Cycle 1
Health 2024-11-05 · Fire 2024-11-05
24 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
12 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Reading, MA
OC Reading Center LLC
1-star overall rating with 1-star inspections with Special Focus status with $54,360 in total fines with 24 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
1364 Main Street, Reading, MA
(781) 942-1210
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
123
Certified beds
Average residents
67
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Azure Healthcare
Operator or chain grouping
Approved since
1990-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
6 facilities
Chain averages 1 overall / 1 health / 2 staffing / 2 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
Hours and turnover
RN hours / resident day
0.44
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.23
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.47
Nurse aide staffing · state 2.26 · national 2.35
Total nurse hours
4.15
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.67
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.67
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.25
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.44
CMS adjusted RN staffing hours
Adjusted total hours
4.16
CMS adjusted total nurse staffing hours
Case-mix index
1.36
Higher values indicate more complex resident acuity
RN turnover
93%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
57%
Annual nurse turnover · state 40% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,054
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
21.59
Composite VBP score used to determine payment impact.
Payment multiplier
0.9827
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.07% · Performance 22.18% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
2.76
Baseline 6.08% · Performance 7.01% · Measure score 2.76 · Achievement 2.76 · Improvement 0
Total nurse turnover
3.52
Baseline 58.90% · Performance 49.28% · Measure score 3.52 · Achievement 3.52 · Improvement 2.33
Adjusted total nurse staffing
2.36
Baseline 3.07 hours · Performance 3.75 hours · Measure score 2.36 · Achievement 2.36 · Improvement 1.99
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.7% |
10.72%
1 pts worse
|
No Different than the National Rate · Eligible stays 78 · Observed rate 16.67% · Lower 95% interval 8.14% |
| Discharge to community | 48.51% |
50.57%
2.1 pts worse
|
No Different than the National Rate · Eligible stays 64 · Observed rate 39.06% · Lower 95% interval 35.33% |
| Medicare spending per beneficiary | 0.9 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 59 · Denominator 59 |
| Falls with major injury | 1.69% |
0.77%
0.9 pts worse
|
Numerator 1 · Denominator 59 |
| Discharge self-care score | 30.3% |
53.69%
23.4 pts worse
|
Numerator 10 · Denominator 33 |
| Discharge mobility score | 30.3% |
50.94%
20.6 pts worse
|
Numerator 10 · Denominator 33 |
| Pressure ulcers or injuries, new or worsened | 5.08% |
2.29%
2.8 pts worse
|
Numerator 3 · Denominator 59 · Adjusted rate 4.92% |
| Healthcare-associated infections requiring hospitalization | 7.01% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 45 · Observed rate 6.67% · Lower 95% interval 3.8% |
| Staff COVID-19 vaccination coverage | 21.84% |
8.2%
13.6 pts better
|
Numerator 19 · Denominator 87 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 48.48% |
56.45%
8 pts worse
|
Numerator 16 · Denominator 33 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 25 · Denominator 25 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 68.97% |
25.2%
43.8 pts better
|
Numerator 20 · Denominator 29 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.3 |
1.9
0.4 pts worse
|
1.9
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 4.4 · Expected 3.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 4.9 |
1.5
3.4 pts worse
|
1.8
3.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 4.9 · Observed 7.6 · Expected 2.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 88.8% |
92.2%
3.4 pts worse
|
93.4%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 89.2% · Q2 91.7% · Q3 93.4% · Q4 81.0% · 4Q avg 88.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 84.6% |
94.8%
10.2 pts worse
|
95.5%
10.9 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 84.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.8% |
3.5%
2.7 pts better
|
3.3%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.7% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · 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 1.9% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% |
| Percentage of long-stay residents who lose too much weight | 3.5% |
5.2%
1.7 pts better
|
5.4%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 0.0% · Q3 2.0% · Q4 6.4% · 4Q avg 3.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 30.2% |
19.2%
11 pts worse
|
19.6%
10.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.9% · Q2 24.5% · Q3 38.0% · Q4 33.3% · 4Q avg 30.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 27.8% |
22.5%
5.3 pts worse
|
16.7%
11.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.5% · Q2 23.5% · Q3 31.6% · Q4 31.7% · 4Q avg 27.8% · 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 | 14.2% |
17.7%
3.5 pts better
|
16.3%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.4% · Q3 15.8% · Q4 12.6% · 4Q avg 14.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.7% |
17.6%
1.9 pts better
|
14.9%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 15.7% · Q3 12.5% · Q4 20.4% · 4Q avg 15.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
1.0%
0.5 pts better
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.3% · Q3 0.0% · Q4 0.9% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.5% |
2.0%
0.5 pts worse
|
1.7%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.5% · Q3 5.0% · Q4 0.0% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.7% |
21.7%
4 pts worse
|
19.8%
5.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.0% · Q2 18.0% · Q3 23.2% · Q4 33.8% · 4Q avg 25.7% |
| Percentage of long-stay residents with pressure ulcers | 15.1% |
4.6%
10.5 pts worse
|
5.1%
10 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.7% · Q2 13.6% · Q3 16.3% · Q4 15.7% · 4Q avg 15.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 75.3% |
77.1%
1.8 pts worse
|
81.7%
6.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 89.5% · Q2 72.7% · Q3 68.4% · Q4 71.4% · 4Q avg 75.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.8% |
11.8%
2 pts worse
|
12.0%
1.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.8% · Observed 15.8% · Expected 12.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.3%
0.2 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 4.8% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 47.7% |
77.7%
30 pts worse
|
79.7%
32 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 47.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 30.5% |
25.8%
4.7 pts worse
|
23.9%
6.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 30.5% · Observed 42.1% · Expected 32.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-13 · Fire 2023-10-13
19 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2022-09-02 · Fire 2022-09-02
13 health deficiencies
Top issue: Infection Control (3 deficiencies)
7 fire-safety deficiencies
Top issue: Miscellaneous (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-11-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-01-02
F · Potential for more than minimal harm
2024-11-05
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-01-02
F · Potential for more than minimal harm
2024-11-05
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2025-01-02
F · Potential for more than minimal harm
2024-11-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-01-02
E · Potential for more than minimal harm
2024-11-05
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2025-01-02
E · Potential for more than minimal harm
2024-11-05
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-01-02
E · Potential for more than minimal harm
2024-11-05
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2025-01-02
E · Potential for more than minimal harm
2024-11-05
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2025-01-02
E · Potential for more than minimal harm
2024-11-05
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2025-01-02
E · Potential for more than minimal harm
2024-11-05
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-01-02
E · Potential for more than minimal harm
2024-11-05
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-01-02
E · Potential for more than minimal harm
2024-11-05
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-01-02
F · Potential for more than minimal harm
2023-10-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-11-17
F · Potential for more than minimal harm
2023-10-13
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-11-17
F · Potential for more than minimal harm
2023-10-13
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-12-05
D · Potential for more than minimal harm
2023-10-13
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2023-11-17
D · Potential for more than minimal harm
2023-10-13
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-11-17
D · Potential for more than minimal harm
2023-10-13
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-12-17
F · Potential for more than minimal harm
2022-09-02
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-11-05
F · Potential for more than minimal harm
2022-09-02
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2022-11-05
F · Potential for more than minimal harm
2022-09-02
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2022-11-05
F · Potential for more than minimal harm
2022-09-02
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-11-05
F · Potential for more than minimal harm
2022-09-02
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-11-05
F · Potential for more than minimal harm
2022-09-02
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-11-05
E · Potential for more than minimal harm
2022-09-02
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2022-11-05
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-14
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2025-12-13
D · Potential for more than minimal harm
2025-07-30
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2025-08-31
D · Potential for more than minimal harm
2025-07-30
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2025-08-31
J · Immediate jeopardy
2024-11-05
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2024-12-05
J · Immediate jeopardy
2024-11-05
F742 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Corrected 2024-12-05
G · Actual harm
2024-11-05
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-12-05
G · Actual harm
2024-11-05
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-12-05
E · Potential for more than minimal harm
2024-11-05
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2024-12-05
D · Potential for more than minimal harm
2024-11-05
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-12-05
D · Potential for more than minimal harm
2024-11-05
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-12-05
D · Potential for more than minimal harm
2024-11-05
F585 · Resident Rights Deficiencies
Health
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.
Corrected 2024-12-05
D · Potential for more than minimal harm
2024-11-05
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-12-05
D · Potential for more than minimal harm
2024-11-05
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-12-05
D · Potential for more than minimal harm
2024-11-05
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-12-05
D · Potential for more than minimal harm
2024-11-05
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-12-05
D · Potential for more than minimal harm
2024-11-05
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2024-12-05
D · Potential for more than minimal harm
2024-11-05
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-12-05
D · Potential for more than minimal harm
2024-11-05
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-12-31
D · Potential for more than minimal harm
2024-11-05
F756 · Pharmacy Service Deficiencies
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 2024-12-05
D · Potential for more than minimal harm
2024-11-05
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-12-31
D · Potential for more than minimal harm
2024-11-05
F761 · Pharmacy Service Deficiencies
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 2024-12-31
D · Potential for more than minimal harm
2024-11-05
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-12-05
D · Potential for more than minimal harm
2024-11-05
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2024-12-05
D · Potential for more than minimal harm
2024-11-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-05
E · Potential for more than minimal harm
2024-09-11
F559 · Resident Rights Deficiencies
Health
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Corrected 2024-10-22
E · Potential for more than minimal harm
2023-10-13
F761 · Pharmacy Service Deficiencies
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 2023-11-16
D · Potential for more than minimal harm
2023-10-13
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-11-16
D · Potential for more than minimal harm
2023-10-13
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-11-16
D · Potential for more than minimal harm
2023-10-13
F578 · Resident Rights Deficiencies
Health
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.
Corrected 2023-11-16
D · Potential for more than minimal harm
2023-10-13
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-11-16
D · Potential for more than minimal harm
2023-10-13
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-11-16
D · Potential for more than minimal harm
2023-10-13
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2023-11-16
D · Potential for more than minimal harm
2023-10-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-16
D · Potential for more than minimal harm
2023-10-13
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2023-11-16
D · Potential for more than minimal harm
2023-10-13
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-11-16
D · Potential for more than minimal harm
2023-10-13
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-11-16
D · Potential for more than minimal harm
2023-10-13
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-11-16
D · Potential for more than minimal harm
2023-10-13
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-11-16
D · Potential for more than minimal harm
2023-10-13
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2023-11-16
D · Potential for more than minimal harm
2023-10-13
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-11-16
D · Potential for more than minimal harm
2023-10-13
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-11-16
D · Potential for more than minimal harm
2023-10-13
F808 · Nutrition and Dietary Deficiencies
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2023-11-16
B · Minimal harm
2023-10-13
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-11-16
D · Potential for more than minimal harm
2023-07-17
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-08-14
D · Potential for more than minimal harm
2023-07-17
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2023-08-14
E · Potential for more than minimal harm
2022-09-02
F584 · Resident Rights Deficiencies
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 2022-10-24
E · Potential for more than minimal harm
2022-09-02
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-10-24
D · Potential for more than minimal harm
2022-09-02
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2022-10-24
D · Potential for more than minimal harm
2022-09-02
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2022-10-24
D · Potential for more than minimal harm
2022-09-02
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2022-10-24
D · Potential for more than minimal harm
2022-09-02
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2022-10-24
D · Potential for more than minimal harm
2022-09-02
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-10-24
D · Potential for more than minimal harm
2022-09-02
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2022-10-24
D · Potential for more than minimal harm
2022-09-02
F761 · Pharmacy Service Deficiencies
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 2022-10-24
D · Potential for more than minimal harm
2022-09-02
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2022-10-24
D · Potential for more than minimal harm
2022-09-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-10-24
Penalties and ownership
What sits behind the stars
$54,360
2024-11-05
Fine
Fine · fine $54,360
Fine
Ownership
Bear Mountain Healthcare LLC
5% Or Greater Direct Ownership Interest · Organization
Doyle, Thomas
5% Or Greater Direct Ownership Interest · Individual
Doyle, Thomas
Corporate Officer · Individual
Katz, Michelle
W-2 Managing Employee · Individual
Wynne, John
5% Or Greater Direct Ownership Interest · Individual
Wynne, John
Corporate Officer · Individual
Ziskin, Scott
5% Or Greater Direct Ownership Interest · Individual
Ziskin, Scott
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Willow Brook Rehabilitation And Healthcare Center
Wilmington, MA
2-star overall rating with 2-star inspections with abuse icon flag with $15,935 in total fines with 12 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#2
Royal Meadow View Center
North Reading, MA
2-star overall rating with 2-star inspections with 13 recent health deficiencies with 16 fire-safety deficiencies in the latest cycle
#3
Care One At Wilmington
Wilmington, MA
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
Jump out