Atlantic View Post AcuteNewport News, VA 2 of 5Bayview Rehabilitation and Healthcare CenterNorth Kingstown, RI 2 of 5Collingswood Rehabilitation And Healthcare CenterRockville, MD 2 of 5Elmhurst Rehabilitation and Healthcare CenterProvidence, RI 2 of 5Graduate Post AcutePhiladelphia, PA 2 of 5Heritage Hills Nursing & Rehabilitation CenterSmithfield, RI 2 of 5Laurel Brook Rehabilitation And Healthcare CenterMount Laurel, NJ 2 of 5Lawrence Rehab & Hcc/The Meadows At LawrenceLawrenceville, NJ 2 of 5Lawrence Rehabilitation HospitalLawrenceville, NJ 2 of 5Lighthouse Rehabilitation And Healthcare CenterRevere, MA 2 of 5Lincolnwood Rehabilitation and Healthcare CenterNorth Providence, RI 2 of 5North End Rehabilitation And Healthcare CenterBoston, MA 2 of 5Orchard Hill Rehabilitation And Healthcare CenterTowson, MD 2 of 5Palm Springs Post AcuteChelmsford, MA 2 of 5Riverview Healthcare CommunityCoventry, RI 2 of 5Roosevelt Rehabilitation And Healthcare CenterPhiladelphia, PA 2 of 5Southampton Rehabilitation And Healthcare CenterRichmond, VA 2 of 5Springfield Rehabilitation And Healthcare CenterSpringfield, PA 2 of 5West Chester Rehabilitation And Healthcare CenterWest Chester, PA 2 of 5Westgate Hills Rehab & Healthcare CtrBaltimore, MD 2 of 5Willow Brook Rehabilitation And Healthcare CenterWilmington, MA 2 of 5YORK Post AcuteYorktown, VA 3 of 5Alexandria Rehabilitation And Healthcare CenterAlexandria, VA 3 of 5Aspen Hill Rehabiliation & Healthcare CenterHaverhill, MA 3 of 5Belmont Bay Rehabilitation And Healthcare CenterWoodbridge, VA 3 of 5Brighton Post Acute CareBrighton, MA 3 of 5Cambridge Rehabilitation And Healthcare CenterMoorestown, NJ 3 of 5Capitol Rehabilitation And Healthcare CenterHarrisburg, PA 3 of 5Chelsea Rehabilitation And Healthcare CenterGoochland, VA 3 of 5Exton Post AcuteExton, PA

Showing 40 of 86; lowest-rated first.

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
HAMPDEN HOLDCO LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 05/28/2025
KAHANOW, AVIVAIndividualINDIRECT OWNERSHIP INTERESTsince 05/28/2025
ROKEACH, FRAIDEIndividualINDIRECT OWNERSHIP INTERESTsince 05/28/2025
POPULAR BANKOrganization5% OR GREATER SECURITY INTEREST; ADP OF THE SNFsince 05/28/2025
CROWLEY, JEFFREYIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/28/2025
VIROJA, YOGESHIndividualMANAGING CONTROL - GOVERNING BODY; ADP OF THE SNFsince 05/19/2025
POSEN, MINDEEIndividualCORPORATE OFFICER; ADP OF THE SNFsince 05/28/2025
MARQUIS LIMITED LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/20/2025
NUTRACO LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/26/2025
RELIANT PRO REHAB LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/20/2025
JAGADEESAN, UDAYAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/28/2025
FLAGLER, OSHERIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 05/26/2025
LEVOVITZ, TZVIIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 05/26/2025
ROKOWSKY, YITZCHOKIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 05/26/2025
HAMPDEN PROPERTY LLCOrganizationADP OF THE SNFsince 05/28/2025
NFR 2020 IRRV TROrganizationADP OF THE SNFsince 05/28/2025
QUINTO NEXGEN LLCOrganizationADP OF THE SNFsince 05/28/2025
RSBRMK HOLDINGS LLCOrganizationADP OF THE SNFsince 05/28/2025
SK NEXGEN TROrganizationADP OF THE SNFsince 05/28/2025
SKILLED VENTURE LLCOrganizationADP OF THE SNFsince 05/28/2025
TRYKO NEXGEN HOLDINGS LLCOrganizationADP OF THE SNFsince 05/28/2025
UAK 2020 IRRV TROrganizationADP OF THE SNFsince 05/28/2025
UKR NEXGEN LLCOrganizationADP OF THE SNFsince 05/28/2025
YK NEXGEN TROrganizationADP OF THE SNFsince 05/28/2025
YR NEXGEN TROrganizationADP OF THE SNFsince 05/28/2025

CMS files one row per role, so the 34 rows in the source record cover these 25 parties — each is shown once here with every role it holds. Nothing is omitted.

16 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.

$13.4M
Net patient revenuemost recent cost report
+0.5%
Operating marginrevenue minus expenses
$1.2M
Related-party expense9% of expenses
Who pays — share of resident-days
Medicaid 45%Medicare 5%Other / private 50%

This home reported $1.2M 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

$324per resident / day
operating cost
$9,865per month
≈ monthly operating cost
$326per 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 225295. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-23, 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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