Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
The Center at Blue Hills
STOUGHTON, MA · 92 certified beds · Last Life Safety survey November 20, 2025
CMS Certification Number 225444 · first certified July 1990
Ownership
Independently operated (no chain recorded by CMS) · For profit - Limited Liability company
- Ownership changed October 15, 2023 (change of ownership)to BLUE HILLS HEALTH AND REHABILITATION CENTER from BEAR MT STOUGHTON LLC
Position within MA
14 citations — more than 63% 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 3 citations; the earlier surveys in the window averaged 5.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens November 2026 — about 2 months from now. This facility’s last Life Safety survey was November 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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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
1 of the 14 citations on file is 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 14 Life Safety citations above. The Physical Environment Index
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 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-0880 Provide and implement an infection prevention and control program.
- F-0919 Make sure that a working call system is available in each resident's bathroom and bathing area.
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 | 14 |
| Median facility in MA | 11 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| July 24, 2023 | 5 |
| October 11, 2024 | 6 |
| November 20, 2025 | 3 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 2 | 2024-10-11 |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | 2 | 2025-11-20 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 2 | 2025-11-20 |
| K-0712 | Have simulated fire drills held at unexpected times. | 2 | 2024-10-11 |
| K-0311 | Have an enclosure around a vertical opening shaft. | 1 | 2024-10-11 |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | 1 | 2024-10-11 |
| E-0041 | Implement emergency and standby power systems. | 1 | 2023-07-24 |
| K-0324 | Provide properly protected cooking facilities. | 1 | 2024-10-11 |
What the citations cover
- Smoke Deficiencies 6
- Gas, Vacuum, and Electrical Systems Deficiencies 3
- Miscellaneous Deficiencies 2
- Egress Deficiencies 2
- Other 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 6 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 3 |
| Miscellaneous Deficiencies | 2 |
| Egress Deficiencies | 2 |
| Emergency Preparedness Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
November 20, 2025 — 3 citations
| 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 (January 23, 2026) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (January 23, 2026) |
| K-0928 | Ensure equipment listed for use in oxygen-enriched atmospheres are correctly labeled. | Deficient, Provider has date of correction (January 23, 2026) |
October 11, 2024 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0311 | Have an enclosure around a vertical opening shaft. | Deficient, Provider has date of correction (November 27, 2024) |
| K-0321 | Ensure 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 (November 27, 2024) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (November 27, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (November 27, 2024) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (November 27, 2024) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (November 27, 2024) |
July 24, 2023 — 5 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0041 | Implement emergency and standby power systems. | Deficient, Provider has date of correction (August 31, 2023) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (August 31, 2023) |
| K-0321 | Ensure 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 31, 2023) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (August 31, 2023) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (August 31, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.