Cycle 1
Health 2025-09-12 · Fire 2025-09-12
4 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Middleboro, MA
Hannah B G Shaw Home
4-star overall rating with 3-star inspections with 4 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
299 Wareham Street, Middleboro, MA
(508) 947-1184
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
107
Certified beds
Average residents
63
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1992-01-29
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
0.93
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.96
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
3.02
Nurse aide staffing · state 2.26 · national 2.35
Total nurse hours
5.91
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
2.89
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
5.61
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.82
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.98
CMS adjusted RN staffing hours
Adjusted total hours
6.28
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
37%
Annual nurse turnover · state 40% · national 46%
SNF VBP
Value-based purchasing
Program rank
508
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
68.59
Composite VBP score used to determine payment impact.
Payment multiplier
1.0216
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.38
Baseline 19.42% · Performance 20.33% · Measure score 2.38 · Achievement 2.38 · Improvement 0
Healthcare-associated infections
10
Baseline 7.20% · Performance 4.31% · Measure score 10 · Achievement 10 · Improvement 9
Total nurse turnover
6.25
Baseline 41.59% · Performance 38.14% · Measure score 6.25 · Achievement 6.25 · Improvement 1.56
Adjusted total nurse staffing
8.81
Baseline 5.84 hours · Performance 5.58 hours · Measure score 8.81 · Achievement 8.81 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.55% |
10.72%
1.2 pts better
|
No Different than the National Rate · Eligible stays 431 · Observed rate 6.03% · Lower 95% interval 7.14% |
| Discharge to community | 68.49% |
50.57%
17.9 pts better
|
Better than the National Rate · Eligible stays 440 · Observed rate 77.5% · Lower 95% interval 65.63% |
| Medicare spending per beneficiary | 0.72 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 242 · Denominator 242 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 242 |
| Discharge self-care score | 80.68% |
53.69%
27 pts better
|
Numerator 167 · Denominator 207 |
| Discharge mobility score | 81.16% |
50.94%
30.2 pts better
|
Numerator 168 · Denominator 207 |
| Pressure ulcers or injuries, new or worsened | 1.65% |
2.29%
0.6 pts better
|
Numerator 4 · Denominator 242 · Adjusted rate 2.03% |
| Healthcare-associated infections requiring hospitalization | 4.31% |
7.12%
2.8 pts better
|
No Different than the National Rate · Eligible stays 235 · Observed rate 0.43% · Lower 95% interval 2.4% |
| Staff COVID-19 vaccination coverage | 8.51% |
8.2%
0.3 pts better
|
Numerator 16 · Denominator 188 |
| Staff flu vaccination coverage | 40.84% |
42%
1.2 pts worse
|
Numerator 78 · Denominator 191 |
| Discharge function score | 81.64% |
56.45%
25.2 pts better
|
Numerator 169 · Denominator 207 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 31 · Denominator 31 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 188 · Denominator 188 |
| Resident COVID-19 vaccinations up to date | 45.9% |
25.2%
20.7 pts better
|
Numerator 56 · Denominator 122 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.6 |
1.9
0.7 pts worse
|
1.9
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 1.6 · Expected 1.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
1.5
0.2 pts better
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.0 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.5% |
92.2%
7.3 pts better
|
93.4%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 98.0% · 4Q avg 99.5% |
| 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 | 11.7% |
3.5%
8.2 pts worse
|
3.3%
8.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.3% · Q2 9.4% · Q3 13.7% · Q4 12.2% · 4Q avg 11.7% · 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 | 4.7% |
5.2%
0.5 pts better
|
5.4%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 7.3% · Q3 2.9% · Q4 0.0% · 4Q avg 4.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 27.1% |
19.2%
7.9 pts worse
|
19.6%
7.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.2% · Q2 28.6% · Q3 22.9% · Q4 25.7% · 4Q avg 27.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.7% |
22.5%
7.8 pts better
|
16.7%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.9% · Q2 13.5% · Q3 10.0% · Q4 15.6% · 4Q avg 14.7% · 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 | 19.8% |
17.7%
2.1 pts worse
|
16.3%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.8% · Q2 15.8% · 4Q avg 19.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.4% |
17.6%
2.8 pts worse
|
14.9%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 18.4% · Q3 25.0% · Q4 12.5% · 4Q avg 20.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.9% |
1.0%
0.9 pts worse
|
1.0%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 1.5% · Q3 3.0% · Q4 1.5% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.5% |
2.0%
1.5 pts better
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 35.2% |
21.7%
13.5 pts worse
|
19.8%
15.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.4% · Q2 36.7% · Q3 41.7% · Q4 37.0% · 4Q avg 35.2% |
| Percentage of long-stay residents with pressure ulcers | 3.3% |
4.6%
1.3 pts better
|
5.1%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 4.6% · Q3 2.3% · Q4 1.4% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
77.1%
22.7 pts better
|
81.7%
18.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 99.1% · 4Q avg 99.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.8% |
11.8%
1 pts worse
|
12.0%
0.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.8% · Observed 10.2% · Expected 9.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.3% |
1.3%
1 pts better
|
1.6%
1.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.7% |
77.7%
19 pts better
|
79.7%
17 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.3% |
25.8%
0.5 pts worse
|
23.9%
2.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.3% · Observed 17.6% · Expected 15.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-09-12 · Fire 2024-09-12
10 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
4 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Cycle 3
Health 2023-07-11 · Fire 2023-07-11
0 health deficiencies
No concentrated health issue counts in this cycle.
4 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-09-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2026-02-09
D · Potential for more than minimal harm
2025-09-12
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2026-02-09
D · Potential for more than minimal harm
2025-09-12
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2026-02-09
D · Potential for more than minimal harm
2025-09-12
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2026-02-09
C · Minimal harm
2025-09-12
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2026-02-09
D · Potential for more than minimal harm
2024-09-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-08
C · Minimal harm
2024-09-12
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-11-08
C · Minimal harm
2024-09-12
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-11-08
C · Minimal harm
2024-09-12
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-11-08
C · Minimal harm
2023-07-11
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-09-30
C · Minimal harm
2023-07-11
K226 · Egress Deficiencies
Fire Safety
Have horizontal exits used in accordance with safety requirements.
Corrected 2023-08-31
C · Minimal harm
2023-07-11
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-07-28
C · Minimal harm
2023-07-11
K907 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure medical gas and vacuum systems have documented maintenance programs.
Corrected 2023-09-30
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-09-12
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 2025-11-03
D · Potential for more than minimal harm
2025-09-12
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 2025-11-03
D · Potential for more than minimal harm
2025-09-12
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2025-11-03
D · Potential for more than minimal harm
2025-09-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-11-03
F · Potential for more than minimal harm
2024-09-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-25
E · Potential for more than minimal harm
2024-09-12
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-10-25
E · Potential for more than minimal harm
2024-09-12
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 2024-10-25
E · Potential for more than minimal harm
2024-09-12
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-10-25
E · Potential for more than minimal harm
2024-09-12
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 2024-10-25
E · Potential for more than minimal harm
2024-09-12
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 2024-10-25
D · Potential for more than minimal harm
2024-09-12
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 2024-10-25
D · Potential for more than minimal harm
2024-09-12
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 2024-10-25
D · Potential for more than minimal harm
2024-09-12
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-10-25
D · Potential for more than minimal harm
2024-09-12
F712 · Nursing and Physician Services Deficiencies
Health
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected 2024-10-25
Penalties and ownership
What sits behind the stars
Ownership
Callan, Susan
Corporate Director · Individual
Donnelly, Kristine
Corporate Director · Individual
Donnelly, Kristine
W-2 Managing Employee · Individual
Wylie, David
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Nemasket Rehabilitation And Healthcare Center
Middleborough, MA
3-star overall rating with 4-star inspections with 5 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#2
Oakhill Healthcare
Middleboro, MA
2-star overall rating with 2-star inspections with 21 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Life Care Center Of Raynham
Raynham, MA
4-star overall rating with 3-star inspections with 7 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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