Swansea, MA

Country Gardens Health And Rehabilitation Center

1-star overall rating with 1-star inspections with $24,635 in total fines with 17 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle

2045 Grand Army Highway, Swansea, MA

(508) 379-9700

Compare this facility

Overall

1 / 5

CMS overall stars

Health inspections

1 / 5

Survey and complaint cycles

Staffing

1 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Alpha SNF Ma

Operator or chain grouping

Approved since

1975-02-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

5 facilities

Chain averages 2 overall / 1 health / 2 staffing / 3 quality stars

Changed ownership

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

0.42

Registered nurse staffing · state 0.65 · national 0.68

LPN hours / resident day

0.78

Licensed practical nurse staffing · state 0.96 · national 0.87

Aide hours / resident day

2.04

Nurse aide staffing · state 2.26 · national 2.35

Total nurse hours

3.24

All reported nurse hours · state 3.86 · national 3.89

Licensed hours

1.20

RN + LPN hours · state 1.60 · national 1.54

Weekend hours

2.92

Weekend nurse staffing · state 3.45 · national 3.43

Weekend RN hours

0.39

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

0.43

CMS adjusted RN staffing hours

Adjusted total hours

3.26

CMS adjusted total nurse staffing hours

Case-mix index

1.36

Higher values indicate more complex resident acuity

RN turnover

Annual RN turnover

Total nurse turnover

Annual nurse turnover

SNF VBP

Value-based purchasing

Program rank

6,452

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

32.80

Composite VBP score used to determine payment impact.

Payment multiplier

0.9873

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

5.33

Baseline 16.90% · Performance 18.96% · Measure score 5.33 · Achievement 5.33 · Improvement 0

Healthcare-associated infections

3.10

Baseline 5.17% · Performance 6.91% · Measure score 3.10 · Achievement 3.10 · Improvement 0

Total nurse turnover

4.69

Baseline 67.69% · Performance 45.45% · Measure score 4.69 · Achievement 4.46 · Improvement 4.69

Adjusted total nurse staffing

Baseline 3.43 hours · Performance 2.49 hours · Measure score 0 · Achievement 0 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	9.32%	10.72% 1.4 pts better	No Different than the National Rate · Eligible stays 113 · Observed rate 6.19% · Lower 95% interval 6.27%
Discharge to community	46.81%	50.57% 3.8 pts worse	No Different than the National Rate · Eligible stays 94 · Observed rate 39.36% · Lower 95% interval 38.06%
Medicare spending per beneficiary	0.82	1.02 0.2 pts better
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 57 · Denominator 57
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 57
Discharge self-care score	27.27%	53.69% 26.4 pts worse	Numerator 9 · Denominator 33
Discharge mobility score	30.3%	50.94% 20.6 pts worse	Numerator 10 · Denominator 33
Pressure ulcers or injuries, new or worsened	3.51%	2.29% 1.2 pts worse	Numerator 2 · Denominator 57 · Adjusted rate 4.35%
Healthcare-associated infections requiring hospitalization	6.91%	7.12% 0.2 pts better	No Different than the National Rate · Eligible stays 75 · Observed rate 6.67% · Lower 95% interval 3.56%
Staff COVID-19 vaccination coverage	100%	8.2% 91.8 pts better	Numerator 87 · Denominator 87
Staff flu vaccination coverage	43.82%	42% 1.8 pts better	Numerator 39 · Denominator 89
Discharge function score	30.3%	56.45% 26.2 pts worse	Numerator 10 · Denominator 33
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly.
Transfer of health information to patient	100%	96.28% 3.7 pts better	Numerator 29 · Denominator 29
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 19 · 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	1.6	1.9 0.3 pts better	1.9 0.3 pts better	Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.2 · Expected 1.5 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	2.5	1.5 1 pts worse	1.8 0.7 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.1 · Expected 1.4 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	89.8%	92.2% 2.4 pts worse	93.4% 3.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 87.0% · Q2 84.6% · Q3 90.6% · Q4 97.0% · 4Q avg 89.8%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	94.2%	94.8% 0.6 pts worse	95.5% 1.3 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 94.2%
Percentage of long-stay residents experiencing one or more falls with major injury	3.4%	3.5% 0.1 pts better	3.3% 0.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 6.2% · Q3 1.6% · Q4 1.5% · 4Q avg 3.4% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	26.9%	12.0% 14.9 pts worse	11.4% 15.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 20.6% · Q3 31.1% · Q4 53.3% · 4Q avg 26.9%
Percentage of long-stay residents who lose too much weight	6.1%	5.2% 0.9 pts worse	5.4% 0.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 5.9% · Q3 4.4% · Q4 4.3% · 4Q avg 6.1%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	20.5%	19.2% 1.3 pts worse	19.6% 0.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 26.3% · Q2 15.4% · Q3 19.6% · Q4 20.0% · 4Q avg 20.5%
Percentage of long-stay residents who received an antipsychotic medication	16.2%	22.5% 6.3 pts better	16.7% 0.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 19.0% · Q2 17.9% · Q3 12.8% · Q4 15.0% · 4Q avg 16.2% · 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	24.1%	17.7% 6.4 pts worse	16.3% 7.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 17.1% · Q2 40.0% · Q3 23.6% · Q4 10.9% · 4Q avg 24.1% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	23.6%	17.6% 6 pts worse	14.9% 8.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 20.8% · Q2 25.0% · Q3 25.6% · Q4 23.4% · 4Q avg 23.6% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.0%	1.0% 1 pts better	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% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	1.2%	2.0% 0.8 pts better	1.7% 0.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.6% · Q3 3.2% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	22.3%	21.7% 0.6 pts worse	19.8% 2.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 26.1% · Q2 19.9% · Q3 26.7% · Q4 16.3% · 4Q avg 22.3%
Percentage of long-stay residents with pressure ulcers	3.5%	4.6% 1.1 pts better	5.1% 1.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 2.7% · Q3 4.6% · Q4 5.3% · 4Q avg 3.5% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	65.7%	77.1% 11.4 pts worse	81.7% 16 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 55.3% · Q2 64.4% · Q3 72.5% · Q4 73.5% · 4Q avg 65.7%
Percentage of short-stay residents who had an outpatient emergency department visit	10.7%	11.8% 1.1 pts better	12.0% 1.3 pts better	Short Stay · 20240701-20250630 · Adjusted 10.7% · Observed 11.6% · Expected 12.2% · 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% · 4Q avg 0.0% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	61.7%	77.7% 16 pts worse	79.7% 18 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 61.7%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	20.2%	25.8% 5.6 pts better	23.9% 3.7 pts better	Short Stay · 20240701-20250630 · Adjusted 20.2% · Observed 20.9% · Expected 24.8% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-06-23 · Fire 2025-06-23

17 health deficiencies

Top issue: Resident Rights (5 deficiencies)

2 fire-safety deficiencies

Top issue: Miscellaneous (1 deficiency)

Cycle 2 Health 2024-07-01 · Fire 2024-07-01

31 health deficiencies

Top issue: Administration (6 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 3 Health 2023-03-28 · Fire 2023-03-28

11 health deficiencies

Top issue: Infection Control (3 deficiencies)

1 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)

Fire safety

Fire-safety citations

C · Minimal harm 2025-06-23

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 2025-07-09

C · Minimal harm 2025-06-23

K754 · Miscellaneous Deficiencies

Fire Safety

Provide properly sized and located linen or trash receptacles.

Corrected 2025-07-09

F · Potential for more than minimal harm 2023-03-28

K911 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Meet requirements for the installation and maintenance of electrical systems.

Corrected 2023-06-15

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-09-10

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2025-10-16

D · Potential for more than minimal harm 2025-09-10

F805 · Nutrition and Dietary Deficiencies

Health

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Corrected 2025-10-16

D · Potential for more than minimal harm 2025-09-10

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 2025-10-16

F · Potential for more than minimal harm 2025-06-23

F851 · Administration Deficiencies

Health

Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.

Corrected 2025-07-21

F · Potential for more than minimal harm 2025-06-23

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-07-21

E · Potential for more than minimal harm 2025-06-23

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 2025-07-21

E · Potential for more than minimal harm 2025-06-23

F867 · Administration Deficiencies

Health

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Corrected 2025-07-21

E · Potential for more than minimal harm 2025-06-23

F887 · Infection Control Deficiencies

Health

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.

Corrected 2025-07-21

D · Potential for more than minimal harm 2025-06-23

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 2025-07-21

D · Potential for more than minimal harm 2025-06-23

F583 · Resident Rights Deficiencies

Health

Keep residents' personal and medical records private and confidential.

Corrected 2025-07-21

D · Potential for more than minimal harm 2025-06-23

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 2025-07-21

D · Potential for more than minimal harm 2025-06-23

F655 · Resident Assessment and Care Planning Deficiencies

Health

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Corrected 2025-07-21

D · Potential for more than minimal harm 2025-06-23

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 2025-07-21

D · Potential for more than minimal harm 2025-06-23

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2025-07-21

D · Potential for more than minimal harm 2025-06-23

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 2025-07-21

D · Potential for more than minimal harm 2025-06-23

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2025-07-21

D · Potential for more than minimal harm 2025-04-22

F557 · Resident Rights Deficiencies

Health

Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

Corrected 2025-04-07

F · Potential for more than minimal harm 2024-07-01

F680 · Quality of Life and Care Deficiencies

Health

Ensure the activities program is directed by a qualified professional.

Corrected 2024-08-09

F · Potential for more than minimal harm 2024-07-01

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 2024-08-09

F · Potential for more than minimal harm 2024-07-01

F868 · Administration Deficiencies

Health

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Corrected 2024-08-09