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

South Hadley Rehabilitation and Nursing Center

SOUTH HADLEY, MA · 132 certified beds · Last Life Safety survey May 27, 2025

CMS Certification Number 225757 · first certified March 2001

Ownership

Independently operated (no chain recorded by CMS) · For profit - Individual

  • Ownership changed February 1, 2023 (change of ownership)to PIONEER VALLEY HEALTH AND REHABILITATION from VERO HEALTH XIII LLC
21
Citations on file
Rolling three-year window
3
Life Safety surveys
In the same window
5
Tags cited more than once
Across separate surveys
13
Inspection & testing records
Of the citations on file

Position within MA

21 citations — more than 82% 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 12 citations; the earlier surveys in the window averaged 4.5. 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 (May 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 May 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

3 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

6 of the 21 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)

7 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 21 Life Safety citations above. The Physical Environment Index

  • F-0880 Provide and implement an infection prevention and control program.
  • F-0909 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.
  • F-0908 Keep all essential equipment working safely.
  • F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

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 facility21MA median11National median11
Citations on file over three years, compared
MeasureCitations
This facility21
Median facility in MA11
Median facility nationally11

Survey history

Citations at each Life Safety survey
42022-1152024-03122025-05
Citations at each Life Safety survey
Survey dateCitations
November 22, 20224
March 27, 20245
May 27, 202512

Most-cited tags

Most-cited tags at this facility
K-09183K-07122E-00412K-03212K-03532E-00291K-03451E-00361
Most-cited tags at this facility
TagWhat the surveyor checksTimes citedLast cited
K-0918Have generator or other power source capable of supplying service within 10 seconds.32025-05-27
K-0712Have simulated fire drills held at unexpected times.22025-05-27
E-0041Implement emergency and standby power systems.22024-03-27
K-0321Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.22025-05-27
K-0353Inspect, test, and maintain automatic sprinkler systems.22025-05-27
E-0029Develop a communication plan.12025-05-27
K-0345Have approved installation, maintenance and testing program for fire alarm systems.12025-05-27
E-0036Establish emergency prep training and testing.12025-05-27

What the citations cover

Citations by CMS category
  • Smoke Deficiencies 7
  • Emergency Preparedness Deficiencies 6
  • Gas, Vacuum, and Electrical Systems Deficiencies 4
  • Miscellaneous Deficiencies 2
  • Other 2
Citations by CMS category
CategoryCitations
Smoke Deficiencies7
Emergency Preparedness Deficiencies6
Gas, Vacuum, and Electrical Systems Deficiencies4
Miscellaneous Deficiencies2
Services Deficiencies1
Egress Deficiencies1

Every citation on file

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

May 27, 2025 — 12 citations

Citations issued on May 27, 2025
TagWhat the surveyor checksStatus
E-0004Develop and maintain an Emergency Preparedness Program (EP).Deficient, Provider has date of correction (August 4, 2025)
E-0006Conduct risk assessment and an All-Hazards approach.Deficient, Provider has date of correction (August 4, 2025)
E-0029Develop a communication plan.Deficient, Provider has date of correction (August 4, 2025)
E-0036Establish emergency prep training and testing.Deficient, Provider has date of correction (August 4, 2025)
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 (August 4, 2025)
K-0324Provide properly protected cooking facilities.Deficient, Provider has date of correction (August 4, 2025)
K-0345Have approved installation, maintenance and testing program for fire alarm systems.Deficient, Provider has date of correction (August 4, 2025)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (August 4, 2025)
K-0372Ensure smoke barriers are constructed to a 1 hour fire resistance rating.Deficient, Provider has date of correction (August 4, 2025)
K-0712Have simulated fire drills held at unexpected times.Deficient, Provider has date of correction (August 4, 2025)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (August 4, 2025)
K-0923Have proper medical gas storage and administration areas.Deficient, Provider has date of correction (August 4, 2025)

March 27, 2024 — 5 citations

Citations issued on March 27, 2024
TagWhat the surveyor checksStatus
E-0041Implement emergency and standby power systems.Deficient, Provider has date of correction (April 30, 2024)
K-0291Install emergency lighting that can last at least 1 1/2 hours.Deficient, Provider has date of correction (June 3, 2024)
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 (June 3, 2024)
K-0712Have simulated fire drills held at unexpected times.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)

November 22, 2022 — 4 citations

Citations issued on November 22, 2022
TagWhat the surveyor checksStatus
E-0041Implement emergency and standby power systems.Deficient, Provider has date of correction (January 16, 2023)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (January 16, 2023)
K-0521Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.Deficient, Provider has date of correction (January 16, 2023)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (January 16, 2023)

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