Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
ELMHURST HEALTHCARE (THE)
MELROSE, MA · 45 certified beds · Last Life Safety survey June 11, 2025
CMS Certification Number 225659 · first certified December 1994
Ownership
Operated by NEXT STEP HEALTHCARE · For profit - Corporation
- Ownership changed September 1, 2017 (change of ownership)to THE ELMHURST HEALTHCARE from GGNSC MELROSE ELMHURST LLC
Position within MA
11 citations — more than 49% 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
The latest survey found 7 citations; the earlier surveys in the window averaged 2. 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 (June 2026 to August 2026), and past the point by which nine in ten MA facilities have been surveyed. This facility’s last Life Safety survey was June 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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1 inspection-and-testing tag has 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.
Physical environment (health survey)
2 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 11 Life Safety citations above. The Physical Environment Index
- F-0880 Provide and implement an infection prevention and control program.
How that compares
Compared with the median facility in MA, and nationally. Surveyors differ markedly between states, so the MA figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 11 |
| Median facility in MA | 11 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| May 10, 2023 | 1 |
| July 10, 2024 | 3 |
| June 11, 2025 | 7 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0712 | Have simulated fire drills held at unexpected times. | 2 | 2025-06-11 |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | 1 | 2025-06-11 |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | 1 | 2023-05-10 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 1 | 2025-06-11 |
| K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | 1 | 2024-07-10 |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | 1 | 2025-06-11 |
| K-0324 | Provide properly protected cooking facilities. | 1 | 2025-06-11 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 1 | 2025-06-11 |
What the citations cover
- Smoke Deficiencies 3
- Egress Deficiencies 3
- Miscellaneous Deficiencies 3
- Gas, Vacuum, and Electrical Systems Deficiencies 2
| Category | Citations |
|---|---|
| Smoke Deficiencies | 3 |
| Egress Deficiencies | 3 |
| Miscellaneous Deficiencies | 3 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 2 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
June 11, 2025 — 7 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0222 | 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. | Deficient, Provider has date of correction (July 10, 2025) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (July 10, 2025) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (July 10, 2025) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (July 10, 2025) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (July 10, 2025) |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | Deficient, Provider has date of correction (July 10, 2025) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (July 10, 2025) |
July 10, 2024 — 3 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Deficient, Provider has date of correction (August 2, 2024) |
| K-0711 | Provide a written emergency evacuation plan. | Deficient, Provider has date of correction (August 2, 2024) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (August 2, 2024) |
May 10, 2023 — 1 citation
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (May 19, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.