Federal inspection record · CMS data as of October 1, 2026
Country Gardens Health and Rehabilitation
2045 Grand Army Highway, Swansea, MA · (508) 379-9700
- Special Focus Facility
- Certified beds
- 86
- Residents per day
- 69
- Ownership
- For-Profit
- Chain
- No chain reported
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- February 1, 1975
1
How this home got 1 star
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
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Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in Massachusetts.
-
Staffing
★★★★★no change
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
-
Quality measures
★★★★★no change (already 1)
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
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Overall
★★★★★1 of 5
Matches the rating CMS publishes on Care Compare.
2
Where it sits among Massachusetts homes
Country Gardens Health and Rehabilitation carries 159 inspection points. That is fewer than 2% of Massachusetts's 339 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in Massachusetts: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–6 pts
- 4★ 6–24 pts
- 3★ 24–41 pts
- 2★ 41–76 pts
- 1★ over 76 pts
Bars show every rated home in Massachusetts by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
58 health citations on record since 2023. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
No citation on record at the harm or immediate-jeopardy level.
Everything else, by area of care
Resident Assessment and Care Planning13E
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- E
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- E
Ensure services provided by the nursing facility meet professional standards of quality.
- E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
- D
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
- B
Ensure each resident receives an accurate assessment.
- E
Ensure services provided by the nursing facility meet professional standards of quality.
- B
Ensure each resident receives an accurate assessment.
- B
Ensure a qualified health professional conducts resident assessments.
Quality of Life and Care10F
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F
Ensure the activities program is directed by a qualified professional.
- E
Provide activities to meet all resident's needs.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
- D
Provide safe and appropriate respiratory care for a resident when needed.
- D
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
- E
Provide safe and appropriate respiratory care for a resident when needed.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Resident Rights9E
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- D
Keep residents' personal and medical records private and confidential.
- D
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.
- D
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
- E
Honor the resident's right to organize and participate in resident/family groups in the facility.
- E
Keep residents' personal and medical records private and confidential.
- E
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Administration8F
- F
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
- E
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
- F
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
- E
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
- E
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
- E
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
- E
Provide training in compliance and ethics.
- E
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Pharmacy Service7E
- D
Ensure medication error rates are not 5 percent or greater.
- E
Ensure each resident’s drug regimen must be free from unnecessary drugs.
- E
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.
- E
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.
- D
Ensure that residents are free from significant medication errors.
- E
Ensure medication error rates are not 5 percent or greater.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Infection Control6F
- F
Provide and implement an infection prevention and control program.
- E
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
- E
Provide and implement an infection prevention and control program.
- E
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
- F
Perform COVID19 testing on residents and staff.
- E
Provide and implement an infection prevention and control program.
Nutrition and Dietary2F
- D
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nursing and Physician Services2E
- E
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
- E
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Freedom from Abuse, Neglect, and Exploitation1D
- D
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Inspection history
2025-06-23
13 health deficiencies · 2 fire-safety deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
2024-07-01
35 health deficiencies · 0 fire-safety deficiencies
Top issue: Resident Assessment and Care Planning (7 deficiencies)
2023-03-28
10 health deficiencies · 1 fire-safety deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
4
Nursing time per resident, per day
Each resident here gets about 3 h 37 min of nursing staff time a day, 34 min of it from a registered nurse.
This home
3 h 37 min
Massachusetts average
3 h 56 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Fines and payment denials
$24,635 in federal fines on record over the past three years.
| Date | Penalty | Amount |
|---|---|---|
| 2024-07-01 | Fine | $15,139 |
| 2024-02-20 | Fine | $2,659 |
| 2024-02-12 | Fine | $2,279 |
| 2024-01-22 | Fine | $4,558 |
6
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days0.2 pts worse | 2.0 | 1.8 | 1.8 |
| Number of outpatient emergency department visits per 1000 long-stay resident days0.4 pts worse | 1.8 | 1.4 | 1.7 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine1 pts worse | 91.9% | 92.9% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine2.2 pts better | 95.7% | 93.5% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury1.1 pts better | 2.3% | 3.4% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms22.8 pts worse | 40.2% | 17.4% | 13.5% |
| Percentage of long-stay residents who lose too much weight3.1 pts worse | 8.1% | 5.0% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication2.2 pts worse | 21.7% | 19.5% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication6.1 pts worse | 27.6% | 21.5% | 15.4% |
| Percentage of long-stay residents who were physically restrained0.1 pts better | 0.0% | 0.1% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened1.7 pts worse | 15.6% | 13.9% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased16.5 pts worse | 32.3% | 15.8% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder0.7 pts better | 0.0% | 0.7% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection0.9 pts better | 0.8% | 1.7% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence0.1 pts worse | 20.5% | 20.4% | 18.3% |
| Percentage of long-stay residents with pressure ulcers1.9 pts worse | 6.1% | 4.2% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine17.8 pts worse | 61.1% | 78.9% | 82.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit7.6 pts worse | 19.4% | 11.8% | 11.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication1.4 pts better | 0.0% | 1.4% | 1.5% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine29.4 pts worse | 48.7% | 78.1% | 80.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission3.4 pts worse | 29.1% | 25.7% | 23.4% |
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Fire safety
3 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Smoke1C
- C
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Miscellaneous1C
- C
Provide properly sized and located linen or trash receptacles.
Gas, Vacuum, and Electrical Systems1F
- F
Meet requirements for the installation and maintenance of electrical systems.
·
Other homes nearby
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★★★★★
- Worst citation, 3 yrs
- E
- Nursing / resident / day
- 3 h 30 min
- Fines
- $0
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Grace Barker Nursing Center
Warren, RI
★★★★★- Worst citation, 3 yrs
- E
- Nursing / resident / day
- 3 h 50 min
- Fines
- $0
-
Warren Operations RI, LLC DBA Warren Center
Warren, RI
★★★★★- Worst citation, 3 yrs
- E
- Nursing / resident / day
- 3 h 46 min
- Fines
- $0