Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Pope Nursing Home
WEYMOUTH, MA · 49 certified beds · Last Life Safety survey April 9, 2026
CMS Certification Number 225613 · first certified March 1994
Ownership
Operated by REHABILITATION ASSOCIATES · For profit - Corporation
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within MA
50 citations — more than 100% 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 16 citations; the earlier surveys on file averaged 17. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens April 2027 — about 5 months from now. This facility’s last Life Safety survey was April 2026. Facilities in MA are typically surveyed 12–14 months after the last one (median 13), measured over 553 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 about three years in Virginia. How the window is measured
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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 cited for sprinkler inspection and testing in CMS’s current file are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
17 of the 50 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)
4 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 50 Life Safety citations above. The Physical Environment Index
- F-0880 Provide and implement an infection prevention and control program.
- 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.
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 | 50 |
| Median facility in MA | 11 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| April 2, 2024 | 12 |
| April 22, 2025 | 22 |
| April 9, 2026 | 16 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | 3 | 2026-04-09 |
| K-0232 | Have corridors or aisles that are unobstructed and are at least 8 feet in width. | 3 | 2026-04-09 |
| K-0311 | Have an enclosure around a vertical opening shaft. | 3 | 2026-04-09 |
| K-0161 | Use approved construction type or materials. | 3 | 2026-04-09 |
| K-0271 | Have exits that are accessible at all times. | 3 | 2026-04-09 |
| K-0241 | Have correct number of accessible exits for each story. | 3 | 2026-04-09 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 3 | 2026-04-09 |
| K-0712 | Have simulated fire drills held at unexpected times. | 3 | 2026-04-09 |
What the citations cover
- Emergency Preparedness Deficiencies 17
- Egress Deficiencies 15
- Smoke Deficiencies 8
- Miscellaneous Deficiencies 4
- Other 6
| Category | Citations |
|---|---|
| Emergency Preparedness Deficiencies | 17 |
| Egress Deficiencies | 15 |
| Smoke Deficiencies | 8 |
| Miscellaneous Deficiencies | 4 |
| Construction Deficiencies | 3 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 2 |
| Services Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
April 9, 2026 — 16 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (June 28, 2026) |
| E-0006 | Conduct risk assessment and an All-Hazards approach. | Deficient, Provider has date of correction (June 28, 2026) |
| E-0009 | Include a process for Emergency Preparedness collaboration. | Deficient, Provider has date of correction (June 28, 2026) |
| E-0026 | Establish roles under a Waiver declared by secretary. | Deficient, Provider has date of correction (June 28, 2026) |
| E-0031 | Provide emergency officials' contact information. | Deficient, Provider has date of correction (June 28, 2026) |
| E-0035 | Provide family notifications of emergency plan. | Deficient, Provider has date of correction (June 28, 2026) |
| E-0036 | Establish emergency prep training and testing. | Deficient, Provider has date of correction (June 28, 2026) |
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has date of correction (June 28, 2026) |
| K-0161 | Use approved construction type or materials. | Deficient, Provider has date of correction (June 28, 2026) |
| K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Deficient, Provider has date of correction (June 28, 2026) |
| K-0232 | Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Deficient, Provider has date of correction (June 28, 2026) |
| K-0241 | Have correct number of accessible exits for each story. | Deficient, Provider has date of correction (June 28, 2026) |
| K-0271 | Have exits that are accessible at all times. | Deficient, Provider has date of correction (June 28, 2026) |
| K-0311 | Have an enclosure around a vertical opening shaft. | Deficient, Provider has date of correction (June 28, 2026) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (June 28, 2026) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (June 28, 2026) |
April 22, 2025 — 22 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0006 | Conduct risk assessment and an All-Hazards approach. | Deficient, Provider has date of correction (June 13, 2025) |
| E-0007 | Address patient/client population and determine types of services needed. | Deficient, Provider has date of correction (June 13, 2025) |
| E-0009 | Include a process for Emergency Preparedness collaboration. | Deficient, Provider has date of correction (June 13, 2025) |
| E-0018 | Establish procedures for tracking staff and patients during an emergency. | Deficient, Provider has date of correction (June 13, 2025) |
| E-0020 | Establish policies and procedures including evacuation. | Deficient, Provider has date of correction (June 13, 2025) |
| E-0022 | Establish policies and procedures for sheltering. | Deficient, Provider has date of correction (June 13, 2025) |
| E-0036 | Establish emergency prep training and testing. | Deficient, Provider has date of correction (June 13, 2025) |
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has date of correction (June 13, 2025) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (June 13, 2025) |
| K-0161 | Use approved construction type or materials. | Deficient, Provider has date of correction (May 1, 2025) |
| 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 (May 1, 2025) |
| K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Deficient, Provider has date of correction (May 1, 2025) |
| K-0232 | Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Deficient, Provider has date of correction (May 1, 2025) |
| K-0241 | Have correct number of accessible exits for each story. | Deficient, Provider has date of correction (May 1, 2025) |
| K-0271 | Have exits that are accessible at all times. | Deficient, Provider has date of correction (May 1, 2025) |
| K-0311 | Have an enclosure around a vertical opening shaft. | Deficient, Provider has date of correction (May 1, 2025) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (May 5, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (May 16, 2025) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (May 29, 2025) |
| K-0711 | Provide a written emergency evacuation plan. | Deficient, Provider has date of correction (May 5, 2025) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (May 17, 2025) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (May 27, 2025) |
April 2, 2024 — 12 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0161 | Use approved construction type or materials. | Deficient, Provider has date of correction (June 5, 2024) |
| K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Deficient, Provider has date of correction (June 5, 2024) |
| K-0232 | Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Deficient, Provider has date of correction (June 5, 2024) |
| K-0241 | Have correct number of accessible exits for each story. | Deficient, Provider has date of correction (June 5, 2024) |
| K-0271 | Have exits that are accessible at all times. | Deficient, Provider has date of correction (June 5, 2024) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (May 10, 2024) |
| K-0300 | Meet other general requirements that are deficient. | Deficient, Provider has date of correction (May 2, 2024) |
| K-0311 | Have an enclosure around a vertical opening shaft. | Deficient, Provider has date of correction (June 5, 2024) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (May 10, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (May 29, 2024) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (May 22, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (May 22, 2024) |
Reflects the CMS posting of October 1, 2026. Surveys conducted in the last few months may not appear yet.