F
28/100BLUEBERRY HILL REHABILITATION AND HEALTHCARE CTR Inspection Report, Violations & Safety Grade (BEVERLY, Massachusetts)
75 BRIMBAL AVENUE, BEVERLY, Massachusetts 01915
Phone: 9789272020
CMS Overall:1/5
Overview & Bed Count
Certified Beds
132
Avg Residents/Day
124.9
Ownership
For profit - Corporation
Provider Type
Medicare and Medicaid
County
Essex
Sprinkler Systems
Yes
Special Focus
SFF Candidate
Abuse Icon
No
CMS Star Ratings
Overall1/5
Health1/5
Staffing2/5
Quality3/5
Nurse Staffing Check
| Metric | This Facility | Massachusetts Avg | Difference |
|---|---|---|---|
| RN Hours per Resident per Day | 0.55 | 0.66 | -0.11 |
| Total Nurse Hours per Resident per Day | 3.44 | 3.94 | -0.50 |
| CMS Staffing Rating | 2/5 | 3.1/5 | - |
| Nursing Staff Turnover | 32.6% | 37.6% | - |
Health Citation History
70 health citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2025-12-17 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | E – Moderate Harm Potential |
| 2025-12-17 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D – Moderate Harm Potential |
| 2025-12-17 | Resident Assessment and Care Planning Deficiencies | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D – Moderate Harm Potential |
| 2025-12-17 | Resident Assessment and Care Planning Deficiencies | Ensure services provided by the nursing facility meet professional standards of quality. | D – Moderate Harm Potential |
| 2025-12-17 | Quality of Life and Care Deficiencies | Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | D – Moderate Harm Potential |
| 2025-12-17 | Pharmacy Service Deficiencies | 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. | D – Moderate Harm Potential |
| 2025-12-17 | Quality of Life and Care Deficiencies | Provide or obtain dental services for each resident. | D – Moderate Harm Potential |
| 2025-02-19 | Pharmacy Service Deficiencies | Ensure that residents are free from significant medication errors. | G – Actual Harm |
| 2025-02-19 | Resident Rights Deficiencies | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | D – Moderate Harm Potential |
| 2024-11-12 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | K – Immediate Jeopardy |
| 2024-11-12 | Resident Rights Deficiencies | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | J – Immediate Jeopardy |
| 2024-11-12 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | J – Immediate Jeopardy |
| 2024-11-12 | Nursing and Physician Services Deficiencies | Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | J – Immediate Jeopardy |
| 2024-11-12 | Quality of Life and Care Deficiencies | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | G – Actual Harm |
| 2024-11-12 | Quality of Life and Care Deficiencies | Provide enough food/fluids to maintain a resident's health. | G – Actual Harm |
| 2024-11-12 | Administration Deficiencies | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | F – Moderate Harm Potential |
| 2024-11-12 | Resident Rights Deficiencies | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | E – Moderate Harm Potential |
| 2024-11-12 | Resident Assessment and Care Planning Deficiencies | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | E – Moderate Harm Potential |
| 2024-11-12 | Resident Assessment and Care Planning Deficiencies | Ensure services provided by the nursing facility meet professional standards of quality. | E – Moderate Harm Potential |
| 2024-11-12 | Quality of Life and Care Deficiencies | Provide activities to meet all resident's needs. | E – Moderate Harm Potential |
| 2024-11-12 | Nursing and Physician Services Deficiencies | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | E – Moderate Harm Potential |
| 2024-11-12 | Quality of Life and Care Deficiencies | Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | E – Moderate Harm Potential |
| 2024-11-12 | Quality of Life and Care Deficiencies | Provide or obtain dental services for each resident. | E – Moderate Harm Potential |
| 2024-11-12 | Nutrition and Dietary Deficiencies | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | E – Moderate Harm Potential |
| 2024-11-12 | Resident Assessment and Care Planning Deficiencies | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | E – Moderate Harm Potential |
| 2024-11-12 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | E – Moderate Harm Potential |
| 2024-11-12 | Resident Rights Deficiencies | Ensure that residents are fully informed and understand their health status, care and treatments. | D – Moderate Harm Potential |
| 2024-11-12 | Resident Rights Deficiencies | Allow resident to participate in the development and implementation of his or her person-centered plan of care. | D – Moderate Harm Potential |
| 2024-11-12 | Resident Rights Deficiencies | Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | D – Moderate Harm Potential |
| 2024-11-12 | Resident Rights Deficiencies | 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. | D – Moderate Harm Potential |
| 2024-11-12 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Respond appropriately to all alleged violations. | D – Moderate Harm Potential |
| 2024-11-12 | Quality of Life and Care Deficiencies | Provide care and assistance to perform activities of daily living for any resident who is unable. | D – Moderate Harm Potential |
| 2024-11-12 | Quality of Life and Care Deficiencies | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | D – Moderate Harm Potential |
| 2024-11-12 | Quality of Life and Care Deficiencies | Provide safe and appropriate respiratory care for a resident when needed. | D – Moderate Harm Potential |
| 2024-11-12 | Quality of Life and Care Deficiencies | Provide safe, appropriate pain management for a resident who requires such services. | D – Moderate Harm Potential |
| 2024-11-12 | Quality of Life and Care Deficiencies | Provide care or services that was trauma informed and/or culturally competent. | D – Moderate Harm Potential |
| 2024-11-12 | Nursing and Physician Services Deficiencies | 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. | D – Moderate Harm Potential |
| 2024-11-12 | Pharmacy Service Deficiencies | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | D – Moderate Harm Potential |
| 2024-11-12 | Pharmacy Service Deficiencies | Ensure each resident’s drug regimen must be free from unnecessary drugs. | D – Moderate Harm Potential |
| 2024-11-12 | Pharmacy Service Deficiencies | 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. | D – Moderate Harm Potential |
| 2024-11-12 | Nutrition and Dietary Deficiencies | Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | D – Moderate Harm Potential |
| 2024-01-23 | Resident Rights Deficiencies | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | D – Moderate Harm Potential |
| 2023-10-26 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | G – Actual Harm |
| 2023-10-26 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | G – Actual Harm |
| 2023-10-26 | Nursing and Physician Services Deficiencies | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | F – Moderate Harm Potential |
| 2023-10-26 | Nursing and Physician Services Deficiencies | 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. | F – Moderate Harm Potential |
| 2023-10-26 | Nursing and Physician Services Deficiencies | Observe each nurse aide's job performance and give regular training. | F – Moderate Harm Potential |
| 2023-10-26 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F – Moderate Harm Potential |
| 2023-10-26 | Nursing and Physician Services Deficiencies | Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility. | F – Moderate Harm Potential |
| 2023-10-26 | Infection Control Deficiencies | Implement a program that monitors antibiotic use. | F – Moderate Harm Potential |
Showing 50 of 70 citations.
Fire Safety Citation History
14 fire safety citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2025-12-17 | Egress Deficiencies | 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. | F – Moderate Harm Potential |
| 2025-12-17 | Egress Deficiencies | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | F – Moderate Harm Potential |
| 2025-12-17 | Smoke Deficiencies | Provide properly protected cooking facilities. | F – Moderate Harm Potential |
| 2025-12-17 | Services Deficiencies | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | F – Moderate Harm Potential |
| 2025-12-17 | Miscellaneous Deficiencies | Have simulated fire drills held at unexpected times. | F – Moderate Harm Potential |
| 2024-11-12 | Construction Deficiencies | Meet requirements for sections of health care facilities separated by fire resistive construction. | F – Moderate Harm Potential |
| 2024-11-12 | Egress Deficiencies | Have ramps, exits, fire escape ladders, steps, and areas of refuge that meet safety requirements. | F – Moderate Harm Potential |
| 2024-11-12 | Smoke Deficiencies | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | E – Moderate Harm Potential |
| 2024-11-12 | Smoke Deficiencies | Provide properly protected cooking facilities. | E – Moderate Harm Potential |
| 2024-11-12 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | E – Moderate Harm Potential |
| 2024-11-12 | Smoke Deficiencies | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | E – Moderate Harm Potential |
| 2024-11-12 | Miscellaneous Deficiencies | Have simulated fire drills held at unexpected times. | E – Moderate Harm Potential |
| 2024-11-12 | Gas, Vacuum, and Electrical Systems Deficiencies | Ensure proper usage of power strips and extension cords. | D – Moderate Harm Potential |
| 2023-10-26 | Smoke Deficiencies | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | F – Moderate Harm Potential |
Total Penalties & Fines
$231,459
Total Fine Amount (CMS)
3
Number of Fines
3
Total Penalties
| Date | Type | Fine Amount | Payment Denial |
|---|---|---|---|
| 2025-02-19 | Fine | $12,935 | - |
| 2024-11-12 | Fine | $157,749 | - |
| 2023-10-26 | Fine | $60,775 | - |
Need Help Finding Safe Care?
Our family advisors can help you find vetted, top-rated facilities in the BEVERLY area at no cost.
Find Safe, Vetted Facilities Near BEVERLY
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.
Need Help Finding Safe Care?
Our family advisors can help you find vetted, top-rated facilities in the BEVERLY area at no cost.
Find Safe, Vetted Facilities Near BEVERLY
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.