C80

WEST ROXBURY HEALTH & REHABILITATION CENTER

Grade C 80/100 composite score

For profit - Limited Liability company

CMS Star Ratings

Overall
3/5
Health Insp.
3/5
Quality
3/5
Staffing
4/5
RN Staffing
Not rated

Certified Beds

76

Ownership

For profit - Limited Liability company

Total Fines

$3,418

Last Survey

N/A

5060 WASHINGTON STREET, WEST ROXBURY, MA 02132
6173235440

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Staffing Hours & Turnover

Hours per Resident per Day (PBJ)

RN
1.04h
LPN
0.63h
CNA
1.94h
Total
3.61h
Facility
State Average

Turnover Rates

RN Turnover
N/A
Total Nurse Turnover
N/A
Admin Turnover
N/A

Ownership

WYNNE, JOHN

IndividualCORPORATE OFFICERSince Dec 2018

BEAR MOUNTAIN HEALTHCARE LLC

Organization5% OR GREATER DIRECT OWNERSHIP INTERESTSince Dec 2018

100%

DOYLE, THOMAS

Individual5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Dec 2018

33%

WYNNE, JOHN

Individual5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Dec 2018

33%

ZISKIN, SCOTT

Individual5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Dec 2018

33%

DOYLE, THOMAS

IndividualCORPORATE OFFICERSince Dec 2018

ZISKIN, SCOTT

IndividualCORPORATE OFFICERSince Dec 2018

CAMBRIDGE, JOSHUA

IndividualW-2 MANAGING EMPLOYEESince Dec 2018

Penalties & Fines (1)

$3,418total fines
DateTypeDescriptionAmount
Feb 6, 2024Fine$3,418

Health Inspection Deficiencies (46)

October 31, 2024Health10 deficiencies
0761DMinimal harm, Isolated

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.

Pharmacy Service Deficiencies

Corrected Dec 6, 2024
0699DMinimal harm, Isolated

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

Quality of Life and Care Deficiencies

Corrected Dec 6, 2024
0641DMinimal harm, Isolated

Ensure each resident receives an accurate assessment.

Resident Assessment and Care Planning Deficiencies

Corrected Dec 6, 2024
0554DMinimal harm, Isolated

Allow residents to self-administer drugs if determined clinically appropriate.

Resident Rights Deficiencies

Corrected Dec 6, 2024
0658DMinimal harm, Isolated

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

Resident Assessment and Care Planning Deficiencies

Corrected Dec 6, 2024
0695DMinimal harm, Isolated

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies

Corrected Dec 6, 2024
0700DMinimal harm, Isolated

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.

Quality of Life and Care Deficiencies

Corrected Dec 6, 2024
0756DMinimal harm, Isolated

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Pharmacy Service Deficiencies

Corrected Dec 6, 2024
0812DMinimal harm, Isolated

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

Nutrition and Dietary Deficiencies

Corrected Dec 6, 2024
0842DMinimal harm, Isolated

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Resident Assessment and Care Planning Deficiencies

Corrected Dec 6, 2024
August 27, 2024Health1 deficiency
0584DMinimal harm, Isolated

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.

Resident Rights Deficiencies

Corrected Sep 6, 2024
June 10, 2024Health3 deficiencies
0561DMinimal harm, Isolated

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Resident Rights Deficiencies

Corrected Jul 12, 2024
0604DMinimal harm, Isolated

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Jul 27, 2024
0607DMinimal harm, Isolated

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

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Jul 27, 2024
May 21, 2024Health1 deficiency
0550DMinimal harm, Isolated

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies

Corrected Jun 5, 2024
November 7, 2023Health14 deficiencies
0880EMinimal harm, Pattern

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Dec 16, 2023
0791DMinimal harm, Isolated

Provide or obtain dental services for each resident.

Quality of Life and Care Deficiencies

Corrected Dec 16, 2023
0761DMinimal harm, Isolated

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.

Pharmacy Service Deficiencies

Corrected Dec 16, 2023
0699EMinimal harm, Pattern

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

Quality of Life and Care Deficiencies

Corrected Dec 16, 2023
0698DMinimal harm, Isolated

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Quality of Life and Care Deficiencies

Corrected Dec 16, 2023
0690DMinimal harm, Isolated

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Quality of Life and Care Deficiencies

Corrected Dec 16, 2023
0689DMinimal harm, Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Corrected Dec 16, 2023
0658DMinimal harm, Isolated

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

Resident Assessment and Care Planning Deficiencies

Corrected Dec 16, 2023
0584DMinimal harm, Isolated

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.

Resident Rights Deficiencies

Corrected Dec 16, 2023
0554DMinimal harm, Isolated

Allow residents to self-administer drugs if determined clinically appropriate.

Resident Rights Deficiencies

Corrected Dec 16, 2023
0550EMinimal harm, Pattern

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies

Corrected Dec 16, 2023
0677EMinimal harm, Pattern

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

Corrected Dec 16, 2023
0693DMinimal harm, Isolated

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Quality of Life and Care Deficiencies

Corrected Dec 16, 2023
0695DMinimal harm, Isolated

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies

Corrected Dec 16, 2023
November 10, 2022Health17 deficiencies
0880EMinimal harm, Pattern

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Dec 17, 2022
0865FMinimal harm, Widespread

Have a plan that describes the process for conducting QAPI and QAA activities.

Administration Deficiencies

Corrected Dec 17, 2022
0842DMinimal harm, Isolated

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Resident Assessment and Care Planning Deficiencies

Corrected Dec 17, 2022
0684DMinimal harm, Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Corrected Dec 17, 2022
0677DMinimal harm, Isolated

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

Corrected Dec 17, 2022
0640EMinimal harm, Pattern

Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

Resident Assessment and Care Planning Deficiencies

Corrected Dec 17, 2022
0637DMinimal harm, Isolated

Assess the resident when there is a significant change in condition

Resident Assessment and Care Planning Deficiencies

Corrected Dec 17, 2022
0552DMinimal harm, Isolated

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

Resident Rights Deficiencies

Corrected Dec 17, 2022
0550EMinimal harm, Pattern

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies

Corrected Dec 17, 2022
0656EMinimal harm, Pattern

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies

Corrected Dec 17, 2022
0657DMinimal harm, Isolated

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Resident Assessment and Care Planning Deficiencies

Corrected Dec 17, 2022
0679DMinimal harm, Isolated

Provide activities to meet all resident's needs.

Quality of Life and Care Deficiencies

Corrected Dec 17, 2022
0689DMinimal harm, Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Corrected Dec 17, 2022
0695DMinimal harm, Isolated

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies

Corrected Dec 17, 2022
0758DMinimal harm, Isolated

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.

Pharmacy Service Deficiencies

Corrected Dec 17, 2022
0761EMinimal harm, Pattern

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.

Pharmacy Service Deficiencies

Corrected Dec 17, 2022
0883DMinimal harm, Isolated

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Infection Control Deficiencies

Corrected Dec 17, 2022

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Frequently Asked Questions

What is the CareGrader rating for WEST ROXBURY HEALTH & REHABILITATION CENTER?

WEST ROXBURY HEALTH & REHABILITATION CENTER in WEST ROXBURY, Massachusetts has a CareGrader grade of C (Average), with a composite score of 79.8 out of 100. This grade is based on health inspections, staffing levels, quality measures, and penalty history from official CMS government data.

What is the CMS star rating for WEST ROXBURY HEALTH & REHABILITATION CENTER?

WEST ROXBURY HEALTH & REHABILITATION CENTER has an overall CMS star rating of 3 out of 5, a health inspection rating of 3/5, and a staffing rating of 4/5. CareGrader combines this with additional data to calculate an A-F grade.

How many health deficiencies does WEST ROXBURY HEALTH & REHABILITATION CENTER have?

WEST ROXBURY HEALTH & REHABILITATION CENTER has 46 health deficiencies on record from CMS health inspection surveys. Deficiencies are rated from A (minimal harm potential) to L (immediate jeopardy, widespread). View the full inspection timeline above for details on each deficiency.

Has WEST ROXBURY HEALTH & REHABILITATION CENTER been fined?

Yes. WEST ROXBURY HEALTH & REHABILITATION CENTER has $3,418 in total fines from CMS enforcement actions across 1 penalty.

How many beds does WEST ROXBURY HEALTH & REHABILITATION CENTER have?

WEST ROXBURY HEALTH & REHABILITATION CENTER has 76 certified beds with approximately 62 current residents (82% occupancy). The facility is located at 5060 WASHINGTON STREET, WEST ROXBURY, Massachusetts 02132. It is a for profit - limited liability company facility.

Data Disclaimer

Inspection data, staffing levels, and star ratings are sourced from CMS Medicare Nursing Home Compare and are largely self-reported by facilities. A 2019 GAO study found that 43% of facilities under-reported falls. CareGrader provides this data for informational purposes only and is not affiliated with CMS or Medicare. Always visit facilities in person before making a decision.