13 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Natick, MA
2-star overall rating with 2-star inspections with 13 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
168 West Central Street, Natick, MA
(508) 655-1000
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Beds
114
Certified beds
Average residents
99
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Azure Healthcare
Operator or chain grouping
Approved since
1990-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
6 facilities
Chain averages 1 overall / 1 health / 2 staffing / 2 quality stars
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
RN hours / resident day
0.28
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.10
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
3.42
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.38
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.20
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.34
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.31
CMS adjusted RN staffing hours
Adjusted total hours
3.73
CMS adjusted total nurse staffing hours
Case-mix index
1.25
Higher values indicate more complex resident acuity
RN turnover
58%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
35%
Annual nurse turnover · state 40% · national 46%
SNF VBP
Program rank
7,614
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
29.26
Composite VBP score used to determine payment impact.
Payment multiplier
0.9854
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
2.18
Baseline 19.90% · Performance 20.42% · Measure score 2.18 · Achievement 2.18 · Improvement 0
Healthcare-associated infections
2.26
Baseline 6.16% · Performance 7.16% · Measure score 2.26 · Achievement 2.26 · Improvement 0
Total nurse turnover
5.55
Baseline 52.24% · Performance 40.98% · Measure score 5.55 · Achievement 5.55 · Improvement 3.61
Adjusted total nurse staffing
1.71
Baseline 4.44 hours · Performance 3.56 hours · Measure score 1.71 · Achievement 1.71 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.6% |
10.72%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 64 · Observed rate 15.63% · Lower 95% interval 7.63% |
| Discharge to community | 41.27% |
50.57%
9.3 pts worse
|
No Different than the National Rate · Eligible stays 60 · Observed rate 28.33% · Lower 95% interval 28.97% |
| Medicare spending per beneficiary | 0.99 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 83.61% |
95.27%
11.7 pts worse
|
Numerator 51 · Denominator 61 |
| Falls with major injury | 1.64% |
0.77%
0.9 pts worse
|
Numerator 1 · Denominator 61 |
| Discharge self-care score | 53.49% |
53.69%
0.2 pts worse
|
Numerator 23 · Denominator 43 |
| Discharge mobility score | 41.86% |
50.94%
9.1 pts worse
|
Numerator 18 · Denominator 43 |
| Pressure ulcers or injuries, new or worsened | 3.28% |
2.29%
1 pts worse
|
Numerator 2 · Denominator 61 · Adjusted rate 2.53% |
| Healthcare-associated infections requiring hospitalization | 7.16% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 48 · Observed rate 10.42% · Lower 95% interval 4.14% |
| Staff COVID-19 vaccination coverage | 44.19% |
8.2%
36 pts better
|
Numerator 38 · Denominator 86 |
| Staff flu vaccination coverage | 24.1% |
42%
17.9 pts worse
|
Numerator 20 · Denominator 83 |
| Discharge function score | 60.47% |
56.45%
4 pts better
|
Numerator 26 · Denominator 43 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 39.39% |
25.2%
14.2 pts better
|
Numerator 13 · Denominator 33 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
1.9
0.2 pts better
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 2.0 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.3 |
1.5
0.8 pts worse
|
1.8
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.5 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 92.3% |
92.2%
0.1 pts better
|
93.4%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 92.3% · Q2 98.9% · Q3 95.7% · Q4 82.6% · 4Q avg 92.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 93.9% |
94.8%
0.9 pts worse
|
95.5%
1.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 93.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.8% |
3.5%
0.3 pts worse
|
3.3%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 4.5% · Q3 4.3% · Q4 4.3% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.2% |
12.0%
7.8 pts better
|
11.4%
7.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 5.2% · Q3 4.9% · Q4 2.6% · 4Q avg 4.2% |
| Percentage of long-stay residents who lose too much weight | 9.3% |
5.2%
4.1 pts worse
|
5.4%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 12.5% · Q3 11.8% · Q4 5.9% · 4Q avg 9.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.0% |
19.2%
5.2 pts better
|
19.6%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.9% · Q2 14.5% · Q3 14.8% · Q4 13.8% · 4Q avg 14.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 24.3% |
22.5%
1.8 pts worse
|
16.7%
7.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.0% · Q2 20.8% · Q3 23.1% · Q4 28.6% · 4Q avg 24.3% · 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 | 24.9% |
17.7%
7.2 pts worse
|
16.3%
8.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.4% · Q2 30.0% · Q3 27.1% · Q4 18.4% · 4Q avg 24.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 27.0% |
17.6%
9.4 pts worse
|
14.9%
12.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.0% · Q2 27.4% · Q3 24.7% · Q4 24.4% · 4Q avg 27.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.3% |
1.0%
0.3 pts worse
|
1.0%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.0% · Q3 1.7% · Q4 2.4% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.4% |
2.0%
0.6 pts better
|
1.7%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.2% · Q3 2.2% · Q4 2.2% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.0% |
21.7%
6.3 pts worse
|
19.8%
8.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 41.3% · Q2 22.6% · Q3 24.5% · Q4 22.9% · 4Q avg 28.0% |
| Percentage of long-stay residents with pressure ulcers | 6.2% |
4.6%
1.6 pts worse
|
5.1%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 5.0% · Q3 6.5% · Q4 8.9% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 54.9% |
77.1%
22.2 pts worse
|
81.7%
26.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 43.6% · Q2 57.1% · Q3 61.1% · Q4 57.7% · 4Q avg 54.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.5% |
11.8%
1.3 pts better
|
12.0%
1.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.5% · Observed 12.0% · Expected 12.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.7% |
1.3%
1.4 pts worse
|
1.6%
1.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 0.0% · Q3 3.0% · Q4 3.7% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 59.4% |
77.7%
18.3 pts worse
|
79.7%
20.3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 59.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.6% |
25.8%
7.2 pts better
|
23.9%
5.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.6% · Observed 22.0% · Expected 28.3% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (3 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Resident Assessment and Care Planning (4 deficiencies)
2 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Top issue: Quality of Life and Care (7 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-03-04
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-03-04
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-04
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-03-04
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-03-04
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-04
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-03-04
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-01-09
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-01-09
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2022-04-29
Fire Safety
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.
Corrected 2022-04-29
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2022-04-29
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-04-29
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-04-29
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-04-29
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2022-04-29
Inspection history
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-02-13
Health
Post nurse staffing information every day.
Corrected 2025-02-13
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-02-13
Health
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.
Corrected 2025-02-13
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 2025-02-13
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-02-13
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-02-13
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-02-13
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 2025-02-13
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 2025-02-13
Health
Provide or obtain dental services for each resident.
Corrected 2025-02-13
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-13
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-02-13
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-12-19
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-12-19
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-12-19
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 2023-12-19
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-12-19
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2023-12-19
Health
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
Corrected 2023-12-19
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-12-19
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-12-19
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-12-19
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-19
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-12-19
Health
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.
Corrected 2022-04-18
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-04-18
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2022-04-18
Health
Assess the resident when there is a significant change in condition
Corrected 2022-04-18
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-04-18
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-04-18
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2022-04-18
Health
Honor each resident's preferences, choices, values and beliefs.
Corrected 2022-04-18
Health
Provide activities to meet all resident's needs.
Corrected 2022-04-18
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-04-18
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-04-18
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-04-18
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 2022-04-18
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-04-18
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2022-04-18
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2022-04-18
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 2022-04-18
Penalties and ownership
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Natick, MA
3-star overall rating with 4-star inspections with $10,517 in total fines with 3 recent health deficiencies with 17 fire-safety deficiencies in the latest cycle
Natick, MA
4-star overall rating with 4-star inspections with $30,186 in total fines
Framingham, MA
4-star overall rating with 4-star inspections with $8,512 in total fines with 6 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
Jump out