Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

REGALCARE AT COURTYARD-MEDFORD

MEDFORD, MA · 224 certified beds · Last Life Safety survey March 11, 2025

CMS Certification Number 225545 · first certified February 1992

Ownership

Operated by REGALCARE · For profit - Limited Liability company

  • Ownership changed May 1, 2024 (change of ownership)to REGALCARE AT COURTYARD from COURTYARD NURSING CARE CENTER PARTNERSHIP
27
Citations on file
Rolling three-year window
3
Life Safety surveys
In the same window
5
Tags cited more than once
Across separate surveys
14
Inspection & testing records
Of the citations on file

Position within MA

27 citations — more than 94% of the 341 certified nursing homes in MA. Compared within MA rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Slippingmore citations at the latest survey than at its earlier surveys in the window.

The latest survey found 10 citations; the earlier surveys in the window averaged 8.5. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

Well past the typical window (March 2026 to May 2026), and past the point by which nine in ten MA facilities have been surveyed. This facility’s last Life Safety survey was March 2025. Facilities in MA are typically surveyed 12–15 months after the last one (median 13), measured over 556 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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Which alerts

4 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Emergency preparedness

8 of the 27 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index

Physical environment (health survey)

5 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 27 Life Safety citations above. The Physical Environment Index

  • F-0584 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.
  • F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  • F-0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
  • F-0880 Provide and implement an infection prevention and control program.

How that compares

Citations on file over three years

Compared with the median facility in MA, and nationally. Surveyors differ markedly between states, so the MA figure is the meaningful one.

This facility27MA median11National median11
Citations on file over three years, compared
MeasureCitations
This facility27
Median facility in MA11
Median facility nationally11

Survey history

Citations at each Life Safety survey
82023-0192024-03102025-03
Citations at each Life Safety survey
Survey dateCitations
January 9, 20238
March 21, 20249
March 11, 202510

Most-cited tags

Most-cited tags at this facility
K-07113K-09183K-07123K-03532K-03242K-05111E-00181K-03111
Most-cited tags at this facility
TagWhat the surveyor checksTimes citedLast cited
K-0711Provide a written emergency evacuation plan.32025-03-11
K-0918Have generator or other power source capable of supplying service within 10 seconds.32025-03-11
K-0712Have simulated fire drills held at unexpected times.32025-03-11
K-0353Inspect, test, and maintain automatic sprinkler systems.22025-03-11
K-0324Provide properly protected cooking facilities.22025-03-11
K-0511Have properly installed electrical wiring and gas equipment.12023-01-09
E-0018Establish procedures for tracking staff and patients during an emergency.12025-03-11
K-0311Have an enclosure around a vertical opening shaft.12023-01-09

What the citations cover

Citations by CMS category
  • Smoke Deficiencies 8
  • Emergency Preparedness Deficiencies 8
  • Miscellaneous Deficiencies 7
  • Gas, Vacuum, and Electrical Systems Deficiencies 3
  • Other 1
Citations by CMS category
CategoryCitations
Smoke Deficiencies8
Emergency Preparedness Deficiencies8
Miscellaneous Deficiencies7
Gas, Vacuum, and Electrical Systems Deficiencies3
Services Deficiencies1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

March 11, 2025 — 10 citations

Citations issued on March 11, 2025
TagWhat the surveyor checksStatus
E-0007Address patient/client population and determine types of services needed.Deficient, Provider has date of correction (May 1, 2025)
E-0018Establish procedures for tracking staff and patients during an emergency.Deficient, Provider has date of correction (May 1, 2025)
E-0020Establish policies and procedures including evacuation.Deficient, Provider has date of correction (May 1, 2025)
E-0022Establish policies and procedures for sheltering.Deficient, Provider has date of correction (April 19, 2025)
E-0030List the names and contact information of those in the facility.Deficient, Provider has date of correction (May 1, 2025)
K-0324Provide properly protected cooking facilities.Deficient, Provider has date of correction (April 19, 2025)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (April 19, 2025)
K-0711Provide a written emergency evacuation plan.Deficient, Provider has date of correction (May 9, 2025)
K-0712Have simulated fire drills held at unexpected times.Deficient, Provider has date of correction (May 9, 2025)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (April 19, 2025)

March 21, 2024 — 9 citations

Citations issued on March 21, 2024
TagWhat the surveyor checksStatus
E-0036Establish emergency prep training and testing.Deficient, Provider has date of correction (April 30, 2024)
E-0037Establish staff and initial training requirements.Deficient, Provider has date of correction (April 30, 2024)
E-0039Conduct testing and exercise requirements.Deficient, Provider has date of correction (April 30, 2024)
K-0345Have approved installation, maintenance and testing program for fire alarm systems.Deficient, Provider has date of correction (April 30, 2024)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (April 30, 2024)
K-0711Provide a written emergency evacuation plan.Deficient, Provider has date of correction (April 30, 2024)
K-0712Have simulated fire drills held at unexpected times.Deficient, Provider has date of correction (April 30, 2024)
K-0761To conduct inspection, testing and maintenance of fire doors by qualified individuals.Deficient, Provider has date of correction (April 30, 2024)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (April 30, 2024)

January 9, 2023 — 8 citations

Citations issued on January 9, 2023
TagWhat the surveyor checksStatus
K-0311Have an enclosure around a vertical opening shaft.Deficient, Provider has date of correction (February 24, 2023)
K-0321Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.Deficient, Provider has date of correction (February 3, 2023)
K-0324Provide properly protected cooking facilities.Deficient, Provider has date of correction (January 30, 2023)
K-0363Install corridor and hallway doors that block smoke.Deficient, Provider has date of correction (February 17, 2023)
K-0511Have properly installed electrical wiring and gas equipment.Deficient, Provider has date of correction (March 10, 2023)
K-0711Provide a written emergency evacuation plan.Deficient, Provider has date of correction (February 17, 2023)
K-0712Have simulated fire drills held at unexpected times.Deficient, Provider has date of correction (February 17, 2023)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (February 17, 2023)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.