Cycle 1
Health 2025-03-18 · Fire 2025-03-18
7 health deficiencies
Top issue: Resident Rights (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Scituate, MA
Cardigan Nursing & Rehabilitation Center
4-star overall rating with 3-star inspections with 7 recent health deficiencies
59 Country Way, Scituate, MA
(781) 545-9477
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
65
Certified beds
Average residents
46
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1997-02-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.82
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
0.52
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
1.87
Nurse aide staffing · state 2.26 · national 2.35
Total nurse hours
3.21
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.34
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
2.83
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.58
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.89
CMS adjusted RN staffing hours
Adjusted total hours
3.50
CMS adjusted total nurse staffing hours
Case-mix index
1.25
Higher values indicate more complex resident acuity
RN turnover
46%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
57%
Annual nurse turnover · state 40% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,649
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
23.01
Composite VBP score used to determine payment impact.
Payment multiplier
0.9830
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.03
Baseline 18.79% · Performance 18.64% · Measure score 6.03 · Achievement 6.03 · Improvement 0.38
Healthcare-associated infections
2.51
Baseline 6.40% · Performance 7.08% · Measure score 2.51 · Achievement 2.51 · Improvement 0
Total nurse turnover
0
Baseline 21.21% · Performance 97.06% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
0.66
Baseline 3.46 hours · Performance 3.26 hours · Measure score 0.66 · Achievement 0.66 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.7% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 66 · Observed rate 9.09% · Lower 95% interval 7.55% |
| Discharge to community | 53.59% |
50.57%
3 pts better
|
No Different than the National Rate · Eligible stays 67 · Observed rate 50.75% · Lower 95% interval 43.99% |
| Medicare spending per beneficiary | 0.85 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 33 · Denominator 33 |
| Falls with major injury | 3.03% |
0.77%
2.3 pts worse
|
Numerator 1 · Denominator 33 |
| Discharge self-care score | 65.52% |
53.69%
11.8 pts better
|
Numerator 19 · Denominator 29 |
| Discharge mobility score | 65.52% |
50.94%
14.6 pts better
|
Numerator 19 · Denominator 29 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 33 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.08% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 39 · Observed rate 5.13% · Lower 95% interval 4.05% |
| Staff COVID-19 vaccination coverage | 12.5% |
8.2%
4.3 pts better
|
Numerator 7 · Denominator 56 |
| Staff flu vaccination coverage | 70.49% |
42%
28.5 pts better
|
Numerator 43 · Denominator 61 |
| Discharge function score | 72.41% |
56.45%
16 pts better
|
Numerator 21 · Denominator 29 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 22 · Denominator 22 |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.8 |
1.9
1.1 pts better
|
1.9
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.5 · Expected 1.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0 |
1.5
1.5 pts better
|
1.8
1.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0 · Observed 0 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
92.2%
7.8 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.8%
5.2 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.5% |
3.5%
3 pts worse
|
3.3%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 7.1% · Q3 7.1% · Q4 7.3% · 4Q avg 6.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
12.0%
12 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 4.0% |
5.2%
1.2 pts better
|
5.4%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 8.3% · Q3 0.0% · Q4 5.4% · 4Q avg 4.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.7% |
19.2%
0.5 pts worse
|
19.6%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 16.2% · Q3 21.1% · Q4 21.6% · 4Q avg 19.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.6% |
22.5%
4.9 pts better
|
16.7%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.6% · Q2 19.4% · Q3 15.2% · Q4 18.2% · 4Q avg 17.6% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 13.6% |
17.7%
4.1 pts better
|
16.3%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 13.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.2% |
17.6%
10.4 pts better
|
14.9%
7.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 11.8% · Q3 5.7% · Q4 5.7% · 4Q avg 7.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.2% |
1.0%
2.2 pts worse
|
1.0%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 4.9% · Q3 2.3% · Q4 3.8% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.0% |
2.0%
1 pts worse
|
1.7%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 9.8% · Q3 2.4% · Q4 0.0% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 2.6% |
21.7%
19.1 pts better
|
19.8%
17.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.8% · Q3 5.2% · Q4 2.7% · 4Q avg 2.6% |
| Percentage of long-stay residents with pressure ulcers | 0.0% |
4.6%
4.6 pts better
|
5.1%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
77.1%
22.9 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.1% |
11.8%
4.7 pts better
|
12.0%
4.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.1% · Observed 6.2% · Expected 9.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 90.0% |
77.7%
12.3 pts better
|
79.7%
10.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 13.1% |
25.8%
12.7 pts better
|
23.9%
10.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 13.1% · Observed 9.4% · Expected 17.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-01 · Fire 2024-02-01
4 health deficiencies
Top issue: Administration (1 deficiency)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-03-31 · Fire 2022-03-31
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-02-01
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-03-08
D · Potential for more than minimal harm
2024-02-01
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-02-16
C · Minimal harm
2024-02-01
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-03-01
C · Minimal harm
2024-02-01
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-01
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-03-18
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2025-04-21
E · Potential for more than minimal harm
2025-03-18
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2025-04-28
E · Potential for more than minimal harm
2025-03-18
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2025-04-21
E · Potential for more than minimal harm
2025-03-18
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2025-04-21
D · Potential for more than minimal harm
2025-03-18
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-04-14
D · Potential for more than minimal harm
2025-03-18
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2025-04-21
D · Potential for more than minimal harm
2025-03-18
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-04-21
F · Potential for more than minimal harm
2024-02-01
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-02-02
F · Potential for more than minimal harm
2024-02-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-01
E · Potential for more than minimal harm
2024-02-01
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-02-08
D · Potential for more than minimal harm
2024-02-01
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2024-02-26
F · Potential for more than minimal harm
2022-03-31
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-04-14
D · Potential for more than minimal harm
2022-03-31
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-03-31
D · Potential for more than minimal harm
2022-03-31
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-04-22
D · Potential for more than minimal harm
2022-03-31
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2022-04-22
Penalties and ownership
What sits behind the stars
Ownership
Hilton, Valmai
5% Or Greater Direct Ownership Interest · Individual
Hilton, Linda
Corporate Director · Individual
Hilton, Linda
W-2 Managing Employee · Individual
Nearby options
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5-star overall rating with 5-star inspections with 2 fire-safety deficiencies in the latest cycle
#2
Royal Norwell Nursing & Rehabilitation Center LLC
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3-star overall rating with 3-star inspections with $114,868 in total fines with 3 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
Southwood At Norwell Nursing Ctr
Norwell, MA
5-star overall rating with 5-star inspections with 11 fire-safety deficiencies in the latest cycle
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