Cycle 1
Health 2025-08-07 · Fire 2025-08-07
2 health deficiencies
Top issue: Infection Control (1 deficiency)
3 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
S Natick, MA
Riverbend Of South Natick
5-star overall rating with 4-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
34 South Lincoln Street, S Natick, MA
(508) 653-8330
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
55
Certified beds
Average residents
27
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Rehabilitation Associates
Operator or chain grouping
Approved since
1994-03-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
6 facilities
Chain averages 3 overall / 3 health / 4 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
0.88
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
2.79
Nurse aide staffing · state 2.26 · national 2.35
Total nurse hours
4.33
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.54
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
4.13
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.64
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
1.05
CMS adjusted RN staffing hours
Adjusted total hours
5.18
CMS adjusted total nurse staffing hours
Case-mix index
1.14
Higher values indicate more complex resident acuity
RN turnover
73%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 40% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,177
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
45.59
Composite VBP score used to determine payment impact.
Payment multiplier
0.9988
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.97
Baseline 18.81% · Performance 20.98% · Measure score 0.97 · Achievement 0.97 · Improvement 0
Healthcare-associated infections
4.17
Baseline 7.45% · Performance 6.59% · Measure score 4.17 · Achievement 4.17 · Improvement 3.02
Total nurse turnover
4.46
Baseline 20.00% · Performance 45.45% · Measure score 4.46 · Achievement 4.46 · Improvement 0
Adjusted total nurse staffing
8.64
Baseline 4.62 hours · Performance 5.54 hours · Measure score 8.64 · Achievement 8.64 · Improvement 7.40
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.77% |
10.72%
2 pts worse
|
No Different than the National Rate · Eligible stays 75 · Observed rate 17.33% · Lower 95% interval 8.47% |
| Discharge to community | 61.23% |
50.57%
10.7 pts better
|
No Different than the National Rate · Eligible stays 60 · Observed rate 58.33% · Lower 95% interval 50.17% |
| Medicare spending per beneficiary | 0.86 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 94.87% |
95.27%
0.4 pts worse
|
Numerator 37 · Denominator 39 |
| Falls with major injury | 2.56% |
0.77%
1.8 pts worse
|
Numerator 1 · Denominator 39 |
| Discharge self-care score | 27.59% |
53.69%
26.1 pts worse
|
Numerator 8 · Denominator 29 |
| Discharge mobility score | 44.83% |
50.94%
6.1 pts worse
|
Numerator 13 · Denominator 29 |
| Pressure ulcers or injuries, new or worsened | 5.13% |
2.29%
2.8 pts worse
|
Numerator 2 · Denominator 39 · Adjusted rate 4.97% |
| Healthcare-associated infections requiring hospitalization | 6.59% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 30 · Observed rate 3.33% · Lower 95% interval 3.36% |
| Staff COVID-19 vaccination coverage | 8% |
8.2%
0.2 pts worse
|
Numerator 4 · Denominator 50 |
| Staff flu vaccination coverage | 74.42% |
42%
32.4 pts better
|
Numerator 32 · Denominator 43 |
| Discharge function score | 37.93% |
56.45%
18.5 pts worse
|
Numerator 11 · Denominator 29 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 21 · Denominator 21 |
| Resident COVID-19 vaccinations up to date | 30% |
25.2%
4.8 pts better
|
Numerator 6 · Denominator 20 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.1 |
1.9
0.2 pts worse
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 1.3 · Expected 1.1 · 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 0.6 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.6% |
92.2%
3.4 pts better
|
93.4%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 87.5% · Q3 100.0% · Q4 95.8% · 4Q avg 95.6% |
| 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 | 2.2% |
3.5%
1.3 pts better
|
3.3%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 4.2% · Q3 0.0% · Q4 0.0% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
12.0%
12 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 2.4% |
5.2%
2.8 pts better
|
5.4%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 0.0% · Q4 4.5% · 4Q avg 2.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.1% |
19.2%
11.1 pts better
|
19.6%
11.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 8.7% · Q3 9.5% · Q4 4.3% · 4Q avg 8.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.1% |
22.5%
4.4 pts better
|
16.7%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q4 14.3% · 4Q avg 18.1% · 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 | 10.9% |
17.7%
6.8 pts better
|
16.3%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.3% |
17.6%
9.3 pts better
|
14.9%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 9.1% · Q3 4.8% · Q4 9.1% · 4Q avg 8.3% · 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 | 3.4% |
2.0%
1.4 pts worse
|
1.7%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 8.7% · Q3 0.0% · Q4 0.0% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 1.9% |
21.7%
19.8 pts better
|
19.8%
17.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.9% |
| Percentage of long-stay residents with pressure ulcers | 0.0% |
4.6%
4.6 pts better
|
5.1%
5.1 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 short-stay residents assessed and appropriately given the pneumococcal vaccine | 69.0% |
77.1%
8.1 pts worse
|
81.7%
12.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 69.2% · Q2 68.2% · Q3 66.7% · Q4 72.0% · 4Q avg 69.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.9% |
11.8%
5.1 pts worse
|
12.0%
4.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.9% · Observed 16.1% · Expected 10.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 62.5% |
77.7%
15.2 pts worse
|
79.7%
17.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 62.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 36.6% |
25.8%
10.8 pts worse
|
23.9%
12.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 36.6% · Observed 32.3% · Expected 21.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-05 · Fire 2024-06-05
11 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2023-01-09 · Fire 2023-01-09
6 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
5 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-08-07
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2025-08-19
F · Potential for more than minimal harm
2025-08-07
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-08-19
F · Potential for more than minimal harm
2025-08-07
K252 · Egress Deficiencies
Fire Safety
Provide at least two remote exits on each floor or fire section of the building.
Corrected 2025-08-19
F · Potential for more than minimal harm
2024-06-05
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-06-17
F · Potential for more than minimal harm
2024-06-05
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-06-17
F · Potential for more than minimal harm
2024-06-05
K252 · Egress Deficiencies
Fire Safety
Provide at least two remote exits on each floor or fire section of the building.
Corrected 2024-06-17
F · Potential for more than minimal harm
2023-01-09
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2023-02-19
F · Potential for more than minimal harm
2023-01-09
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-02-19
F · Potential for more than minimal harm
2023-01-09
K252 · Egress Deficiencies
Fire Safety
Provide at least two remote exits on each floor or fire section of the building.
Corrected 2023-02-19
F · Potential for more than minimal harm
2023-01-09
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 2023-02-19
F · Potential for more than minimal harm
2023-01-09
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2023-02-19
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-08-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-05
B · Minimal harm
2025-08-07
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-08-08
D · Potential for more than minimal harm
2024-06-05
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 2024-07-15
D · Potential for more than minimal harm
2024-06-05
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 2024-07-02
D · Potential for more than minimal harm
2024-06-05
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-07-02
D · Potential for more than minimal harm
2024-06-05
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 2024-07-02
D · Potential for more than minimal harm
2024-06-05
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-07-02
D · Potential for more than minimal harm
2024-06-05
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 2024-07-15
D · Potential for more than minimal harm
2024-06-05
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-07-15
D · Potential for more than minimal harm
2024-06-05
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-07-15
D · Potential for more than minimal harm
2024-06-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-15
D · Potential for more than minimal harm
2024-06-05
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-07-15
B · Minimal harm
2024-06-05
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-07-15
F · Potential for more than minimal harm
2023-01-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-01-30
E · Potential for more than minimal harm
2023-01-09
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-01-30
D · Potential for more than minimal harm
2023-01-09
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 2023-01-30
D · Potential for more than minimal harm
2023-01-09
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 2023-01-30
D · Potential for more than minimal harm
2023-01-09
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 2023-01-30
D · Potential for more than minimal harm
2023-01-09
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2023-01-30
Penalties and ownership
What sits behind the stars
Ownership
Thisse, Marion
5% Or Greater Direct Ownership Interest · Individual
Danahy, Elaine
Operational/Managerial Control · Individual
Rehabilitation Associates Inc
Operational/Managerial Control · Organization
Thisse, Peter
Corporate Director · Individual
Nearby options
Other facilities in reach
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Mary Ann Morse Nursing & Rehabilitation
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4-star overall rating with 4-star inspections with $30,186 in total fines
#2
Adviniacare Newton Wellesley
Wellesley, MA
2-star overall rating with 1-star inspections with $132,408 in total fines with 7 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#3
Beaumont Rehab & Skilled Nursing Ctr - Natick
Natick, MA
3-star overall rating with 4-star inspections with $10,517 in total fines with 3 recent health deficiencies with 17 fire-safety deficiencies in the latest cycle
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