Cycle 1
Health 2024-11-06 · Fire 2024-11-06
21 health deficiencies
Top issue: Resident Assessment and Care Planning (5 deficiencies)
4 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Middleboro, MA
Oakhill Healthcare
2-star overall rating with 2-star inspections with 21 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
76 North Street, Middleboro, MA
(508) 947-4774
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
123
Certified beds
Average residents
90
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Next Step Healthcare
Operator or chain grouping
Approved since
1967-11-06
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
14 facilities
Chain averages 2 overall / 2 health / 2 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
0.58
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
0.88
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
1.82
Nurse aide staffing · state 2.26 · national 2.35
Total nurse hours
3.27
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.45
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
2.96
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.50
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
0.57
CMS adjusted RN staffing hours
Adjusted total hours
3.23
CMS adjusted total nurse staffing hours
Case-mix index
1.39
Higher values indicate more complex resident acuity
RN turnover
53%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
51%
Annual nurse turnover · state 40% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,585
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
3.39
Composite VBP score used to determine payment impact.
Payment multiplier
0.9805
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 22.43% · Performance 26.32% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 6.87% · Performance 10.28% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
1.36
Baseline 59.70% · Performance 58.14% · Measure score 1.36 · Achievement 1.36 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.47 hours · Performance 3.07 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.94% |
10.72%
1.2 pts worse
|
No Different than the National Rate · Eligible stays 131 · Observed rate 15.27% · Lower 95% interval 9.24% |
| Discharge to community | 43.51% |
50.57%
7.1 pts worse
|
No Different than the National Rate · Eligible stays 124 · Observed rate 35.48% · Lower 95% interval 35.73% |
| Medicare spending per beneficiary | 1.09 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 97.39% |
95.27%
2.1 pts better
|
Numerator 112 · Denominator 115 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 115 |
| Discharge self-care score | 32.84% |
53.69%
20.8 pts worse
|
Numerator 22 · Denominator 67 |
| Discharge mobility score | 31.34% |
50.94%
19.6 pts worse
|
Numerator 21 · Denominator 67 |
| Pressure ulcers or injuries, new or worsened | 4.35% |
2.29%
2.1 pts worse
|
Numerator 5 · Denominator 115 · Adjusted rate 5.11% |
| Healthcare-associated infections requiring hospitalization | 10.28% |
7.12%
3.2 pts worse
|
No Different than the National Rate · Eligible stays 102 · Observed rate 15.69% · Lower 95% interval 6.83% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 63 |
| Staff flu vaccination coverage | 14.41% |
42%
27.6 pts worse
|
Numerator 16 · Denominator 111 |
| Discharge function score | 49.25% |
56.45%
7.2 pts worse
|
Numerator 33 · Denominator 67 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 69 · Denominator 69 |
| Transfer of health information to patient | 71.43% |
96.28%
24.8 pts worse
|
Numerator 15 · Denominator 21 |
| Resident COVID-19 vaccinations up to date | 28.57% |
25.2%
3.4 pts better
|
Numerator 16 · Denominator 56 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
1.9
0.5 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.3 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.4 |
1.5
0.9 pts worse
|
1.8
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 2.6 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 89.4% |
92.2%
2.8 pts worse
|
93.4%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 97.4% · Q2 84.8% · Q3 90.1% · Q4 85.7% · 4Q avg 89.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.3% |
94.8%
0.5 pts worse
|
95.5%
1.2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.6% |
3.5%
1.9 pts better
|
3.3%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 1.3% · Q3 2.5% · Q4 1.2% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.1% |
12.0%
6.9 pts better
|
11.4%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 8.3% · Q3 6.1% · Q4 4.2% · 4Q avg 5.1% |
| Percentage of long-stay residents who lose too much weight | 2.7% |
5.2%
2.5 pts better
|
5.4%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 4.8% · Q3 4.5% · Q4 0.0% · 4Q avg 2.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.7% |
19.2%
2.5 pts worse
|
19.6%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 20.0% · Q3 22.4% · Q4 23.9% · 4Q avg 21.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 34.0% |
22.5%
11.5 pts worse
|
16.7%
17.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.5% · Q2 31.9% · Q3 35.3% · Q4 35.8% · 4Q avg 34.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 2.5% |
0.1%
2.4 pts worse
|
0.1%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 2.5% · Q3 2.5% · Q4 2.4% · 4Q avg 2.5% |
| Percentage of long-stay residents whose ability to walk independently worsened | 12.9% |
17.7%
4.8 pts better
|
16.3%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 16.0% · Q3 14.0% · Q4 10.0% · 4Q avg 12.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.4% |
17.6%
6.2 pts better
|
14.9%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 13.3% · Q3 16.1% · Q4 10.3% · 4Q avg 11.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.4% |
1.0%
0.4 pts worse
|
1.0%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.5% · Q3 2.2% · Q4 0.6% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.2% |
2.0%
1.2 pts worse
|
1.7%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 3.9% · Q3 2.5% · Q4 1.2% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.6% |
21.7%
4.9 pts worse
|
19.8%
6.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.9% · Q2 27.2% · Q3 28.5% · Q4 32.3% · 4Q avg 26.6% |
| Percentage of long-stay residents with pressure ulcers | 10.9% |
4.6%
6.3 pts worse
|
5.1%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 13.7% · Q3 10.6% · Q4 6.8% · 4Q avg 10.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 78.5% |
77.1%
1.4 pts better
|
81.7%
3.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 74.5% · Q2 76.1% · Q3 86.6% · Q4 80.9% · 4Q avg 78.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.7% |
11.8%
1.9 pts worse
|
12.0%
1.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.7% · Observed 14.9% · Expected 12.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.1% |
1.3%
0.8 pts worse
|
1.6%
0.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.9% · Q3 3.6% · Q4 0.0% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 73.9% |
77.7%
3.8 pts worse
|
79.7%
5.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 73.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 33.5% |
25.8%
7.7 pts worse
|
23.9%
9.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 33.5% · Observed 32.4% · Expected 23.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-09 · Fire 2023-08-09
8 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Cycle 3
Health 2020-02-06 · Fire 2020-02-06
8 health deficiencies
Top issue: Resident Rights (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-11-06
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-12-17
D · Potential for more than minimal harm
2024-11-06
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2025-01-10
D · Potential for more than minimal harm
2024-11-06
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2025-01-10
D · Potential for more than minimal harm
2024-11-06
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2025-01-10
D · Potential for more than minimal harm
2023-08-09
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-09-15
C · Minimal harm
2023-08-09
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-09-15
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-11-06
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 2024-12-11
E · Potential for more than minimal harm
2024-11-06
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-12-11
E · Potential for more than minimal harm
2024-11-06
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 2024-12-11
E · Potential for more than minimal harm
2024-11-06
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 2024-12-11
E · Potential for more than minimal harm
2024-11-06
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 2024-12-11
E · Potential for more than minimal harm
2024-11-06
F847 · Administration Deficiencies
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2024-12-11
E · Potential for more than minimal harm
2024-11-06
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2024-12-11
E · Potential for more than minimal harm
2024-11-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-11
D · Potential for more than minimal harm
2024-11-06
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2024-12-11
D · Potential for more than minimal harm
2024-11-06
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 2024-12-11
D · Potential for more than minimal harm
2024-11-06
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 2024-12-11
D · Potential for more than minimal harm
2024-11-06
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-12-11
D · Potential for more than minimal harm
2024-11-06
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 2024-12-11
D · Potential for more than minimal harm
2024-11-06
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-12-11
D · Potential for more than minimal harm
2024-11-06
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-12-11
D · Potential for more than minimal harm
2024-11-06
F712 · Nursing and Physician Services Deficiencies
Health
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected 2024-12-11
D · Potential for more than minimal harm
2024-11-06
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 2024-12-11
D · Potential for more than minimal harm
2024-11-06
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 2024-12-11
D · Potential for more than minimal harm
2024-11-06
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 2024-12-11
C · Minimal harm
2024-11-06
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-12-11
C · Minimal harm
2024-11-06
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2024-12-11
D · Potential for more than minimal harm
2024-01-22
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 2024-02-19
D · Potential for more than minimal harm
2024-01-22
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 2024-02-19
E · Potential for more than minimal harm
2023-08-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-13
D · Potential for more than minimal harm
2023-08-09
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-09-13
D · Potential for more than minimal harm
2023-08-09
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 2023-09-13
D · Potential for more than minimal harm
2023-08-09
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 2023-09-13
D · Potential for more than minimal harm
2023-08-09
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-09-13
D · Potential for more than minimal harm
2023-08-09
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2023-09-13
D · Potential for more than minimal harm
2023-08-09
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-09-13
B · Minimal harm
2023-08-09
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-09-13
D · Potential for more than minimal harm
2023-07-13
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 2023-08-08
D · Potential for more than minimal harm
2023-07-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-08-08
D · Potential for more than minimal harm
2023-07-13
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-08-08
E · Potential for more than minimal harm
2020-02-06
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2020-03-02
D · Potential for more than minimal harm
2020-02-06
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2020-03-02
D · Potential for more than minimal harm
2020-02-06
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2020-03-02
Penalties and ownership
What sits behind the stars
Ownership
Next Step Healthcare LLC
5% Or Greater Direct Ownership Interest · Organization
Dell'anno, Damian
5% Or Greater Indirect Ownership Interest · Individual
Stephan, William
5% Or Greater Indirect Ownership Interest · Individual
Dell'anno, Damian
Corporate Officer · Individual
Next Step Healthcare LLC
Operational/Managerial Control · Organization
Restituyo, Irving
Operational/Managerial Control · Individual
Soares, Kyle
Operational/Managerial Control · Individual
Stephan, William
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Hannah B G Shaw Home
Middleboro, MA
4-star overall rating with 3-star inspections with 4 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
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
#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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