Odd Fellows Home of Massachusetts
104 Randolph Road, Worcester, MA 01606 · Non profit - Corporation · 100 certified beds · (508) 853-6687 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- a high payroll-based staffing rating (4/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0600), cited Dec 2023
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 3 actual-harm citations
- a high number of inspection citations overall (32) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $106,301 in federal fines (most recent 2023-10-06)
- its facility-reported quality-measure rating is low (1/5)
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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 1 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
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 | 1 of 5 |
| Long-stay residentspeople who live here | 1 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 29.7% | 16.4% | 15.4% | worse |
| Long-stay residents who lose too much weight | 6.3% | 5.1% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 2.5% | 0.8% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 2.3% | 1.8% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 0.0% | 15.5% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 5.1% | 3.4% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 24.1% | 15.4% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 17.9% | 19.5% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 93.5% | 94.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.4% | 4.2% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 25.8% | 21.2% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 30.0% | 21.4% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.4% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 62.1% | 77.7% | 79.4% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.08 | 1.88 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 2.03 | 1.50 | 1.80 | worse |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
§ 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.
Therapy staffing: this home’s payroll records show 0.26 therapist hours per resident per day in 2026Q1 — more than 38% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 7% 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 95.0% | 98.7% | Oct 2024–Sep 2025 | CMS 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 setting | not 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 discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 5.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 5.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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
How full it usually is: this home is certified for 100 beds and averages 90.5 residents a day — about 90% occupied, or roughly 10 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 3.74 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.54 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.19 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 3.40 hrs/resident/day on weekends vs 3.88 on weekdays — 13% thinner on weekends. RN hours go from 0.60 to 0.40 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 38% is about the same as the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
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.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
32 citations, most serious first. The 13 most serious are shown; the remaining 19 are one tap away and print in full.
- Actual harm · G2023-12-20 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on records reviewed, review of surveillance camera video footage and interviews, for one of three sampled residents (Resident #1) who had moderate cognitive impairment, history of behaviors and was dependent on staff for care, the Facility failed to ensure he/she was free from physical and verbal abuse when on 12/06/23/23, during the day shift, Certified Nurse Aide (CNA) #1 was seen on video footage pulling Resident #1 backward out of the elevator, then he hit/slapped him/her on the left side of the back of his/her head/neck/face area, and can then be seen standing over him/her engaging verbally and physically as he moves his arms/hands in front of Resident #1's face. The altercation between Resident #1 and CNA #1 was witnessed by another resident and other staff members, who said CNA #1 was antagonizing and threatening Resident #1 and that he/she was visibly upset by the incident. Findings include: Review of the Facility's Policy titled, Abuse Prohibition, dated as revised February 2023, indicated the following: -The Facility has the responsibility to ensure that each…
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.
- Actual harm · G2023-10-06 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, records reviewed, and interviews, the facility failed to provide treatment and care in accordance with professional standards of practice and the Resident's/Resident Representative's (RRs) choices for one Resident (#27), out of a total sample of 19 residents. Specifically, the facility failed to adequately assess Resident #27's acute change in condition and accurately monitor his/her food intake or fluid intake and fluid output when the Resident demonstrated frequent refusal of medications, had reduced food and fluid intake, had a history of constipation, and complained of abdominal pain, which resulted in rectal fecal impaction and hospitalization. Findings include: Review of the facility's policy titled, Change of Resident Condition, revised June 2020, included the following: -The purpose was to ensure timely communication of a resident's change in condition between nursing staff and the prescriber to better evaluate and manage residents in the facility and to thereby avoid transfer 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.
- Actual harm · G2023-10-06 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide 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 observations, records reviewed, and interviews, the facility failed to provide necessary nutrition and hydration treatment, services, assessment and monitoring for one Resident (#27) out of a total sample of 19 residents. Specifically, the facility failed to: Provide necessary treatment and services to promote food and fluid consumption, and accurately monitor food and fluid intake for Resident #27 when the Resident was identified as having potential nutrition and swallowing problems. The facility also failed to assess and manage changes in the Resident's functional status pertaining to eating and drinking and an unidentified rectal fecal impaction (inability to evacuate large hard stool, most commonly found in the rectum), and provide required assistance from facility staff to eat and drink. Findings include: Review of the facility's policy titled, Intake and Output (I & O) Policy, undated, indicated: -The Nursing personnel would keep an accurate record of a resident's fluid balance when the resident…
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.
- Potential for harm · E2026-03-26 · tag F0791 — failed to provide routine dental services — patternProvide or obtain dental services for each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to assist three Residents (#30, #62, and #88), with signed consents, out of a total sample of 19 residents, in obtaining routine dental care, increasing the Residents' risks for unidentified dental disease and deteriorating oral health.Findings include:Review of the facility's Dental Services Policy, last revised [DATE], indicated the following: -Residents and/or their responsible party are responsible for the selection of a dentist or dental service to be used by the resident for dental supervision while in the facility. -Residents are assisted in obtaining regular and emergency dental care through the dentist or the dental service indicated at the time of admission. -Each resident may have an annual oral examination by a licensed dentist, and this examination shall be recorded on the resident's record. Review of the American Dental Association (ADA) guidance titled Your Top Nine Questions About Going to the Dentist - Answered, dated 2026…
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.
- Potential for harm · Ecited before2026-03-26 · tag F0880 — failed to prevent and control infections — patternProvide 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 record review, the facility failed to implement infection control practices to prevent transmission of infections for three Residents (#64, #13, and #32), out of a total sample size of 19 residents. Specifically, the facility failed:1. For Resident #64, to implement Contact precautions (the use of protective equipment such as gowns and gloves to prevent the spread of parasites from one person to another) in accordance with Resident's plan of care plan increasing the risk to other residents, staff and visitors for contracting scabies (tiny mites that burrow under a person's skin, lay eggs and trigger an allergic reaction that causes itching). 2. For Resident #13, to implement Contact Precautions when the Resident became symptomatic and tested positive for Clostridioides difficile (C. diff: a bacterium causing severe diarrhea and colitis), which increased the risk for transmission of C. diff among residents and staff. 3. For Resident #32, to ensure that Enhanced Barrier Precautions (EBPs - the use of protective gowns and gloves during high…
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.
- Potential for harm · Dcited before2026-03-26 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record review, and interviews, the facility failed to maintain a clean and homelike environment for two Residents (#52 and #70), out of a total sample of 19 residents, on one unit (Second Floor-South) out of five units observed. Specifically, the facility staff failed to ensure that: -Resident #52's bedroom floor was maintained in a clean and sanitary manner. -Resident #70's bed frame, bed rail, mattress, floor mat and bedroom floor were maintained in a clean and sanitary manner. Findings include: Review of the facility's Resident Handbook, last revised 3/24/26, indicated: >Environment- The Healthcare Center must provide a safe, clean, comfortable and home-like environment, allowing each resident the opportunity to use his/her personal belongings to the greatest extent, provide housekeeping and maintenance services, and assuring clean bath and bed linens that are in good repair. A. Resident #52 was admitted to the facility in December 2025 with diagnoses including benign prostatic hyperplasia and obstructive and reflux uropathy. Review of the Minimum Data Set…
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.
- Potential for harm · D2026-03-26 · tag F0685 — isolatedAssist a resident in gaining access to vision and hearing services.
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 coordinate vision care services for one Resident (#62), out of a total sample of 19 residents, increasing the Resident's risk for further deterioration of vision when the Resident, who was diagnosed with diabetes and hypertension, had bilateral cataracts and left eye blindness. Specifically, for Resident #62, the facility failed to schedule vision care appointments and ensure that the Resident was seen and received appropriate treatment to maintain vision abilities, when the Resident consented to and requested vision care services. Findings include:Review of the facility's policy titled Ancillary Physician Services, revised 4/2024, included but was not limited to:-Routine and emergency Optometry services are available to meet the resident's health services by the resident's assessment and plan of care.-Routine and emergency Optometry services are provided to our residents through:>A contract agreement with a licensed optometrist that comes to the facility routinely.>Referral to the resident's personal…
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.
- Potential for harm · D2026-03-26 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide 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 provide respiratory care and services in accordance with professional standards of practice for one Resident (#88), out a total sample of 19 residents. Specifically, for Resident #88, the facility failed to obtain a physician's order for a baseline oxygen flow rate, oxygen titration liter flow range, and portable oxygen flow rate when the Resident was diagnosed with chronic obstructive pulmonary disease (COPD) and dependence on supplemental oxygen use placing the Resident at risk for respiratory complications related to oxygen use.Findings include:Review of the facility's policy titled Oxygen and Nebulizer Setup/Tubing Infection Control Policy & Plan, undated, included the following:*To provide guidelines to prevent the spread of health care acquired infections associated with respiratory therapy equipment and to prevent transmission of infections to residents and staff.-Oxygen Administration>A practitioner's order is required to initiate oxygen therapy, except in an emergency situation.>A practitioner's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-26 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop 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 and record review, the facility failed to offer pneumococcal immunization to one Resident (#119), out of five applicable residents reviewed for pneumococcal immunization in a total sample size of 19 residents. Specifically, the facility staff failed to offer pneumococcal immunization to Resident #119 who was at high risk for pneumococcal infection complications due to a diagnosis of Chronic Obstructive Pulmonary Disease (COPD), had no evidence of prior pneumococcal immunizations in his/her medical record, and pneumococcal immunization had not been identified as medically contraindicated. Findings include: Review of the facility's policy titled Pneumococcal Vaccinations, undated, included but was not limited to the following: -All residents are provided the opportunity and encouraged to receive the pneumococcal vaccinations. -Pneumococcal vaccine will be administered according to the latest guidelines from the Massachusetts Department of Public Health issued each year. -The program coordinator .will be responsible to research the medical record and history 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.
- Potential for harm · D2026-03-26 · tag F0887 — isolatedEducate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to offer COVID-19 immunization to one Resident (#119), out of five applicable residents reviewed for COVID-19 vaccination in a total sample size of 19 residents. Specifically, the facility staff failed to offer COVID-19 immunization to Resident #119 who was at high risk for COVID-19 infection complications due to a diagnosis of Chronic Obstructive Pulmonary Disease (COPD), had no evidence of prior 2025-2026 COVID-19 variant immunizations in his/her medical record, and COVID-19 vaccinations had not been identified as being medically contraindicated. Findings include: Resident #119 was admitted to the facility in November 2018 with diagnoses including COPD and Dependance on Supplemental Oxygen.Review of Resident #119's Minimum Data Set (MDS) Assessment, dated 1/2/26, included but was not limited to the following: -the Resident's COVID-19 vaccination was not up to date. Review of Resident #119's March 2026 Physician's Orders indicated: -the Resident had an invoked Health Care Proxy (HCP- an appointed person to make health care…
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.
- Potential for harm · Ecited before2024-12-10 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure 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 review, and interview, the facility failed to provide and environment as free of accident hazards as possible for three Residents (#83, #35, and #53) out of a total sample of 18 residents. Specifically, facility failed to: 1. implement safe swallow strategies for Resident #83 when the Resident had a history of swallowing difficulty, oropharyngeal (middle part of the throat and back of the mouth) dysphagia (difficulty swallowing), Dementia, and had an overall decline in function requiring dependence on staff for eating, which increased the Resident's risk for choking and/or aspiration (when food or liquids enters one's airway or lungs). 2. complete fall risk assessments for Resident #35 when the Resident was re-admitted to the facility following hospitalizations, including one hospitalization resulting from a fall with fracture that required surgical intervention, putting the Resident at risk for further falls, injury and abnormal bleeding resulting from anticoagulation (medication…
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.
- Potential for harm · E2024-12-10 · tag F0790 — failed to provide dental care — patternProvide routine and 24-hour emergency dental care for each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to provide routine dental services for one Resident (#46), out of a total sample of 18 residents. Specifically, the facility failed to schedule dental appointments when consent was given, to ensure that Resident #46 received routine dental services as requested, resulting in complications related to dental deterioration for the Resident. Findings include: Review of the facility policy titled Dental Services dated 11/28/17, indicated but was not limited to the following: - residents are assisted in obtaining regular and emergency dental care through the dentist or dental services indicated at the time of the admission Resident #46 was admitted to the facility in January 2020, with diagnoses including Dementia and Dysphagia. On 12/4/24 at 10:29 A.M., the surveyor observed Resident #46 lying in bed. The Resident was observed to have several missing and broken teeth in his/her mouth. Review of the Minimum Data Set (MDS) assessment dated [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.
- Potential for harm · Dcited before2024-12-10 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
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 provide a clean and homelike environment for one Resident (#35) out of a total sample of 18 residents. Specifically, the facility failed to provide Resident #35 with a wheelchair that was maintained in a clean manner and address promptly any cleaning needs as required. Findings include: Resident #35 was admitted to the facility in October 2023 with diagnoses including Dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident was mildly cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 12 out of 15 total possible points. On 12/4/24 at 8:30 A.M., Resident #35 was observed seated in a wheelchair next to the bed in his/her room eating his/her breakfast meal. The surveyor observed the wheelchair was dusty with crumbs and debris on the frame of the chair and cushion. During an interview at the time, Resident #35 said that he/she uses the wheelchair at times because he/she was worried…
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.
Show the remaining 19 citations
- Potential for harm · D2024-12-10 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to accurately complete a Level I PASRR for one Resident (#83) out of a total sample of 18 residents, which resulted in the Resident not receiving a Level II PASRR Evaluation to determine whether the Resident met criteria for serious mental illness (SMI) and whether specialized services were required to treat the Resident's SMI. Specifically, the facility failed to: -Identify Resident #83's diagnosis of Schizophrenia on the Resident's Level I PASRR when the Resident had a diagnosis of Schizophrenia. -Indicate legal involvement within two years prior to admission to the facility when the Resident had a legal guardian appointed through the court system within two years prior to admission to the facility. Findings include: Resident #83 was admitted to the facility in August 2023 with a diagnosis of Schizophrenia. Review of Resident #83's Hospital Patient Health Summary, dated 1/20/23, indicated the following: -The Resident had been admitted to the hospital for steadily worsening Dementia and developing hallucinations and violent…
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.
- Potential for harm · D2024-12-10 · tag F0658 — failed to meet professional standards of care — isolatedEnsure 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 provide services that met professional standards of quality for two Residents (#83 and #37) out of a total sample of 18 residents. Specifically, the facility failed to: 1. assess Resident #83's swallowing ability in a timely manner, as ordered by the Nurse Practitioner (NP) when the Resident had experienced a decline in swallowing function and weight loss, and required a diet texture downgrade, resulting in a delayed treatment for the Resident. 2. ensure Resident #37 had the correct Physician ordered size indwelling urinary catheter (a soft flexible tube that drains urine from the bladder) in place, placing the Resident at risk for complications related to the urinary catheter. Findings include: 1. Resident #83 was admitted to the facility in August 2023 with diagnoses including Dementia and Muscle Weakness. Review of Resident #83's Nutrition Care Plan, initiated 8/14/23 and last revised 10/11/24, indicated: -The Resident presented at potential nutrition risk related to medical conditions requiring long term…
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.
- Potential for harm · D2024-12-10 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
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 one Resident (#46) out of a total sample of 18 residents with contractures received services and treatment to increase range of motion and/or prevent further decrease in range of motion. Specifically, the facility failed to timely assess, monitor and/or treat Resident #46's right third and fourth finger mild contractures. Findings include: Review of the facility's policy titled Resident Mobility and Range of Motion (ROM) Policy (undated) indicated but was not limited to the following: >Residents with limited ROM will receive treatment and services to increase and/or prevent a further decrease in ROM. >As part of the residents' comprehensive assessment, the nurse will identify the residents': -Current ROM of his or her joints >As part of the comprehensive assessment, the nurse will also identify conditions that place the residents at risk for complications related to ROM and mobility, including: -Contractures . >The care plan will be developed by the interdisciplinary team based on 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.
- Potential for harm · Dcited before2024-12-10 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard 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 observation, record review and interview, the facility failed to maintain complete and accurate medical records for three Residents (#46, #69, and #83), out of a total sample of 18 residents. Specifically, the facility failed to: 1. accurately document measurements of urinary output as ordered when Resident #46 was identified as having a urinary catheter drainage system that provided numerical output measurements. 2. accurately document 24-hour fluid intake and urinary output (I & O) for Resident #69 when the Physician ordered 24-hour I & O monitoring to be completed and documented by staff. 3. maintain a complete clinical record for Resident #83 to include the Resident's Speech Therapy Evaluations, Speech Therapy Treatment Notes, and Speech Therapy Discharge Summary when the Resident had been evaluated, treated, and discharged from speech therapy services and recommendations for safe swallowing strategies were included in the Resident's Speech Therapy Discharge Summary. Findings include: Review of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-12-10 · tag F0880 — failed to prevent and control infections — isolatedProvide 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, interview, and record review, the facility failed to adhere to infection control standards of practice for one Resident (#69) out of a total sample of 18 residents. Specifically, for Resident #69, the facility failed to: -appropriately follow Enhanced Barrier Precautions (EBP's: the use of protective gowns and gloves during high contact care activities that may provide opportunity for transmission of medication resistant organisms through staff hands and/or clothing), when providing high contact care for the Resident, increasing the risk of contamination and spreading infections to the Resident and other Residents within the facility. Findings include: Review of the facility policy titled Enhanced Barrier Precautions (EBP), indicated the following: -The facility will implement EBP during high contact resident care activities for those residents who are colonized with an MDRO (multi-drug-resistant organisms) unless otherwise ordered by healthcare provider. >Examples of high-contact resident…
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.
- Potential for harm · D2024-12-10 · tag F0909 — failed to maintain a comfortable temperature — isolatedRegularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
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 complete an inspection of the bed rails, to identify areas of possible entrapment, for one Resident (#49) out of a total sample of 18 residents. Specifically, the facility failed to assess the side rails and mattress in active use for entrapment when Resident #49 had limited mobility and utilized bilateral side rails, placing the Resident at risk for possible entrapment. Findings include: Review of the facility policy titled Side Rail Policy, undated, indicated: -An assessment will be made to determine the resident's symptoms, risk of entrapment, and reason for using side rails . -The resident will be checked periodically for safety relative to side rail use. -When said rail usage is appropriate, the facility will assess the space between the mattress and the side rails to reduce the risk for entrapment . Review of the facility policy titled Falls Accident/Accident Policy and Procedure, dated 2/24/24, indicated: -All mattresses and side…
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.
- Potential for harm · D2023-12-20 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on records reviewed, interviews and review of surveillance camera video footage, for one of three sampled residents (Resident #1) who was physically abused by a staff member, the Facility failed to ensure they reported a reasonable suspicion of a crime, when although the Administrator was aware on 12/06/23, that Certified Nurse Aide (CNA) #1 hit Resident #1 in the head/neck/face area, and substantiated the incident as physical abuse, the Facility did not notify local law enforcement until 12/20/23, the day of survey. Findings include: Review of the Facility's Policy titled, Abuse Prohibition, dated as revised February 2023, indicated the following: - Physical abuse is defined as hitting, slapping, pinching, kicking, and control of behavior through corporal punishment, -The Facility will ensure reporting of a reasonable suspicion of crimes against a resident or individuals receiving care from the Facility within prescribed timeframes to the appropriate entities within two hours after forming suspicion if serious bodily arm or if the allegation involves abuse, neglect,…
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.
- Potential for harm · D2023-12-20 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had moderate cognitive impairment and was dependent on staff to meet his/her care needs, the Facility failed to ensure that after being made aware on 12/06/23 of an allegation of physical and verbal abuse, that they obtained and maintained evidence that a thorough investigation was completed. Findings include: Review of the Facility's Policy titled, Abuse Prohibition, dated as revised February 2023, indicated the following: -The Supervisory personnel are responsible to ensure that the initial investigation regarding the incident occurs timely and appropriate interventions are put into place to ensure resident safety or protect the resident from additional harm, -The interventions include, obtaining statements from witnesses of incidents, the outcome of the supervisory investigation, and timely notification of Administrative personnel regarding the incident to ensure that a comprehensive internal facility investigation is completed in a timely fashion, and - The Administrator shall assume…
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.
- Potential for harm · E2023-10-06 · tag F0550 — failed to protect resident dignity and rights — patternHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to ensure that four Residents (#37, #42, #9 and #57) out of total sample of 19 residents, were afforded a dignified dining experience. Specifically, the facility staff failed to be seated next to the Residents while assisting them during meals on one (Unit Two) of two units observed. Finding include: On 9/29/23 at 8:23 A.M., the surveyor observed the breakfast meal distribution in the Unit Two Dining Room where 14 residents were present. At 8:33 A.M., Certified Nurse Aide (CNA) #1 was observed standing while assisting Resident #37 with his/her meal while the Resident was seated at a dining room table. After several minutes, CNA #1 then walked over to Resident #42 who was seated in a geriatric chair and continued to stand while assisting him/her with the breakfast meal. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #37 had severe cognitive impairment as evidenced by staff interview and required supervision (cueing 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.
- Potential for harm · Ecited before2023-10-06 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and policies reviewed, the facility failed to provide a sanitary and homelike environment during dining on one of two resident units. Specifically, the facility staff failed to: -ensure that residents were served meals at the same time for residents seated at the same table. -ensure meals were served off of meal trays. -ensure that staff conducted hand hygiene while providing meals and between assisting residents with meals. -ensure that staff were seated while assisting residents with meals in the Unit Two Dining Room. Findings include: Review of the facility Hand Hygiene Policy, dated 4/15/20, indicated hand hygiene (hand washing) is the single most important means of preventing the spread of infection. Application of nursing facility approved hand hygiene disinfectant is allowed in place of soap and water. The policy also included that hand washing should be done during the following: -Before and after each resident contact -Before eating or preparing food -Before and after feeding a resident -Before setting up a resident's tray On 9/29/23 from…
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.
- Potential for harm · Ecited before2023-10-06 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to obtain a completed Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST) form for one Resident (#239) out of a total sample of 19 residents. Specifically, the facility staff failed to have Resident #239, and/or their Resident Representative date as required, a completed MOLST form. Findings include: Review of MOLST instructions, approved by The Department of Public Health (DPH), dated 8/10/13, indicated the following: -Sections A-C are valid orders only if sections D and E are complete. -Sections D and E are the signature and the date section of the MOLST form to be signed by the Resident or Resident Representative and the Medical Provider. Review of Resident #239's MOLST, section D, indicated the form was signed but was not dated by the Resident and/or the Resident Representative. The MOLST form was signed and dated by the Physician on 9/27/23, and indicated the following: - Do Not Resuscitate (DNR) - Do Not Intubate and Ventilate (DNI/DNV) - Do not use Non-Invasive Ventilation (NIV) - Do not Transfer 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.
- Potential for harm · Ecited before2023-10-06 · tag F0880 — failed to prevent and control infections — patternProvide 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 policies reviewed, the facility failed to prevent and reduce the potential spread of infection by maintaining an effective infection surveillance program. Specifically, the facility failed to ensure that: 1. residents with active respiratory symptoms were identified and interventions put in place to reduce the spread of infection to other residents. 2. staff were conducting hand hygiene as indicated during resident care activities, including meals and a wound treatment for Resident # 48. Findings include: Review of the facility Hand Hygiene Policy, dated 4/15/20, indicated hand hygiene (hand washing) is the single most important means of preventing the spread of infection. Application of nursing facility approved hand hygiene disinfectant is allowed in place of soap and water. The policy also included that hand washing should be done during the following: -Before and after each resident contact -Before eating or preparing food -Before and after feeding a resident -Before setting up a resident's tray -After use of the bathroom -Before and after…
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.
- Potential for harm · D2023-10-06 · tag F0657 — failed to keep the care plan current — isolatedDevelop 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 records reviewed and interviews, the facility failed to develop, review, and revise comprehensive care plans with the interdisciplinary team (IDT) and include the participation of the Residents/Resident Representatives (RRs) for two Residents (#27 and #14), out of a total sample of 19 residents. Specifically, the facility failed to: 1. Develop and review Resident #27's comprehensive care plan with the Resident and/or RR's participation when the RR was available for participation. 2. Notify Resident #14 and his/her RR of a scheduled interdisciplinary care plan meeting that was held to review the Resident's comprehensive care plan, resulting in the care plan review occurring without the Resident and/or his/her Representative participation. Findings include: Review of the facility policy titled, Interdisciplinary Care Planning, undated, included the following: -The care planning schedules were developed by the case manager, social services, and nursing supervisors. -Family members were notified by phone or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-06 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, records and policy review, the facility failed to ensure that two Residents (#51 and #54) out of a total sample of 19 residents, were provided timely activities of daily living (ADLs - Daily self-care activities like grooming, eating, dressing) assistance. Specifically, the facility staff failed to ensure: 1. For Resident #54, that timely assistance during meals and personal hygiene relative to nail care were provided. 2. For Resident #51, that timely assistance during meals and grooming assistance relative to facial hair were provided. Findings include: Review of the facility ADL/Maintain Abilities Policy, undated, indicated: -the facility will create and sustain an environment that humanizes and individualizes each resident's quality of life by ensuring all staff, across all shifts and departments, understand the principles of quality of life, and honor and support these principles for each resident, -and that the care and services provided are person-centered, and support…
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.
- Potential for harm · Dcited before2023-10-06 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 observations, records reviewed, and interviews, the facility failed to provide two residents (#12 and #54) with an environment as free of accident hazards as possible. Specifically, the facility failed to: 1. Implement effective fall prevention interventions for Resident #12, to reduce the risk for fall related injuries when the Resident was identified as having a seizure disorder, abnormal gait, and a history of falling, and sustained frequent falls resulting in striking his/her head and sustaining upper extremity bruising and skin tears. 2. Ensure supervision was provided to minimize accidents/hazards related to falls, drinking fluids not ordered by the Physician, and potential resident to resident interactions for Resident #54. Findings include: Review of the facility's policy, titled Falls Accident/Accident Policy and Procedure, revised 2/24/22, included the following: -The purpose was to identify residents at high risk for falls and alteration in skin integrity and establish appropriate…
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.
- Potential for harm · D2023-10-06 · tag F0698 — failed to provide proper dialysis care — isolatedProvide 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 interview and record review, the facility failed to ensure one Resident (#33), out of 2 applicable residents who receive dialysis (removal of toxins from the blood in people whose kidneys stop working properly), out of a total sample of 19 residents, received care and services relative to dialysis services. Specifically, the facility staff failed to ensure that Resident #33 received breakfast as required and medications as ordered by the Physician on scheduled dialysis days. Findings include: Review of the facility policy titled, Dialysis, undated, indicated the facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Resident #33 was admitted to the facility in August 2014 with diagnoses including End Stage Renal Disease (ESRD - medical condition in which a person's kidneys cease to function normally leading to a need for regular dialysis or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-06 · tag F0759 — failed to keep medication error rate low — isolatedEnsure 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 pass error rate of less than five percent (%) for two Residents (#4 and #99), out of five applicable residents, out of 32 opportunities. Specifically, the medication error rate was observed to be 6.5% when: 1. For Resident #4, relative to the administration of eye drops not given as ordered. 2. For Resident #99, relative to the total dose of Potassium Chloride medications not given as ordered by the Practitioner. Findings include: Review of the Facility's policy, titled Medication Administration, undated, indicated medications are administered in accordance with written orders of the attending Physician or Physician extender. 1.Resident #4 was admitted to the facility in October 2021 with a diagnosis of Neurocognitive Disorder with Lewy bodies (a type of dementia that leads to a decline in thinking, reasoning, and independent function). On 10/3/23 at 8:26 A.M., during a medication pass administration, the surveyor observed Nurse #3 remove oral (by mouth) medications from 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.
- No harm found · B2024-12-10 · tag F0582 — patternGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure that Skilled Nursing Facility Advanced Beneficiary Notices of Non-coverage (SNF ABN- notice issued to a resident when a facility determines the beneficiary no longer qualifies for Medicare Part A skilled services and the resident has not used all his/her Medicare benefit days) were issued for three Residents (#17, #35 and #38), out of three applicable residents, so that the Residents could decide if they wished to continue receiving skilled services that may not be paid for by Medicare, and were aware of the financial responsibility they may have to assume. Specifically, the facility failed to issue a SNF ABN: 1. For Resident #17, when the Resident no longer qualified for Medicare Part A skilled services and chose to remain in the facility. 2. For Resident #35, when the Resident no longer qualified for Medicare Part A skilled services and chose to remain a Resident in the facility. 3. For Resident #38, when the Resident no longer qualified for Medicare Part A skilled services and chose to remain in the facility.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · B2024-12-10 · tag F0868 — patternHave 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 record review and interview, the facility failed to ensure that the required members were included in the Quality Assessment and Performance Improvement (QAPI) committee quarterly meetings. Specifically, the facility failed to provide evidence that the Medical Director attended two out of the four quarterly QAPI meetings as required. Findings include: Review of the facility document titled Facility QAPI Plan dated 1/16/2019, indicated the following: -Medical Director must attend at least quarterly, preferred monthly. -All attendees present sign in. If a member is unable to attend in person, due to an occasional schedule conflict, or vacation, indicate the reason they are not in attendance at the meeting. Review of the facility QAPI meeting schedule indicated the QAPI Team met quarterly on 1/18/24, 4/18/24, 7/18/24 and 10/18/24. During an interview on 12/10/24 at 3:15 P.M., the Administrator said the Medical Director is required to attend the quarterly QAPI meetings and that all attendees of the QAPI meeting were required to sign the attendance sheet. The surveyor 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.
“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.
- 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.
Fines & penalties
$106,301 in federal fines across 1 penalty. 1 Medicare payment denial on record.
- $106,301 — penalty dated 2023-10-06
- Medicare payment denial — starting 2024-01-06 for 13 days
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| INDEPENDENT ORDER OF ODD FELLOWS GRAND LODGE | Organization | DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 01/01/1966 |
| BENNETTE, JAMES | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | since 06/12/2024 |
| BROWNING, HAROLD | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | since 06/11/2025 |
| BUTTS, BRENDAN | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | since 06/11/2025 |
| FIFE, DONNA | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | since 06/08/2019 |
| RIVIECCIO, JO-ANN | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | since 06/11/2025 |
| SLANEY, JOHN | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | since 06/11/2008 |
| CYR, NANCY | Individual | CORPORATE OFFICER; TRUSTEE OF THE SNF | since 07/12/2024 |
| FEARING, ERIK | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; TRUSTEE OF THE SNF | since 06/09/2021 |
| MULLEN, GREGORY | Individual | CORPORATE OFFICER; TRUSTEE OF THE SNF | since 06/08/2022 |
| NEEDLE, SUSAN | Individual | CORPORATE OFFICER; TRUSTEE OF THE SNF | since 06/08/2022 |
| BRYANT, PRECIOUS | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/02/2025 |
| CUSSON, SUSAN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2024 |
| NEDELESCU, BOGDAN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2024 |
| CELTIC CONSULTING LLC | Organization | ADP OF THE SNF | since 01/01/2024 |
| CLIFTONLARSONALLEN LLP | Organization | ADP OF THE SNF | since 01/01/2024 |
CMS files one row per role, so the 31 rows in the source record cover these 16 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
3 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.
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
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
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.
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 225439. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-26, 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.