Cycle 1
Health 2025-01-31 · Fire 2025-01-31
13 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
16 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
North Reading, MA
Royal Meadow View Center
2-star overall rating with 2-star inspections with 13 recent health deficiencies with 16 fire-safety deficiencies in the latest cycle
134 North Street, North Reading, MA
(978) 276-2000
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
113
Certified beds
Average residents
96
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Royal Health Group
Operator or chain grouping
Approved since
1990-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
12 facilities
Chain averages 3 overall / 3 health / 2 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
Hours and turnover
RN hours / resident day
0.59
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
0.91
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
1.80
Nurse aide staffing · state 2.26 · national 2.35
Total nurse hours
3.30
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.49
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
2.90
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.41
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.57
CMS adjusted RN staffing hours
Adjusted total hours
3.20
CMS adjusted total nurse staffing hours
Case-mix index
1.41
Higher values indicate more complex resident acuity
RN turnover
65%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
54%
Annual nurse turnover · state 40% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,984
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
34.37
Composite VBP score used to determine payment impact.
Payment multiplier
0.9883
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.78
Baseline 24.71% · Performance 21.42% · Measure score 3.78 · Achievement 0 · Improvement 3.78
Healthcare-associated infections
4.63
Baseline 7.30% · Performance 6.45% · Measure score 4.63 · Achievement 4.63 · Improvement 3.19
Total nurse turnover
4.46
Baseline 45.33% · Performance 45.45% · Measure score 4.46 · Achievement 4.46 · Improvement 0
Adjusted total nurse staffing
0.88
Baseline 3.83 hours · Performance 3.33 hours · Measure score 0.88 · Achievement 0.88 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.31% |
10.72%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 118 · Observed rate 12.71% · Lower 95% interval 8.29% |
| Discharge to community | 64.41% |
50.57%
13.8 pts better
|
Better than the National Rate · Eligible stays 64 · Observed rate 56.25% · Lower 95% interval 51.07% |
| Medicare spending per beneficiary | 0.87 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 63 · Denominator 63 |
| Falls with major injury | 1.59% |
0.77%
0.8 pts worse
|
Numerator 1 · Denominator 63 |
| Discharge self-care score | 51.06% |
53.69%
2.6 pts worse
|
Numerator 24 · Denominator 47 |
| Discharge mobility score | 53.19% |
50.94%
2.2 pts better
|
Numerator 25 · Denominator 47 |
| Pressure ulcers or injuries, new or worsened | 7.94% |
2.29%
5.7 pts worse
|
Numerator 5 · Denominator 63 · Adjusted rate 5.86% |
| Healthcare-associated infections requiring hospitalization | 6.45% |
7.12%
0.7 pts better
|
No Different than the National Rate · Eligible stays 71 · Observed rate 4.23% · Lower 95% interval 3.83% |
| Staff COVID-19 vaccination coverage | 33.87% |
8.2%
25.7 pts better
|
Numerator 21 · Denominator 62 |
| Staff flu vaccination coverage | 52.34% |
42%
10.3 pts better
|
Numerator 56 · Denominator 107 |
| Discharge function score | 65.96% |
56.45%
9.5 pts better
|
Numerator 31 · Denominator 47 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 27.27% |
25.2%
2.1 pts better
|
Numerator 9 · Denominator 33 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.8 |
1.9
0.9 pts worse
|
1.9
0.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.8 · Observed 2.4 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.7 |
1.5
1.2 pts worse
|
1.8
0.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 2.5 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 92.8% |
92.2%
0.6 pts better
|
93.4%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 84.4% · Q2 95.5% · Q3 95.6% · Q4 95.7% · 4Q avg 92.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 89.8% |
94.8%
5 pts worse
|
95.5%
5.7 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 89.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.4% |
3.5%
2.1 pts better
|
3.3%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 1.1% · Q3 0.0% · Q4 0.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 9.0% |
12.0%
3 pts better
|
11.4%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.5% · Q2 7.8% · Q3 3.5% · Q4 8.2% · 4Q avg 9.0% |
| Percentage of long-stay residents who lose too much weight | 1.3% |
5.2%
3.9 pts better
|
5.4%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 0.0% · Q4 3.6% · 4Q avg 1.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 25.8% |
19.2%
6.6 pts worse
|
19.6%
6.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.3% · Q2 28.2% · Q3 25.3% · Q4 23.9% · 4Q avg 25.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 23.5% |
22.5%
1 pts worse
|
16.7%
6.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.6% · Q2 25.9% · Q3 17.7% · Q4 22.6% · 4Q avg 23.5% · 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 | 8.3% |
17.7%
9.4 pts better
|
16.3%
8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.5% · Q2 8.9% · Q3 10.2% · Q4 1.9% · 4Q avg 8.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.0% |
17.6%
9.6 pts better
|
14.9%
6.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 12.7% · Q3 9.1% · Q4 8.6% · 4Q avg 8.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.2% |
1.0%
0.2 pts worse
|
1.0%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.9% · Q3 2.3% · Q4 0.8% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.7% |
2.0%
0.3 pts better
|
1.7%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 4.8% · Q3 1.1% · Q4 0.0% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.5% |
21.7%
2.8 pts worse
|
19.8%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.7% · Q2 29.1% · Q3 15.8% · Q4 25.5% · 4Q avg 24.5% |
| Percentage of long-stay residents with pressure ulcers | 6.2% |
4.6%
1.6 pts worse
|
5.1%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 5.7% · Q3 5.8% · Q4 4.9% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 78.0% |
77.1%
0.9 pts better
|
81.7%
3.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 71.7% · Q2 88.1% · Q3 82.1% · Q4 68.0% · 4Q avg 78.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.2% |
11.8%
2.6 pts better
|
12.0%
2.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.2% · Observed 10.7% · Expected 13.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.6% |
1.3%
3.3 pts worse
|
1.6%
3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.5% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 81.0% |
77.7%
3.3 pts better
|
79.7%
1.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 81.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 12.8% |
25.8%
13 pts better
|
23.9%
11.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 12.8% · Observed 12.5% · Expected 23.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-29 · Fire 2024-02-29
20 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
6 fire-safety deficiencies
Top issue: Construction (3 deficiencies)
Cycle 3
Health 2023-01-19 · Fire 2023-01-19
10 health deficiencies
Top issue: Resident Rights (3 deficiencies)
13 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-31
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2025-03-14
F · Potential for more than minimal harm
2025-01-31
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2025-03-14
F · Potential for more than minimal harm
2025-01-31
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2025-03-21
F · Potential for more than minimal harm
2025-01-31
K163 · Construction Deficiencies
Fire Safety
Install noncombustible or limited-combustible interior walls.
Corrected 2025-03-21
F · Potential for more than minimal harm
2025-01-31
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2025-03-14
F · Potential for more than minimal harm
2025-01-31
K321 · Smoke Deficiencies
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 2025-03-14
F · Potential for more than minimal harm
2025-01-31
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-03-14
F · Potential for more than minimal harm
2025-01-31
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-14
F · Potential for more than minimal harm
2025-01-31
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-03-14
F · Potential for more than minimal harm
2025-01-31
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-03-14
F · Potential for more than minimal harm
2025-01-31
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-03-14
F · Potential for more than minimal harm
2025-01-31
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-03-14
F · Potential for more than minimal harm
2025-01-31
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-03-14
F · Potential for more than minimal harm
2025-01-31
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2025-03-14
F · Potential for more than minimal harm
2025-01-31
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-14
D · Potential for more than minimal harm
2025-01-31
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-03-14
F · Potential for more than minimal harm
2024-02-29
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2024-04-19
F · Potential for more than minimal harm
2024-02-29
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-05-17
F · Potential for more than minimal harm
2024-02-29
K163 · Construction Deficiencies
Fire Safety
Install noncombustible or limited-combustible interior walls.
Corrected 2024-05-17
F · Potential for more than minimal harm
2024-02-29
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-04-19
F · Potential for more than minimal harm
2024-02-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-19
F · Potential for more than minimal harm
2024-02-29
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-04-19
F · Potential for more than minimal harm
2023-01-19
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-03-17
F · Potential for more than minimal harm
2023-01-19
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-03-17
F · Potential for more than minimal harm
2023-01-19
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2023-03-17
F · Potential for more than minimal harm
2023-01-19
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2023-03-20
F · Potential for more than minimal harm
2023-01-19
K163 · Construction Deficiencies
Fire Safety
Install noncombustible or limited-combustible interior walls.
Corrected 2023-03-20
F · Potential for more than minimal harm
2023-01-19
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-03-17
F · Potential for more than minimal harm
2023-01-19
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-03-17
F · Potential for more than minimal harm
2023-01-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-03-17
F · Potential for more than minimal harm
2023-01-19
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-03-17
F · Potential for more than minimal harm
2023-01-19
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-03-17
F · Potential for more than minimal harm
2023-01-19
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-03-17
D · Potential for more than minimal harm
2023-01-19
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-03-17
D · Potential for more than minimal harm
2023-01-19
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-03-17
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-01-31
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-03-07
E · Potential for more than minimal harm
2025-01-31
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 2025-03-07
E · Potential for more than minimal harm
2025-01-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-01-31
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 2025-03-07
D · Potential for more than minimal harm
2025-01-31
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 2025-03-07
D · Potential for more than minimal harm
2025-01-31
F657 · Resident Assessment and Care Planning Deficiencies
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 2025-03-07
D · Potential for more than minimal harm
2025-01-31
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-01-31
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 2025-03-07
D · Potential for more than minimal harm
2025-01-31
F690 · Quality of Life and Care Deficiencies
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 2025-03-07
D · Potential for more than minimal harm
2025-01-31
F700 · Quality of Life and Care Deficiencies
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 2025-03-07
D · Potential for more than minimal harm
2025-01-31
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 2025-03-07
D · Potential for more than minimal harm
2025-01-31
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 2025-03-07
D · Potential for more than minimal harm
2025-01-31
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 2025-03-07
D · Potential for more than minimal harm
2024-03-15
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 2024-03-06
D · Potential for more than minimal harm
2024-03-15
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 2024-03-06
F · Potential for more than minimal harm
2024-02-29
F725 · Nursing and Physician Services Deficiencies
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 2024-03-29
F · Potential for more than minimal harm
2024-02-29
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-03-29
F · Potential for more than minimal harm
2024-02-29
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2024-03-29
F · Potential for more than minimal harm
2024-02-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-29
E · Potential for more than minimal harm
2024-02-29
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 2024-03-29
E · Potential for more than minimal harm
2024-02-29
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-03-29
E · Potential for more than minimal harm
2024-02-29
F909 · Environmental Deficiencies
Health
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Corrected 2024-03-29
D · Potential for more than minimal harm
2024-02-29
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 2024-03-29
D · Potential for more than minimal harm
2024-02-29
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2024-03-29
D · Potential for more than minimal harm
2024-02-29
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-03-29
D · Potential for more than minimal harm
2024-02-29
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 2024-03-29
D · Potential for more than minimal harm
2024-02-29
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-03-29
D · Potential for more than minimal harm
2024-02-29
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 2024-03-29
D · Potential for more than minimal harm
2024-02-29
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 2024-03-29
D · Potential for more than minimal harm
2024-02-29
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-03-29
D · Potential for more than minimal harm
2024-02-29
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-03-29
D · Potential for more than minimal harm
2024-02-29
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2024-03-29
D · Potential for more than minimal harm
2024-02-29
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 2024-03-29
E · Potential for more than minimal harm
2023-01-19
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 2023-02-10
E · Potential for more than minimal harm
2023-01-19
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 2023-02-10
E · Potential for more than minimal harm
2023-01-19
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 2023-02-10
D · Potential for more than minimal harm
2023-01-19
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 2023-02-10
D · Potential for more than minimal harm
2023-01-19
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-02-10
D · Potential for more than minimal harm
2023-01-19
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 2023-02-10
D · Potential for more than minimal harm
2023-01-19
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-02-10
D · Potential for more than minimal harm
2023-01-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-02-10
D · Potential for more than minimal harm
2023-01-19
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 2023-02-10
D · Potential for more than minimal harm
2023-01-19
F803 · Nutrition and Dietary Deficiencies
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 2023-02-10
Penalties and ownership
What sits behind the stars
Ownership
Mamary, James
5% Or Greater Direct Ownership Interest · Individual
Mamary, Jonathan
5% Or Greater Direct Ownership Interest · Individual
Mamary, Joshua
5% Or Greater Direct Ownership Interest · Individual
Mamary, James
Operational/Managerial Control · Individual
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OC Reading Center LLC
Reading, MA
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
#2
Andover Forest Post Acute Care Center
North Andover, MA
2-star overall rating with 2-star inspections with $44,265 in total fines with 12 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#3
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
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