Cycle 1
Health 2025-06-17 · Fire 2025-06-17
0 health deficiencies
No concentrated health issue counts in this cycle.
4 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Hyannis, MA
Pavilion , The
5-star overall rating with 5-star inspections with 4 fire-safety deficiencies in the latest cycle
876 Falmouth Road, Hyannis, MA
(508) 775-6663
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
82
Certified beds
Average residents
75
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1990-07-01
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
0.70
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.12
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.23
Nurse aide staffing · state 2.26 · national 2.35
Total nurse hours
4.05
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.82
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.55
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
0.29
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.60
CMS adjusted RN staffing hours
Adjusted total hours
3.48
CMS adjusted total nurse staffing hours
Case-mix index
1.59
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
6,191
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
33.70
Composite VBP score used to determine payment impact.
Payment multiplier
0.9879
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.48% · Performance 21.80% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
2.53
Baseline 7.40% · Performance 7.08% · Measure score 2.53 · Achievement 2.53 · Improvement 0.83
Total nurse turnover
8.88
Baseline 33.33% · Performance 27.40% · Measure score 8.88 · Achievement 8.88 · Improvement 6.50
Adjusted total nurse staffing
2.07
Baseline 3.52 hours · Performance 3.67 hours · Measure score 2.07 · Achievement 2.07 · Improvement 0.13
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.54% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 555 · Observed rate 8.83% · Lower 95% interval 8.23% |
| Discharge to community | 63.43% |
50.57%
12.9 pts better
|
Better than the National Rate · Eligible stays 610 · Observed rate 59.02% · Lower 95% interval 58.99% |
| Medicare spending per beneficiary | 0.95 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 99.46% |
95.27%
4.2 pts better
|
Numerator 366 · Denominator 368 |
| Falls with major injury | 0.54% |
0.77%
0.2 pts better
|
Numerator 2 · Denominator 368 |
| Discharge self-care score | 59.65% |
53.69%
6 pts better
|
Numerator 170 · Denominator 285 |
| Discharge mobility score | 68.77% |
50.94%
17.8 pts better
|
Numerator 196 · Denominator 285 |
| Pressure ulcers or injuries, new or worsened | 1.63% |
2.29%
0.7 pts better
|
Numerator 6 · Denominator 367 · Adjusted rate 2.09% |
| Healthcare-associated infections requiring hospitalization | 7.08% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 370 · Observed rate 6.22% · Lower 95% interval 4.25% |
| Staff COVID-19 vaccination coverage | Not Available |
8.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Staff flu vaccination coverage | 55.23% |
42%
13.2 pts better
|
Numerator 132 · Denominator 239 |
| Discharge function score | 60.7% |
56.45%
4.2 pts better
|
Numerator 173 · Denominator 285 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 65 · Denominator 65 |
| Transfer of health information to patient | 99.62% |
96.28%
3.3 pts better
|
Numerator 265 · Denominator 266 |
| Resident COVID-19 vaccinations up to date | 54.31% |
25.2%
29.1 pts better
|
Numerator 107 · Denominator 197 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
1.9
0.6 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.3 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
1.5
0.7 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.7 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
92.2%
7.8 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 | 1.6% |
3.5%
1.9 pts better
|
3.3%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.1% · Q4 4.4% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.9% |
12.0%
7.1 pts better
|
11.4%
6.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 2.4% · Q3 2.1% · Q4 14.0% · 4Q avg 4.9% |
| Percentage of long-stay residents who lose too much weight | 8.7% |
5.2%
3.5 pts worse
|
5.4%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 12.8% · Q3 8.6% · Q4 8.8% · 4Q avg 8.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 26.4% |
19.2%
7.2 pts worse
|
19.6%
6.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.3% · Q2 25.6% · Q3 28.2% · Q4 24.3% · 4Q avg 26.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 26.6% |
22.5%
4.1 pts worse
|
16.7%
9.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.2% · Q2 23.3% · Q3 30.3% · Q4 32.1% · 4Q avg 26.6% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 2.6% |
0.1%
2.5 pts worse
|
0.1%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 2.1% · Q3 4.2% · Q4 2.2% · 4Q avg 2.6% |
| Percentage of long-stay residents whose ability to walk independently worsened | 12.6% |
17.7%
5.1 pts better
|
16.3%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.3% · Q2 10.9% · Q3 14.0% · Q4 3.7% · 4Q avg 12.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.3% |
17.6%
1.3 pts better
|
14.9%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 22.9% · Q3 16.7% · Q4 17.1% · 4Q avg 16.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.0%
1 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.6% |
2.0%
0.4 pts better
|
1.7%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 2.1% · Q3 0.0% · Q4 2.3% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.2% |
21.7%
3.5 pts worse
|
19.8%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.2% · Q2 39.8% · Q3 20.4% · Q4 19.2% · 4Q avg 25.2% |
| Percentage of long-stay residents with pressure ulcers | 0.4% |
4.6%
4.2 pts better
|
5.1%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
77.1%
22.5 pts better
|
81.7%
17.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 99.1% · Q3 99.5% · Q4 100.0% · 4Q avg 99.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.8% |
11.8%
3 pts worse
|
12.0%
2.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.8% · Observed 13.2% · Expected 9.9% · 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 0.7% · Q2 0.0% · Q3 0.0% · Q4 0.6% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.5% |
77.7%
21.8 pts better
|
79.7%
19.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.0% |
25.8%
6.8 pts better
|
23.9%
4.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.0% · Observed 16.0% · Expected 20.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-13 · Fire 2024-06-13
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 2023-04-05 · Fire 2023-04-05
0 health deficiencies
No concentrated health issue counts in this cycle.
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-06-17
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2025-08-01
D · Potential for more than minimal harm
2025-06-17
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-08-01
D · Potential for more than minimal harm
2025-06-17
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-09-03
D · Potential for more than minimal harm
2025-06-17
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2025-08-14
E · Potential for more than minimal harm
2023-04-05
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-05-12
D · Potential for more than minimal harm
2023-04-05
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-05-17
D · Potential for more than minimal harm
2023-04-05
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-04-14
C · Minimal harm
2023-04-05
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-04-27
C · Minimal harm
2023-04-05
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-04-14
C · Minimal harm
2023-04-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-04-14
C · Minimal harm
2023-04-05
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-04-14
C · Minimal harm
2023-04-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-04-27
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-06-13
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-07-01
D · Potential for more than minimal harm
2024-06-13
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-07-01
D · Potential for more than minimal harm
2024-06-13
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 2024-07-01
D · Potential for more than minimal harm
2024-06-13
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 2024-07-01
Penalties and ownership
What sits behind the stars
Ownership
Bentley Health Group LLC
5% Or Greater Direct Ownership Interest · Organization
Benoit, Mary
Operational/Managerial Control · Individual
Landmark Health Solutions, LLC
Operational/Managerial Control · Organization
Raso, Steven
5% Or Greater Indirect Ownership Interest · Individual
Raso, Steven
Corporate Officer · Individual
Wellington Healthcare LLC
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
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Cape Regency Rehabilitation & Health Care Center
Centerville, MA
1-star overall rating with 2-star inspections with 18 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Mayflower Place Nursing & Rehabilitation Center
West Yarmouth, MA
3-star overall rating with 3-star inspections with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Windsor Nursing & Retirement Home
South Yarmouth, MA
1-star overall rating with 2-star inspections with $12,386 in total fines with 8 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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