Plymouth, MA

Plymouth Rehabilitation & Health Care Center

1-star overall rating with 2-star inspections with $141,373 in total fines with 12 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle

123 South Street, Plymouth, MA

(508) 746-4343

Compare this facility

Overall

1 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

1 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

186

Certified beds

Average residents

138

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Athena Healthcare Systems

Operator or chain grouping

Approved since

1972-01-28

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

0.42

Registered nurse staffing · state 0.65 · national 0.68

LPN hours / resident day

0.81

Licensed practical nurse staffing · state 0.96 · national 0.87

Aide hours / resident day

1.97

Nurse aide staffing · state 2.26 · national 2.35

Total nurse hours

3.20

All reported nurse hours · state 3.86 · national 3.89

Licensed hours

1.23

RN + LPN hours · state 1.60 · national 1.54

Weekend hours

2.71

Weekend nurse staffing · state 3.45 · national 3.43

Weekend RN hours

0.30

Weekend registered nurse coverage · state 0.46 · national 0.47

Physical therapist

0.08

Reported PT staffing · state 0.08 · national 0.07

Adjusted RN hours

0.39

CMS adjusted RN staffing hours

Adjusted total hours

2.96

CMS adjusted total nurse staffing hours

Case-mix index

1.48

Higher values indicate more complex resident acuity

RN turnover

20%

Annual RN turnover · state 45% · national 45%

Total nurse turnover

31%

Annual nurse turnover · state 40% · national 46%

SNF VBP

Value-based purchasing

Program rank

8,310

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

Performance score

27.18

Composite VBP score used to determine payment impact.

Payment multiplier

0.9845

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

0

Baseline 21.18% · Performance 22.73% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

3.63

Baseline 6.21% · Performance 6.75% · Measure score 3.63 · Achievement 3.63 · Improvement 0

Total nurse turnover

7.25

Baseline 54.70% · Performance 34.07% · Measure score 7.25 · Achievement 7.25 · Improvement 6.41

Adjusted total nurse staffing

0

Baseline 3.22 hours · Performance 3.02 hours · Measure score 0 · Achievement 0 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure Facility National Note
Potentially preventable 30-day readmission 12.48%
10.72%
1.8 pts worse
No Different than the National Rate · Eligible stays 135 · Observed rate 17.04% · Lower 95% interval 8.8%
Discharge to community 39.48%
50.57%
11.1 pts worse
No Different than the National Rate · Eligible stays 70 · Observed rate 30% · Lower 95% interval 27.58%
Medicare spending per beneficiary 0.82
1.02
0.2 pts better
Drug regimen review with follow-up 96.04%
95.27%
0.8 pts better
Numerator 97 · Denominator 101
Falls with major injury 1.98%
0.77%
1.2 pts worse
Numerator 2 · Denominator 101
Discharge self-care score 9.52%
53.69%
44.2 pts worse
Numerator 6 · Denominator 63
Discharge mobility score 19.05%
50.94%
31.9 pts worse
Numerator 12 · Denominator 63
Pressure ulcers or injuries, new or worsened 2.97%
2.29%
0.7 pts worse
Numerator 3 · Denominator 101 · Adjusted rate 2.08%
Healthcare-associated infections requiring hospitalization 6.75%
7.12%
0.4 pts better
No Different than the National Rate · Eligible stays 88 · Observed rate 6.82% · Lower 95% interval 3.89%
Staff COVID-19 vaccination coverage 26.17%
8.2%
18 pts better
Numerator 39 · Denominator 149
Staff flu vaccination coverage 47.37%
42%
5.4 pts better
Numerator 72 · Denominator 152
Discharge function score 9.52%
56.45%
46.9 pts worse
Numerator 6 · Denominator 63
Transfer of health information to provider 100%
95.95%
4 pts better
Numerator 43 · Denominator 43
Transfer of health information to patient Not Available
96.28%
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date 28%
25.2%
2.8 pts better
Numerator 14 · Denominator 50

Quality measures

Resident outcomes and process scores

Measure Facility State National Note
Number of hospitalizations per 1000 long-stay resident days 3.5
1.9
1.6 pts worse
1.9
1.6 pts worse
Long Stay · 20240701-20250630 · Adjusted 3.5 · Observed 4.7 · Expected 2.6 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days 2.8
1.5
1.3 pts worse
1.8
1 pts worse
Long Stay · 20240701-20250630 · Adjusted 2.8 · Observed 3.7 · Expected 2.2 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine 98.7%
92.2%
6.5 pts better
93.4%
5.3 pts better
Long Stay · 2024Q4-2025Q3 · Q1 96.9% · Q2 100.0% · Q3 98.5% · Q4 99.2% · 4Q avg 98.7%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine 99.3%
94.8%
4.5 pts better
95.5%
3.8 pts better
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.3%
Percentage of long-stay residents experiencing one or more falls with major injury 5.1%
3.5%
1.6 pts worse
3.3%
1.8 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 5.3% · Q3 4.6% · Q4 6.1% · 4Q avg 5.1% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms 15.0%
12.0%
3 pts worse
11.4%
3.6 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 8.4% · Q3 17.4% · Q4 25.0% · 4Q avg 15.0%
Percentage of long-stay residents who lose too much weight 4.0%
5.2%
1.2 pts better
5.4%
1.4 pts better
Long Stay · 2024Q4-2025Q3 · Q1 7.6% · Q2 2.5% · Q3 3.5% · Q4 2.4% · 4Q avg 4.0%
Percentage of long-stay residents who received an antianxiety or hypnotic medication 32.6%
19.2%
13.4 pts worse
19.6%
13 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 33.9% · Q2 29.3% · Q3 31.7% · Q4 35.5% · 4Q avg 32.6%
Percentage of long-stay residents who received an antipsychotic medication 39.1%
22.5%
16.6 pts worse
16.7%
22.4 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 39.1% · Q2 40.0% · Q3 38.8% · Q4 38.4% · 4Q avg 39.1% · 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 10.0%
17.7%
7.7 pts better
16.3%
6.3 pts better
Long Stay · 2024Q4-2025Q3 · Q1 12.8% · Q2 14.5% · Q3 6.9% · Q4 6.8% · 4Q avg 10.0% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased 6.6%
17.6%
11 pts better
14.9%
8.3 pts better
Long Stay · 2024Q4-2025Q3 · Q1 10.7% · Q2 3.8% · Q3 5.0% · Q4 6.7% · 4Q avg 6.6% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder 0.7%
1.0%
0.3 pts better
1.0%
0.3 pts better
Long Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 0.0% · Q3 0.8% · Q4 1.3% · 4Q avg 0.7% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection 1.9%
2.0%
0.1 pts better
1.7%
0.2 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 1.5% · Q3 1.6% · Q4 3.1% · 4Q avg 1.9% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence 24.4%
21.7%
2.7 pts worse
19.8%
4.6 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 23.0% · Q2 24.4% · Q3 30.1% · Q4 20.4% · 4Q avg 24.4%
Percentage of long-stay residents with pressure ulcers 1.5%
4.6%
3.1 pts better
5.1%
3.6 pts better
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 0.7% · Q3 2.1% · Q4 1.3% · 4Q avg 1.5% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine 92.9%
77.1%
15.8 pts better
81.7%
11.2 pts better
Short Stay · 2024Q4-2025Q3 · Q1 96.2% · Q2 95.5% · Q3 90.6% · Q4 89.2% · 4Q avg 92.9%
Percentage of short-stay residents who had an outpatient emergency department visit 18.0%
11.8%
6.2 pts worse
12.0%
6 pts worse
Short Stay · 20240701-20250630 · Adjusted 18.0% · Observed 24.5% · Expected 15.2% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication 1.9%
1.3%
0.6 pts worse
1.6%
0.3 pts worse
Short Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 2.3% · Q3 0.0% · Q4 3.7% · 4Q avg 1.9% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 92.3%
77.7%
14.6 pts better
79.7%
12.6 pts better
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.3%
Percentage of short-stay residents who were rehospitalized after a nursing home admission 30.5%
25.8%
4.7 pts worse
23.9%
6.6 pts worse
Short Stay · 20240701-20250630 · Adjusted 30.5% · Observed 36.2% · Expected 28.2% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-12-26 · Fire 2024-12-26

12 health deficiencies

Top issue: Pharmacy Service (3 deficiencies)

8 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Cycle 2 Health 2023-09-29 · Fire 2023-09-29

22 health deficiencies

Top issue: Quality of Life and Care (6 deficiencies)

4 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Cycle 3 Health 2021-11-16 · Fire 2021-11-16

42 health deficiencies

Top issue: Quality of Life and Care (11 deficiencies)

5 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-12-26

K345 · Smoke Deficiencies

Fire Safety

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

Corrected 2025-02-22

F · Potential for more than minimal harm 2024-12-26

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-02-22

E · Potential for more than minimal harm 2024-12-26

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 2025-02-22

E · Potential for more than minimal harm 2024-12-26

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2025-02-22

D · Potential for more than minimal harm 2024-12-26

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2025-02-22

D · Potential for more than minimal harm 2024-12-26

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2025-02-22

D · Potential for more than minimal harm 2024-12-26

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2025-02-22

D · Potential for more than minimal harm 2024-12-26

K911 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Meet requirements for the installation and maintenance of electrical systems.

Corrected 2025-02-22

F · Potential for more than minimal harm 2023-09-29

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2023-12-01

E · Potential for more than minimal harm 2023-09-29

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2023-12-01

D · Potential for more than minimal harm 2023-09-29

K345 · Smoke Deficiencies

Fire Safety

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

Corrected 2023-12-01

D · Potential for more than minimal harm 2023-09-29

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-12-01

E · Potential for more than minimal harm 2021-11-16

K311 · Smoke Deficiencies

Fire Safety

Have an enclosure around a vertical opening shaft.

Corrected 2022-01-01

E · Potential for more than minimal harm 2021-11-16

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2022-01-01

E · Potential for more than minimal harm 2021-11-16

K374 · Smoke Deficiencies

Fire Safety

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Corrected 2022-01-01

D · Potential for more than minimal harm 2021-11-16

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 2022-01-01

D · Potential for more than minimal harm 2021-11-16

K911 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Meet requirements for the installation and maintenance of electrical systems.

Corrected 2022-01-01

Inspection history

Recent health citations

E · Potential for more than minimal harm 2024-12-26

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 2025-02-02

E · Potential for more than minimal harm 2024-12-26

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2025-02-02

E · Potential for more than minimal harm 2024-12-26

F695 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-02-02

E · Potential for more than minimal harm 2024-12-26

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 2025-02-02

E · Potential for more than minimal harm 2024-12-26

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 2025-02-02

D · Potential for more than minimal harm 2024-12-26

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 2025-02-02

D · Potential for more than minimal harm 2024-12-26

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 2025-02-02

D · Potential for more than minimal harm 2024-12-26

F645 · Resident Assessment and Care Planning Deficiencies

Health

PASARR screening for Mental disorders or Intellectual Disabilities

Corrected 2025-02-02

D · Potential for more than minimal harm 2024-12-26

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 2025-02-02

D · Potential for more than minimal harm 2024-12-26

F694 · Quality of Life and Care Deficiencies

Health

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Corrected 2025-02-02

D · Potential for more than minimal harm 2024-12-26

F757 · Pharmacy Service Deficiencies

Health

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected 2025-02-02

D · Potential for more than minimal harm 2024-12-26

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 2025-02-02

G · Actual harm 2023-10-25

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 2023-10-16

G · Actual harm 2023-10-25

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 2023-10-16

G · Actual harm 2023-09-29

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2023-11-06

F · Potential for more than minimal harm 2023-09-29

F802 · Nutrition and Dietary Deficiencies

Health

Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

Corrected 2023-11-06

F · Potential for more than minimal harm 2023-09-29

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 2023-11-06

F · Potential for more than minimal harm 2023-09-29

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-11-06

E · Potential for more than minimal harm 2023-09-29

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 2023-11-06

E · Potential for more than minimal harm 2023-09-29

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 2023-11-06

E · Potential for more than minimal harm 2023-09-29

F695 · Quality of Life and Care Deficiencies

Health

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

Corrected 2023-11-06

E · Potential for more than minimal harm 2023-09-29

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 2023-11-06

E · Potential for more than minimal harm 2023-09-29

F947 · Nursing and Physician Services Deficiencies

Health

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Corrected 2023-11-06

D · Potential for more than minimal harm 2023-09-29

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 2023-11-06

D · Potential for more than minimal harm 2023-09-29

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 2023-11-06

D · Potential for more than minimal harm 2023-09-29

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 2023-11-06

D · Potential for more than minimal harm 2023-09-29

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2023-11-06

D · Potential for more than minimal harm 2023-09-29

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 2023-11-06

D · Potential for more than minimal harm 2023-09-29

F699 · Quality of Life and Care Deficiencies

Health

Provide care or services that was trauma informed and/or culturally competent.

Corrected 2023-11-06

D · Potential for more than minimal harm 2023-09-29

F757 · Pharmacy Service Deficiencies

Health

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected 2023-11-06

D · Potential for more than minimal harm 2023-09-29

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 2023-11-06

D · Potential for more than minimal harm 2023-09-29

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 2023-11-06

D · Potential for more than minimal harm 2023-09-29

F791 · Quality of Life and Care Deficiencies

Health

Provide or obtain dental services for each resident.

Corrected 2023-11-06

B · Minimal harm 2023-09-29

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 2023-11-06

B · Minimal harm 2023-09-29

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 2023-11-06

B · Minimal harm 2023-09-29

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2023-11-06

I · Actual harm 2021-11-16

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 2022-01-13

H · Actual harm 2021-11-16

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2022-01-13

G · Actual harm 2021-11-16

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2022-01-13

G · Actual harm 2021-11-16

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2022-02-25

G · Actual harm 2021-11-16

F686 · Quality of Life and Care Deficiencies

Health

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

Corrected 2022-01-17

G · Actual harm 2021-11-16

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 2022-01-13

G · Actual harm 2021-11-16

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 2022-01-13

G · Actual harm 2021-11-16

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 2022-01-13

G · Actual harm 2021-11-16

F695 · Quality of Life and Care Deficiencies

Health

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

Corrected 2022-02-25

G · Actual harm 2021-11-16

F790 · Quality of Life and Care Deficiencies

Health

Provide routine and 24-hour emergency dental care for each resident.

Corrected 2022-01-13

F · Potential for more than minimal harm 2021-11-16

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 2022-01-13

F · Potential for more than minimal harm 2021-11-16

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 2022-01-13

F · Potential for more than minimal harm 2021-11-16

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 2022-04-22

F · Potential for more than minimal harm 2021-11-16

F835 · Administration Deficiencies

Health

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

Corrected 2022-01-13

F · Potential for more than minimal harm 2021-11-16

F838 · Administration Deficiencies

Health

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

Corrected 2022-01-13

F · Potential for more than minimal harm 2021-11-16

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2022-02-25

F · Potential for more than minimal harm 2021-11-16

F881 · Infection Control Deficiencies

Health

Implement a program that monitors antibiotic use.

Corrected 2022-01-13

F · Potential for more than minimal harm 2021-11-16

F886 · Infection Control Deficiencies

Health

Perform COVID19 testing on residents and staff.

Corrected 2022-01-13

E · Potential for more than minimal harm 2021-11-16

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2022-04-22

E · Potential for more than minimal harm 2021-11-16

F757 · Pharmacy Service Deficiencies

Health

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected 2022-02-25

E · Potential for more than minimal harm 2021-11-16

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2022-02-25

E · Potential for more than minimal harm 2021-11-16

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 2022-01-13

D · Potential for more than minimal harm 2021-11-16

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 2022-01-13

D · Potential for more than minimal harm 2021-11-16

F554 · Resident Rights Deficiencies

Health

Allow residents to self-administer drugs if determined clinically appropriate.

Corrected 2022-01-13

D · Potential for more than minimal harm 2021-11-16

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2022-01-13

D · Potential for more than minimal harm 2021-11-16

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 2022-04-22

D · Potential for more than minimal harm 2021-11-16

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 2022-04-22

D · Potential for more than minimal harm 2021-11-16

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 2022-01-13

D · Potential for more than minimal harm 2021-11-16

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2022-01-13

D · Potential for more than minimal harm 2021-11-16

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 2022-04-22

D · Potential for more than minimal harm 2021-11-16

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 2022-04-22

D · Potential for more than minimal harm 2021-11-16

F694 · Quality of Life and Care Deficiencies

Health

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Corrected 2022-01-13

D · Potential for more than minimal harm 2021-11-16

F698 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Corrected 2022-04-22

D · Potential for more than minimal harm 2021-11-16

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 2022-02-25

D · Potential for more than minimal harm 2021-11-16

F712 · Nursing and Physician Services Deficiencies

Health

Ensure that the resident and his/her doctor meet face-to-face at all required visits.

Corrected 2022-04-22

D · Potential for more than minimal harm 2021-11-16

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 2022-01-13

D · Potential for more than minimal harm 2021-11-16

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 2022-04-22

D · Potential for more than minimal harm 2021-11-16

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 2022-01-13

D · Potential for more than minimal harm 2021-11-16

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 2022-01-13

D · Potential for more than minimal harm 2021-11-16

F849 · Administration Deficiencies

Health

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Corrected 2022-01-13

Penalties and ownership

What sits behind the stars

$141,373 2023-09-29

Fine

Fine · fine $141,373

Fine

Ownership

Athena Health Care Systems Ma R LLC

5% Or Greater Direct Ownership Interest · Organization

100% 6 facilities 2012-09-01
Santilli, Lawrence

5% Or Greater Indirect Ownership Interest · Individual

74% 27 facilities 2020-05-04
Mosier, Michael

5% Or Greater Indirect Ownership Interest · Individual

6% 27 facilities 2012-09-01
Chakalos-Santilli, Valerie

5% Or Greater Indirect Ownership Interest · Individual

5% 14 facilities 2012-09-01
Athena Health Care Associates, Inc.

Operational/Managerial Control · Organization

0% 27 facilities 2012-09-01
Curtis, Diane

5% Or Greater Indirect Ownership Interest · Individual

0% 16 facilities 2012-09-01
Kaufman, Danielle

5% Or Greater Indirect Ownership Interest · Individual

0% 4 facilities 2018-07-01
Mosier, Michael

W-2 Managing Employee · Individual

0% 27 facilities 2012-09-01
Rezendes, Lorrie

5% Or Greater Indirect Ownership Interest · Individual

0% 11 facilities 2012-09-01
Santilli, Lawrence

Corporate Officer · Individual

0% 27 facilities 2012-09-25
Whitcraft, Carly

5% Or Greater Indirect Ownership Interest · Individual

0% 3 facilities 2019-05-01

Nearby options

Other facilities in reach

#1

Life Care Center Of Plymouth

Plymouth, MA

5-star overall rating with 5-star inspections with 6 fire-safety deficiencies in the latest cycle

Overall
5 / 5
Health
5 / 5
Staffing
4 / 5
Fines
$0
#2

Plymouth Harborside Healthcare

Plymouth, MA

1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $460,269 in total fines with 20 recent health deficiencies

Overall
1 / 5
Health
1 / 5
Staffing
1 / 5
Fines
$460,269

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