St Mary Health Care Center
39 Queen Street, Worcester, MA 01610 · Non profit - Corporation · 172 certified beds · (508) 753-4791 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a high payroll-based staffing rating (4/5)
- lower-than-typical staff turnover (31% vs 45% nationally) — better care continuity
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has 1 actual-harm citation
- a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $8,788 in federal fines (most recent 2025-10-29)
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 4 to 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
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 | 18.9% | 16.4% | 15.4% | worse |
| Long-stay residents who lose too much weight | 4.6% | 5.1% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.7% | 0.8% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.2% | 1.8% | 2.0% | better |
| Long-stay residents with depressive symptoms | 2.2% | 15.5% | 6.5% | better than state‡ — see note marked double-dagger 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 | 3.4% | 3.4% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 12.7% | 15.4% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 11.7% | 19.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 99.1% | 94.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.0% | 4.2% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 27.5% | 21.2% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 20.2% | 21.4% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 6.1% | 1.4% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 65.8% | 77.7% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 33.0% | 25.7% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 0.0% | 11.9% | 12.0% | check this* — see note marked star below the table |
| Long-stay hospitalizations per 1,000 resident days | 1.77 | 1.88 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 0.53 | 1.50 | 1.80 | better |
* 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.
‡ 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.
Therapy staffing: this home’s payroll records show 0.16 therapist hours per resident per day in 2026Q1 — more than 13% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 35% 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 | 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 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 — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims for this measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 | 0.76 | 1.02 | Oct 2022–Sep 2024 | CMS 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
How full it usually is: this home is certified for 172 beds and averages 118.8 residents a day — about 69% occupied, or roughly 53 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 3.54 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.39 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.21 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 3.37 hrs/resident/day on weekends vs 3.61 on weekdays — 7% thinner on weekends. RN hours go from 0.44 to 0.25 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 31% is below the national median of 45%.
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.
27 citations, most serious first. The 11 most serious are shown; the remaining 16 are one tap away and print in full.
- Actual harm · G2025-10-29 · 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
Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure he/she was provided with quality of care that met professional standards of practice, when he/she did not receive routine laboratory testing to ensure his/her Type 2 Diabetes Mellitus was controlled, when on 09/12/25 he/she experienced a significant change in condition, was found to be hyperglycemic (elevated blood sugar level) with critically high blood sugar reading, he/she required transfer to the Hospital Emergency Department (ED) for evaluation and was admitted for treatment. Findings include:Review of the Facility's policy, titled Diabetes, undated, indicated the following:-For residents who meet the criteria for diabetes testing, the Physician will order pertinent screening; for example [Hg] A1c (Hemoglobin A1c is a test that measures the average glucose level over the previous two to three months).Review of the American Diabetes Association website indicated the following:- A1C testing should be performed routinely in all people with diabetes at initial…
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 · E2026-04-14 · tag F0688 — failed to keep residents mobile / prevent decline — patternProvide 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to provide appropriate assistance for one Resident (#3) out of a total sample of 23 residents, to maintain left-hand range of motion (ROM) when the Resident had a left-hand contracture.Specifically, the facility failed to adequately identify and treat Resident #3's left-hand contracture in a timely manner, when the severity of the Resident's left-hand contracture changed, increasing the Resident's risk for further decrease in ROM and skin breakdown. Findings include:Review of the facility policy titled Resident Mobility and ROM, last revised July 2017, indicated:-Residents with limited ROM will receive treatment and services to increase and/or prevent further decrease in ROM.-The care plan will be developed by the interdisciplinary team (IDT) based on the comprehensive assessment and will be revised as needed. Resident #3 was admitted to the facility in January 2022 with diagnoses including symptoms and signs involving cognitive functions…
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 · E2026-04-14 · tag F0726 — failed to have competent, trained nursing staff — patternEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure that competency and skills necessary to provide the level and type of care needed for one Resident (#12) were demonstrated by one Licensed Nurse (Nurse #3). Specifically, the facility failed to ensure that Nurse #3 completed the necessary training and competencies relative to gastrointestinal feeding tube management prior to providing tube feeding care and services for Resident #12. Findings include:Review of the Facility Assessment Tool (self-completed assessment that indicated what types of care a facility provided as well as what their staffing and educational plans to meet the Resident's needs), dated 10/1/25, included but was not limited to:*Nursing facilities will conduct, document, and review a facility-wide assessment, which includes both their resident population and the resources the facility needs to care for their residents. The assessment will be reviewed annually and updated as needed. >The purpose of the assessment is to evaluate the resident population and determine what resources are…
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 · D2026-04-14 · 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 interviews and records reviewed, the facility failed to ensure that three Residents (#96, #1 and #5) out of a total sample of 23 residents were provided the right to participate in the care plan process.Specifically, the facility failed to: 1. For Resident #96, ensure that the Resident was provided with the required information for participation in the care planning process when he/she was not informed of where the care meetings were held and the facility did not provide rationale why the Resident's participation in the care planning process was not practicable when the Resident's Healthcare Proxy declined to attend.2. For Resident #1, the facility failed to ensure the Resident was invited to participate in and attended his/her care plan meetings and provide facility rationale as to why the participation of the Resident was determined to be not practicable for the development of his/her care plan.3. For Resident #5, the facility failed to ensure that the Resident was invited to participate in 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 · D2026-04-14 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure 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 (delivery of nutrients through a feeding tube into the stomach/intestines), for one Resident (#12) out of a total sample of 23 residents. Specifically, for Resident #12, the facility failed to ensure that the accurate amount of water flushes as ordered by the Physician, and the appropriate tube feed flush procedure was being administered via the Resident's enteral feeding tube, when more than the ordered amount of water flushes was administered, placing the Resident at risk for gastrointestinal complications. Findings include:Review of the facility's policy titled, flushing a Feeding Tube, undated, included but limited to:*It is the policy of this facility to ensure that staff providing care and services to the residents via a feeding tube are aware of, competent in, and utilize facility protocols regarding feeding nutrition and care. Feeding tube care and services will be…
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 · D2026-04-14 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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
Based on observation, interview, and record review, the facility failed to ensure that drugs and biologicals were stored in accordance with professional requirements on one unit's (Dementia Unit -Third Floor Side A) medication cart, out of a total of three units reviewed. Specifically, the facility failed to ensure that a medication cart on the Third floor Side A was locked, and prepared medications were secured when the medication cart were left unattended, to prevent unauthorized personnel and residents' access to medications on and in the medication cart. Findings include:Review of the facility policy titled, Medication Storage, Storage of Medications, dated 1/2025, included but was not limited to:*Medications and biologicals are stored properly, following manufacturers or provider pharmacy recommendations, to keep their integrity and to support safe, effective drug administration. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.-The provider pharmacy dispenses medications…
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 · D2026-04-14 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure 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 observations, interviews, and record review, the facility failed to ensure that food was stored in a safe and sanitary manner, in accordance with professional standards for food service safety to prevent the spread of foodborne illness. Specifically, the facility's dietary staff failed to: -ensure food items were properly labeled and dated in the main kitchen refrigerators placing residents at risk for food borne illness. -discard left over food within 72 hours that had been clearly labeled and dated, placing residents at risk for foodborne illness. -maintain a clean and sanitary food storage freezer, stove, and blender used for the storage or preparation of resident food placing residents at risk for food borne illness. -store chemicals away from the drink station, placing residents at risk for receiving contaminated beverages. Findings include: Review of the Food and Drug Administration (FDA) Food Code 2017 included the following: Nonfood Contact Surfaces: The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-14 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure that Pneumococcal Vaccination was offered as required to one Resident (#1), of five applicable residents reviewed for Pneumococcal immunization, out of a total sample of 23 residents. Specifically, for Resident #1, the facility failed to offer Pneumococcal Vaccination to the Resident when he/she was eligible for Pneumococcal Vaccination PCV20 or PCV21 (Pneumococcal Conjugate Vaccine: vaccine used to protect against 20 and 21 types of pneumococcal bacteria that commonly cause serious infections) at the time of admission to the facility. Findings include: Review of the CDC (Centers for Disease Control and Prevention) guidelines reviewed at www.cdc.gov indicated: >Based on shared clinical decision-making, adults 65 years or older have the option to get PCV20 or PCV21, or to not get additional pneumococcal vaccines. They can get PCV20 or PCV21 if they have received both: PCV13 (but not PCV15, PCV20, or PCV21) at any age PPSV23 at or after the age…
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 before2025-10-29 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on records reviewed and interviews for one of three sampled residents, (Resident #1), who had an invoked Health Care Proxy, the facility failed to ensure his/her representative was notified when he/she developed an alteration of his/her skin integrity to his/her buttocks and a fluid filled blister on his/her left foot, requiring physician ordered treatments.Findings include:Review of the Facility's policy, titled Notification of Changes, dated 08/2024, indicated the following:-The purpose of the policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his/her authority, the resident's representative when there is a change requiring notification.-Circumstances requiring notification include: A new treatment.Resident #1 was admitted to the facility in February 2023, diagnoses included Type II Diabetes Mellitus and vascular dementia.Review of Resident #1's medical record indicated his/her Health Care Agent (HCA) was invoked permanently due to severe dementia on 08/12/2020 (prior to admission to the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-06-23 · tag F0557 — patternHonor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
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 5 of 5 sampled residents (Residents #1, #2, #3, #4 and #5), who were alert and able to made their needs known, the Facility failed to ensure they were treated in a dignified and respectful manner, when they all reported that Nurse #1 responded to their request for assistance with yelling, rudeness and disrespect. Findings include: Review of the Facility Resident Rights Policy, undated, indicated residents had the right to be treated with dignity and respect in full recognition of their individuality and to receive services with reasonable accommodations to individual needs and preferences. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 6/13/25, indicated that 5 residents (Residents #1, #2, #3, #4 and #5) reported that Nurse #1 withheld medications, used a curt or aggressive tone of voice, threw medications on the resident's table and/or yelled at them. Resident #1 was admitted to the Facility in June of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-18 · tag F0637 — isolatedAssess the resident when there is a significant change in condition
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 identify and complete in the required time frame, a Minimum Data Set (MDS) for a Significant Change in Status Assessments (SCSA) for two Residents (#9 and #34) out of a total sample of 21 residents. Specifically, the facility failed to: 1. For Resident #9, complete a SCSA within 14 days after the Resident had a decline in bowel functioning, bladder functioning, and a new pressure injury. 2. For Resident #34, complete a SCSA within 14 days after the Resident was admitted to a Hospice program. Findings include: Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.19.1 dated October 2024 indicates: -A significant change is a major decline or improvement in a resident's status that: >Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered self-limiting. >Impacts more than one area of the resident's health…
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 16 citations
- Potential for harm · D2024-12-18 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, and interview, the facility failed to coordinate an assessment with the Preadmission Screening and Resident Review (PASRR - a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) program for two Residents (#13 and #84) out of a total sample of 21 residents. Specifically, the facility failed to complete a new Level I PASRR Assessment for: 1. For Resident #13, when there was a significant change in status on two dates with behavioral changes identified, new diagnoses of Major Depressive Disorder on 11/30/23 and Delusional Disorders on 7/30/24, were added to the Resident's clinical record, and adjustments to the Resident's psychotropic medication and plan of care were made. 2. For Resident #84, when there was a significant change in status on 2/8/22 with behavioral changes identified, a new diagnosis of Psychotic Disorder with delusions due to known physiological condition was added to the Resident's clinical record, and adjustments to the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-18 · 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 observation, record review, and interview, the facility failed to ensure the environment was free from accidents and hazards for one Resident (#24) out of a total sample of 21 residents. Specifically, the facility failed to ensure hazardous items (razor blades) were not stored on the Resident's bedside table and easily accessible to Resident #24, who had a history of suicidal ideation (thoughts or ideas centered around death or self-harm) and other cognitively impaired residents on the unit. Findings include: Review of the facility policy for Behavioral Health Services, last reviewed February 2024 , indicated: -the facility will provide, and residents will receive behavioral health services as needed to attain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care. -staff must promote dignity, autonomy, privacy, socialization and safety as appropriate for each resident and are trained in ways to support residents in distress.…
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 · D2024-12-18 · tag F0742 — isolatedProvide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interview, the facility failed to provide mental health services for one Resident (#24) out of a total sample of 21 residents, with a documented history of mental health concerns. Specifically, the facility failed to assess Resident #24's mental health status in timely manner after he/she expressed a plan to self-harm. Findings include: Review of the facility policy for Suicide Threats, last reviewed 2/2024, indicated: -Resident suicide threats shall be taken seriously and addressed appropriately. -all nursing personnel and other staff involved in caring for the resident shall be informed of the suicide threat and instructed to report changes in the resident's behavior immediately. -as indicated, a psychiatric consultation or transfer for emergency psychiatric evaluation may be initiated. -if the resident remains in the facility, staff will monitor the resident's mood and behavior and updated care plans accordingly, until a physician has determined the risk does not appear to be…
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 · D2024-12-18 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, and interview, the facility failed to ensure that pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) were available to meet the needs of each resident in the facility for two medication storage rooms (Fourth and Fifth Floor Units). Specifically, the facility failed to ensure that Insulin (medication used to treat Diabetes) emergency medication kits (E-Kits) were re-ordered and replaced timely by the Pharmacy after being opened. Findings Include: Review of the facility Pharmacy policy titled Emergency Kit Policy & Procedure dated 01/01/2024, indicated the following: -A portable emergency kit or kits shall be made available for immediate administration of a medication not otherwise obtainable in the time required. The emergency kits are not a source of supplemental supply but are for emergency use. -The nurse will complete a full record of the drug withdrawal from the emergency kit on the emergency kit usage log. The pharmacy copy of this log is placed inside 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 · D2024-12-18 · tag F0772 — isolatedHave an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interview, the facility failed to provide laboratory services for one Resident, (#33), out of a total sample of 21 residents. Specifically, the facility failed to obtain blood tests every three months for Resident #33 as ordered by the Resident's Physician. Findings include: Review of the facility policy Lab and Diagnostic Test Results - Clinical Protocol, Reviewed February of 2024 indicated: -The physician will identify, and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs. -The staff will process test requisition and arrange for tests. Resident #33 was admitted to the facility in November 2017 with diagnoses including Schizophrenia, Major Depressive Disorder and Benign Prostatic Hyperplasia. Review of Resident #33's most recent Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of nine out of 15 points. Review of 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 · D2024-12-18 · tag F0776 — isolatedProvide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interview, the facility failed to provide or obtain diagnostic services for one Resident (#4) out of a total sample of 21 residents. Specifically, the facility failed to provide electrocardiogram (EKG- a test which records the electrical activity of the heart through repeated cardiac cycles) testing every six months for Resident #4 as ordered by the Resident's Physician for monitoring of antipsychotic medication use. Findings include: Review of the facility policy Lab and Diagnostic Test Results - Clinical Protocol, Reviewed February 2024 indicated: -The physician will identify, and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs. -The staff will process test requisition and arrange for tests. Resident #4 was admitted to the facility in January 2022 with diagnoses including Unspecified Systolic Congestive Heart Failure, Major Depressive Disorder, and Borderline Personality Disorder. Review of Resident #4's most recent Minimum Data Set (MDS)…
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 before2024-12-18 · 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
Based on observation, interview, and record review, the facility failed to adhere to infection control standards to prevent the potential transmission of communicable diseases and infections for one Resident (#9) out of a total sample of 21 residents. Specifically, the facility failed to ensure that staff performed proper hand hygiene between glove changes while providing wound care to Resident #9 to prevent contamination and the spread of infections. Findings include: Review of the facility policy titled Hand Hygiene Policy, dated 1/1/24 - 12/31/24 indicated: -Hand Hygiene: cleaning your hands with either antiseptic hand rubs (i.e. alcohol-based hand sanitizer including foam or gel) or by handwashing (with soap and water). -The Centers of Disease Control (CDC) and Prevention Hand Hygiene Guidelines in Healthcare Settings will be followed: 1. Alcohol-based hand sanitizers are the preferred method for hand hygiene, as it reduces the number of microorganisms on hands. Hand Sanitizers must be 60-95% alcohol. >When to wash with alcohol-based sanitizer: -before and after glove use…
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 · Fcited before2023-10-17 · tag F0880 — failed to prevent and control infections — widespreadProvide 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 policy and records reviewed, the facility failed to adhere to infection control guidelines to prevent contamination and the potential spread of infection. Specifically, the facility failed to: 1. Ensure that staff doffed (removed) personal protective equipment (PPE) when exiting a COVID-19 positive resident's room; and 2a. Ensure PPE was doffed as required after exiting a COVID positive resident room (Resident #55), and b. that social distancing was maintained for one Resident (#21), who was identified as having COVID-19, and was seated in the Unit Dining Room with other residents who were COVID-19 negative putting the other residents at increased risk for transmission of the virus. Findings include: 1. Review of the Commonwealth of Massachusetts Memorandum titled Update to Infection Prevention and Control Considerations When Caring for Long-Term Care Residents, including Visitation Conditions, Communal Dining, and Congregate Activities, dated May 10, 2023, included but was not limited to: -Use of PPE - Effective May 12, 2023, all 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 · E2023-10-17 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide 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
Based on observations, interviews, and policy and records reviewed, the facility failed to ensure feeding assistance was provided for eight Residents (#4, #15, #40, #47, #55, #56, #76 and #78) who resided on two of the three units observed. Specifically, the facility failed to ensure timely meal assistance was provided when the meal had been served for residents determined to need assistance from staff. Findings include: Review of the facility's policy titled Activities of Daily Living (ADL), Supporting, revised March 2018, indicated the following: -Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: dining (meals and snacks) Review of the facility's policy titled The Dining Experience, dated 2021, indicated the dining experience will be person centered with the purpose of enhancing each individual's quality of life and being supportive of each individual's needs during dining and also included 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 · D2023-10-17 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and interviews, the facility failed to ensure that two Residents (#367 and #86), out of a total sample of 25 residents on one (Unit Three) of three units observed were afforded dignity during dining. Specifically, the facility failed to: 1. Provide appropriate clothing for Resident #367 to prevent exposure of his/her backside and incontinence briefs; and 2. Sit while assisting Resident #86 to eat during a meal. Findings include: 1. Resident #367 was admitted to the facility in October 2023 with diagnoses including dementia (a condition where problems with memory or other types of thinking make it hard for a person to do everyday activities by themselves), bipolar disorder (a mental illness that causes severe mood swings), and anxiety. Review of Resident #367's Activities of Daily Living (ADL) Comprehensive Care Plan, initiated 10/9/23, indicated the Resident had a self-care performance deficit related to dementia, bipolar disorder, and anxiety. Further review of the Care Plan indicated that: -Resident #367 will be assisted by staff to choose simple comfortable…
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 before2023-10-17 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews, and policy and records reviewed, the facility failed to notify the Physician in a timely manner, of the unavailability and multiple missed doses of the antipsychotic medication Risperidone (a medication used to treat the symptoms of psychosis- a symptom of losing touch with reality) for one Resident (#102), out of a total sample of 25 residents. Specifically, the facility failed to notify the Physician so an alternate medication could be considered when multiple doses of the prescribed medication Risperidone were not administered to Resident #102. Findings include: Review of the facility's policy for Guidelines for Notifying Physicians of Clinical Problems, last revised September 2017, indicated that the Physician should be notified as soon as possible .: -If it involves a medication with significant side effects, risks, or adverse consequences. -If the nature of the medication or severity of the reaction to the medication warrants discussion with the Physician. Resident #102 was admitted to the facility in October 2022 with diagnoses including psychotic…
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 · D2023-10-17 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
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 records reviewed, the facility failed to refer one Resident (#34) for a Preadmission Screening and Resident Review (PASSAR- a federal requirement to help ensure individuals are not inappropriately placed in long term care) Level II evaluation (an in-depth evaluation of a person who has a positive Level I screen (a preadmission screening process used to determine if a person has a diagnosis or suspected diagnosis of developmental disabilities/related conditions or mental illness) for mental illness (MI), intellectual disability, or related condition to determine if they require specialized services, out of a total sample of 25 residents. Specifically, the facility failed to refer Resident (#34) for a Level II evaluation when the Resident had documented diagnoses of mental illness and had experienced limitations in major life activities within the six months prior to the facility admission. (A positive Level 1 screen necessitates an in-depth evaluation of the individual, by 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 · D2023-10-17 · 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 interview and records reviewed, the facility failed to ensure one Resident (#97), out of a total sample of 25 residents, was scheduled for a medical appointment to obtain needed services. Specifically, the facility failed to schedule a follow up consultation appointment with a glaucoma specialist after a recommendation from the facility eye doctor. Findings include: Resident #97 was admitted to the facility in November 2022 with diagnoses of glaucoma (a condition where the eye's optic nerve, which provides information to the brain, is damaged with or without raised intraocular pressure) and macular degeneration (a vision impairment resulting from deterioration of the central part of retina, a thin layer at the back of the eye on the inner side). Review of the medical record for Resident #97 indicated that the Resident was seen in the facility by the Ophthalmologist (a Physician who specializes in diagnosing and treatment of disorders of the eye) on 5/23/23, with the following recommendations: -no glasses are recommended, -monitor intraocular pressure [IOP- measurement of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-17 · 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 policy and records reviewed, the facility failed to provide respiratory care in accordance with professional standards of practice for one Resident (#103), out of one applicable sampled resident, in a total sample of 25 residents. Specifically, the facility failed to change Resident #103's oxygen (O2) tubing on a routine basis or place signage outside the Resident's room to indicate Oxygen was in use. Findings include: Resident #103 was admitted to the facility in January 2023 with a diagnosis of asthma (a condition that can cause difficulty breathing). Review of the facility's policy titled Oxygen Administration, undated, indicated the following: -Place an Oxygen in Use sign in a designated place on or over the resident's bed. -Check the tubing connected to the Oxygen cylinder to assure that it is free of kinks. -Place an Oxygen in Use sign on the outside of the room entrance door. -Periodically re-check water level in humidifying jar. Review of Resident #103's Physician's Order, initiated on 1/19/23, indicated the following: -Oxygen: Continuous…
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 · Ccited before2024-12-18 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, and interview, the facility failed to post the required nurse staffing information daily. Specifically, the facility failed to: -post the total number and actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: >Registered Nurses (RN), >Licensed Practical Nurses (LPN) or Licensed Vocational Nurses (LVN), >and Certified Nurses Aides (CNA). -maintain a copy of the staffing records for 18 months as required. Findings include: During the facility survey, the surveyor observed that the nurse staffing information was posted in the front lobby on the following days: -12/12/24 -12/16/24 -12/17/24 The surveyor observed that the nurse staffing postings did not include the total number of hours and actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: RNs, LPNs, LVNs, and CNAs. On 12/17/24, the surveyor requested copies of the nurse staffing information for the month of December 2024 which was provided by…
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 · Ccited before2023-10-17 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and interview, the facility failed to ensure its staff posted the daily Nursing staffing data with current information. Findings include: On 10/16/23 at 7:00 A.M., the surveyor observed the facility's posting for daily Nursing staffing in the facility entrance. The daily Nursing staffing posting was dated 10/13/23. There was no evidence that the required daily Nursing staffing had been posted on 10/14/23, 10/15/23, or 10/16/23, as required. During an interview on 10/17/23 at 8:28 A.M., the Staff Scheduler said that she was responsible for updating the Nursing staff posting daily. She said that she did not update the staff posting for 10/14/23, 10/15/23, or 10/16/23, as required.
“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
$8,788 in federal fines across 1 penalty.
- $8,788 — penalty dated 2025-10-29
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.
Part of a chain
This home belongs to COVENANT HEALTH — 8 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 3.0 | -1.0 vs chain |
| Health inspection | 2 of 5 | 2.8 | -0.8 vs chain |
| Staffing | 4 of 5 | 4.4 | -0.4 vs chain |
| Quality measures | 4 of 5 | 2.9 | +1.1 vs chain |
The other 7 homes this chain runs (chain average 3.0★, 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 / manager | Type | Role | Since |
|---|---|---|---|
| BOYLE, MELISSA | Individual | MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | since 03/01/2011 |
| DOTY, RONALD | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 11/12/2020 |
| FREIJE, RICHARD | Individual | MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | since 01/01/2007 |
| LAVALLEE, EILEEN | Individual | MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | since 04/26/2019 |
| MARONEY, JAMES | Individual | MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | since 03/01/2020 |
| CASTILLO, NICOLE | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/18/2018 |
| GARCIA, HOLLY | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | since 10/21/2019 |
| MCCARTHY, JENNIFER | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/18/2019 |
| FORNEY, STEPHEN | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | since 09/16/2019 |
| GRUBBS, STEPHEN | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 09/24/2018 |
| WAITE, DOUGLAS | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2019 |
| COVENANT HEALTH | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/01/1998 |
| BECKER, DAVID | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/09/2016 |
| LUCKE, KELLY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/19/2022 |
| MANGO, ALAINA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 10/01/2020 |
| OKOLI, CHIDIMMA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/01/2019 |
CMS files one row per role, so the 38 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.
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.
About 95% 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 $519K paid to related parties (affiliated landlords or management companies) in its most recent cost report. 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
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 225305. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-14, 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 →
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