Home / Massachusetts / Lexington
30 Watertown Street, Lexington, MA 02420 · Middlesex County · (781) 862-8151
81 certified beds, about 69 residents a day · For profit - Corporation · Medicare and Medicaid since 1967
CMS Care Compare ratings, data as of September 1, 2026 · CCN 225049 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on March 2, 2026, inspectors cited 33 health deficiencies (the Massachusetts average is 6.8, the national average 9.2).
Of 82 health citations since September 2024, 12 were rated as actual harm or immediate jeopardy to residents (5 immediate jeopardy).
CMS lists 2 fines totaling $432,082 in the last three years; the largest was $219,077, and the latest is dated March 2, 2026.
Nurses and nurse aides worked 3.39 hours per resident per day, against 3.86 across Massachusetts and 3.86 nationally. Registered nurses accounted for 0.65 of those hours.
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.
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 82 health citations on file.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure three Residents (#24, #6, and #11) received appropriate treatment and services to prevent a decrease in range of motion. Specifically:1. For Resident #24, the facility failed to implement interventions to prevent a new contracture of the left fifth finger from developing and then worsening resulting in the amputation of this left fifth finger. The facility failed to:1a.) Ensure Occupational Therapy (OT) evaluated Resident #24 timely and provided therapy at the frequency ordered. [...]
Inspectors wroteBased on observations, record review and interviews, the facility failed to notify four Resident's (#24, #6, #21 and #9) physicians and legal guardian of a change in condition out of a total sample of 34 residents. [...]
Inspectors wroteBased on observation, record review and interview the facility failed to ensure two Residents (#36 and #24) were free from abuse out of a total sample of 34 residents. Specifically,1.) For Resident #36, despite repeated emails sent by the Resident to the facility Administrator, Director of Nursing and Social Worker, the facility failed to prevent sexual abuse and protect the Resident from psychological harm due to the fear he/she lived with from this abuse and lack of protection provided by the facility. 2.) For Resident #24, the facility failed to ensure the Resident was free from abuse, when the facility failed to ensure after Resident #24 reported that another Resident (#47) kept entering his/her room to climb into his/her bed, exposing his/her private areas, and touching him/her and his/her belongings, which made him/her feel afraid and unsafe.
Inspectors wroteBased on record review and interview the facility failed to ensure two Resident (#36 and #24) were provided with the necessary behavioral health service to attain the highest level of psych-social well-being out of a total sample of 34 residents. Specifically:for Resident #36, the facility failed to provide psychotherapy or necessary behavioral health services when the Resident expressed fear and anxiety related to the intrusive wandering and sexual threats of another resident and despite Resident #36 sending multiple emails to the facility's Administrator, Director of Nursing and Social Worker regarding the ongoing concern. Resident #24, the facility failed to provide behavioral health services when the Resident expressed fearfulness and emotional distress related to another Resident's repeated intrusive wandering, indecent exposure, unwanted touching and attempts to enter his/her bed.
Inspectors wroteBased on observations, record review and interviews, the facility failed to provide specialized rehabilitative services for two Residents (# 24 and #3) out of a total sample of 34 residents. Specifically,1. For Resident #24, the facility failed to obtain a timely Occupational Therapy (OT) evaluation and failed to provide OT treatments at the frequency ordered to treat a left-hand contracture. The Resident's contracture worsened and he/she required an amputation of the left fifth finger. 2. For Resident #3, the facility failed to obtain a Physical Therapy (PT) evaluation as ordered by the Nurse Practitioner.
Inspectors wroteBased on record review and interview the facility failed to report allegations of abuse within the required two hour time frame to the Health Care Facility Reporting System for 5 Residents (#36, #47, #25, #55, #45 and #10) out of a total sample of 34 residents. Specifically, 1. For Resident #36 the facility failed to report an allegation of sexual abuse.2. For Resident #47 the facility failed to report an allegation of sexual abuse. 3. For Resident #25 the facility failed to report a resident-to-resident altercation. 4. For Resident #55 the facility failed to report an allegation of sexual abuse.5. For Resident #10 the facility failed to report a resident-to-resident abuse.6. For Resident #45 the facility failed to report an allegation of physical abuse by staff.
Inspectors wroteBased on record review and interview the facility failed to investigate allegations of abuse for 5 Residents (#36, #47, #25 and #45 and #10) out of a total sample of 34 residents. Specifically,1. For Resident #36, the facility failed to investigate an allegation of sexual abuse.2. For Resident #47, the facility failed to investigate an allegation of sexual abuse.3. For Resident #25, the facility failed to investigate an allegation of resident-to-resident altercation. 4. For Resident #45, the facility failed to investigate an allegation of physical abuse by staff. 5. For Resident #10, the facility failed to investigate an allegation of resident-to-resident altercation. Review of the policy titled Suspected Adult, Disabled Resident or Elderly Abuse/Neglect/Exploitation, dated as revised 6/26/25, indicated the following: Sexual Abuse: [...]
Inspectors wroteBased on observations and interviews, the facility failed to ensure staff stored drugs and biologicals in accordance with State and Federal requirements. Specifically:1.) The facility failed to ensure medications with shortened expiry dates were dated once opened in two out of three medication carts and to ensure insulin that required refrigeration was refrigerated in one out of two medication rooms observed.2.) The facility failed to properly secure medication carts when unattended on one of three units.3.) The facility failed to ensure the medication room was locked when unattended.4.) The facility failed to ensure unauthorized staff did not have access to medication room.5.) The facility failed to ensure lorazepam, a controlled drug, was separately locked in a permanently affixed compartment for storage of controlled drugs.
Inspectors wroteBased on observation and interview, the facility failed to store and prepare food in accordance with professional standards for food service safety. Specifically, the facility failed to:1) Ensure food was labeled and stored under sanitary conditions without significant signs of decomposition. 2) Practice proper food handling during meals in the [NAME] Unit dining room.
Inspectors wroteBased on observation and interview, the facility failed to provide a dignified existence for one Resident (#74) out of a total sample of 34 residents. Specifically, staff failed to pull the privacy curtain for Resident #74 when he/she was in bed receiving assistance with bathing, which exposed Resident #74 to his/her roommates.
Inspectors wroteBased on record review and interviews, the facility failed to inform residents or their representatives of charges for services available in the facility not covered under Medicare/Medicaid or by the facility's per diem rate for two out of two applicable records reviewed.
Inspectors wroteBased on observations and interviews, the facility failed to maintain a home-like environment. Specifically, the facility failed to ensure that the [NAME] Wing was free from odors.
Inspectors wroteBased on record review and interview, the facility failed to ensure that its staff completed a quarterly Minimum Data Set (MDS) assessment in a timely manner for one Resident (#27), out of 34 sampled residents.
Inspectors wroteBased on record review and interviews, the facility failed to develop a care plan for suicidal ideation for one Resident (#33) out of a total sample of 34 residents.
Inspectors wroteBased on record review and interviews, for 2 Residents (#47 and #50) out of a total sample of 34 residents, the facility failed to ensure they reviewed and revised the Comprehensive Care Plan following the completion of his/her scheduled Quarterly Minimum Data (MDS) assessment. Specifically,For Resident #47 the facility failed to update the care plan to remove interventions of 15-minute checks when they were no longer being implemented. For Resident #50, the facility failed to revise the comprehensive care plan relating to communication problem, which did not include any interventions related to his/her language barrier.
Inspectors wroteBased on observation, record review and interview, the facility failed to provide care in accordance with professional standards of practice for one Residents (#74) out of a total of 34 sampled residents. Specifically:1. For Resident #74, the facility failed to ensure a physician's order was implemented for padded side rails.
Inspectors wroteBased on observation, record review and interviews, the facility failed to provide assistance with Activities of Daily Living (ADLs) for 3 Residents (#69, #67 and #45) out of a total sample of 34 residents. Specifically, the facility failed to:1) Provide incontinence care for Residents #69 and #67. 2) Provide assistance to Resident #45 for grooming tasks and removal of unwanted facial hair.
Inspectors wroteBased on observations and interviews, the facility failed to provide an activities program for residents on the [NAME] Unit.
Inspectors wroteBased on observation, record review and interview, the facility failed to ensure that one Resident (#48) out of a total sample of 34 residents received proper treatment and assistive devices to maintain hearing abilities. Specifically, the facility failed to facilitate an audiology appointment for Resident #48 who was hard of hearing routinely and when his/her hearing aids went missing.
Inspectors wroteBased on observations, interviews and record review, the facility failed to maintain a safe environment for one Resident (#38) out of 34 total sampled residents. Specifically, the facility failed to ensure that Resident #38 was not left unattended in his/her room in accordance with plan of care.
Inspectors wroteBased on observations, interviews and record review, the facility failed to identify and address a significant weight loss for one Resident (#51) out of a total sample of 34 residents. Specifically, once a weight loss was identified, the facility failed to refer the Resident to the dietitian, assess the Resident and add nutritional interventions.
Inspectors wroteBased on observations, record review and interviews, the facility failed to provide oxygen as ordered to two Residents (#21 and #9) out of a total sample of 34 residents.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that care and services for pain management consistent with professional standards of practice were provided for one Resident (#3) out of a total sample of 34 residents. Specifically, the facility failed to provide pain management interventions as ordered by the Nurse Practitioner for a pain consult to manage chronic pain.
Inspectors wroteBased on record review and interview the facility failed to ensure one Resident (#36) was provided a trauma informed plan of care out of a total sample of 34 residents. Specifically, the facility failed to ensure a trauma care plan was updated to mitigate potential triggers following Resident #36's report of sexual abuse by a peer.
Inspectors wroteBased on observation, record review and interview the facility failed to provide appropriate treatment and services for 1 Resident (#47) out of a total sample of 34 residents who is diagnosed with Dementia, to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being. Specifically, the facility failed to provide dementia interventions to adequately supervise Resident #47 when he/she was sexually inappropriate, paced the hallways and wandered in and out of peers' rooms.
Inspectors wroteBased on observation, interviews, and record review, the facility failed to provide social services to attain the highest practicable mental and psychological well-being for one Resident (#36), out of a total sample of 34 residents. Specifically, for Resident #36, the facility failed to follow up after Resident #36 was sexually threatened by another resident to ensure effective interventions were implemented to prevent additional incidents of sexual abuse, resulting in Resident #36 living in fear and experiencing repeated abuse by this peer.
Inspectors wroteBased on interview and record review, the facility failed to address and implement licensed Pharmacist recommendations in a timely manner for one Resident (#3) out of a total sample of 34 residents. Specifically, the facility failed to ensure the Consultant Pharmacist's recommendation from December 2025 to separate eye drops by at least five minutes during administration was reviewed and responded to in a timely manner.
Inspectors wroteBased on record reviews and interviews, the facility failed to ensure four Residents (#13, #8, #33, and #3) were free from unnecessary psychotropic medications out of a total sample of 34 residents. Specifically, 1. For Resident #13, the facility failed to follow the recommendation from the psychiatrist to lower the dose of the Resident's antipsychotic. 2. For Residents #8, #33 and #3, the facility failed to complete an AIMS (Abnormal Involuntary Movement Scale) assessment to determine possible adverse reactions to antipsychotic medications.
Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to provide dental services and replace missing dentures for one Resident (#18) out of a total sample of 34 residents.
Inspectors wroteBased on interview, document review, and policy review, the facility failed to develop, implement, and maintain a Quality Assurance and Performance Improvement (QAPI) program which addressed the full range of care and services, was comprehensive and data-driven, and focused on indicators of outcomes of quality of life, quality of care, and services to residents in the facility. Specifically, the facility failed to use a systematic approach to determine underlying causes of problems impacting larger systems, develop corrective actions, and monitor effectiveness of its performance improvement activities to ensure improvements are sustained.
Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections on one unit (North Unit), out of three units and for two Residents (#74 and #6) residing on North Unit. Specifically, the facility failed to implement Enhanced Barrier Precautions (EBP) when providing care:1. For Resident #74, the facility staff failed to wear the appropriate Personal Protective Equipment (PPE) when providing direct care for the Resident on EBP who had a gastrostomy tube (a medical device inserted through the abdominal wall directly into the stomach to deliver nutrition).2. [...]
Inspectors wroteBased on record review and interviews, the facility provided the COVID-19 vaccination without consent from the resident or resident health care proxy for one Resident (#18) out of a total sample of 34 residents.
Inspectors wroteBased on observation, interview and record review, the facility failed to accurately code in the Minimum Data Set (MDS) for four Residents (#1, #50, and #24) of 34 total sampled residents. Specifically:1.) For Resident #1, the use of restraints was inaccurately coded on the MDS assessment.2.) For Resident #50, the Resident was inaccurately coded on the MDS assessment as rarely/never understood when he/she was able to communicate in Swahili.3.) For Resident #24, the presence of a pressure ulcer was inaccurately coded on two MDS assessments.
Inspectors wroteBased on interview and record review the facility failed to ensure requests to access personal funds for less than $100 ($50 for Medicaid residents) were honored within the same day for one Resident (#15), out of a total sample of 18 residents and the facility failed to ensure Resident #15's funds, as well as the funds of 7 of 18 Residents in the sample were maintained in an interest-bearing account.
Inspectors wroteBased on record review and interviews, the facility failed to offer/administer influenza and pneumococcal vaccinations per the Centers for Disease Control and Prevention (CDC) recommendations for four Residents (#6, #21, #25, and #42) out of a total of five residents reviewed. Specifically, for 1. Residents #6, #21, and #25 the facility failed to administer the annual influenza vaccine during the most recent influenza season (2024 to 2025).2. Resident #6 and #42 the facility failed to administer pneumococcal vaccinations.
Inspectors wroteBased on observation, record review and interview, the facility failed to ensure the comprehensive care plan was revised by the interdisciplinary team for one Residents (#21) out of a total sample of 18 residents, after each assessment, including both the comprehensive and quarterly review assessments. Specifically, the facility failed to review and revise the care plan after a significant change of status assessment was completed to reflect the current status of the Resident after the Resident had a fall and sustained a wrist fracture.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that services provided met professional standards for two Residents (#35 and #8), out of 18 total sampled residents. 1. For Resident #35 the facility failed to ensure nursing implemented heel booties according to the physician's order.2. For Resident #8 the facility failed to ensure nursing implemented geri sleeves (arm protectors for residents who are at risk for bruising/injury) according to the physician's order.
Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents at risk for developing pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to prevent new ulcers from developing for one Resident (#18) out of a total of 18 Residents. Specifically, the facility failed to ensure the Resident's air mattress was set at the correct setting according to the physician's order.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure professional standards of practice for the care of a urinary catheter (a tube inserted into the bladder to drain urine) for one Resident (#23) out of a total sample of 18 residents. Specifically, the facility failed to ensure nursing changed Resident #23's urinary catheter and urinary catheter drainage bag in accordance with physician's orders.
Inspectors wroteBased on record review and interview, the facility failed to designate a person who met the minimum qualifications to serve as the Food Service Director (FSD). Specifically, the facility did not employ a full-time dietitian or have a qualified dietary employee who met the minimum qualifications to serve as the FSD.
Inspectors wroteBased on observation, record review and interview, the facility failed to serve what was listed on the menu for the pureed meal during three meals observed during the survey period. Specifically, the facility failed to ensure residents who required a pureed entree received the meal as indicated on the menu.
Inspectors wroteBased on observation, record review and interview, the facility failed to provide the appropriate dessert for one Resident (#42) out of a total sample of 18 residents. Specifically, Resident #42, who required nectar thickened liquids was provided gelatin for dessert.
Inspectors wroteBased on observations, interviews and record review, the facility failed to provide adaptive equipment for one Resident (#62) out of a total sample of 18 residents. Specifically, the facility failed to ensure Resident #62 was provided with a two handled cup and built-up utensils for use during his/her meals to maximize intake.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure nursing accurately documented in the electronic health record for three Residents (#35, #8, and #62), out of 18 total sampled residents. Specifically, the facility failed to ensure the nurses accurately documented skin checks.
Inspectors wroteBased on Minimum Data Set (MDS) assessment review and staff interview, the facility failed to ensure staff completed the Quarterly MDS assessment within the required time frame for two Residents (#20 and #6), out of a total of 18 residents.
Inspectors wroteBased on interview and record review, the facility failed to ensure that Minimum Data Set (MDS) assessments were transmitted within 14 days after a resident assessment was completed for three Residents (#38, #7, and #28), out of a total sample of 18 residents.
Inspectors wroteBased on record review and interview the facility failed to ensure the Minimum Data Set (MDS) assessment was coded accurately for four Residents (#24, #42, #3 and #7) out of a total sample of 18 residents. Specifically:1) For Resident #24, the Resident was erroneously coded as receiving an antianxiety medication on the 7/01/25 MDS.2) For Resident #42, the Resident was erroneously coded as receiving antianxiety medication, and not receiving hypoglycemic and anticonvulsant medication on the MDS dated [DATE]) For Resident #3, the Resident was erroneously coded as receiving an antianxiety medication on the 7/23/25 MDS.4) For Resident #7, the Resident was erroneously coded as having a diagnosis of Schizophrenia on the 5/03/25 MDS.
Inspectors wroteBased on record review and interview, the facility failed to protect three Residents (#20, #23, #26), from neglect, out of a total sample of 26 residents. Specifically, 1. For Resident #20, the facility neglected to a.) implement wound treatments as recommended by the Consultant Wound Physician resulting in the deterioration of a closed unstageable pressure injury to a Stage 4 pressure injury and b.) failed to follow up on a progress note indicating right hip redness dated 8/28/24, and implement the use of an air mattress. 2. For Resident #23, the facility neglected to implement treatment recommendations by the Wound Consultant Physician for wound care. 3. [...]
Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide care and treatment to prevent the development and worsening of pressure injury's (wounds that occur when the skin and tissue are damaged by prolonged pressure, usually on bony areas like the coccyx, hips, heels, or elbows) for three Residents (#20, #23, and #26) out of a total sample of 26 residents. Specifically, 1a. For Resident #20 the facility failed to implement treatments and physician orders recommended by the Consultant Wound Physician resulting in the wound requiring antibiotic therapy resulting in the deterioration of an unstageable pressure wound progressing to a Stage 4 pressure injury. 1b. [...]
Inspectors wroteBased on observation, record review, and interviews the facility failed to ensure the nursing staff were trained and demonstrated the competencies and skill sets necessary to provide the level and types of care and services needed as outlined in the Facility Assessment. Specifically, the facility failed to: 1. Ensure licensed nursing staff were trained and demonstrated clinical competency related to pressure injury/wound care, including recognizing and reporting wound deterioration, evaluation and measurements for one resident (#20), out of a total sample of 26 residents. For Resident #20 the facility staff failed to implement treatments and physician orders recommended by the consulting wound physician resulting in the wound requiring antibiotic therapy, resulting in the deterioration of an unstageable pressure injury wound progressing to a Stage 4 pressure injury. 2. [...]
Inspectors wroteBased on observations, interviews and record review the facility failed to ensure its administration used its resources effectively to provide appropriate wound care. Specifically, the facility administration failed to: 1. Provide nursing staff education and training to provide competent, safe, and effective wound care management. 2. Provide continuation of the pressure injury prevention and care services following the absence of the Director of Nursing (DON) and implement an effective system for pressure injury (wounds that occur when the skin and tissue are damaged by prolonged pressure, usually on bony areas like the hips, heels, or elbows) prevention and care per the Facility Assessment Tool. These failures resulted in the development of an infected Stage 4 pressure injury for one Resident (#20) out of a total sample of 26 residents. Findings Include: [...]
Inspectors wrote3a. Resident #6 was admitted to the facility in March 2022 with diagnoses including chronic obstructive pulmonary disease (COPD), acute respiratory failure, dysphagia, and anxiety. Review of Resident #6 most recent Minimum Data Set assessment (MDS) dated [DATE], indicated that the Resident had a Brief Interview for Mental Status score of 15 out of a possible 15 indicating an intact cognitive status. Further review of the MDS indicated that the Resident requires assistance with activities of daily living and receives respiratory care. On 9/3/24 at 10:01 A.M., Resident #6 was observed sitting in a wheelchair in the dining room. A portable oxygen concentrator was observed hanging off the back of the wheelchair, oxygen tubing attached, the nasal cannula was placed around the Residents head but was not placed in his/her nostrils. [...]
Inspectors wroteBased on observation, record review, and interview, the facility failed to address the nutritional status in a timely manner for one Resident (#6) out of a total sample of 26 residents. Specifically, the facility failed to address a significant weight loss in a timely manner for Resident #6, resulting in a 12% weight loss in one month.
Inspectors wroteBased on observations, record review and interview, the facility failed to ensure Residents received respiratory care and treatment according to professional standards of practice and in accordance with physician's orders for one Resident (#6) out of a total sample of 26 residents. Specifically, The facility failed to provide consistent oxygen therapy for Resident #6 who required oxygen continuously resulting in the resident's oxygen saturation to drop to 77% resulting in respiratory distress.
Inspectors wroteBased on observation, record review and interview the facility failed to ensure sufficient staffing to assure residents attain or maintain the highest practicable physical, mental, and psychosocial wellbeing. Specifically, the facility failed to have sufficient staffing on the weekends as indicated on the payroll-based journal report submitted to The Centers of Medicare and Medicaid (CMS) for Fiscal Year Quarter 2, 2024.
Inspectors wroteBased on observations and interviews, the facility failed to ensure there was a Registered Nurse (RN) to serve as the Director of Nurses (DON) on a full-time basis.
Inspectors wroteBased on personnel file review and interviews, the facility failed to ensure that one of seven Certified Nurse Assistants (CNA) reviewed were not employed as CNA's for more than four months after hire without passing the CNA exam and obtaining a CNA license.
Inspectors wroteBased on record review and interview the facility failed to ensure for three of three applicable Certified Nursing Assistant (CNA) employee files out of five CNA employees files reviewed had a performance review at least every twelve months.
Inspectors wroteBased on review of the Facility Assessment and interviews, the facility failed to conduct and document a facility wide assessment that accurately reflected the resources necessary to care for its residents. Specifically, the facility failed to ensure licensed nursing staff were competent in wound care.
Inspectors wroteBased on observation, record review and interview the facility failed to implement an infection control program to prevent infection. Specifically, 1. The facility failed to develop and implement a plan for water borne illness, 2. The facility failed to develop and implement enhanced barrier precautions, 3. The facility failed to ensure infection control practices for the use of respiratory equipment was implemented for one Resident (#36) out of a total sample of 26 residents.
Inspectors wroteBased on policy review and interview, the facility failed to implement an antibiotic stewardship program to promote and monitor the appropriate use of antibiotics.
Inspectors wroteBased on interviews and review of the Facility Assessment, the facility failed to designate one or more individuals as the infection preventionist who are responsible for the facility's infection prevention and control plan. Specifically, the facility failed to have a qualified infection preventionist with completed specialized training in infection prevention and control.
Inspectors wroteBased on review of the Facility Assessment, employee education record review, and interview, the facility failed to implement and maintain and effective training program per the facility assessment for all new and existing staff. Specifically, the facility failed to provide the required training necessary to meet the needs of each resident.
Inspectors wroteBased on review of the Facility Assessment, employee education record review, and interviews, the facility failed to implement mandatory infection control training for 10 out of 10 direct care staff.
Inspectors wroteBased on observations and interviews, the facility failed to ensure resident protected health information (PHI) was secure and not visible to others on three of three nursing units.
Inspectors wroteBased on observation, record review and interview the facility failed to ensure standards of quality of care to maintain a resident's highest level of well-being for three Residents (#7, #26, #67), out of a total sample of 26 residents. Specifically, 1. For Resident #7, the facility staff failed to document, and assess the alteration of the skin on his/her lower extremities to determine if the areas were healing or worsening and failed to report the condition of Resident #7's lower extremities to the medical provider resulting in the Resident requiring the treatment with an oral antibiotic for the condition of his/her right and left lower extremities. 2a. For Resident #26, the facility failed to implement the treatments for pressure wounds and non-pressure wound injuries as recommended by the wound physician. 2b. [...]
Inspectors wroteBased on observation and interview, the facility failed to ensure nursing staff stored all drugs and biologicals in accordance with accepted professional standards of practice. Specifically, the facility failed to properly secure the medication cart on three of three units.
Inspectors wroteBased on record review and interview, the facility failed to ensure a current hospice care plan was present in the medical record and coordinated with facility staff for two Residents (#5 and #7) out of four applicable residents in a total sample of 26 residents.
Inspectors wroteBased on record review and interview the facility failed to obtain informed consent for the administration of a psychotropic medication for one Resident (#7), out of a total sample of 26 residents.
Inspectors wroteBased on record review, policy review, and interview, the facility failed to ensure Advance Directives (written documents that instructs health care providers of the decisions for specific medical treatment if a person was unable to speak or lacked the capacity to make decisions for themselves) were consistently documented in the medical record for three Residents (#23, #38 and #21), out of a total sample of 26 residents.
Inspectors wroteBased on observation, record review and interview the facility failed to ensure a homelike environment for one Resident (#5), out of a total sample of 26 residents. Specifically, Resident #5 was sleeping on a mattress that was torn and not in good condition.
Inspectors wroteBased on record review and interviews, the facility failed to complete a Significant Change in Status (SCSA) Minimum Data Set assessment (MDS) for one Resident (#7), out of a total sample of 26 residents, when the Resident was admitted to hospice services.
Inspectors wroteBased on observations, record review and interview, the facility failed to maintain an accurate Minimum Data Set Assessment for one Resident (#67) out of a total sample of 26 residents. Specifically, the facility documented that Resident #67 does not use bed rails while the resident has an active physician's order for the use of bed rails.
Inspectors wroteBased on observations, record review and interview the facility failed to develop a comprehensive resident centered care plan for two Residents (#38, #67) out of a total sample of 26 residents. Specifically, 1. For Resident #38, the facility failed to develop a comprehensive pacemaker care plan, 2. For Resident #67, the facility failed to develop an activities of daily living (ADL) for dependent residents care plan.
Inspectors wroteBased on observation, record review, and interviews, for two Residents (#63 and #23) of 26 sampled residents, the facility failed to ensure nursing provided services in accordance with the comprehensive care plan that met professional standards of quality. Specifically, 1. For Resident #63, the facility failed to ensure nursing implemented the Neurologist's recommended medication that was verified and ordered by the Resident's Nurse Practitioner (NP), 2. For Resident #23, the facility failed to ensure nursing implemented a physician order to obtain a stool sample for colon cancer screening.
Inspectors wroteBased on observations, record review and interviews, the facility failed to provide assistance with Activities of Daily Living (ADLs), for two Residents (#23 and #38) out of a total sample of 26 residents. Specifically, the facility failed to provide assistance with meals as per the plan of care for Resident #23 and for Resident #38.
Inspectors wroteBased on observations, interview and record review, the facility failed to maintain a safe environment for two Residents (#67, #2) out of a total sample of 26 residents. Specifically, 1. For Resident #67, the facility failed to implement physician's orders and the plan of care for the use of bed siderails and fall mats while in bed. 2. For Resident #2, the facility failed to conduct a complete, thorough and accurate investigation after the Resident sustained a fall resulting in hospitalization with a frontal scalp soft tissue hematoma and right nasal bone nondisplaced fracture.
Inspectors wroteBased on observations, record reviews and interviews, the facility failed to follow professional standards of practice relating to catheter care and bladder incontinence for two Residents (#66, #67) out of a total sample of 26 residents. Specifically, 1. The facility failed to have an order for the catheter tube size and balloon volume amount for Resident #66, who was identified by the facility matrix as being the only resident in the facility with an indwelling catheter. 2. The facility failed to develop a comprehensive resident centered care plan for bladder incontinence with individualized, resident-focused interventions for Resident #67
Inspectors wroteBased on observations, record review and interviews, the facility failed to provide behavioral health services for one Resident (#34) out of a total sample of 26 residents.
Inspectors wroteBased on record review and interview the facility failed to ensure for one Resident (#7), out of a total sample of 26 residents, that psychotropic medication ordered as PRN (as needed) was limited to 14 days, and that the medical provider documented their rationale for continued PRN use in the resident's medical record. Specifically, the facility failed to limit the use of Lorazepam initially for 14 days
Inspectors wroteBased on observations, record review and interviews the facility failed to ensure that one Resident (#9), out of a total sample of 26 residents, was provided the correct therapeutic diet in accordance with the physician's orders.
Inspectors wroteBased on record review, observations and interview, the facility failed to maintain accurate medical records. Specifically, staff signed off on the Treatment Administration Record (TAR) that weekly skin checks were completed when they were not for two Residents (#67, #26) out of a total sample of 26 residents.
6 fire safety citations on file: 6 on September 26, 2024.
| Date | Penalty | Amount or length |
|---|---|---|
| March 2, 2026 | Fine | $213,005 |
| September 26, 2024 | Fine | $219,077 |
A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Massachusetts | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 3.39 | 3.86 | 3.86 |
| Registered nurses | 0.65 | 0.65 | 0.69 |
| All nursing staff on weekends | 3.22 | 3.48 | 3.42 |
| Nurse aides | 2.17 | ||
| Licensed practical nurses | 0.57 | ||
| Nursing staff turnover (share who left in a year) | not reported | 38.2% | 45.8% |
| Registered nurse turnover | not reported | 42.6% | 42.9% |
| Administrators who left | not reported |
CMS expects 3.27 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.46 on weekdays and 3.22 on weekends, 7% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 4.9% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.35 in April to June 2025 to 3.39 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 3.39 | 0.65 | 3.46 | 3.22 | 4.9% | 0 of 90 | 69 |
| Jul to Sep 2025 | 3.40 | 0.82 | 3.46 | 3.25 | 3.5% | 0 of 92 | 69 |
| Apr to Jun 2025 | 3.35 | 0.81 | 3.41 | 3.20 | 2.2% | 0 of 91 | 68 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Massachusetts, Jan to Mar 2026 | 3.79 | 0.61 | 3.94 | 3.41 | 5.0% | 0.4% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Staff pay reports
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review. If you work here, your report helps start one.
| Job | Median | Middle half | Employed |
|---|---|---|---|
| Massachusetts, all employers | |||
| CNAs (nursing assistants) | $22.44 | $21.32 to $23.94 | 38,130 |
| LPNs and LVNs | $38.57 | $34.91 to $40.66 | 13,210 |
| Registered nurses | $50.27 | $42.05 to $65.44 | 88,200 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Massachusetts | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 9.6 | 16.4 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 1.0 | 0.8 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 1.5 | 1.8 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 5.1 | 3.5 | 3.2 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 12.5 | 15.4 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 5.4 | 4.2 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 38.6 | 21.4 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 16.5 | 25.7 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 8.4 | 11.9 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 2.2 | 1.9 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.7 | 1.5 | 1.8 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Pine Knoll Nursing Center's Medicare short-stay residents. How to read these, and what Medicare pays for.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
US median of homes 51.5% · Massachusetts: 121 better, 19 worse
Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 16 eligible stays.
11.8% this home
No different from the national rate
US median of homes 10.7% · Massachusetts: 4 better, 15 worse
Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 40 eligible stays.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
US median of homes 7.1% · Massachusetts: 5 better, 4 worse
Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 15 eligible stays.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Median of homes: Massachusetts51.6% · US 56.6%
Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 18 residents counted.
4.0% this home
Median of homes: Massachusetts0.4% · US 0.0%
Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 25 residents counted.
7.5% this home
Median of homes: Massachusetts2.0% · US 1.7%
Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 25 residents counted.
Not reported
CMS note: Newly certified nursing home with less than 12-15 months of data available or the nursing opened less than 6 months ago, and there were no data to submit or claims for this measure.
Median of homes: Massachusetts99.5% · US 98.7%
Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025.
Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.
Legal business name: LONG TERM CENTERS OF LEXINGTON INC.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Sweeney, Matthew | Corporate officer | Individual | 07/31/2024 | |
| Woods, Thomas | Corporate officer | Individual | 12/01/1999 | |
| Gouveia, Jessica | Operational/managerial control | Individual | 08/01/2024 | |
| Merchant, Asif | Operational/managerial control | Individual | 01/01/2014 | |
| Sweeney, Matthew | Operational/managerial control | Individual | 05/01/2018 | |
| Woods, Thomas | Operational/managerial control | Individual | 05/01/2018 | |
| Gouveia, Jessica | Adp of the SNF | Individual | 08/01/2024 | |
| Merchant, Asif | Adp of the SNF | Individual | 01/01/2014 | |
| Sweeney, Matthew | Adp of the SNF | Individual | 05/01/2018 | |
| Woods, Thomas | Adp of the SNF | Individual | 05/01/2018 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Chosen from this home's own inspection record.