Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 31 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
26D
3E
1F
Potential for minimal harm
0A
0B
0C
October 15, 2025Complaint inspection · 1 citation
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on records reviewed, interviews, and observations for one of three sampled residents (Resident #1), who was dependent on staff members for bathing, dressing, incontinence care, bed mobility, and positioning, the Facility failed to ensure his/her safety was maintained during care, when during the provision of care, Certified Nurse Aide (CNA) #1 positioned Resident #1 on his/her side in bed then turned away from him/her to obtain a wet cloth, and Resident #1 rolled off the bed and onto the floor. Resident #1 sustained a laceration to the back of his/her head, was transferred to the Hospital Emergency Department (ED) for evaluation, where he/she required staples to close the wound and was diagnosed with an epidural hematoma (a collection of blood between the skull and outermost protective membrane of the brain).
September 15, 2025Standard inspection · 3 citations
- F
Dispose of garbage and refuse properly.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that garbage was disposed of properly. Specifically, the facility failed to ensure the area on the ground around three trash dumpsters outside of the facility building was kept free of various debris, garbage and waste.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview, and record review, the facility failed to follow professional standards of practice for food safety to prevent the potential of foodborne illness to residents at high risk. Specifically, the facility failed to utilize pasteurized eggs in the preparation of over easy (eggs fried on both sides with a runny yolk) eggs to safely accommodate residents' choice during the breakfast meals and ensure that the unpasteurized eggs being used were cooked until all parts of the egg were completely firm to prevent the potential spread of foodborne illness.
- D
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Inspectors wroteBased on record reviews, and interviews, the facility failed to resolve a grievance timely for one Resident (#7) out of a total sample of 24 residents. Specifically, for Resident #7, the facility failed to ensure that a reported grievance of missing hearing aids was resolved in a reasonable time period.
May 15, 2025Complaint inspection · 5 citations
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on record review and interview, for one of eight sampled residents (Resident #3), the facility failed to ensure they obtained written informed consent for his/her psychotropic medication prior to administering the medication.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on records reviewed and interviews, for one of eight sampled residents (Resident #7), who had an above the knee amputation, and whose Physician Orders and Plan of Care indicated that he/she required the use of bedrails for transfers, turning and positioning, the Facility failed to ensure that he/she had the necessary assistive equipment to maintain his/her safety when the left bedrail had fallen off the bed but was not repaired or replaced timely and on 04/02/25, Resident #7 sat up on the side of his/her bed reached for the bedrail, and when it wasn't there, lost his/her balance and fell.
- D
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Inspectors wroteBased on records reviewed, observations and interviews for one of eight sampled residents (Resident #7) who was alert, oriented and made his/her own medical decisions, the Facility failed to ensure that he/she was assessed for the use of bedrails and that alternatives were trialed, prior to installing bilateral bedrails.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on record review and interviews, for one of eight sampled residents (Resident #3), whose physician's orders included the administration of a medication to manage his/her bipolar disorder, the Facility failed to ensure he/she was free from significant medication errors, when upon admission, the medication was inaccurately reconciled from his/her Hospital Discharge Summary by nursing and he/she was administered incorrect dosages of the medication for multiple days.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on records reviewed and interviews, for two of eight sampled residents (Resident #2 and Resident #3), who were dependent on assistance from staff for activities of daily living, the facility failed to ensure they maintained complete and accurate medical records.
March 26, 2025Complaint inspection · 1 citation
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), the facility failed to ensure they maintained complete and accurate medical record when, 1) nursing documentation in Resident #1's Medication Administration Record (MAR) was incomplete, with spaces for medication administration left blank, and 2) required information in the Controlled Substance Register (record/log book used by the facility for maintaining accurate records of all narcotics and other controlled medications ordered and administered to each resident) related to resident specific medications and physician's orders, was inaccurate and incomplete.
July 16, 2024Standard inspection · 11 citations
- D
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on interview, record and policy review, the facility failed to ensure that Advance Directives (legal documents that provide instructions for medical care and only go into effect if you are unable to communicate your own wishes) were accurate for three Residents (#3, #62 and #39) out of a total sample of 24 residents. Specifically, the facility failed to: 1. For Resident's #3 and #62, ensure that the MOLST (Massachusetts Medical Order for Life-Sustaining Treatment) form was valid and reflected the signature of the Resident's invoked (made active by a Physician) Health Care Proxy (HCP- a legal document that allows you to appoint someone you trust to make medical decisions on your behalf if you are unable to do so). 2. For Resident #39, offer the opportunity to formulate an Advance Directive for the Resident after his/her HCP had been deactivated by the Physician.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on interview, record and policy review, the facility failed to notify the Physician/Non-Physician Practitioner (NPP/ Nurse Practitioner [NP]) of a significant change in condition for two Residents (#62 and #86) out of a total sample of 24 residents. Specifically, the facility staff failed to notify the Physician/NPP: 1. For Resident #62, when the blood sugar reading was greater than 400 mg/dL. 2. For Resident #86, when the Resident experienced an unplanned, significant weight loss of -10.73% in one month.
- D
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on record review and interview, the facility failed to ensure the timely completion and transmission of the Minimum Data Set (MDS) Assessments as required for four Residents (#65, #33, #92, #72) out of five applicable residents. Specifically, the facility staff failed to ensure that the components of the MDS Assessments were completed and transmitted within the required timeframes when: 1. For Resident #65, the Assessment was transmitted 28 days after the MDS completion date. 2. For Resident #33, the MDS Assessment was completed 17 days after the ARD (Assessment Reference Date). 3. For Resident #92, A Quarterly MDS assessment with an ARD of 5/28/24, completed 6/11/24, was not yet transmitted as required. 4. For Resident #72, the MDS Assessment was completed 22 days after the ARD, and was not yet transmitted as required.
- D
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
Inspectors wroteBased on interview, record and policy review, the facility failed to notify the State Mental Health Authority for a resident review after a significant change in mental condition occurred for one Resident (#2) out of a total sample of 24 residents. Specifically, the facility failed to request a Preadmission Screening and Resident Review Level II screen (PASRR- an evaluation done to determine if a resident has an intellectual or developmental disability and/or serious mental illness[SMI] and if a Resident is in need of additional specialized support services at the facility) after Resident #2 received emergency mental health interventions and experienced limitations in major life activities due to mental illness.
- D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services to address a hearing problem for one Resident (#57), out of a total sample of 24 residents. Specifically, the facility staff failed to provide care and services that would maintain or improve Resident #57's hearing and communication when there was a decline in hearing ability, and the Resident/ Resident Representative had consented to be seen for audiology (the science of hearing, balance and related disorders) services.
- D
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Inspectors wroteBased on observation, interview, policy and record review, the facility failed to ensure that the administration of enteral (also referred to as tube feeding) nutrition was consistent with and followed the Physician's orders for one Resident (#76) out of a total sample of 24 residents. Specifically, the facility staff failed to administer the Physician ordered volume (quantity) of tube feeding for Resident #76, whose sole source of nutrition are enteral feeds thus placing the Resident at risk for altered nutritional status.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, policy and record review, the facility failed to ensure that respiratory care and services, consistent with professional standards of practice, were provided for one Resident (#15), out of a total sample of 24 residents. Specifically, the facility failed to maintain an oxygen concentrator (a device used to deliver supplemental oxygen) filter for Resident #15 in a clean, safe and functional manner in accordance with Physician orders, placing Resident #15 at risk for impaired oxygen delivery and equipment malfunction.
- D
Provide or obtain dental services for each resident.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide dental care and services as required for one Resident (#39) out of a total sample of 24 residents. Specifically, the facility staff failed to refer Resident #39 for dental services, when the Resident had consents for dental care and services.
- D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview, and policy review, the facility failed to maintain safe and sanitary conditions in accordance with professional standards for food service safety on three unit kitchenettes (F Wing, C Wing, and A Wing) out of four applicable unit kitchenettes, to prevent contamination and food borne infections. Specifically, 1) The facility failed to maintain clean and sanitary conditions for the unit kitchenette refrigerators on the F Wing, C Wing and A Wing unit. 2) The facility failed to maintain clean and sanitary conditions for a unit microwave on the F Wing unit. 3) The facility failed to store food safely in the refrigerator in the kitchenette on the A Wing unit.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on interview, policy and record review, the facility failed to maintain complete and accurate medical records, including provision of support services for one Resident (#2) out of a total sample of 24 residents. Specifically, the facility failed to document social service supportive visits for Resident #2 after the Resident required multiple hospital evaluations for suicidal ideation (verbal expressions of thoughts of harming oneself that may or may not lack specific intent).
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to implement appropriate infection control measures to prevent the transmission of communicable diseases and infections for one Resident (#266), out of a total sample of 24 residents. Specifically, the facility staff failed to implement the use of appropriate Personal Protective Equipment (PPE) as indicated for Resident #266 when the Resident had been identified as having a COVID-19 infection.
April 26, 2023Standard inspection · 10 citations
- E
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observation, interview and policy review, the facility failed to ensure its staff appropriately and safely stored medications, for three Residents (#79, #55 and #62), out of a total sample of 24 residents, on three out of four units. Specifically, facility staff failed to secure self-administration medications for Residents #79, #55 and #62, leaving them unsecured and available at the resident's bedside.
- E
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on record review and interview, the facility failed to ensure staff educated and offered the Pneumococcal Vaccine to four Residents (#5, #22, #32 and #66) out of five Residents sampled for immunizations.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observations, interviews, record and policy review, the facility failed to ensure its staff assessed one Resident (#55) for self-administration of medications, out of a total sample of 24 residents. Specifically, Resident #55 was not assessed for the safety of self-administration of medications and was observed to have numerous medications accessible at his/her beside.
- D
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observation and interview, the facility failed to maintain a clean, homelike environment for two Residents (#59 and #98) out of a total sample of 24 residents. Specifically, 1. For Resident #59, ensuring the wheelchair was free from built up debris and cleaned, and repairs to the bedroom walls were done as required. 2. For Resident #98, providing repairs to the walls in the resident's bedroom as needed.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review and interviews the facility failed to ensure its staff completed a comprehensive Minimum Data Set (MDS) Assessment that accurately reflected the resident's status for two Residents (#51 and #22), out of a total sample of 25 residents. Specifically, the facility failed: 1. For Resident #51, to accurately assess the cognitive and mood status, and 2. For Resident #22, accurately reflect the resident was receiving Hospice services.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on observation, interview, record and policy reviews, the facility failed to implement the plan of care relative to the Physician's orders for three Residents (#16, #64 and #87), out of a total sample of 25 residents. Specifically, the facility staff failed to ensure: 1) treatment was administered as ordered by the Physician for Resident #16, and 2) the Physician's orders were implemented relative to wound observations and required documentation with scheduled treatments for Resident's #64 and #87.
- D
Provide activities to meet all resident's needs.
Inspectors wroteBased on observation, interview and record review, the facility failed to customize activities to meet the needs of one Resident (#87), out of a total sample of 24 residents. Specifically, the facility staff failed to ensure that the activities, needs, and preferences of Resident #87 were met and that one to one (1:1) visits were implemented as careplanned.
- D
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Inspectors wroteBased on record review and interview the facility failed to ensure recommended behavioral health services was obtained for one Resident (#30), out of a total sample of 25 residents. Specifically, the facility staff failed to obtain psychotherapy services as recommended by Behavioral Health.
- D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on record review and interview, the facility failed to communicate MMR recommendations timely for one Resident (#62) out of five applicable residents reviewed, out of a total sample of 25 residents. Specifically, facility staff failed to ensure the attending Physician reviewed and acted upon documented recommendations for unnecessary medications made by the Pharmacist regarding Resident #62.
- D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on record review and interview, the facility failed to monitor the use and appropriateness of Psychotrophic medications for one Resident (#7), out of a total sample of 25 residents. Specifically, facility staff failed to limit the timeframe for a PRN (as needed) Antipsychotic medication (medication used to treat certain types of mental health conditions) to 14 days.
Fire safety inspections
8 fire safety citations on file: 3 on September 15, 2025, 3 on July 16, 2024, 2 on April 26, 2023.
Every fire safety citation8 citations
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · September 15, 2025 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · September 15, 2025 · Corrected (the home has a date of correction)
- D
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · September 15, 2025 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · July 16, 2024 · Corrected (the home has a date of correction)
- D
Implement emergency and standby power systems.
E 41 · July 16, 2024 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · July 16, 2024 · Corrected (the home has a date of correction)
- D
Have proper openings in smoke barrier doors.
K 379 · April 26, 2023 · Corrected (the home has a date of correction)
- D
Have simulated fire drills held at unexpected times.
K 712 · April 26, 2023 · Corrected (the home has a date of correction)