Weymouth, MA

Pope Nursing Home

2-star overall rating with 2-star inspections with 14 recent health deficiencies with 22 fire-safety deficiencies in the latest cycle

140 Webb Street, Weymouth, MA

(781) 335-4352

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

4 / 5

RN + nurse staffing

Quality measures

2 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Rehabilitation Associates

Operator or chain grouping

Approved since

1994-03-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Staffing

Hours and turnover

RN hours / resident day

0.50

Registered nurse staffing

LPN hours / resident day

0.94

Licensed practical nurse staffing

Aide hours / resident day

2.37

Nurse aide staffing

Weekend hours

3.41

Weekend nurse staffing

RN turnover

50%

Annual RN turnover

Total nurse turnover

30%

Annual nurse turnover

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.4	1.9 0.5 pts better	1.9 0.5 pts better	Long Stay · 20240701-20250630
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
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	97.3%	92.2% 5.1 pts better	93.4% 3.9 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	94.9%	94.8% 0.1 pts better	95.5% 0.6 pts worse	Long Stay · 2024Q3-2025Q2
Percentage of long-stay residents experiencing one or more falls with major injury	7.3%	3.5% 3.8 pts worse	3.3% 4 pts worse	Long Stay · 2024Q4-2025Q3
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
Percentage of long-stay residents who lose too much weight	4.2%	5.2% 1 pts better	5.4% 1.2 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antianxiety or hypnotic medication	19.8%	19.2% 0.6 pts worse	19.6% 0.2 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antipsychotic medication	29.3%	22.5% 6.8 pts worse	16.7% 12.6 pts worse	Long Stay · 2024Q4-2025Q3
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
Percentage of long-stay residents whose ability to walk independently worsened	24.2%	17.7% 6.5 pts worse	16.3% 7.9 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose need for help with daily activities has increased	31.0%	17.6% 13.4 pts worse	14.9% 16.1 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a catheter inserted and left in their bladder	2.9%	1.0% 1.9 pts worse	1.0% 1.9 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a urinary tract infection	4.2%	2.0% 2.2 pts worse	1.7% 2.5 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	15.6%	21.7% 6.1 pts better	19.8% 4.2 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with pressure ulcers	7.6%	4.6% 3 pts worse	5.1% 2.5 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	78.7%	77.1% 1.6 pts better	81.7% 3 pts worse	Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who had an outpatient emergency department visit	0.0%	11.8% 11.8 pts better	12.0% 12 pts better	Short Stay · 20240701-20250630
Percentage of short-stay residents who newly received an antipsychotic medication	8.7%	1.3% 7.4 pts worse	1.6% 7.1 pts worse	Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	65.0%	77.7% 12.7 pts worse	79.7% 14.7 pts worse	Short Stay · 2024Q3-2025Q2
Percentage of short-stay residents who were rehospitalized after a nursing home admission	9.5%	25.8% 16.3 pts better	23.9% 14.4 pts better	Short Stay · 20240701-20250630

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-04-22 · Fire 2025-04-22

14 health deficiencies

Top issue: Nursing and Physician Services (3 deficiencies)

22 fire-safety deficiencies

Top issue: Emergency Preparedness (9 deficiencies)

Cycle 2 Health 2024-04-02 · Fire 2024-04-02

2 health deficiencies

Top issue: Quality of Life and Care (1 deficiency)

12 fire-safety deficiencies

Top issue: Egress (6 deficiencies)

Cycle 3 Health 2022-12-02 · Fire 2022-12-02

7 health deficiencies

Top issue: Resident Rights (5 deficiencies)

13 fire-safety deficiencies

Top issue: Egress (5 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-04-22

E18 · Emergency Preparedness Deficiencies

Fire Safety

Establish procedures for tracking staff and patients during an emergency.

Corrected 2025-06-13

F · Potential for more than minimal harm 2025-04-22

E20 · Emergency Preparedness Deficiencies

Fire Safety

Establish policies and procedures including evacuation.

Corrected 2025-06-13

F · Potential for more than minimal harm 2025-04-22

E22 · Emergency Preparedness Deficiencies

Fire Safety

Establish policies and procedures for sheltering.

Corrected 2025-06-13

F · Potential for more than minimal harm 2025-04-22

E36 · Emergency Preparedness Deficiencies

Fire Safety

Establish emergency prep training and testing.

Corrected 2025-06-13

F · Potential for more than minimal harm 2025-04-22

E37 · Emergency Preparedness Deficiencies

Fire Safety

Establish staff and initial training requirements.

Corrected 2025-06-13

F · Potential for more than minimal harm 2025-04-22

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2025-06-13

F · Potential for more than minimal harm 2025-04-22

E6 · Emergency Preparedness Deficiencies

Fire Safety

Conduct risk assessment and an All-Hazards approach.

Corrected 2025-06-13

F · Potential for more than minimal harm 2025-04-22

E7 · Emergency Preparedness Deficiencies

Fire Safety

Address patient/client population and determine types of services needed.

Corrected 2025-06-13

F · Potential for more than minimal harm 2025-04-22

E9 · Emergency Preparedness Deficiencies

Fire Safety

Include a process for Emergency Preparedness collaboration.

Corrected 2025-06-13

F · Potential for more than minimal harm 2025-04-22

K161 · Construction Deficiencies

Fire Safety

Use approved construction type or materials.

Corrected 2025-05-01

F · Potential for more than minimal harm 2025-04-22

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 2025-05-01

F · Potential for more than minimal harm 2025-04-22

K311 · Smoke Deficiencies

Fire Safety

Have an enclosure around a vertical opening shaft.

Corrected 2025-05-01

F · Potential for more than minimal harm 2025-04-22

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2025-05-05

F · Potential for more than minimal harm 2025-04-22

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-05-16

F · Potential for more than minimal harm 2025-04-22

K711 · Miscellaneous Deficiencies

Fire Safety

Provide a written emergency evacuation plan.

Corrected 2025-05-05

F · Potential for more than minimal harm 2025-04-22

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2025-05-17

E · Potential for more than minimal harm 2025-04-22

K225 · Egress Deficiencies

Fire Safety

Have stairways and smokeproof enclosures used as exits that meet safety requirements.

Corrected 2025-05-01

E · Potential for more than minimal harm 2025-04-22

K232 · Egress Deficiencies

Fire Safety

Have corridors or aisles that are unobstructed and are at least 8 feet in width.

Corrected 2025-05-01

E · Potential for more than minimal harm 2025-04-22

K241 · Egress Deficiencies

Fire Safety

Have correct number of accessible exits for each story.

Corrected 2025-05-01

E · Potential for more than minimal harm 2025-04-22

K271 · Egress Deficiencies

Fire Safety

Have exits that are accessible at all times.

Corrected 2025-05-01

E · Potential for more than minimal harm 2025-04-22

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2025-05-27

C · Minimal harm 2025-04-22

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2025-05-29

F · Potential for more than minimal harm 2024-04-02

K161 · Construction Deficiencies

Fire Safety

Use approved construction type or materials.

Corrected 2024-06-05

F · Potential for more than minimal harm 2024-04-02

K311 · Smoke Deficiencies

Fire Safety

Have an enclosure around a vertical opening shaft.

Corrected 2024-06-05

F · Potential for more than minimal harm 2024-04-02

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2024-05-22

E · Potential for more than minimal harm 2024-04-02

K225 · Egress Deficiencies

Fire Safety

Have stairways and smokeproof enclosures used as exits that meet safety requirements.

Corrected 2024-06-05

E · Potential for more than minimal harm 2024-04-02

K232 · Egress Deficiencies

Fire Safety

Have corridors or aisles that are unobstructed and are at least 8 feet in width.

Corrected 2024-06-05

E · Potential for more than minimal harm 2024-04-02

K241 · Egress Deficiencies

Fire Safety

Have correct number of accessible exits for each story.

Corrected 2024-06-05

E · Potential for more than minimal harm 2024-04-02

K271 · Egress Deficiencies

Fire Safety

Have exits that are accessible at all times.

Corrected 2024-06-05

E · Potential for more than minimal harm 2024-04-02

K300 · Egress Deficiencies

Fire Safety

Meet other general requirements that are deficient.

Corrected 2024-05-02

E · Potential for more than minimal harm 2024-04-02

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2024-05-10

E · Potential for more than minimal harm 2024-04-02

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-05-29

E · Potential for more than minimal harm 2024-04-02

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-05-22

D · Potential for more than minimal harm 2024-04-02

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2024-05-10

F · Potential for more than minimal harm 2022-12-02

K161 · Construction Deficiencies

Fire Safety

Use approved construction type or materials.

Corrected 2023-01-10

F · Potential for more than minimal harm 2022-12-02

K311 · Smoke Deficiencies

Fire Safety

Have an enclosure around a vertical opening shaft.

Corrected 2023-01-10

E · Potential for more than minimal harm 2022-12-02

E41 · Emergency Preparedness Deficiencies

Fire Safety

Implement emergency and standby power systems.

Corrected 2022-12-20

E · Potential for more than minimal harm 2022-12-02

K225 · Egress Deficiencies

Fire Safety

Have stairways and smokeproof enclosures used as exits that meet safety requirements.

Corrected 2023-01-10

E · Potential for more than minimal harm 2022-12-02

K232 · Egress Deficiencies

Fire Safety

Have corridors or aisles that are unobstructed and are at least 8 feet in width.

Corrected 2023-01-10

E · Potential for more than minimal harm 2022-12-02

K241 · Egress Deficiencies

Fire Safety

Have correct number of accessible exits for each story.

Corrected 2023-01-10

E · Potential for more than minimal harm 2022-12-02

K271 · Egress Deficiencies

Fire Safety

Have exits that are accessible at all times.

Corrected 2023-01-10

E · Potential for more than minimal harm 2022-12-02

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2022-12-31

E · Potential for more than minimal harm 2022-12-02

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2022-12-20

D · Potential for more than minimal harm 2022-12-02

E20 · Emergency Preparedness Deficiencies

Fire Safety

Establish policies and procedures including evacuation.

Corrected 2022-12-21

D · Potential for more than minimal harm 2022-12-02

E4 · Emergency Preparedness Deficiencies

Fire Safety

Develop and maintain an Emergency Preparedness Program (EP).

Corrected 2022-12-21

D · Potential for more than minimal harm 2022-12-02

K223 · Egress Deficiencies

Fire Safety

Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

Corrected 2022-12-31

D · Potential for more than minimal harm 2022-12-02

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2022-12-31

Inspection history

Recent health citations

F · Potential for more than minimal harm 2025-04-22

F801 · Nutrition and Dietary Deficiencies

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 2025-05-13

F · Potential for more than minimal harm 2025-04-22

F838 · Administration Deficiencies

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 2025-05-22

E · Potential for more than minimal harm 2025-04-22

F694 · Quality of Life and Care Deficiencies

Health

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Corrected 2025-05-20

E · Potential for more than minimal harm 2025-04-22

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 2025-06-05

E · Potential for more than minimal harm 2025-04-22

F727 · Nursing and Physician Services Deficiencies

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 2025-04-30

E · Potential for more than minimal harm 2025-04-22

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 2025-05-20

E · Potential for more than minimal harm 2025-04-22

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2025-06-06

E · Potential for more than minimal harm 2025-04-22

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-05-25

E · Potential for more than minimal harm 2025-04-22

F947 · Nursing and Physician Services Deficiencies

Health

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Corrected 2025-05-25

D · Potential for more than minimal harm 2025-04-22

F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Corrected 2025-05-20

D · Potential for more than minimal harm 2025-04-22

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2025-05-20

D · Potential for more than minimal harm 2025-04-22

F699 · Quality of Life and Care Deficiencies

Health

Provide care or services that was trauma informed and/or culturally competent.

Corrected 2025-05-20

D · Potential for more than minimal harm 2025-04-22

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 2025-05-30

D · Potential for more than minimal harm 2025-04-22

F814 · Nutrition and Dietary Deficiencies

Health

Dispose of garbage and refuse properly.

Corrected 2025-06-06

E · Potential for more than minimal harm 2024-04-02

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 2024-04-22

E · Potential for more than minimal harm 2024-04-02

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 2024-04-22

E · Potential for more than minimal harm 2022-12-02

F567 · Resident Rights Deficiencies

Health

Honor the resident's right to manage his or her financial affairs.

Corrected 2022-12-05

E · Potential for more than minimal harm 2022-12-02

F568 · Resident Rights Deficiencies

Health

Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.

Corrected 2022-12-05

E · Potential for more than minimal harm 2022-12-02

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2022-12-06

D · Potential for more than minimal harm 2022-12-02

F551 · Resident Rights Deficiencies

Health

Give the resident's representative the ability to exercise the resident's rights.

Corrected 2023-01-05

D · Potential for more than minimal harm 2022-12-02

F552 · Resident Rights Deficiencies

Health

Ensure that residents are fully informed and understand their health status, care and treatments.

Corrected 2023-01-05

D · Potential for more than minimal harm 2022-12-02

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 2022-12-05

D · Potential for more than minimal harm 2022-12-02

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 2022-12-05

Penalties and ownership