Elderwood Of Scallop Shell at Wakefield

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

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.

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

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

51.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 185 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 46.2% 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 106 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 0.33 therapist hours per resident per day in 2026Q1 — more than 54% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 26% 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.

Staffing

How full it usually is: this home is certified for 80 beds and averages 69.4 residents a day — about 87% occupied, or roughly 11 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.58 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.28 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.10 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 3.13 hrs/resident/day on weekends vs 3.76 on weekdays — 17% thinner on weekends. RN hours go from 1.44 to 0.87 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 56% is about the same as 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 unchanged from the previous inspection. 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.

25 citations, most serious first. The 16 most serious are shown; the remaining 9 are one tap away and print in full.

• Immediate jeopardy · J2025-11-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review and staff interview, the facility failed to ensure adequate supervision and timely intervention for Resident ID #9, a resident with documented dysphagia (swallowing difficulties), to prevent accident hazards related to choking. Despite multiple documented episodes of the resident coughing and choking during meal and medication consumption between October 23, 2025, and October 27, 2025, the facility staff failed to implement any immediate, necessary interventions or notify the medical provider of the significant change in condition as required by policy and the resident's care plan. This failure resulted in a severe choking event on October 28, 2025, where the resident was found to be cyanotic (blue in the face) and required staff intervention to manually remove food, placing the resident in Immediate Jeopardy of serious injury, aspiration pneumonia, or death.Findings are as follows:Review of a policy titled Physician Notification of Emergency or Change of Condition, last modified on 5/30/2019, states in part, On an ongoing basis, the Resident Care Manager,…

  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
• Actual harm · Gcited before2025-11-20 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation, record review, and staff interview, the facility failed to ensure that appropriate treatment and services were provided to one resident (Resident ID #70) who was reviewed for fluid management. This failure included missing two physician-ordered doses of Lasix (a medication used to treat excess fluid trapped in the body's tissue) and failing to obtain daily weights as ordered by the physician. As a direct result of these failures, the resident experienced clinical deterioration, including increased shortness of breath and an elevated respiratory rate (30 breaths per minute), requiring an immediate transfer to the hospital for evaluation of potential congestive heart failure exacerbation.Findings are as follows:Review of a policy titled Electronic Physicians Orders (Create, Confirm, Processing orders) last modified 8/28/2024, states in part, .Routine orders- Electronic prescriptions/orders will be obtained in the following manner: Verbally.written in the paper chart or entered into…

  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
• Actual harm · Gcited before2025-11-20 · tag F0726 — failed to have competent, trained nursing staff — isolated
  Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review and staff interview, the facility failed to ensure that Registered Nurse, Staff F, was competent to provide nursing services related to acute changes in condition, which resulted in actual harm to Resident ID #9. Despite having been competency-trained and observing the resident choking on food and medication on 10/26 and 10/27/2025, Registered RN, Staff F failed to follow policy and the resident's care plan by neglecting to immediately implement an intervention (such as removing the meal or providing a softer diet option) and failing to notify the resident's provider. This immediate failure to act and notify on a serious change in condition led to the resident experiencing a severe, life-threatening choking episode on 10/28/2025, requiring emergency physical intervention and resulting in signs of aspiration pneumonia, which mandated a diet change and further medical workup.Findings are as follows:Review of a policy titled, Physician Notification of Emergency or Change of Condition, last modified on 5/30/2019, states in part, On an ongoing basis, the Resident…

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

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Actual harm · Hcited before2023-09-22 · tag F0684 — failed to provide proper treatment and quality of care — pattern
  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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident and staff interviews it has been determined that the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, for 1 of 1 resident reviewed for adverse medication reactions and following physicians' orders for specialist medical appointments, Resident ID #36 and 1 of 1 resident reviewed for Hospice Services, Resident ID #21. Findings are as follows: 1a. Review of a facility policy titled, Allergy Notification dated 9/25/2018, states in part, Harmful unintended reactions to medicines, foods and to items in the environment are called adverse drug, food or environmental reactions or allergic reactions .To help ensure that adverse allergy reactions for a resident are not overlooked, the allergy design within the EMR [Electronic Medical Record] provides a structured format for users to document and monitor resident allergies .The allergies will be listed on the front…

  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
• Actual harm · H2023-09-22 · tag F0697 — failed to manage pain — pattern
  Provide safe, appropriate pain management 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 surveyor observation, record review, resident, and staff interviews, it has been determined that the facility failed to ensure that pain management was provided to a resident who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 2 of 3 residents reviewed for pain management, Resident ID #s 46 and 257. Findings are as follows: Per the American Nurses Association (ANA) Statement The Ethical Responsibility to Manage Pain and the Suffering It Causes (2018): Nurses have an ethical responsibility to relieve pain and the suffering it causes; Nurses should provide individualized nursing interventions; The nursing process should guide the nurse's actions to improve pain management; Multimodal and interprofessional approaches are necessary to achieve pain relief . Review of a facility provided policy titled Pain Management dated 2/3/2023 states in part, .If the resident's pain is not controlled 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2023-09-22 · tag F0757 — failed to avoid unnecessary drugs — isolated
  Ensure each resident’s drug regimen must be free from unnecessary drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review and staff interview, it has been determined that the facility failed to ensure a resident's drug regimen is free from unnecessary drugs for 1 of 1 resident reviewed for adverse medication reactions, Resident ID # 36. Findings are as follows: Review of a facility policy titled, Allergy Notification dated 9/25/2018, states in part, Harmful unintended reactions to medicines, foods and to items in the environment are called adverse drug, food or environmental reactions or allergic reactions .To help ensure that adverse allergy reactions for a resident are not overlooked, the allergy design within the EMR [Electronic Medical Record] provides a structured format for users to document and monitor resident allergies .The allergies will be listed on the front cover of the medical record or computerized listing will be available in the medical record for reference . Record review revealed that Resident ID #36 was admitted to the facility in December of 2022 with diagnoses including, but not limited to, history of urinary tract infections (UTIs) and dysuria (painful…

  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 · Ecited before2025-11-20 · tag F0757 — failed to avoid unnecessary drugs — pattern
  Ensure each resident’s drug regimen must be free from unnecessary drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review and staff interview, it has been determined that the facility failed to ensure that each resident's drug regimen is free from unnecessary medications for 2 of 2 residents reviewed for blood pressure medications with parameters, Resident ID #s 4 and 83 and for 1 of 1 resident reviewed for pain, Resident ID #79. Findings are as follows:1a. Review of a policy titled, Medication Administration Methods, dated 1/25/2024, states in part, .The nurse will take the pulse or blood pressure when a medication requires such. He/She will then record the results on the Medication Administration Record/ EMAR prior to medication administration.Record review revealed Resident ID #4 was readmitted to the facility in October of 2025 with diagnoses including, but not limited to, hypotension (low blood pressure) and heart failure.Record review revealed a physician's order dated 10/27/2025 for Metoprolol Succinate (a blood pressure medication) tablet extended release 25 milligrams (mg), to administer 1 tablet by mouth in the morning and hold if the heart rate is less than 60 beats…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-09-13 · tag F0658 — failed to meet professional standards of care — isolated
  Ensure services provided by the nursing facility meet professional standards of quality.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to meet professional standards of quality related to not following physician's orders for 1 of 2 residents reviewed for wound care, Resident ID #1. Findings are as follows: Record review of a community reported complaint submitted to the Rhode Island Department of Health, dated 9/12/2024 alleges the resident's wound dressings on his/her leg, hip and lower back are not being changed as ordered. According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states in part, .The physician is responsible for directing medical treatment, Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients . Record review revealed the resident was admitted to the facility in August of 2024 with diagnoses including, but not limited to, pressure ulcer of left hip, pressure ulcer of sacral region and osteomyelitis (bone infection). Review of a Minimum…

  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 · Ecited before2024-09-06 · tag F0684 — failed to provide proper treatment and quality of care — pattern
  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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice and the comprehensive care plan relative to 1 of 1 resident reviewed with a skin graft, Resident ID #24 and 2 of 4 residents reviewed with known skin impairments who lacked weekly skin assessments, Resident ID #s 9 and 257. Findings are as follows: 1. Record review revealed Resident ID #24 was admitted to the facility in June of 2023 with diagnoses including, but not limited to, heart failure and malignant neoplasm of the skin (skin cancer). Review of a Dermatology Professionals Visit Note dated 8/23/2024 revealed that Resident ID #24 has a new skin graft (a type of surgery where providers take healthy skin from one part of the body and move it. The healthy skin covers or replaces skin that is damaged or missing) to his/her left upper arm. Additionally, it revealed that the skin graft requires daily dressing changes.…

  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 · E2024-09-06 · tag F0760 — failed to prevent significant medication errors — pattern
  Ensure that residents are free from significant medication errors.
  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 staff interview it has been determined that the facility failed to ensure that all residents are free from significant medication errors for 1 of 1 resident reviewed relative to heparin (anticoagulant), Resident ID #48. Findings are as follows: Record review revealed that the resident was admitted to the facility in July of 2024 with diagnoses including, but not limited to, fracture of the right clavicle, fracture of the right ulna, fracture of the left femur and long-term use of anticoagulants (medications that prevent blood clots). Review of a hospital Discharge summary dated [DATE] revealed an order for heparin 5000 units per milliliter (ml), administer 1.5 ml to equal 7500 units total daily. Further review revealed a check mark next to the order indicating the order had been verified by the on-call Nurse Practitioner. Review of the physician orders revealed the order was inaccurately transcribed on 7/8/2024 as heparin 5000 units per ml, administer 1 ml to equal 5000 units total…

  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 · E2024-09-06 · tag F0849 — pattern
  Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review and staff interview, it has been determined that the facility failed to ensure that hospice services meet professional standards of principles that apply to individuals providing services in the facility for 2 of 2 residents reviewed who are receiving hospice services, Resident ID #s 23 and 28. Findings are as follows: 1) Record review revealed that Resident ID #23 was admitted to the facility in December of 2023 with a diagnosis including, but not limited to, Alzheimer's disease. Record review revealed the resident started with hospice services in 12/2023. Review of the electronic and paper medical records failed to reveal evidence of the following hospice information, per regulation: - The most recent hospice plan of care - Hospice election form - Physician certification and recertification of the terminal illness - Names and contact information for hospice personnel involved in hospice care - Instructions on how to access the hospice's 24-hour on-call system - Hospice medication information - Hospice physician and attending physician orders 2) Record review…

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

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2024-09-06 · tag F0880 — failed to prevent and control infections — pattern
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections for failing to place residents on enhanced barrier precautions (EBP; involves using gown and gloves during high-contact resident care activities) for residents that require such for 3 of 5 residents reviewed with wounds, Resident ID #s 24, 28, and 267, and 1 of 2 residents reviewed for a Multi-Drug Resistant Organism (MDRO) infection, Extended Spectrum Beta Lactamase (ESBL), Resident ID #258. Findings are as follows: Review of a facility policy titled, Transmission Based Precaution Levels (Type of Infectious Condition, Techniques and Documentation) SNF [Skilled Nursing Facility] last modified on 6/6/2024, states in part, .Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-09-06 · 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 surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that a resident with pressure ulcers receive the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 1 resident reviewed for Negative-Pressure Wound Therapy, (vacuum assisted closure, a therapeutic technique using a suction pump, tubing, and a dressing to remove excess drainage and promote healing in acute or chronic wounds), Resident ID #254. Findings are as follows: a. Review of a policy titled Wound Vac (Negative Pressure Wound Therapy) states in part, .Wound Vac therapy requires an order from the attending physician/nurse practitioner and will include the following: a) Exact location of placement and number of hours per day that the Wound vac should be activated. (Recommended 22 to 24 hours per day). And therapy setting (Continuous or intermittent) b) Type of dressing…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2024-01-03 · tag F0883 — failed to offer flu and pneumonia vaccines — pattern
  Develop and implement policies and procedures for flu and pneumonia vaccinations.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, it has been determined that the facility failed to ensure the resident's medical record includes documentation that the resident was offered the influenza and pneumococcal vaccinations or that they either received or did not receive the influenza or pneumococcal vaccination due to medical contraindications or refusal for 4 of 5 residents reviewed, Residents ID #s 1, 2, 4 and 5. Findings are follows: The Rhode Island Department of Health received a community reported complaint on 1/2/2024 which alleges in part, . [Resident ID #1] never received proper vaccinations that were supposed to be administered weeks earlier. Many residents have yet to receive vaccinations that were scheduled to be issued. According to the Centers for Disease Control and Prevention (CDC) pneumococcal vaccination is recommended for all adults 19 through [AGE] years old who have certain chronic medical conditions or are 65 years or older who have only received PPSV23 [23 vaccination], the PCV13…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2023-09-22 · tag F0658 — failed to meet professional standards of care — pattern
  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 record review and staff interview, it has been determined that the facility failed to ensure that services provided meet professional standards of quality for 1 of 4 residents reviewed relative to wound assessments and following physician orders for skin checks, Resident ID #36. Findings are as follows: A. Record review revealed that the resident was admitted to the facility in December of 2022 with a diagnosis including, but not limited to, cellulitis of the right lower extremity. Review of a care plan for skin integrity revealed an intervention dated 12/20/2022 to conduct systemic skin inspections weekly, as needed, and document the findings. Review of a physician's order dated 8/9/2023 states, Skin Examination Report to RN [Registered Nurse] and document in Medical Record if new skin condition is identified. Weekly every Tuesday evening. Record review failed to reveal evidence that skin examinations were completed as ordered on the following dates 8/29, 9/5, 9/12 and 9/19/2023. This indicates that skin examinations had not been completed for 4 consecutive weeks. During a…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2023-09-22 · tag F0726 — failed to have competent, trained nursing staff — pattern
  Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on surveyor obseratio, record review, resident and staff interviews, it has been determined that the facility failed to ensure that all licensed nurses have the specific skill sets necessary to care for residents' needs for 4 of 5 residents reviewed, relative to changes in condition, Resident ID #s 257, 46, 21, and 15. Findings are as follows: Review of a facility in-service titled, Change in Condition, Symptoms, or Signs, held on 6/26/2023, indicated a change in condition, symptoms, or signs include but are not limited to, pain, behavior symptoms, altered mental status, abnormal vital signs, and shortness of breath. 1. Record review revealed Resident ID #257 was admitted to the facility in September of 2023 with diagnoses including, but not limited to, osteomyelitis (infection in the bone), pressure ulcer of the sacral region stage 4 (stage 4 pressure ulcer is the most severe type of pressure ulcer. The skin is severely damaged, and the surrounding tissue begins to die. The underlying muscles or bone may also be damaged), pressure ulcer of the right buttocks stage 4, and…

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

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction

“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.

Fines & penalties

$89,882 in federal fines across 2 penalties.

• $19,383 — penalty dated 2025-11-20
• $70,499 — penalty dated 2023-08-24

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 ELDERWOOD — 17 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 →

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

CMS files one row per role, so the 10 rows in the source record cover these 6 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.

This home reported $1.9M paid to related parties — landlords or management companies under common ownership — equal to about 17% 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

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 RI