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 28 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
17D
6E
3F
Potential for minimal harm
0A
2B
0C
December 9, 2025Standard inspection · 8 citations
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations, interviews and record review the facility failed to follow professional standards of practice for food safety to prevent the potential spread of foodborne illness in the main facility kitchen and on three (Unit #2, #3 and #4) of three unit kitchenettes. Specifically, the facility failed to:1. Implement control measures for monthly cleaning of the facility's ice machine located in the main kitchen, and proper storage of the ice scoop, increasing the risks for residents to develop foodborne illnesses and infections.2. ensure that food items were properly stored in the kitchenettes on Unit #2, #3 and #4 and that Unit #2 and Unit #3 kitchenettes were maintained in safe, clean, and sanitary conditions.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, interviews, and records review, 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 in the facility main laundry area, and on one unit (Unit #2) out of three resident units. Specifically, the facility failed to:1. Ensure that laundry personnel in the main facility laundry room wore the indicated Personal Protective Equipment (PPE-items such as gowns and gloves worn by staff to decrease the spread of infections) when sorting dirty laundry and linens soiled with feces.2. Ensure that facility staff followed appropriate hand hygiene standards on Unit #2 when: [...]
- D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to provide necessary care and services in a timely manner, consistent with Residents' needs and choices, to improve the Resident's ability to carry out activities of daily living (ADLs) relative to mobility for one Resident (#10) out of a total sample of 21 residents. Specifically, the facility failed to respond to Resident #10's request to be assessed for the use of a walker and the ability to walk when: -The Resident used a wheelchair for mobility. -The Resident reported improved abilities to move his/her legs. -The Resident requested therapy services to address his/her ability to stand and use a walker.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one Resident (#14) out of a total sample of 21 residents was provided assistance with personal hygiene care and services. Specifically, the facility failed to ensure that Resident #14 was offered and/or provided grooming assistance timely for nail care when the Resident required total dependence of staff for hygiene, bathing, and dressing.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on record review, and interviews, the facility failed to ensure that a Physician ordered pain medication was available to be administered for one Resident (#4) out of a total sample of 21 residents. Specifically, for Resident #4, the facility failed to ensure that Morphine Sulfate (pain medication) was available to be administered to the Resident every four hours as ordered by the Physician, over six consecutive opportunities, for two consecutive days.
- D
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, and interview, the facility failed to ensure that medications were stored according to professional standards of practice for one unit (4th floor) out of three total units. Specifically, for the 4th floor unit, the facility failed to: -ensure that a controlled substance medication was stored in a safe and secure compartment for controlled substances and/or other drugs subject to abuse inside the medication cart, when an Oxycodone tablet was found in a medication cup during a medication cart observation. -ensure that a controlled substance medication that was refused by a resident was appropriately destroyed and not left unlabeled and accessible in the medication cart with the potential of being diverted or accidentally administered to a resident.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on record review, and interview, the facility to ensure that medical records were complete and accurate for one Resident (#4) out of a total sample of 21 residents. Specifically, for Resident #4, the facility staff failed to provide documentation that the Provider was notified when the Resident's Morphine Sulfate Oral Solution was not available to be administered as ordered placing the Resident at risk of not having pain appropriately managed.
- B
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on interviews, and records review, the facility failed to refer one Resident (#3) out of a total sample of 21 residents to the PASRR office when the Resident experienced a significant change in status assessment. Specifically, the facility failed to refer Resident #3 to the PASRR office when the Resident:-had a previous negative PASRR screening for serious mental illness (SMI).-expressed a wish to commit suicide.-required modification to his/her care plan relative to his/her suicidal statement.-required antipsychotic medication that was previously discontinued to be re-ordered and administered following his/her suicidal statement.
August 22, 2024Standard inspection · 5 citations
- 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 staff failed to maintain a clean, orderly, homelike environment on one unit (Unit Four) out of three units. Specifically, the facility failed to ensure that the air conditioning (AC) vent located on the ceiling, and the ceiling tiles surrounding the vent in the hallway outside of the resident rooms were maintained in good repair and a clean, homelike environment.
- D
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Inspectors wroteBased on record and policy review, and interview, the facility failed to ensure that the required transfer documentation was completed and the transfer documentation communicated the appropriate information to the receiving health care institution for one Resident (#13), out of a total sample of 22 residents. Specifically, the facility failed to ensure Resident #13 was transferred to the emergency room with a form that included important information relative to the Resident's medical history and the reason for transfer, putting the Resident at risk for complications and adverse events upon transfer to the hospital.
- 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 interview, record and policy review, the facility failed to ensure the risks and benefits of bed rails was reviewed with the Resident and/or Resident Representative and informed written consent was obtained prior to the use of bed rails for one Resident (#15) out of a total sample of 22 residents. Specifically, for Resident #15, the facility failed to ensure the risks and benefits of bed rails was reviewed with Resident #15's Guardian (a court appointed person who makes important personal and healthcare decisions for an adult who lacks the capacity to make their own decisions) and written consent was obtained from the Guardian prior to the installation and use of bed rails.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on record review and interview, the facility failed to maintain complete and accurate medical records for one Resident (#15) out of a total sample of 22 residents. Specifically, for Resident #15, the facility failed to contact the Resident's Guardian (a court appointed person who makes important personal and healthcare decisions for an adult who lacks the capacity to make their own decisions) and ensure that the Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST- form that indicates what types of medical treatment a resident wishes to have concerning life-sustaining treatment) form was signed by the Guardian and not by the Resident.
- B
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review and interview, the facility failed to ensure that a Minimum Data Set (MDS) Assessment was accurately coded for one Resident (#39) out of a total sample of 22 residents. Specifically, for Resident #39, the facility staff failed to accurately code that the Resident had falls on the most recent Quarterly MDS Assessment.
May 4, 2023Standard inspection · 15 citations
- F
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on interview and record review the facility failed to ensure its staff completed a Comprehensive Minimum Data Set (MDS) Assessment within the required time frames for eleven Residents (#141, #142, #145. #190, #191, #14, #18, #24, #30, #36, and #59) out of 38 sampled residents. Specifically, 1. for Residents #141, #142, #145, #190, and #191 the facility failed to ensure its staff completed admission MDS Assessments within the required 14 days of admission to the facility and 2. For Residents #14, #18, #30 #36, and #59 the facility failed to ensure its staff completed an Annual MDS Assessment at least every 12 months. 1. For Residents #141, #142, #145, #190, and #191 the facility failed to complete an admission MDS Assessment within 14 days of Admission a. Resident #141 was admitted to the facility 3/22/23. [...]
- F
Assure that each resident’s assessment is updated at least once every 3 months.
Inspectors wroteBased on record review and interview the facility failed to ensure its staff completed quarterly review Minimum Data Set (MDS) Assessments for 22 Residents (#3, #4, #6, #10, #16, #20, #25, #34, #37, #39, #42, #53, #55, #57, #60, #68, #71, #79, #81, #82, #83, and #84) out of a total of 38 sampled residents. Review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual indicated the Quarterly MDS Assessment must be completed no later than 14 calendar days after the Assessment Reference Date (ARD-refers to the last day of the observation period that the assessment covers for the resident). 1. Resident #3 was admitted to the facility in July 2016. Review of the Quarterly MDS Assessment with an Assessment Reference Date (ARD) of 3/22/23 indicated it had not been completed within 14 days of the ARD. 2. [...]
- F
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observations and interviews, the facility failed to ensure its staff provided meals that were palatable, and of appropriate temperatures on three (Second Floor, Third Floor, and Fourth Floor) out of three Units observed.
- E
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteBased on record review and interview, the facility failed to ensure its staff: 1. provided a written Notice of Transfer and Discharge to the resident and/or residents representative at the time of discharge and 2. failed to notify a representative in the Office of the State Long Term Care Ombudsman when a resident was transferred from the facility for six Residents (#241, #13, #29, #85, #61, and #70) out of a total of 22 residents sampled.
- E
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Inspectors wroteBased on record review and interview, the facility failed to ensure its staff provided written notification of the Bed-Hold policy to the Resident and/or the Resident's Representative for four Residents (#61, #70, #241 and #85) who were transferred to the hospital, out of a total sample of 22 residents.
- E
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 its staff completed and/or transmitted discharge information for five Residents (#13, #29, #60, and #241) out of 38 sampled residents.
- E
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wrote2. For Resident #60 the facility failed to ensure its staff developed a comprehensive, individualized, person-centered care plan relative to the Resident's psychosocial well-being. Resident #60 was admitted to the facility in September 2022 with diagnoses including anxiety and adjustment disorder with depressed mood. Review of the medical record indicated no documented evidence that a psychosocial assessment was completed upon admission or anytime thereafter. PCC indicated that a Psychosocial History and Assessment was 211 days overdue. Additionally, the medical record indicated no documented evidence that an individualized, person-centered care plan had been developed relative to psychosocial well-being, that included mood or Adjustment Disorder. [...]
- D
Assess the resident when there is a significant change in condition
Inspectors wroteBased on interview and record review, the facility failed to ensure its staff completed the necessary comprehensive Significant Change in Status Minimum Data Set assessment (SCSA MDS) for one Resident (#13) out of a total of 22 sampled residents.
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on interview and record review, the facility failed to ensure its staff completed a Level II Preadmission Screening and Resident Review (PASRR-evaluation done if it was determined by the Level I screen that a resident had an intellectual or developmental disability and/or serious mental illness and if resident was in need of additional support services at the facility) for one Resident 2 (#2) out of a total sample of 22 residents. Specifically, For Resident #2, facility staff failed to request a Level II PASRR evaluation when the Resident exceeded their 30-day convalescent care stay (time frame certified by a doctor indicating the Resident's stay will not exceed 30 days at the facility).
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on interview and record review, the facility failed to ensure its staff included two Residents (#29 and #191) and/or their representatives out of 22 sampled residents in the care planning process.
- D
Provide activities to meet all resident's needs.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure its staff provided activities designed to support the physical, mental, and psychosocial well-being for two Residents (#29 and#24) out of 22 sampled residents.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, and record review the facility failed to provide care and services for a BiPAP (Bi-level positive airway pressure machine capable of generating two adjustable pressure levels used for obstructive sleep apnea (OSA) and other breathing disorders to provide a person with continuous positive airway pressure) machine for one Resident (#241) out of 22 residents sampled.
- D
Provide care or services that was trauma informed and/or culturally competent.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure its staff completed a Trauma-Informed Care screening at the time of admission or after it was identified one Resident (#2) who had a diagnosis of Post-Traumatic Stress Disorder (PTSD-a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event) out of 22 sampled residents.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on interview and record review the facility failed to ensure staff documented if Resident's had consented to and received pneumococcal immunization or had received pneumococcal immunization due to medical contraindication or refusal for two Residents (#76 and #190) out of 5 sampled residents.
- D
Have policies on smoking.
Inspectors wroteBased on policy review, observation and interviews, the facility failed to ensure its staff implemented the facility smoking policy for one Resident (#142) out of a total of 22 residents sampled. Specifically, the facility staff failed to 1. obtain a Physician's Order allowing Resident #143 to smoke, and 2. maintain a safe smoking environment by ensuring a fire blanket was available in the smoking area.
Fire safety inspections
7 fire safety citations on file: 2 on December 9, 2025, 4 on August 22, 2024, 1 on May 4, 2023.
Every fire safety citation7 citations
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · December 9, 2025 · Corrected (the home has a date of correction)
- D
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · December 9, 2025 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · August 22, 2024 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 22, 2024 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · August 22, 2024 · Corrected (the home has a date of correction)
- D
Provide a written emergency evacuation plan.
K 711 · August 22, 2024 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 4, 2023 · Corrected (the home has a date of correction)