Cycle 1
Health 2025-02-03 · Fire 2025-02-03
26 health deficiencies
Top issue: Resident Rights (6 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Webster, MA
Lanessa Extended Care
1-star overall rating with 1-star inspections with $119,962 in total fines with 26 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
751 School Street, Webster, MA
(508) 949-1334
Overall
1 / 5
CMS overall stars
Health inspections
1 / 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
96
Certified beds
Average residents
87
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Athena Healthcare Systems
Operator or chain grouping
Approved since
1990-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
24 facilities
Chain averages 2 overall / 2 health / 3 staffing / 3 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
Hours and turnover
RN hours / resident day
0.43
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
0.66
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
1.78
Nurse aide staffing · state 2.26 · national 2.35
Total nurse hours
2.86
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.08
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
2.62
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.29
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.46
CMS adjusted RN staffing hours
Adjusted total hours
3.12
CMS adjusted total nurse staffing hours
Case-mix index
1.25
Higher values indicate more complex resident acuity
RN turnover
25%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
33%
Annual nurse turnover · state 40% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,006
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
46.44
Composite VBP score used to determine payment impact.
Payment multiplier
0.9998
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
8.46
Performance 29.09% · Measure score 8.46 · Achievement 8.46 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0.82
Baseline 2.93 hours · Performance 3.30 hours · Measure score 0.82 · Achievement 0.80 · Improvement 0.82
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 22 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 13 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.9 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 93.75% |
95.27%
1.5 pts worse
|
Numerator 30 · Denominator 32 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 32 |
| Discharge self-care score | 25% |
53.69%
28.7 pts worse
|
Numerator 5 · Denominator 20 |
| Discharge mobility score | 35% |
50.94%
15.9 pts worse
|
Numerator 7 · Denominator 20 |
| Pressure ulcers or injuries, new or worsened | 3.13% |
2.29%
0.8 pts worse
|
Numerator 1 · Denominator 32 · Adjusted rate 3.36% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 22 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 7.61% |
8.2%
0.6 pts worse
|
Numerator 7 · Denominator 92 |
| Staff flu vaccination coverage | 63.04% |
42%
21 pts better
|
Numerator 87 · Denominator 138 |
| Discharge function score | 55% |
56.45%
1.5 pts worse
|
Numerator 11 · Denominator 20 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 18 · 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 | 0.9 |
1.9
1 pts better
|
1.9
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 1.0 · Expected 2.0 · 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 3.1 · Expected 2.0 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 78.9% |
92.2%
13.3 pts worse
|
93.4%
14.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 80.8% · Q2 72.5% · Q3 76.8% · Q4 85.5% · 4Q avg 78.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 84.1% |
94.8%
10.7 pts worse
|
95.5%
11.4 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 84.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.8% |
3.5%
3.3 pts worse
|
3.3%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 5.0% · Q3 9.8% · Q4 8.4% · 4Q avg 6.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 26.8% |
12.0%
14.8 pts worse
|
11.4%
15.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.7% · Q2 22.2% · Q3 33.3% · Q4 34.9% · 4Q avg 26.8% |
| Percentage of long-stay residents who lose too much weight | 9.5% |
5.2%
4.3 pts worse
|
5.4%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 7.2% · Q3 10.7% · Q4 16.2% · 4Q avg 9.5% |
| 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 24.6% · Q2 25.4% · Q3 28.0% · Q4 29.9% · 4Q avg 27.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 38.2% |
22.5%
15.7 pts worse
|
16.7%
21.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.5% · Q2 36.0% · Q3 36.8% · Q4 41.5% · 4Q avg 38.2% · 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 | 16.8% |
17.7%
0.9 pts better
|
16.3%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.2% · Q2 17.3% · Q3 12.6% · Q4 13.4% · 4Q avg 16.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.1% |
17.6%
1.5 pts worse
|
14.9%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.2% · Q2 17.4% · Q3 12.3% · Q4 21.3% · 4Q avg 19.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
1.0%
0.2 pts better
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.1% · Q3 1.1% · Q4 1.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.2% |
2.0%
0.2 pts worse
|
1.7%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 1.3% · Q3 1.2% · Q4 2.5% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.8% |
21.7%
9.1 pts worse
|
19.8%
11 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.4% · Q2 32.6% · Q3 24.7% · Q4 37.3% · 4Q avg 30.8% |
| Percentage of long-stay residents with pressure ulcers | 5.4% |
4.6%
0.8 pts worse
|
5.1%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 5.3% · Q3 5.1% · Q4 7.2% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 53.9% |
77.1%
23.2 pts worse
|
81.7%
27.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 29.7% · Q2 53.8% · Q3 66.7% · Q4 58.8% · 4Q avg 53.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.0% |
11.8%
6.8 pts better
|
12.0%
7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.0% · Observed 5.9% · Expected 13.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.4% |
1.3%
0.1 pts worse
|
1.6%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q2 0.0% · Q4 4.8% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 54.7% |
77.7%
23 pts worse
|
79.7%
25 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 54.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 34.8% |
25.8%
9 pts worse
|
23.9%
10.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 34.8% · Observed 29.4% · Expected 20.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-08 · Fire 2023-11-08
20 health deficiencies
Top issue: Nursing and Physician Services (4 deficiencies)
9 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Cycle 3
Health 2022-09-07 · Fire 2022-09-07
25 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-03
K222 · Egress Deficiencies
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 2025-02-28
F · Potential for more than minimal harm
2025-02-03
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-02-28
F · Potential for more than minimal harm
2025-02-03
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-02-03
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 2025-02-28
F · Potential for more than minimal harm
2023-11-08
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-12-13
F · Potential for more than minimal harm
2023-11-08
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-12-13
F · Potential for more than minimal harm
2023-11-08
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-12-13
F · Potential for more than minimal harm
2023-11-08
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-12-13
F · Potential for more than minimal harm
2023-11-08
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-12-13
F · Potential for more than minimal harm
2023-11-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-12-13
E · Potential for more than minimal harm
2023-11-08
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-12-13
E · Potential for more than minimal harm
2023-11-08
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-12-13
D · Potential for more than minimal harm
2023-11-08
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-12-13
F · Potential for more than minimal harm
2022-09-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-10-28
D · Potential for more than minimal harm
2022-09-07
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-10-28
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-21
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 2026-01-12
D · Potential for more than minimal harm
2025-06-10
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 2025-07-01
D · Potential for more than minimal harm
2025-06-10
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-07-01
F · Potential for more than minimal harm
2025-02-03
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-02-28
F · Potential for more than minimal harm
2025-02-03
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-02-28
E · Potential for more than minimal harm
2025-02-03
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-02-28
E · Potential for more than minimal harm
2025-02-03
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-02-28
E · Potential for more than minimal harm
2025-02-03
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 2025-02-28
E · Potential for more than minimal harm
2025-02-03
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 2025-02-28
D · Potential for more than minimal harm
2025-02-03
F551 · Resident Rights Deficiencies
Health
Give the resident's representative the ability to exercise the resident's rights.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-02-03
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-02-03
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-02-03
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-02-03
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-02-03
F584 · Resident Rights Deficiencies
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 2025-02-28
D · Potential for more than minimal harm
2025-02-03
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-02-03
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 2025-02-28
D · Potential for more than minimal harm
2025-02-03
F690 · Quality of Life and Care Deficiencies
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 2025-02-28
D · Potential for more than minimal harm
2025-02-03
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 2025-02-28
D · Potential for more than minimal harm
2025-02-03
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 2025-02-28
D · Potential for more than minimal harm
2025-02-03
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-02-03
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-02-03
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 2025-02-28
D · Potential for more than minimal harm
2025-02-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-28
C · Minimal harm
2025-02-03
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-02-28
B · Minimal harm
2025-02-03
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2025-02-28
D · Potential for more than minimal harm
2024-04-03
F603 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Corrected 2024-04-24
D · Potential for more than minimal harm
2024-04-03
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-04-24
D · Potential for more than minimal harm
2024-04-03
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-04-26
D · Potential for more than minimal harm
2024-04-03
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 2024-04-24
D · Potential for more than minimal harm
2024-04-03
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 2024-04-26
G · Actual harm
2023-11-08
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2023-12-19
F · Potential for more than minimal harm
2023-11-08
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 2023-11-21
F · Potential for more than minimal harm
2023-11-08
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 2023-11-21
E · Potential for more than minimal harm
2023-11-08
F690 · Quality of Life and Care Deficiencies
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 2024-01-21
E · Potential for more than minimal harm
2023-11-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-21
D · Potential for more than minimal harm
2023-11-08
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 2023-11-21
D · Potential for more than minimal harm
2023-11-08
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 2023-11-21
D · Potential for more than minimal harm
2023-11-08
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-01-21
D · Potential for more than minimal harm
2023-11-08
F756 · Pharmacy Service Deficiencies
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 2023-11-21
D · Potential for more than minimal harm
2023-11-08
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-11-21
D · Potential for more than minimal harm
2023-11-08
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-11-21
D · Potential for more than minimal harm
2023-11-08
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 2023-11-21
D · Potential for more than minimal harm
2023-11-08
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2023-11-21
D · Potential for more than minimal harm
2023-11-08
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-11-21
B · Minimal harm
2023-11-08
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-11-21
D · Potential for more than minimal harm
2023-09-14
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2023-10-21
H · Actual harm
2022-09-07
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 2022-10-14
G · Actual harm
2022-09-07
F657 · Resident Assessment and Care Planning Deficiencies
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 2022-10-14
F · Potential for more than minimal harm
2022-09-07
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 2022-10-14
F · Potential for more than minimal harm
2022-09-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-11-03
E · Potential for more than minimal harm
2022-09-07
F584 · Resident Rights Deficiencies
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 2022-10-14
E · Potential for more than minimal harm
2022-09-07
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 2022-11-09
E · Potential for more than minimal harm
2022-09-07
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-10-14
E · Potential for more than minimal harm
2022-09-07
F675 · Quality of Life and Care Deficiencies
Health
Honor each resident's preferences, choices, values and beliefs.
Corrected 2022-10-14
E · Potential for more than minimal harm
2022-09-07
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2022-11-09
E · Potential for more than minimal harm
2022-09-07
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2022-10-14
E · Potential for more than minimal harm
2022-09-07
F711 · Nursing and Physician Services Deficiencies
Health
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Corrected 2022-10-14
E · Potential for more than minimal harm
2022-09-07
F712 · Nursing and Physician Services Deficiencies
Health
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected 2022-11-09
E · Potential for more than minimal harm
2022-09-07
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2022-10-14
E · Potential for more than minimal harm
2022-09-07
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2022-11-09
E · Potential for more than minimal harm
2022-09-07
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 2022-10-14
E · Potential for more than minimal harm
2022-09-07
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2022-10-14
E · Potential for more than minimal harm
2022-09-07
F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2022-10-14
D · Potential for more than minimal harm
2022-09-07
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2022-10-14
D · Potential for more than minimal harm
2022-09-07
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 2022-11-09
D · Potential for more than minimal harm
2022-09-07
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 2022-10-14
D · Potential for more than minimal harm
2022-09-07
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2022-10-14
D · Potential for more than minimal harm
2022-09-07
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-10-14
D · Potential for more than minimal harm
2022-09-07
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2022-10-14
D · Potential for more than minimal harm
2022-09-07
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2022-10-14
Penalties and ownership
What sits behind the stars
$119,962
2023-11-08
Fine
Fine · fine $119,962
Fine
Ownership
Athena Health Care Systems Ma Iii LLC
5% Or Greater Direct Ownership Interest · Organization
Santilli, Lawrence
5% Or Greater Indirect Ownership Interest · Individual
Mosier, Michael
5% Or Greater Indirect Ownership Interest · Individual
Chakalos-Santilli, Valerie
5% Or Greater Indirect Ownership Interest · Individual
Athena Health Care Associates, Inc.
Operational/Managerial Control · Organization
Curtis, Diane
5% Or Greater Indirect Ownership Interest · Individual
Mosier, Michael
W-2 Managing Employee · Individual
Santilli, Lawrence
Corporate Officer · Individual
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