14 health deficiencies
Top issue: Resident Assessment and Care Planning (6 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Lexington, MA
0-star overall rating with 0-star inspections with Special Focus status with $241,047 in total fines with 14 recent health deficiencies
30 Watertown Street, Lexington, MA
(413) 693-3330
Overall
0 / 5
CMS overall stars
Health inspections
0 / 5
Survey and complaint cycles
Staffing
0 / 5
RN + nurse staffing
Quality measures
0 / 5
Resident outcomes and process measures
Quick facts
Beds
81
Certified beds
Average residents
69
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.82
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
0.58
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.00
Nurse aide staffing · state 2.26 · national 2.35
Total nurse hours
3.40
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.40
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.25
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.69
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.89
CMS adjusted RN staffing hours
Adjusted total hours
3.70
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
25%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
31%
Annual nurse turnover · state 40% · national 46%
SNF VBP
Program rank
6,755
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
31.80
Composite VBP score used to determine payment impact.
Payment multiplier
0.9867
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
5.79
Performance 40.00% · Measure score 5.79 · Achievement 5.79 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0.57
Baseline 3.33 hours · Performance 3.24 hours · Measure score 0.57 · Achievement 0.57 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.76% |
10.72%
1 pts worse
|
No Different than the National Rate · Eligible stays 40 · Observed rate 15% · Lower 95% interval 8.16% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 16 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.27 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 73.91% |
95.27%
21.4 pts worse
|
Numerator 17 · Denominator 23 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 23 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 8.7% |
2.29%
6.4 pts worse
|
Numerator 2 · Denominator 23 · Adjusted rate 6.39% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 15 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 13.04% |
8.2%
4.8 pts better
|
Numerator 9 · Denominator 69 |
| Staff flu vaccination coverage | 36.49% |
42%
5.5 pts worse
|
Numerator 27 · Denominator 74 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
1.9
0.3 pts worse
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 1.5 · Expected 1.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
1.5
0.2 pts better
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.0 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 73.2% |
92.2%
19 pts worse
|
93.4%
20.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 79.7% · Q2 84.2% · Q3 72.3% · Q4 58.8% · 4Q avg 73.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 81.0% |
94.8%
13.8 pts worse
|
95.5%
14.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 81.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.8% |
3.5%
0.7 pts better
|
3.3%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 0.0% · Q3 3.1% · Q4 4.4% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
12.0%
12 pts better
|
11.4%
11.4 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 who lose too much weight | 2.8% |
5.2%
2.4 pts better
|
5.4%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.1% · Q3 5.8% · Q4 3.4% · 4Q avg 2.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.4% |
19.2%
3.8 pts better
|
19.6%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.0% · Q2 16.0% · Q3 20.3% · Q4 11.5% · 4Q avg 15.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 42.0% |
22.5%
19.5 pts worse
|
16.7%
25.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 51.3% · Q2 39.4% · Q3 39.0% · Q4 38.6% · 4Q avg 42.0% · 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 | 11.5% |
17.7%
6.2 pts better
|
16.3%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.4% · Q2 13.6% · Q3 3.6% · Q4 9.9% · 4Q avg 11.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.5% |
17.6%
5.1 pts better
|
14.9%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.6% · Q2 13.6% · Q3 5.9% · Q4 11.1% · 4Q avg 12.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
1.0%
0.7 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.2% |
2.0%
0.8 pts better
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.7% · Q4 3.1% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 8.8% |
21.7%
12.9 pts better
|
19.8%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.7% · Q2 9.2% · Q3 6.4% · Q4 5.6% · 4Q avg 8.8% |
| Percentage of long-stay residents with pressure ulcers | 5.3% |
4.6%
0.7 pts worse
|
5.1%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 3.9% · Q3 4.9% · Q4 8.0% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 27.9% |
77.1%
49.2 pts worse
|
81.7%
53.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 27.9% |
Survey summary
Top issue: Resident Assessment and Care Planning (6 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Top issue: Quality of Life and Care (8 deficiencies)
6 fire-safety deficiencies
Top issue: Emergency Preparedness (6 deficiencies)
Top issue: Quality of Life and Care (9 deficiencies)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Fire safety
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2024-10-29
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2024-10-31
Fire Safety
Provide emergency officials' contact information.
Corrected 2024-10-30
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-10-30
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-10-29
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-10-31
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2023-09-28
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-09-28
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-09-28
Inspection history
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2025-09-25
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-09-25
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-09-25
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-09-25
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-09-25
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 2025-09-25
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2025-09-25
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2025-09-25
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2025-09-25
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2025-09-25
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-09-26
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2025-09-25
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2025-09-25
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-09-25
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-10-23
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-10-23
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 2024-10-23
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2024-10-23
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-10-24
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-10-23
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-10-23
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-10-22
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2024-10-22
Health
Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
Corrected 2024-10-22
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-10-22
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2024-10-23
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-23
Health
Implement a program that monitors antibiotic use.
Corrected 2024-11-15
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2024-11-15
Health
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Corrected 2024-10-23
Health
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
Corrected 2024-10-23
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-10-22
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-11-15
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 2024-11-15
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2024-10-22
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-10-22
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 2024-10-22
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 2024-10-22
Health
Assess the resident when there is a significant change in condition
Corrected 2024-11-15
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-10-22
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-11-15
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-10-23
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-10-23
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-10-22
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 2024-10-23
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2024-10-23
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 2024-11-15
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2024-10-22
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-10-23
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 2023-10-13
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-10-15
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-10-13
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-10-15
Health
Provide activities to meet all resident's needs.
Corrected 2023-09-21
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-09-21
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 2023-10-13
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2023-09-21
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-09-21
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2023-09-21
Health
Respond appropriately to all alleged violations.
Corrected 2023-09-21
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-09-21
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-09-21
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2023-09-21
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-10-15
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2023-09-21
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 2023-09-21
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 2023-11-03
Health
Provide or obtain dental services for each resident.
Corrected 2023-09-21
Health
Provide or get specialized rehabilitative services as required for a resident.
Corrected 2023-09-21
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-09-21
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-21
Health
Implement a program that monitors antibiotic use.
Corrected 2023-10-13
Penalties and ownership
Fine · fine $219,077
Fine
Fine · fine $21,970
Fine
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Nearby options
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Arlington, MA
1-star overall rating with 1-star inspections with $113,612 in total fines with 17 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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