9 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
West Roxbury, MA
3-star overall rating with 3-star inspections with $3,418 in total fines with 9 recent health deficiencies
5060 Washington Street, West Roxbury, MA
(617) 323-5440
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Beds
76
Certified beds
Average residents
63
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Bear Mountain Healthcare
Operator or chain grouping
Approved since
1990-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
8 facilities
Chain averages 3 overall / 3 health / 3 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
RN hours / resident day
0.97
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
0.59
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
1.82
Nurse aide staffing · state 2.26 · national 2.35
Total nurse hours
3.38
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.56
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.10
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.77
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
1.04
CMS adjusted RN staffing hours
Adjusted total hours
3.61
CMS adjusted total nurse staffing hours
Case-mix index
1.28
Higher values indicate more complex resident acuity
RN turnover
31%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
23%
Annual nurse turnover · state 40% · national 46%
SNF VBP
Program rank
931
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
61.99
Composite VBP score used to determine payment impact.
Payment multiplier
1.0170
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
10
Baseline 22.73% · Performance 11.91% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
2.40
Baseline 3.36 hours · Performance 3.76 hours · Measure score 2.40 · Achievement 2.40 · Improvement 1.17
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.17% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 40 · Observed rate 7.5% · Lower 95% interval 6.97% |
| Discharge to community | 58.64% |
50.57%
8.1 pts better
|
No Different than the National Rate · Eligible stays 28 · Observed rate 53.57% · Lower 95% interval 43.35% |
| Medicare spending per beneficiary | 1.22 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 43 · Denominator 43 |
| Falls with major injury | 4.65% |
0.77%
3.9 pts worse
|
Numerator 2 · Denominator 43 |
| Discharge self-care score | 34.62% |
53.69%
19.1 pts worse
|
Numerator 9 · Denominator 26 |
| Discharge mobility score | 26.92% |
50.94%
24 pts worse
|
Numerator 7 · Denominator 26 |
| Pressure ulcers or injuries, new or worsened | 2.33% |
2.29%
About the same
|
Numerator 1 · Denominator 43 · Adjusted rate 2.02% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 22 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 13.7% |
8.2%
5.5 pts better
|
Numerator 10 · Denominator 73 |
| Staff flu vaccination coverage | 39.81% |
42%
2.2 pts worse
|
Numerator 41 · Denominator 103 |
| Discharge function score | 26.92% |
56.45%
29.5 pts worse
|
Numerator 7 · Denominator 26 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 50% |
25.2%
24.8 pts better
|
Numerator 11 · Denominator 22 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.1 |
1.9
1.2 pts worse
|
1.9
1.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.1 · Observed 3.2 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
1.5
0.7 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.8 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 71.9% |
92.2%
20.3 pts worse
|
93.4%
21.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 58.9% · Q2 55.0% · Q3 81.0% · Q4 91.8% · 4Q avg 71.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 92.2% |
94.8%
2.6 pts worse
|
95.5%
3.3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 92.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.3% |
3.5%
2.2 pts better
|
3.3%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 0.0% · Q3 1.7% · Q4 1.6% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.5% |
12.0%
11.5 pts better
|
11.4%
10.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.9% · Q4 0.0% · 4Q avg 0.5% |
| Percentage of long-stay residents who lose too much weight | 2.8% |
5.2%
2.4 pts better
|
5.4%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 3.8% · Q3 1.9% · Q4 3.7% · 4Q avg 2.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.3% |
19.2%
4.9 pts better
|
19.6%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.9% · Q2 11.7% · Q3 14.0% · Q4 14.0% · 4Q avg 14.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.5% |
22.5%
3 pts better
|
16.7%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.7% · Q2 16.3% · Q3 20.5% · Q4 16.7% · 4Q avg 19.5% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 16.0% |
17.7%
1.7 pts better
|
16.3%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 25.6% · Q2 21.5% · Q3 12.1% · Q4 3.7% · 4Q avg 16.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.0% |
17.6%
5.4 pts worse
|
14.9%
8.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.0% · Q2 29.2% · Q3 24.5% · Q4 10.2% · 4Q avg 23.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.6% |
1.0%
1.6 pts worse
|
1.0%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 3.8% · Q3 3.8% · Q4 1.4% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.3% |
2.0%
0.3 pts worse
|
1.7%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 3.8% · Q3 0.0% · Q4 3.4% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 5.6% |
21.7%
16.1 pts better
|
19.8%
14.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 4.2% · Q3 5.5% · Q4 8.8% · 4Q avg 5.6% |
| Percentage of long-stay residents with pressure ulcers | 4.2% |
4.6%
0.4 pts better
|
5.1%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 3.9% · Q3 1.9% · Q4 5.6% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 51.9% |
77.1%
25.2 pts worse
|
81.7%
29.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 61.0% · Q2 50.0% · Q3 37.9% · Q4 56.0% · 4Q avg 51.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.5% |
11.8%
5.3 pts better
|
12.0%
5.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.5% · Observed 7.9% · Expected 13.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 5.5% |
1.3%
4.2 pts worse
|
1.6%
3.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 8.3% · 4Q avg 5.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 78.9% |
77.7%
1.2 pts better
|
79.7%
0.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 78.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.4% |
25.8%
2.6 pts worse
|
23.9%
4.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.4% · Observed 34.2% · Expected 28.7% · Used in QM five-star |
Survey summary
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Top issue: Resident Rights (4 deficiencies)
13 fire-safety deficiencies
Top issue: Emergency Preparedness (5 deficiencies)
Top issue: Quality of Life and Care (8 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-01-09
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-01-09
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-01-09
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-01-09
Fire Safety
Have a properly installed and maintained dumbwaiter or escalator.
Corrected 2025-01-09
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-01-09
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2025-01-09
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2025-01-09
Fire Safety
Provide a means of sharing information on occupancy/needs.
Corrected 2025-01-09
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-01-09
Fire Safety
Implement emergency and standby power systems.
Corrected 2025-01-09
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-01-09
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-01-09
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-12-20
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-12-31
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-12-15
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-12-22
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-12-18
Inspection history
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-12-12
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-12-12
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2025-12-12
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-12-12
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-12-12
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2025-12-12
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2025-12-12
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2025-12-12
Health
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.
Corrected 2025-12-12
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-12-06
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-12-06
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-12-06
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-12-06
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-12-06
Health
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.
Corrected 2024-12-06
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-12-06
Health
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.
Corrected 2024-12-06
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-12-06
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-12-06
Health
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.
Corrected 2024-09-06
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2024-07-12
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2024-07-27
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-07-27
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-06-05
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-12-16
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-12-16
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2023-12-16
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-16
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-12-16
Health
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.
Corrected 2023-12-16
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-12-16
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-12-16
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-12-16
Health
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.
Corrected 2023-12-16
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-12-16
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-12-16
Health
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.
Corrected 2023-12-16
Health
Provide or obtain dental services for each resident.
Corrected 2023-12-16
Penalties and ownership
Fine · fine $3,418
Fine
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Organization
Corporate Officer · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
5% Or Greater Security Interest · Organization
Corporate Officer · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Nearby options
Boston, MA
5-star overall rating with 4-star inspections with 3 fire-safety deficiencies in the latest cycle
Boston, MA
1-star overall rating with 1-star inspections with $187,199 in total fines with 30 recent health deficiencies with 16 fire-safety deficiencies in the latest cycle
Dedham, MA
5-star overall rating with 5-star inspections with 1 fire-safety deficiencies in the latest cycle
Jump out