Danvers, MA

Hathorne Hill Rehabilitation And Healthcare Center

4-star overall rating with 4-star inspections with $242,785 in total fines with 3 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle

15 Kirkbride Drive, Danvers, MA

(978) 716-3600

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

120

Certified beds

Average residents

107

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Atlas Healthcare

Operator or chain grouping

Approved since

1990-07-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

28 facilities

Chain averages 4 overall / 3 health / 2 staffing / 4 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

0.65

Registered nurse staffing · state 0.65 · national 0.68

LPN hours / resident day

1.09

Licensed practical nurse staffing · state 0.96 · national 0.87

Aide hours / resident day

2.06

Nurse aide staffing · state 2.26 · national 2.35

Total nurse hours

3.80

All reported nurse hours · state 3.86 · national 3.89

Licensed hours

1.74

RN + LPN hours · state 1.60 · national 1.54

Weekend hours

3.44

Weekend nurse staffing · state 3.45 · national 3.43

Weekend RN hours

0.45

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

0.55

CMS adjusted RN staffing hours

Adjusted total hours

3.19

CMS adjusted total nurse staffing hours

Case-mix index

1.63

Higher values indicate more complex resident acuity

RN turnover

40%

Annual RN turnover · state 45% · national 45%

Total nurse turnover

48%

Annual nurse turnover · state 40% · national 46%

SNF VBP

Value-based purchasing

Program rank

9,839

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

Performance score

22.35

Composite VBP score used to determine payment impact.

Payment multiplier

0.9829

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

3.93

Baseline 24.80% · Performance 21.36% · Measure score 3.93 · Achievement 0 · Improvement 3.93

Healthcare-associated infections

2.77

Baseline 3.91% · Performance 7.01% · Measure score 2.77 · Achievement 2.77 · Improvement 0

Total nurse turnover

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Adjusted total nurse staffing

Baseline 4.04 hours · Performance 3.22 hours · Measure score 0 · Achievement 0 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.18%	10.72% 0.5 pts worse	No Different than the National Rate · Eligible stays 730 · Observed rate 10.55% · Lower 95% interval 8.91%
Discharge to community	65.2%	50.57% 14.6 pts better	Better than the National Rate · Eligible stays 739 · Observed rate 61.57% · Lower 95% interval 61.18%
Medicare spending per beneficiary	0.88	1.02 0.1 pts better
Drug regimen review with follow-up	97.66%	95.27% 2.4 pts better	Numerator 375 · Denominator 384
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 384
Discharge self-care score	44.02%	53.69% 9.7 pts worse	Numerator 114 · Denominator 259
Discharge mobility score	53.67%	50.94% 2.7 pts better	Numerator 139 · Denominator 259
Pressure ulcers or injuries, new or worsened	4.95%	2.29% 2.7 pts worse	Numerator 19 · Denominator 384 · Adjusted rate 5.28%
Healthcare-associated infections requiring hospitalization	7.01%	7.12% 0.1 pts better	No Different than the National Rate · Eligible stays 362 · Observed rate 6.35% · Lower 95% interval 5.26%
Staff COVID-19 vaccination coverage	9.32%	8.2% 1.1 pts better	Numerator 11 · Denominator 118
Staff flu vaccination coverage	71.05%	42% 29 pts better	Numerator 135 · Denominator 190
Discharge function score	51.35%	56.45% 5.1 pts worse	Numerator 133 · Denominator 259
Transfer of health information to provider	97.07%	95.95% 1.1 pts better	Numerator 232 · Denominator 239
Transfer of health information to patient	97.26%	96.28% 1 pts better	Numerator 71 · Denominator 73
Resident COVID-19 vaccinations up to date	10%	25.2% 15.2 pts worse	Numerator 22 · Denominator 220

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 2.6 · Expected 1.9 · 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 1.2 · Expected 1.5 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	87.5%	92.2% 4.7 pts worse	93.4% 5.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 89.2% · Q2 88.3% · Q3 87.3% · Q4 84.9% · 4Q avg 87.5%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	72.9%	94.8% 21.9 pts worse	95.5% 22.6 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 72.9%
Percentage of long-stay residents experiencing one or more falls with major injury	3.3%	3.5% 0.2 pts better	3.3% About the same	Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.3% · Q3 3.8% · Q4 6.8% · 4Q avg 3.3% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	50.7%	12.0% 38.7 pts worse	11.4% 39.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 15.9% · Q2 40.8% · Q3 57.5% · Q4 88.4% · 4Q avg 50.7%
Percentage of long-stay residents who lose too much weight	7.8%	5.2% 2.6 pts worse	5.4% 2.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 13.3% · Q3 9.5% · Q4 3.4% · 4Q avg 7.8%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	15.3%	19.2% 3.9 pts better	19.6% 4.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 14.5% · Q2 9.4% · Q3 17.6% · Q4 19.7% · 4Q avg 15.3%
Percentage of long-stay residents who received an antipsychotic medication	21.2%	22.5% 1.3 pts better	16.7% 4.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 14.8% · Q2 14.3% · Q3 20.8% · Q4 34.6% · 4Q avg 21.2% · 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	13.9%	17.7% 3.8 pts better	16.3% 2.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 15.2% · Q2 9.0% · Q3 21.3% · Q4 10.4% · 4Q avg 13.9% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	18.1%	17.6% 0.5 pts worse	14.9% 3.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 16.4% · Q2 27.4% · Q3 18.2% · Q4 10.2% · 4Q avg 18.1% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	1.5%	1.0% 0.5 pts worse	1.0% 0.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.0% · Q3 2.0% · Q4 2.0% · 4Q avg 1.5% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.0%	2.0% 2 pts better	1.7% 1.7 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 new or worsened bowel or bladder incontinence	36.4%	21.7% 14.7 pts worse	19.8% 16.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 44.1% · Q2 28.5% · Q3 31.9% · Q4 41.4% · 4Q avg 36.4%
Percentage of long-stay residents with pressure ulcers	8.1%	4.6% 3.5 pts worse	5.1% 3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 10.4% · Q2 8.1% · Q3 8.9% · Q4 4.8% · 4Q avg 8.1% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	73.3%	77.1% 3.8 pts worse	81.7% 8.4 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 74.0% · Q2 77.3% · Q3 74.1% · Q4 67.7% · 4Q avg 73.3%
Percentage of short-stay residents who had an outpatient emergency department visit	9.5%	11.8% 2.3 pts better	12.0% 2.5 pts better	Short Stay · 20240701-20250630 · Adjusted 9.5% · Observed 8.9% · Expected 10.5% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	1.6%	1.3% 0.3 pts worse	1.6% About the same	Short Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 0.6% · Q3 1.9% · Q4 2.0% · 4Q avg 1.6% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	68.0%	77.7% 9.7 pts worse	79.7% 11.7 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 68.0%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	23.6%	25.8% 2.2 pts better	23.9% 0.3 pts better	Short Stay · 20240701-20250630 · Adjusted 23.6% · Observed 21.8% · Expected 22.1% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-12-04 · Fire 2025-12-04

3 health deficiencies

Top issue: Infection Control (1 deficiency)

11 fire-safety deficiencies

Top issue: Emergency Preparedness (4 deficiencies)

Cycle 2 Health 2024-12-05 · Fire 2024-12-05

4 health deficiencies

Top issue: Quality of Life and Care (2 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 3 Health 2023-12-15 · Fire 2023-12-15

22 health deficiencies

Top issue: Quality of Life and Care (9 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-12-04

E13 · Emergency Preparedness Deficiencies

Fire Safety

Develop Emergency Preparedness policies and procedures.

Corrected 2026-01-06

F · Potential for more than minimal harm 2025-12-04

E29 · Emergency Preparedness Deficiencies

Fire Safety

Develop a communication plan.

Corrected 2026-01-06

F · Potential for more than minimal harm 2025-12-04

E36 · Emergency Preparedness Deficiencies

Fire Safety

Establish emergency prep training and testing.

Corrected 2026-01-06

F · Potential for more than minimal harm 2025-12-04

E4 · Emergency Preparedness Deficiencies

Fire Safety

Develop and maintain an Emergency Preparedness Program (EP).

Corrected 2026-01-06

F · Potential for more than minimal harm 2025-12-04

K223 · Egress Deficiencies

Fire Safety

Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

Corrected 2026-01-06

F · Potential for more than minimal harm 2025-12-04

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2026-01-06

F · Potential for more than minimal harm 2025-12-04

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2026-01-06

F · Potential for more than minimal harm 2025-12-04

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2026-01-23

F · Potential for more than minimal harm 2025-12-04

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2026-01-06

F · Potential for more than minimal harm 2025-12-04

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2026-01-06

F · Potential for more than minimal harm 2025-12-04

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2026-01-06

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-12-04

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 2025-12-17

D · Potential for more than minimal harm 2025-12-04

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2025-12-17

D · Potential for more than minimal harm 2025-12-04

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 2025-12-17

D · Potential for more than minimal harm 2024-12-05

F686 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-12-31

D · Potential for more than minimal harm 2024-12-05

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2024-12-31

D · Potential for more than minimal harm 2024-12-05

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 2024-02-16

D · Potential for more than minimal harm 2024-12-05

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 2024-12-31

K · Immediate jeopardy 2023-12-15

F686 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-01-10

J · Immediate jeopardy 2023-12-15

F726 · Nursing and Physician Services Deficiencies

Health

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.

Corrected 2024-01-26

J · Immediate jeopardy 2023-12-15

F835 · Administration Deficiencies

Health

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Corrected 2024-01-10

G · Actual harm 2023-12-15

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 2024-01-10

G · Actual harm 2023-12-15

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 2024-01-10

G · Actual harm 2023-12-15

F742 · Quality of Life and Care Deficiencies

Health

Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.

Corrected 2024-01-10

E · Potential for more than minimal harm 2023-12-15

F697 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate pain management for a resident who requires such services.

Corrected 2024-01-10

E · Potential for more than minimal harm 2023-12-15

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 2024-01-26

E · Potential for more than minimal harm 2023-12-15