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Regalcare At Worcester

25 Oriol Drive, Worcester, MA 01605 · For profit - Corporation · 160 certified beds · (508) 852-3330 Medicare & Medicaid certified

Call the home — (508) 852-3330 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Resident-funds citation (F0565)Behavioral-health or dementia-care citations — no harm found (F0740, F0758)
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • lower-than-typical staff turnover (34% vs 45% nationally) — better care continuity
Worth asking about
  • it has a citation for mishandling residents’ money or property (F0565)
  • a high number of inspection citations overall (31) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure rating is low (1/5)
  • about 18% of its spending goes to commonly-owned related companies

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

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

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 1 of 5

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
591 Lincoln St · (508) 853-2020 · Call to confirm hours
Pharmacy
481 Lincoln St · (508) 852-3578 · Call to confirm hours
Grocery
627 Lincoln St · (508) 873-5201 · Call to confirm hours
Park
Trinity Ave · (508) 799-1190 · 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 1 of 5
Long-stay residentspeople who live here 3 of 5
Short-stay residentsrehab / post-hospital 1 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating 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.

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased12.1%16.4%15.4%better
Long-stay residents who lose too much weight3.5%5.1%5.4%better
Long-stay residents with a catheter left in their bladder1.8%0.8%0.9%worse
Long-stay residents with a urinary tract infection0.8%1.8%2.0%better
Long-stay residents with depressive symptoms11.6%15.5%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury1.7%3.4%3.3%better
Long-stay residents whose ability to walk worsened19.3%15.4%16.1%worse
Long-stay residents on antianxiety or hypnotic medication16.4%19.5%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%94.8%95.3%typical
Long-stay residents with pressure ulcers2.2%4.2%4.7%better
Long-stay residents with worsening bladder/bowel control20.1%21.2%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table17.7%21.4%17.1%typical
Short-stay residents who newly got an antipsychotic medication3.1%1.4%1.4%worse
Short-stay residents given the seasonal flu vaccine87.3%77.7%79.4%typical
Short-stay residents rehospitalized after admission21.9%25.7%22.6%typical
Short-stay residents with an outpatient ER visit16.2%11.9%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.281.881.67worse
Long-stay outpatient ER visits per 1,000 resident days2.351.501.80worse

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

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

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

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

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

27.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 42 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

27.2%U.S. median 51.5%
Got home and stayed home
10.1%U.S. median 10.7%
Went back to hospital
29.4%U.S. median 56.6%
Met the expected recovery
0.13U.S. median 0.31
Therapy hours / resident / day
0.04hours / resident / day
Physical therapy
0.07hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Met the expected recovery: 29.4% 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 51 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 0.13 therapist hours per resident per day in 2026Q1 — more than 9% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 40% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF27.2%CMS range 18.0–42.151.5%Oct 2022–Sep 2024worse than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.1%CMS range 7.6–13.610.7%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 discharge29.4%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 discharge27.4%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 discharge17.6%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified92.7%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay1.5%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened2.9%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.4%CMS range 3.3–11.27.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.871.02Oct 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

0.40
RN hours/ resident / day
1.08
LPN hours/ resident / day
1.93
Aide hours/ resident / day
3.41
Total nurse hours/ resident / day
0.33
RN hoursweekends
34.0%
Total nursing turnover
35.7%
RN turnover

How full it usually is: this home is certified for 160 beds and averages 119.0 residents a day — about 74% occupied, or roughly 41 beds typically open. It usually has some room. 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 3.41 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.40 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.93 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 3.25 hrs/resident/day on weekends vs 3.48 on weekdays — 6% thinner on weekends. RN hours go from 0.43 to 0.33 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 34% is below the national median of 45%. 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

8
deficiencies at the latest standard inspection (2025-04-17)
7
at the previous standard inspection (2024-01-04)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

31 citations, most serious first. The 10 most serious are shown; the remaining 21 are one tap away and print in full.

  • Potential for harm · D2025-05-06 · 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 records reviewed and interviews, for one of three sampled residents (Resident #1), who upon admission had specific physician's orders for treatment of his/her pressure injury, the facility failed to ensure that the treatment orders transcribed and provided by nursing were appropriate and adequate to treat his/her wound. Findings include: Review of the Facility's policy titled Pressure Ulcer/Injuries Overview, with a revision date of 03/2022, indicated the following: -Pressure Ulcer/Injury refers to localize damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. -Debridement is the removal of devitalized/necrotic tissue and foreign matter from a wound to improve or facilitate the healing process. Debridement methods may include a range of treatments such as the use of enzymatic dressings to surgical debridement in order to remove tissue or matter from a wound to promote healing. Resident #1 was admitted to the facility in April 2025,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-06 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who required hemodialysis (a life-saving treatment that filters waste products and excess fluid when the kidneys stop working) three times a week for end stage renal disease (ESRD), the facility failed to ensure Resident #1 received the care and services consistent with his/her care plan, when Resident #1 missed a dialysis session because of a transportation issue and miscommunication with the dialysis center, he/she went four days without receiving dialysis and when he/she was transported to the dialysis center for treatment, he/she required Hospital transfer due to a change in status. Findings include: Review of the Facility's Policy, titled Care of Resident with End Stage Renal Disease, dated as revised 4/2022, indicated the following: -Residents with ESRD will be cared for according to currently recognized standards of care. -If a resident has been identified in need of hemodialysis, the resident will receive dialysis…

    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 · E2025-04-17 · tag F0565 — failed to support the resident council — pattern
    Honor the resident's right to organize and participate in resident/family groups in the facility.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to provide privacy for residents during Resident Council meetings. Specifically, the facility failed to provide a private meeting space for Resident Council meetings where facility staff was not using the meeting space area as a conduit to other building areas during times when Resident Council meetings were in progress. Findings include: Review of the facility's Residents Rights located in the admission Packet, undated indicated: -You have the right to organize and participate in Resident groups in the facility. -You have the right to privacy in accommodations, in receiving personal and medical care and treatment, in written and telephone communications, in visits, and meetings with family and Resident groups. During the Resident Group meeting held on 4/16/25 at 11:00 A.M., the surveyor interviewed 15 residents who were in attendance: -10 of the 15 Residents in attendance said that the space provided by the facility was not private and that staff frequently cut through the space during their meetings to get to other units 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-04-17 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor 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 observations, and interviews, the facility failed to maintain a homelike environment on two units (Unit 2 and Unit 4) out of four resident units. Specifically, the facility failed to: -On Unit 2, maintain eight out of 22 resident rooms and the activity room in a safe, clean, comfortable and homelike environment. -On Unit 4, ensure that 19 out of 19 resident rooms were maintained in a safe, clean, comfortable and homelike environment. Findings include: Review of the facility policy titled, Resident Rights: Accommodation of Needs and Preferences and Homelike Environment, not dated, indicated: -that the facility will provide a safe, clean, comfortable and homelike environment. On 4/15/25 from 2:49 P.M. to 3:08 P.M., on Unit 2, the following was observed in Resident Rooms and the Activity Room by Surveyor #1: room [ROOM NUMBER]- Gouges in the wall behind the headboard of one resident's bed. room [ROOM NUMBER]- The room nightlight was nonfunctional. room [ROOM NUMBER]- The bathroom door and both closet doors…

    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 · Ecited before2025-04-17 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, and interviews, the facility failed to maintain a safe and sanitary smoking environment for residents, staff, and visitors. Specifically, the facility failed to: -Ensure that proper signage was visible to designate resident smoking areas. -Ensure residents were smoking in the designated smoking areas and not on the facility sidewalks and driveways. -Ensure residents were safely disposing of cigarette materials/refuse in the designated receptacles to prevent the risk of starting a fire when cigarettes were thrown near shrubs, mulch and on the ground with other trash. Findings include: Review of the facility policy titled, Smoking, effective April 2017 Revised March 2022, indicated: -This facility shall establish and maintain safe resident smoking practices. -Smoking is only permitted in designated resident smoking areas, which are located outside of the building. -Metal containers with self-closing cover devices are available in smoking areas. -Ashtrays are emptied only into designated receptacles. On 4/16/25 between 10:02 A.M. - 10:27 A.M., surveyor #1…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-17 · 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 observation, interview, and record review, the facility failed to provide necessary care and services relative to enteral feeding (providing nutrition directly into the stomach/intestines through a feeding tube), for one Resident (#114) out of a total sample of 25 residents. Specifically, for Resident #114, the facility failed to record the total amount of administered enteral feeding as ordered by the Physician, and perform weekly weight monitoring with the Resident experiencing a significant weight loss over a one-month period. Findings include: Review of the facility policy titled Weight Management last revised 4/2022, indicated: -Weights will be done weekly for the first four weeks and then monthly unless otherwise recommended by the Dietician or RN. -Weekly weights should be done on residents who are (identified) as high nutritional risk. -Weight change is defined as any unplanned weight gain or loss as follows: >+/- 5% weight change in one month >+/- 7.5% weight change in 3 months >+/- 10% weight…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-17 · tag F0761 — failed to label and store drugs safely — isolated
    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, record review, and interview, the facility failed to ensure that medications were secure and inaccessible to unauthorized persons, for one Resident (#91), out of a total sample of 25 residents. Specifically, for Resident #91, the facility failed to ensure that medications prepared for the Resident was handled in a safe and secure manner, when Nurse #3 left medications reconstituted in a cup of coffee, with Certified Nurses Aide (CNA) #4, and instructions that CNA #4 ensure the Resident consumed the coffee/ medications, and Nurse #3 did not remain with the Resident to ensure safe medication administration. Findings include: Review of the facility's policy titled Oral Medication Administration, effective April 2017 and last revised April 2022, indicated the following: -The purpose of this procedure is to provide guidelines for safe administration of oral medications. -Verify that there is a Physician's medication order for this procedure. -If the resident cannot hold his or her own…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-17 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and observation, the facility failed to provide routine dental services for one Resident (#29) out of a total sample of 25 residents. Specifically, for Resident #29, the facility failed to schedule a follow-up appointment for dental care in a timely manner which resulted in a delay in dental care and increased risk for oral pain and infection. Findings include: Review of the facility policy titled Dental Services, last revised January 2025, indicated: -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 >referral to the resident's personal dentist >referral to community dentists >referral to other health care organizations that provide dental services -Selected dentists must be available to provide follow-up care. Failure of a dentist to provide follow-up services will result in the facility's right to use its consultant dentist to provide the resident's dental…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-17 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to adhere to infection control standards of practice for one Resident (#48) out of a total sample of 25 residents, increasing the risk of contamination and the spread of infections within the facility. Specifically, for Resident #48, the facility staff 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), while providing high contact care to the Resident during ADLs (Activities of Daily Living: such as bathing, dressing, grooming, personal hygiene) when providing high contact care to the Resident. Findings include: Review of the facility policy titled Enhanced Barrier Precautions (EBP), last revised September 2022, indicated the following: -Enhanced barrier precautions are infection prevention intervention designed to reduce 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-04 · tag F0552 — isolated
    Ensure that residents are fully informed and understand their health status, care and treatments.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record and policy review, the facility failed to ensure the resident's right to make healthcare decisions for one Resident (#8) out of a total sample of 21 residents. Specifically, the facility failed to obtain written informed consent prior to administering a psychotropic (any drug that affects behavior, mood, thoughts, or perception) medication, including providing education on the risks and benefits of proposed care related to the use of the medication. Findings Include: Review of the facility policy titled Psychotropic Medication, revised April 2022, indicated the following: -Purpose is to administer and monitor the effects of psychoactive (also known as psychotropic) medications when prescribed. -Guidelines include: <Obtaining a Physician's order and an appropriate diagnosis is required for all psychoactive medications. <An informed consent from the resident (or legally authorized individual in the case of resident incompetence) is required for the administration of psychoactive…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 21 citations
  • Potential for harm · D2024-01-04 · 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 interviews, record and policy review, the facility failed to arrange for services or care that accepted standards of quality dictate should have been provided for one Resident (#65) out of a total sample of 21 residents, to aid in treating Tardive Dyskinesia (TD - abnormal movements in the face, tongue, or other body parts that cannot be controlled). Specifically, for Resident #65, the facility staff failed to communicate Behavioral Health recommendations to the Physician so an increased dosage of the medication, Ingrezza (used to treat -TD) could be initiated to manage TD symptoms for the Resident. Findings include: Review of the facility policy, Abnormal Involuntary Movement (AIM), dated 4/2022 indicated the following: -A rating of 2 or higher on the AIMS scale is evidence of Tardive Dyskinesia (TD). Review of the facility policy, Physician Services and Discipline Recommendations dated 3/2022, indicated the following: -The attending Physician will determine the relevance of any recommended interventions from any discipline. -The Physician is not obligated to accept these…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-04 · tag F0691 — failed to provide colostomy / ostomy care — isolated
    Provide appropriate colostomy, urostomy, or ileostomy 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 provide care and services for an ileostomy (a surgically made opening that connects the lower end of the small intestine to the abdominal wall. Through the abdominal wall opening, or stoma, the lower intestine is stitched into place. A wafer [a dressing that surrounds the stoma] is applied to the surrounding skin and allows for a bag/pouch to be attached to collect stool) appliance per professional standards, for one Resident (#13) out of a total sample of 21 residents. Specifically, the facility staff did not change the ileostomy bag and appliance (baseplate [or wafer] where the bag/pouch attaches) as required. Findings include: Resident #13 was admitted to the facility in February 2020 with diagnoses including ileostomy and Schizoaffective Disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #13 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of a total score…

    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 · D2024-01-04 · 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, policy and record review, the facility failed to provide respiratory care services as ordered for one Resident (#29), out of one applicable resident, in a total sample of 21 residents. Specifically, the facility staff failed to change Resident #29's oxygen (O2) tubing weekly, as ordered by the Physician putting the Resident at risk for sinus and airway infections resulting from contaminated equipment. Findings include: Review of the facility's policy titled Oxygen Use; revised April 2022 indicated: -Verify that there is a Physician's order. -Review the Physician's orders or facility protocol for Oxygen administration. -Review the residents care plan to assess any special needs of the resident. Resident #29 was admitted to the facility in December 2021 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD - lung disease that makes it difficult to breathe) and Shortness of Breath (SOB - difficult or labored breathing). Review of Resident #29's Physician's orders dated 9/25/23, included the following order: -change O2 tubing weekly 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 · D2024-01-04 · 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 interview and record review, the facility failed to provide coverage by a Registered Nurse (RN) for at least eight consecutive hours a day for seven days a week, as required. Specifically, the facilty was not able to provide evidence that a Registered Nurse (RN) was scheduled and worked for a minimum of eight hours on Saturday, 12/30/2023. Findings include: Review of the facility's daily nursing schedule provided by Administration to the surveyor, indicated for the period 12/1/23 to 12/31/23, that no RN had not been scheduled to work on Saturday 12/30/23. During an interview on 1/2/24 at 11:05 A.M., the Director of Nurses (DON) said that she had been experiencing difficulty with hiring RN's at the facility. During an interview on 1/2/23 at 11:16 A.M., the facility Scheduler said that there was no RN coverage provided by the facility on Saturday 12/30/23, as required.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-04 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and policy review, the facility failed to store and serve food in accordance with professional standards for food safety in two out of the three nourishment kitchens. Specifically, the facility failed to properly label and date resident food items, discard perishable foods by the sell by date, and maintain a clean microwave to prevent contamination and the risk of food-borne infections. Findings include: Review of the facility policy for Food Brought into the Facility, dated April 2017, indicated: -perishable foods must be stored and identified with Resident's name, food item and use by date. -the nursing staff is responsible for discarding perishable foods on or before the use by date. On 1/3/24 at 9:12 A.M., the surveyor and the Food Service Director (FSD) observed the following: Nourishment Kitchen #2: -microwave with a black caked-on substance that was flaking off the edges of the appliance -two staff lunch bags (identified by the FSD) -one subway sandwich, partially exposed to air with no date in the refrigerator -an unlabeled and undated bag…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-01-04 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record and policy review, the facility failed to maintain appropriate infection control measures related to a wound dressing change for one Resident (#46) out of a total sample of 21 residents. Specifically, the facility staff failed to perform hand hygiene as required between glove changes during a wound dressing change for Resident #46, putting the resident at risk for contamination and infection of the wound. Findings include: Review of the facility policy titled Dressings, Dry/Clean, revised 3/2022, included: -pull glove over dressing and discard into plastic bag or receptacle -perform hand hygiene and apply new gloves -remove dirty gloves, perform hand hygiene, put clean gloves on Review of the facility policy titled Hand Hygiene, revised 4/2022, included: -This facility considers hand hygiene the primary means to prevent the spread of infections. -Use an alcohol-based hand rub .or soap and water .after removing gloves -Hand hygiene is the final step after removing and disposing of personal protective equipment -The use of gloves does 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2022-06-07 · tag F0885 — failed to notify residents/families about COVID-19 — widespread
    Report COVID19 data to residents and families.
    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 staff informed residents, their representatives, and their families by 5:00 P.M. the next calendar day following the occurence of a single confirmed COVID-19 infection in the facility as required. Findings include: Review of the Centers for Medicare and Medicaid Services Interim Final Rule Updating Requirements for Notification of Confirmed and Suspected COVID-19 cases among Residents and staff in Nursing Homes, Reference: QSO-20-29-NH dated May 6, 2020 indicated: (3) Inform residents, their representatives, and families of those residing in facilities by 5 p.m. the next calendar day following the occurrence of either a single confirmed infection of COVID-19, or three or more residents or staff with new-onset of respiratory symptoms occurring within 72 hours of each other . Review of the facility policy titled Coronavirus Prevention and Control dated 4/17 indicated: the Administrator is identified as the Emergency Response Communications Coordinator who is responsible for disseminating information to the staff,…

    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 · F2022-06-07 · tag F0886 — failed to test for COVID-19 as required — widespread
    Perform COVID19 testing on residents and staff.
    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 staff were tested for COVID-19, based on parameters for outbreak testing, for 2 staff members out of a total of 8 staff members sampled. Findings include: Review of the Centers for Medicare and Medicaid Services Memorandum reference #QSO-20-38-NH revised 3/10/2022, indicated: -Upon identification of a single new case of COVID-19 infection in any staff or residents, testing should begin immediately. Facilities have the option to perform outbreak testing through two approaches, contact tracing or broad-based (e.g. facility-wide) testing. Resident # 52 was admitted to the facility in April 2022. Review of the Resident's clinical record showed evidence of a positive result for COVID-19 dated 5/27/22. Review of the time card for CNA #7 indicated that she worked at the facility on: -5/28/22 from 11:02 P.M. to 7:11 A.M. -5/30/22 from 3:00 P.M. to 10:51 P.M. Review of the COVID testing logs showed no evidence of any COVID testing for CNA #7 from 5/27/22 through 5/31/22 Review of the time card for CNA #8 indicated that…

    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 · E2022-06-07 · tag F0687 — failed to care for feet properly — pattern
    Provide appropriate foot care.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on interview and record review the facility failed to ensure staff provided one Resident (#100) proper foot care, out of 25 sampled residents. Findings include: Resident #100 was admitted to the facility in May 2022 with diagnosis including Diabetes Mellitus. Review of the facility's policy, Diabetic Care, dated 4/2017, indicated the following: -The staff will identify and report complications such as foot infections, skin ulcerations .staff will perform daily foot care to ensure foot concerns are addressed. Review of the May 2022 Treatment Administration Record (TAR) indicated no daily diabetic foot care (DFC) was provided from 5/5/22 through 5/31/22. Review of the June 2022 TAR indicated no daily DFC was provided from 6/1/22 through 6/5/22. During an interview on 6/7/22 at 9:32 A.M., Unit Manager #2 reviewed the TARs and said that DFC should be done nightly and it should have been on the TARs since the start of the Resident's admission, and she didn't know why it wasn't.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-06-07 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    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 ensure staff: (1) provided adequate supervision during smoking for one Resident (#36), (2) failed to evaluate risks associated with smoking for one Resident (#15), and (3) failed to maintain two out of four laundry dryers per manufacturer's guidelines. Findings include: Review of the facility's Smoking Policy, dated March 2022, indicated the following: -The resident will be evaluated on admission to determine if he or she is a smoker or non-smoker. If a smoker, the evaluation will include the ability to smoke safely with or without supervision (per a completed Safe Smoking Evaluation). -Residents are not permitted to give smoking articles to other residents. 1. For Resident #36 the facility failed to provide adequate supervision during smoking. Resident #36 was admitted to the facility in February 2020. Review of the Smoking Evaluation, dated 3/21/22, indicated the following: -the Resident smoked safely and did not burn clothing. -the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-06-07 · tag F0814 — failed to dispose of garbage properly — pattern
    Dispose of garbage and refuse properly.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and interview, the facility failed to ensure staff maintained safe sanitation practices to properly dispose garbage by failing to ensure the garbage dumpsters remained covered. Findings include: - On 06/01/22 at 08:33 A.M., the survey team observed the dumpster covers were open on 1 out of 2 dumpsters. - On 06/03/22 08:30 A.M., the survey team observed the dumpster covers were open on 1 out of 2 dumpsters. - On 06/03/22 12:51 P.M., the survey team observed both dumpsters covers were open. - On 06/07/22 10:47 A.M., the survey team observed both dumpsters covers were open. During an interview on 06/01/22 at 04:25 P.M. with the Administrator, the surveyor observed from the Administrator's office window, that the dumpster was uncovered. When the surveyor asked the Administrator about the dumpster being uncovered, she said the dumpsters contained both trash and recycling and that staff often left them open.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-06-07 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility staff failed to implement the plan of care for two Residents (#52 and #117) out of a total sample of 25 residents, specifically for Resident #52 a medication was not administered as ordered by the physician, and for Resident #52 and #117 weights were not recorded as per the care plan. Findings include: 1. Resident #52 was admitted to the facility in April 2022 with diagnoses including cerebral infarction (a lack of blood supply to brain cells which can cause parts of the brain to die), hemiplegia (paralysis on one side of the body), diabetes, and diseases of the pulmonary (lung) vessels. Review of the Resident's physician's orders as of 6/1/22 included: -Paxlovid (an antiviral medication) Tablet Therapy Pack 20 x 150 Milligrams (MG) & 10 x 100 MG Give 300 MG by mouth two times a day for COVID-19 for 5 days. Order date 5/27/22, start date 5/28/22, and end date 6/2/22. Review of the Resident's Medication Administration Record (MAR) dated May 2022 indicated: -May 28…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-06-07 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, observation and interview, the facility staff failed to revise the care plan within 7 days after a significant change assessment, for one Resident (#76) out of 25 sampled residents. Findings include: Resident #76 was admitted to the facility in May 2017. Review of the nurse ' s progress note, dated 4/4/22, indicated that an x ray was done on 4/3/22 and showed a right humerus (the long bone in the upper arm) fracture. Review of the Minimum Data Set (MDS) with an assessment reference date (ARD) 4/14/22, indicated the resident sustained multiple falls, one with major injury. Further review indicated the Resident had a primary diagnosis of displaced fracture of the upper end of the right humerus, initial encounter for closed fracture. Review of the Occupational Therapy (OT) Evaluation and Plan of Treatment, dated 4/27/22, indicated the Resident ' s prior level of function was as follows: -ambulation: independent with rolling walker -bathing, dressing, toileting: independent Further review of the resident ' s current level of function indicated the following: -Max…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-06-07 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility staff failed to provide one Resident (#100) out of 25 sampled residents with (1.) care and services related to skin breakdown, and (2.) an adequate sized bed. Findings include: Resident #100 was admitted to the facility in May 2022 with diagnoses including obesity and Diabetes Mellitus. Review of a Minimum Data Set (MDS) assessment, dated 5/11/22, indicated the Resident was 72 inches tall and weighed 269 pounds. 1. Review of a progress note, dated 5/5/22, indicated the Resident was admitted to the facility and had excoriated (worn off, abraded skin) buttocks, with mushy tissue. Review of care plan for skin integrity, dated 5/6/22, indicated the Resident has suspected Deep Tissue Injury (DTI) on admission with a red, excoriated sacrum. Goal was to show evidence of wound healing through next review. Interventions included: to follow physician orders for skin care and treatment. Review of weekly skin assessment, dated 5/12/22, indicated red, excoriated buttocks. Review of weekly skin assessment, dated 5/20/22, indicated…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-06-07 · tag F0740 — failed to provide behavioral / mental-health care — isolated
    Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure that staff provided the necessary behavioral health services and individualized approaches to care directed toward understanding, preventing, relieving, and/or accommodating a resident's distress or loss of abilities related to suicidal ideation and long-term care placement for one Resident (#81) in a total sample of 25 residents. Findings include: Resident #81 was admitted to the facility in April 2022 with diagnoses including unspecified dementia with behavioral disturbance and adult failure to thrive. Review of a Minimum Data Set (MDS) assessment, dated 4/27/22, indicated cognition, mood and behavior were not assessed. Review of a Nursing assessment dated [DATE] indicated Resident #81 was alert and oriented x 3, communicated verbally with clear speech and was able to understand and be understood. Review of an ancillary service consent form, dated 4/21/22, indicated Resident #81 consented to behavioral health services. Review of a Consultant…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-06-07 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview the facility failed to ensure that staff acted upon pharmacy recommendations, that were approved by the physician, for a psychiatry (psych) consult to review the appropriateness of psychotropic medications and/or consider a possible decrease in dosages, for three Residents (#59, #81 and #39) in a total sample of 25 residents. Findings include: 1. For Resident #59 the facility staff failed to provide a psych consult recommended by the pharmacist and approved by the physician, to review the appropriateness of Seroquel (antipsychotic) and/or consider a possible decrease in dosage if warranted. Resident #59 was admitted to the facility in April 2022 with diagnoses including bipolar disease and dementia. Review of an ancillary service consent form, dated 4/11/22, indicated Resident #59 consented to behavioral health services. Review of a Consultant Pharmacist Recommendations to Prescriber form, dated 4/23/22, indicated a recommendation to consider a psych consult to review the appropriateness of the use of Seroquel and/or possible decrease in dosage.…

    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 · D2022-06-07 · 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 interview and record review, the facility failed to ensure staff did not administer an unnecessary psychotropic medication, specifically an anti-anxiety medication, to one Resident (#61) out of 25 sampled residents. Finding include: Resident #61 was admitted to the facility in April 2021 with diagnosis including epilepsy. Review of the June 2022 physician's orders, indicated to administer Klonopin (anti-anxiety) 0.5 milligrams (mg) via gastric tube (g-tube) every 12 hours as needed for seizure. Review of April 2022 MAR indicated the Resident was administered Klonopin 0.5 mg via g-tube on 4/5/22, 4/6/22, 4/9/22 (twice), 4/10/22, 4/12/22, 4/13/22, 4/16/22, 4/19/22, 4/24/22, 4/26/22, and 4/28/22 for seizure activity. Review of the physician's note, dated 4/19/22, indicated the last seizure activity was 2/24/22. Review of the May 2022 MAR indicated the Resident was administered Klonopin 0.5 mg via g-tube on 5/2/22, 5/3/22, 5/4/22, 5/5/22 for seizure activity. Review of the progress notes for 5/2/22 through 5/5/22 indicated no reports of seizure activity. During an interview 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-06-07 · tag F0825 — isolated
    Provide or get specialized rehabilitative services as required for a resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to provide specialized rehabilitative services, specifically speech-language pathology, for one Resident (#61) out of 25 sampled residents, and one Resident (#125) out of 3 sampled closed records. Findings include: 1. Resident #61 was admitted to the facility in April 2021 with diagnoses including dysphagia (difficulty swallowing) and dependence on tube feeding. Review of the June 2022 physician's orders, indicated to administer Osmolite (liquid nutrient) 1.2 at 90 milliliters (ml) per hour for 18 hours per day via gastrostomy tube (g-tube). Further review indicated the Resident was on a NPO (nothing by mouth) diet. Review of a Physician's Assistant (PA) note, dated 4/13/22, indicated the Resident told the PA that he/she would like to be able to eat real food. The Resident would need a barium swallow (an imaging test to determine if food or liquid is entering the lungs) and because there was no Speech Language Pathologist (SLP) in the building, the Resident would have to be sent to an area hospital for the test. Review 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-06-07 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure the clinical records for two residents (#27 and #52) were readily accessible relative to monthly weights, and accurate, relative to the documentation of the administration of a medication, in a total sample of 25 residents. Findings include: 1. Resident #27 was admitted to the facility in September 2021. Review of the resident's weight record indicated the resident had not been weighed between 1/4/22, when he/she weighed 172.4 pounds, and 5/20/22, when he/she weighed 162.6 pounds. Review of the physician's current orders indicated the resident was to be weighed monthly. On 6/1/22 at 4:58 P.M. during an interview with Unit Manager (UM) #3, she said that Nurse #4 keeps the resident weights on a clip board which is not accessible to the rest of the staff. UM #3 said she did not know where the clipboard was but would ask Nurse #4 about it in the morning. On 6/2/22 at 12:47 P.M. during an interview with Nurse #4, she said Resident #27's weight was taken but not documented in the clinical record. Nurse #4 said she…

    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
  • No harm found · B2025-04-17 · tag F0641 — pattern
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, and interviews, the facility failed to accurately code a Minimum Data Set (MDS) Assessment for one Resident (#102), out of a total sample of 25 residents. Specifically, the facility failed to: 1. For Resident #102, accurately code that the Resident used corrective lenses during the MDS observation period putting the Resident at risk for not receiving required vision care and services. Findings include: Review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual version 1.19.1 dated October 2024, indicated the following: >Hearing, Speech and Vision: Document whether the resident is comatose, the resident's ability to hear, understand, and communicate with others and the resident's ability to see objects nearby in their environment. >Corrective Lenses: -Decreased ability to see can limit the enjoyment of everyday activities and can contribute to social isolation and mood and behavior disorders. -Many residents…

    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
  • No harm found · B2022-06-07 · tag F0625 — pattern
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview the facility staff failed to provide a bed-hold notice upon transfer from the facility as required for two residents (#18 and #97) out of a total sample of 25 residents. Findings include: 1. Resident #18 was admitted to the facility in March 2021. Review of the Resident's record indicated a transfer to the hospital 8/9/21 and 4/4/22. Further review of the Resident's record showed no evidence that bed-hold notices were provided to the resident or resident representative on 8/9/21 or 4/4/22. During an interview on 6/7/22 at 11:28 A.M., Social Worker #1 said she could not provide evidence that bed-hold notices were provided to the resident or resident representative as required. 2. Resident #97 was admitted to the facility in July 2021. Review of the Resident's record indicated a transfer to the hospital 4/6/22. There was no evidence in the record that a bed-hold notice was provided to the resident or resident representative on 4/6/22. During an interview on 6/7/22 at 9:58 A.M., Social Worker #1 said she could not provide evidence that a bed-hold…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to REGALCARE — 9 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 2 of 51.7+0.3 vs chain
Health inspection 3 of 51.9+1.1 vs chain
Staffing 3 of 53.0≈ chain avg
Quality measures 1 of 52.2-1.2 vs chain
The other 8 homes this chain runs (chain average 1.7★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
OC AZURE OF WORCESTER HOLDINGS LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 02/01/2022
MIRLIS, ELIYAHUIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; W-2 MANAGING EMPLOYEE; CORPORATE OFFICER100%since 02/01/2022

CMS files one row per role, so the 4 rows in the source record cover these 2 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

$10.4M
Net patient revenuemost recent cost report
-12.3%
Operating marginrevenue minus expenses
$2.1M
Related-party expense18% of expenses
Who pays — share of resident-days
Medicaid 91%Medicare 5%Other / private 4%

About 91% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $2.1M paid to related parties — landlords or management companies under common ownership — equal to about 18% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

Cost & finances

$316per resident / day
operating cost
$9,594per month
≈ monthly operating cost
$281per 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 225467. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-17, 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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