Cycle 1
Health 2025-12-03 · Fire 2025-12-03
8 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Stoughton, MA
Copley At Stoughton Nursing Care Center
5-star overall rating with 4-star inspections with $10,517 in total fines with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
380 Sumner Street, Stoughton, MA
(781) 341-2300
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
123
Certified beds
Average residents
103
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1994-11-15
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
0.92
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
0.75
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.30
Nurse aide staffing · state 2.26 · national 2.35
Total nurse hours
3.97
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.68
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.65
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.77
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.15
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
1.03
CMS adjusted RN staffing hours
Adjusted total hours
4.41
CMS adjusted total nurse staffing hours
Case-mix index
1.23
Higher values indicate more complex resident acuity
RN turnover
24%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
24%
Annual nurse turnover · state 40% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,097
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
59.92
Composite VBP score used to determine payment impact.
Payment multiplier
1.0151
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.58
Baseline 20.27% · Performance 18.38% · Measure score 6.58 · Achievement 6.58 · Improvement 5.32
Healthcare-associated infections
2.99
Baseline 8.17% · Performance 7.06% · Measure score 2.99 · Achievement 2.59 · Improvement 2.99
Total nurse turnover
10
Baseline 44.76% · Performance 22.34% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
4.4
Baseline 4.15 hours · Performance 4.33 hours · Measure score 4.4 · Achievement 4.4 · Improvement 0.58
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.06% |
10.72%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 412 · Observed rate 10.44% · Lower 95% interval 9.57% |
| Discharge to community | 65.13% |
50.57%
14.6 pts better
|
Better than the National Rate · Eligible stays 421 · Observed rate 63.66% · Lower 95% interval 61.12% |
| Medicare spending per beneficiary | 0.94 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 98.44% |
95.27%
3.2 pts better
|
Numerator 253 · Denominator 257 |
| Falls with major injury | 0.39% |
0.77%
0.4 pts better
|
Numerator 1 · Denominator 257 |
| Discharge self-care score | 63.77% |
53.69%
10.1 pts better
|
Numerator 132 · Denominator 207 |
| Discharge mobility score | 68.6% |
50.94%
17.7 pts better
|
Numerator 142 · Denominator 207 |
| Pressure ulcers or injuries, new or worsened | 1.17% |
2.29%
1.1 pts better
|
Numerator 3 · Denominator 257 · Adjusted rate 1.32% |
| Healthcare-associated infections requiring hospitalization | 7.06% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 265 · Observed rate 5.66% · Lower 95% interval 4.87% |
| Staff COVID-19 vaccination coverage | 24.84% |
8.2%
16.6 pts better
|
Numerator 40 · Denominator 161 |
| Staff flu vaccination coverage | 55.02% |
42%
13 pts better
|
Numerator 115 · Denominator 209 |
| Discharge function score | 67.15% |
56.45%
10.7 pts better
|
Numerator 139 · Denominator 207 |
| Transfer of health information to provider | 92.5% |
95.95%
3.5 pts worse
|
Numerator 37 · Denominator 40 |
| Transfer of health information to patient | 98.92% |
96.28%
2.6 pts better
|
Numerator 184 · Denominator 186 |
| Resident COVID-19 vaccinations up to date | 34.17% |
25.2%
9 pts better
|
Numerator 41 · Denominator 120 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
1.9
0.6 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.1 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
1.5
0.5 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.8 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 84.2% |
92.2%
8 pts worse
|
93.4%
9.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 92.0% · Q2 91.8% · Q3 70.5% · Q4 81.0% · 4Q avg 84.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 88.2% |
94.8%
6.6 pts worse
|
95.5%
7.3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 88.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.8% |
3.5%
1.3 pts worse
|
3.3%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 4.7% · Q3 7.7% · Q4 5.1% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.6% |
12.0%
11.4 pts better
|
11.4%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.2% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% |
| Percentage of long-stay residents who lose too much weight | 5.4% |
5.2%
0.2 pts worse
|
5.4%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 5.9% · Q3 3.2% · Q4 3.4% · 4Q avg 5.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.6% |
19.2%
0.4 pts worse
|
19.6%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 25.3% · Q2 17.8% · Q3 19.4% · Q4 15.2% · 4Q avg 19.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.4% |
22.5%
9.1 pts better
|
16.7%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.0% · Q2 13.0% · Q3 12.5% · Q4 13.0% · 4Q avg 13.4% · 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 | 19.4% |
17.7%
1.7 pts worse
|
16.3%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.3% · Q2 22.9% · Q3 15.7% · Q4 22.9% · 4Q avg 19.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.4% |
17.6%
0.8 pts worse
|
14.9%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.7% · Q2 19.7% · Q3 17.2% · Q4 14.5% · 4Q avg 18.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.2% |
1.0%
1.2 pts worse
|
1.0%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 1.9% · Q3 3.2% · Q4 3.0% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.2% |
2.0%
1.2 pts worse
|
1.7%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 2.5% · Q3 2.7% · Q4 1.4% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.0% |
21.7%
2.7 pts better
|
19.8%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.5% · Q2 22.2% · Q3 19.1% · Q4 14.5% · 4Q avg 19.0% |
| Percentage of long-stay residents with pressure ulcers | 2.8% |
4.6%
1.8 pts better
|
5.1%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 3.0% · Q3 2.5% · Q4 2.4% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 41.7% |
77.1%
35.4 pts worse
|
81.7%
40 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 53.1% · Q2 45.3% · Q3 36.9% · Q4 33.1% · 4Q avg 41.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.8% |
11.8%
4 pts better
|
12.0%
4.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.8% · Observed 6.8% · Expected 9.7% · 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 · 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 who were assessed and appropriately given the seasonal influenza vaccine | 63.6% |
77.7%
14.1 pts worse
|
79.7%
16.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 63.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.5% |
25.8%
7.3 pts better
|
23.9%
5.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.5% · Observed 14.8% · Expected 19.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-10-08 · Fire 2024-10-08
8 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-07-31 · Fire 2023-07-31
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
14 fire-safety deficiencies
Top issue: Emergency Preparedness (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-12-03
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2026-01-30
F · Potential for more than minimal harm
2025-12-03
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2026-01-30
D · Potential for more than minimal harm
2025-12-03
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2026-01-30
F · Potential for more than minimal harm
2024-10-08
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-11-04
F · Potential for more than minimal harm
2024-10-08
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-11-04
D · Potential for more than minimal harm
2024-10-08
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-11-04
F · Potential for more than minimal harm
2023-07-31
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2023-10-06
F · Potential for more than minimal harm
2023-07-31
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-10-06
F · Potential for more than minimal harm
2023-07-31
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-10-06
F · Potential for more than minimal harm
2023-07-31
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-09-22
F · Potential for more than minimal harm
2023-07-31
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-10-06
F · Potential for more than minimal harm
2023-07-31
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-10-06
F · Potential for more than minimal harm
2023-07-31
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-10-06
F · Potential for more than minimal harm
2023-07-31
K522 · Services Deficiencies
Fire Safety
Have an externally vented heating system.
Corrected 2023-09-29
F · Potential for more than minimal harm
2023-07-31
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-09-29
F · Potential for more than minimal harm
2023-07-31
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-09-29
F · Potential for more than minimal harm
2023-07-31
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-10-06
E · Potential for more than minimal harm
2023-07-31
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2023-09-29
E · Potential for more than minimal harm
2023-07-31
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-09-29
E · Potential for more than minimal harm
2023-07-31
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-09-29
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-14
F627 · Resident Rights Deficiencies
Health
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Corrected 2026-02-06
E · Potential for more than minimal harm
2025-12-03
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 2025-12-30
D · Potential for more than minimal harm
2025-12-03
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-12-30
D · Potential for more than minimal harm
2025-12-03
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 2025-12-30
D · Potential for more than minimal harm
2025-12-03
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2025-12-30
D · Potential for more than minimal harm
2025-12-03
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 2025-12-30
D · Potential for more than minimal harm
2025-12-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-12-30
B · Minimal harm
2025-12-03
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-12-30
F · Potential for more than minimal harm
2024-10-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-26
E · Potential for more than minimal harm
2024-10-08
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-10-26
E · Potential for more than minimal harm
2024-10-08
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 2024-10-26
D · Potential for more than minimal harm
2024-10-08
F551 · Resident Rights Deficiencies
Health
Give the resident's representative the ability to exercise the resident's rights.
Corrected 2024-10-26
D · Potential for more than minimal harm
2024-10-08
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-10-26
D · Potential for more than minimal harm
2024-10-08
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-10-26
B · Minimal harm
2024-10-08
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2024-10-11
B · Minimal harm
2024-10-08
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-11-20
G · Actual harm
2023-07-31
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 2023-08-01
E · Potential for more than minimal harm
2023-07-31
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-08-01
D · Potential for more than minimal harm
2023-07-31
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 2023-08-18
D · Potential for more than minimal harm
2023-07-31
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-08-18
D · Potential for more than minimal harm
2023-07-31
F808 · Nutrition and Dietary Deficiencies
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2023-08-18
D · Potential for more than minimal harm
2023-07-31
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-08-18
Penalties and ownership
What sits behind the stars
$10,517
2023-07-31
Fine
Fine · fine $10,517
Fine
Ownership
Goddard Restorative Care Unit In
5% Or Greater Direct Ownership Interest · Organization
Saving Long Term Care Corporation
5% Or Greater Direct Ownership Interest · Organization
Connor, Maria
Operational/Managerial Control · Individual
Goddard Restorative Care Unit In
General Partnership Interest · Organization
O'connell Unda, Maria
Corporate Director · Individual
Saving Long Term Care Corporation
General Partnership Interest · Organization
Tyer, Steven
Operational/Managerial Control · Individual
Nearby options
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#2
Alliance Health At West Acres
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4-star overall rating with 4-star inspections with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Brockton Post Acute Care
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3-star overall rating with 3-star inspections with 7 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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