Cycle 1
Health 2024-08-13 · Fire 2024-08-13
9 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Harwich, MA
Regalcare At Harwich
3-star overall rating with 3-star inspections with 9 recent health deficiencies
111 Headwaters Drive, Harwich, MA
(508) 430-1717
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
135
Certified beds
Average residents
99
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Regalcare
Operator or chain grouping
Approved since
1990-10-11
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
9 facilities
Chain averages 2 overall / 2 health / 3 staffing / 2 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
0.96
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
0.47
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.01
Nurse aide staffing · state 2.26 · national 2.35
Total nurse hours
3.45
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.44
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.06
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.73
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
1.02
CMS adjusted RN staffing hours
Adjusted total hours
3.63
CMS adjusted total nurse staffing hours
Case-mix index
1.30
Higher values indicate more complex resident acuity
RN turnover
32%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
26%
Annual nurse turnover · state 40% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,736
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
35.19
Composite VBP score used to determine payment impact.
Payment multiplier
0.9889
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.77% · Performance 24.95% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
2.57
Baseline 8.28% · Performance 7.27% · Measure score 2.57 · Achievement 1.89 · Improvement 2.57
Total nurse turnover
10
Baseline 43.75% · Performance 23.81% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
1.51
Baseline 2.93 hours · Performance 3.50 hours · Measure score 1.51 · Achievement 1.48 · Improvement 1.51
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.93% |
10.72%
2.2 pts worse
|
No Different than the National Rate · Eligible stays 311 · Observed rate 13.83% · Lower 95% interval 9.87% |
| Discharge to community | 50.7% |
50.57%
0.1 pts better
|
No Different than the National Rate · Eligible stays 310 · Observed rate 43.87% · Lower 95% interval 44.74% |
| Medicare spending per beneficiary | 0.92 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 97.56% |
95.27%
2.3 pts better
|
Numerator 200 · Denominator 205 |
| Falls with major injury | 0.98% |
0.77%
0.2 pts worse
|
Numerator 2 · Denominator 204 |
| Discharge self-care score | 67.39% |
53.69%
13.7 pts better
|
Numerator 93 · Denominator 138 |
| Discharge mobility score | 65.22% |
50.94%
14.3 pts better
|
Numerator 90 · Denominator 138 |
| Pressure ulcers or injuries, new or worsened | 3.45% |
2.29%
1.2 pts worse
|
Numerator 7 · Denominator 203 · Adjusted rate 3.74% |
| Healthcare-associated infections requiring hospitalization | 7.27% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 215 · Observed rate 7.44% · Lower 95% interval 4.97% |
| Staff COVID-19 vaccination coverage | 7.2% |
8.2%
1 pts worse
|
Numerator 9 · Denominator 125 |
| Staff flu vaccination coverage | 69.84% |
42%
27.8 pts better
|
Numerator 88 · Denominator 126 |
| Discharge function score | 72.46% |
56.45%
16 pts better
|
Numerator 100 · Denominator 138 |
| Transfer of health information to provider | 98.31% |
95.95%
2.4 pts better
|
Numerator 58 · Denominator 59 |
| Transfer of health information to patient | 92.05% |
96.28%
4.2 pts worse
|
Numerator 81 · Denominator 88 |
| Resident COVID-19 vaccinations up to date | 16.82% |
25.2%
8.4 pts worse
|
Numerator 18 · Denominator 107 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
1.9
0.1 pts better
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.4 · Expected 1.5 · 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 2.5 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.4% |
92.2%
7.2 pts better
|
93.4%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.7% · Q3 100.0% · Q4 98.6% · 4Q avg 99.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.7% |
94.8%
2.9 pts better
|
95.5%
2.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.2% |
3.5%
0.7 pts worse
|
3.3%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 5.1% · Q3 2.6% · Q4 5.4% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.7% |
12.0%
10.3 pts better
|
11.4%
9.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 1.3% · Q3 1.4% · Q4 2.8% · 4Q avg 1.7% |
| Percentage of long-stay residents who lose too much weight | 4.5% |
5.2%
0.7 pts better
|
5.4%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 4.4% · Q3 4.6% · Q4 6.2% · 4Q avg 4.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.2% |
19.2%
About the same
|
19.6%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 23.0% · Q2 18.7% · Q3 17.4% · Q4 17.6% · 4Q avg 19.2% |
| 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 25.9% · Q2 30.0% · Q3 25.5% · Q4 25.0% · 4Q avg 26.6% · 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 | 14.9% |
17.7%
2.8 pts better
|
16.3%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.8% · Q2 13.9% · Q3 15.1% · Q4 17.0% · 4Q avg 14.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.8% |
17.6%
1.2 pts worse
|
14.9%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.6% · Q2 17.6% · Q3 19.4% · Q4 17.5% · 4Q avg 18.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
1.0%
0.7 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.3% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.0% |
2.0%
1 pts better
|
1.7%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.7% · Q4 1.4% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 11.9% |
21.7%
9.8 pts better
|
19.8%
7.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 10.5% · Q3 8.7% · Q4 15.6% · 4Q avg 11.9% |
| Percentage of long-stay residents with pressure ulcers | 2.9% |
4.6%
1.7 pts better
|
5.1%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 3.1% · Q3 3.8% · Q4 1.5% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 86.3% |
77.1%
9.2 pts better
|
81.7%
4.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 88.8% · Q2 91.3% · Q3 88.0% · Q4 77.9% · 4Q avg 86.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.7% |
11.8%
4.9 pts worse
|
12.0%
4.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.7% · Observed 16.3% · Expected 10.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.0% |
1.3%
1.7 pts worse
|
1.6%
1.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.3% · Q3 6.9% · Q4 2.7% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 82.5% |
77.7%
4.8 pts better
|
79.7%
2.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 82.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.8% |
25.8%
About the same
|
23.9%
1.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.8% · Observed 22.6% · Expected 20.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-05-03 · Fire 2023-05-03
9 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
1 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Cycle 3
Health 2020-01-08 · Fire 2020-01-08
11 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
2023-05-03
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-06-29
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-08-28
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-09-22
E · Potential for more than minimal harm
2024-08-13
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 2024-09-25
E · Potential for more than minimal harm
2024-08-13
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 2024-09-25
E · Potential for more than minimal harm
2024-08-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-27
D · Potential for more than minimal harm
2024-08-13
F551 · Resident Rights Deficiencies
Health
Give the resident's representative the ability to exercise the resident's rights.
Corrected 2024-09-25
D · Potential for more than minimal harm
2024-08-13
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 2024-09-25
D · Potential for more than minimal harm
2024-08-13
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 2024-09-25
D · Potential for more than minimal harm
2024-08-13
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 2024-09-25
B · Minimal harm
2024-08-13
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-09-25
E · Potential for more than minimal harm
2023-05-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-05-30
E · Potential for more than minimal harm
2023-05-03
F888 · Infection Control Deficiencies
Health
Ensure staff are vaccinated for COVID-19
Corrected 2023-05-30
D · Potential for more than minimal harm
2023-05-03
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 2023-05-30
D · Potential for more than minimal harm
2023-05-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-05-30
D · Potential for more than minimal harm
2023-05-03
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-05-30
D · Potential for more than minimal harm
2023-05-03
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 2023-05-30
D · Potential for more than minimal harm
2023-05-03
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-05-30
D · Potential for more than minimal harm
2023-05-03
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 2023-05-30
D · Potential for more than minimal harm
2023-05-03
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-05-30
G · Actual harm
2020-01-08
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 2020-02-21
F · Potential for more than minimal harm
2020-01-08
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2020-02-21
E · Potential for more than minimal harm
2020-01-08
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2020-02-21
E · Potential for more than minimal harm
2020-01-08
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 2020-02-21
D · Potential for more than minimal harm
2020-01-08
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2020-02-21
D · Potential for more than minimal harm
2020-01-08
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2020-02-21
D · Potential for more than minimal harm
2020-01-08
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 2020-02-21
D · Potential for more than minimal harm
2020-01-08
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2020-02-21
D · Potential for more than minimal harm
2020-01-08
F712 · Nursing and Physician Services Deficiencies
Health
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected 2020-02-21
D · Potential for more than minimal harm
2020-01-08
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 2020-02-21
B · Minimal harm
2020-01-08
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 2020-02-21
Penalties and ownership
What sits behind the stars
Ownership
Mirlis, Eliyahu
5% Or Greater Indirect Ownership Interest · Individual
Regalcare At Harwich Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Mirlis, Eliyahu
Corporate Director · Individual
Mirlis, Eliyahu
W-2 Managing Employee · Individual
Nearby options
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#3
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5-star overall rating with 4-star inspections with 5 recent health deficiencies
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