Cycle 1
Health 2025-04-29 · Fire 2025-04-29
17 health deficiencies
Top issue: Infection Control (4 deficiencies)
11 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Wrentham, MA
Serenity Hill Nursing Center
1-star overall rating with 1-star inspections with 17 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
655 Dedham St, Wrentham, MA
(508) 384-3400
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
44
Certified beds
Average residents
35
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1999-10-01
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
0.40
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
0.99
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.67
Nurse aide staffing · state 2.26 · national 2.35
Total nurse hours
4.06
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.39
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.54
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.31
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.48
CMS adjusted RN staffing hours
Adjusted total hours
4.78
CMS adjusted total nurse staffing hours
Case-mix index
1.16
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
58%
Annual nurse turnover · state 40% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,510
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
43.98
Composite VBP score used to determine payment impact.
Payment multiplier
0.9970
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
5.79
Baseline 54.84% · Performance 40.00% · Measure score 5.79 · Achievement 5.79 · Improvement 4.45
Adjusted total nurse staffing
3
Baseline 3.9 hours · Performance 3.93 hours · Measure score 3 · Achievement 3 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.06% |
10.72%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 32 · Observed rate 12.5% · Lower 95% interval 6.81% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 19 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.7 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 19 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 12 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 55 |
| Staff flu vaccination coverage | 79.31% |
42%
37.3 pts better
|
Numerator 46 · Denominator 58 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.8 |
1.9
0.9 pts worse
|
1.9
0.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.8 · Observed 2.1 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.8 |
1.5
0.3 pts worse
|
1.8
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.4 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.2% |
92.2%
2 pts better
|
93.4%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.2% · Q2 97.1% · Q3 88.9% · Q4 93.8% · 4Q avg 94.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.4% |
94.8%
2.6 pts better
|
95.5%
1.9 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.5%
3.5 pts better
|
3.3%
3.3 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 who have depressive symptoms | 1.9% |
12.0%
10.1 pts better
|
11.4%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.9% |
| Percentage of long-stay residents who lose too much weight | 7.0% |
5.2%
1.8 pts worse
|
5.4%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 6.9% · Q3 9.7% · Q4 8.3% · 4Q avg 7.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.6% |
19.2%
0.6 pts better
|
19.6%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 22.6% · Q3 15.6% · Q4 16.0% · 4Q avg 18.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 36.3% |
22.5%
13.8 pts worse
|
16.7%
19.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.8% · Q2 36.4% · Q3 43.5% · Q4 35.0% · 4Q avg 36.3% · 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 | 24.8% |
17.7%
7.1 pts worse
|
16.3%
8.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 24.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 24.1% |
17.6%
6.5 pts worse
|
14.9%
9.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 25.0% · Q3 23.3% · Q4 22.7% · 4Q avg 24.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 5.3% |
1.0%
4.3 pts worse
|
1.0%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 3.3% · Q3 7.0% · Q4 6.0% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.5% |
2.0%
0.5 pts better
|
1.7%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.1% · Q3 2.9% · Q4 0.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 12.8% |
21.7%
8.9 pts better
|
19.8%
7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 10.1% · Q3 8.8% · Q4 35.1% · 4Q avg 12.8% |
| Percentage of long-stay residents with pressure ulcers | 3.3% |
4.6%
1.3 pts better
|
5.1%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 2.9% · Q3 2.6% · Q4 0.0% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 35.1% |
77.1%
42 pts worse
|
81.7%
46.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 35.1% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-14 · Fire 2024-05-14
10 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
20 fire-safety deficiencies
Top issue: Emergency Preparedness (6 deficiencies)
Cycle 3
Health 2023-03-09 · Fire 2023-03-09
8 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
7 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-29
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2025-07-08
F · Potential for more than minimal harm
2025-04-29
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-07-08
F · Potential for more than minimal harm
2025-04-29
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2025-07-08
F · Potential for more than minimal harm
2025-04-29
K241 · Egress Deficiencies
Fire Safety
Have correct number of accessible exits for each story.
Corrected 2025-07-08
F · Potential for more than minimal harm
2025-04-29
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2025-07-08
F · Potential for more than minimal harm
2025-04-29
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 2025-06-18
F · Potential for more than minimal harm
2025-04-29
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-06-18
F · Potential for more than minimal harm
2025-04-29
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2025-07-08
F · Potential for more than minimal harm
2025-04-29
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-06-18
F · Potential for more than minimal harm
2025-04-29
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-06-18
D · Potential for more than minimal harm
2025-04-29
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-07-08
F · Potential for more than minimal harm
2024-05-14
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-07-09
F · Potential for more than minimal harm
2024-05-14
K241 · Egress Deficiencies
Fire Safety
Have correct number of accessible exits for each story.
Corrected 2024-07-09
F · Potential for more than minimal harm
2024-05-14
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2024-07-09
F · Potential for more than minimal harm
2024-05-14
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2024-07-09
F · Potential for more than minimal harm
2024-05-14
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-06-17
F · Potential for more than minimal harm
2024-05-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-06-17
E · Potential for more than minimal harm
2024-05-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-06-17
D · Potential for more than minimal harm
2024-05-14
E23 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2024-06-07
D · Potential for more than minimal harm
2024-05-14
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2024-06-07
D · Potential for more than minimal harm
2024-05-14
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2024-06-07
D · Potential for more than minimal harm
2024-05-14
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2024-06-07
D · Potential for more than minimal harm
2024-05-14
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2024-06-07
D · Potential for more than minimal harm
2024-05-14
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-06-07
D · Potential for more than minimal harm
2024-05-14
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-06-17
D · Potential for more than minimal harm
2024-05-14
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 2024-06-10
D · Potential for more than minimal harm
2024-05-14
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-06-10
D · Potential for more than minimal harm
2024-05-14
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-06-10
C · Minimal harm
2024-05-14
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-07-09
C · Minimal harm
2024-05-14
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2024-07-09
C · Minimal harm
2024-05-14
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-07-09
F · Potential for more than minimal harm
2023-03-09
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2023-04-07
F · Potential for more than minimal harm
2023-03-09
K241 · Egress Deficiencies
Fire Safety
Have correct number of accessible exits for each story.
Corrected 2023-04-07
F · Potential for more than minimal harm
2023-03-09
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2023-04-07
F · Potential for more than minimal harm
2023-03-09
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2023-04-07
C · Minimal harm
2023-03-09
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-04-07
C · Minimal harm
2023-03-09
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2023-04-07
C · Minimal harm
2023-03-09
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-04-07
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-04-29
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 2025-06-03
F · Potential for more than minimal harm
2025-04-29
F909 · Environmental Deficiencies
Health
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Corrected 2025-06-03
E · Potential for more than minimal harm
2025-04-29
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2025-05-31
E · Potential for more than minimal harm
2025-04-29
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 2025-06-03
E · Potential for more than minimal harm
2025-04-29
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 2025-06-03
E · Potential for more than minimal harm
2025-04-29
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 2025-06-03
E · Potential for more than minimal harm
2025-04-29
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-05-31
E · Potential for more than minimal harm
2025-04-29
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2025-05-31
E · Potential for more than minimal harm
2025-04-29
F742 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Corrected 2025-05-31
E · Potential for more than minimal harm
2025-04-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-03
E · Potential for more than minimal harm
2025-04-29
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2025-06-03
D · Potential for more than minimal harm
2025-04-29
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 2025-05-31
D · Potential for more than minimal harm
2025-04-29
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 2025-06-03
D · Potential for more than minimal harm
2025-04-29
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 2025-06-03
D · Potential for more than minimal harm
2025-04-29
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 2025-06-03
D · Potential for more than minimal harm
2025-04-29
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2025-06-03
D · Potential for more than minimal harm
2025-04-29
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-06-03
F · Potential for more than minimal harm
2024-05-14
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 2024-05-31
E · Potential for more than minimal harm
2024-05-14
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-05-31
E · Potential for more than minimal harm
2024-05-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-31
E · Potential for more than minimal harm
2024-05-14
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-05-31
D · Potential for more than minimal harm
2024-05-14
F551 · Resident Rights Deficiencies
Health
Give the resident's representative the ability to exercise the resident's rights.
Corrected 2024-05-31
D · Potential for more than minimal harm
2024-05-14
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 2024-05-31
D · Potential for more than minimal harm
2024-05-14
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-05-31
D · Potential for more than minimal harm
2024-05-14
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 2024-05-31
D · Potential for more than minimal harm
2024-05-14
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 2024-05-31
D · Potential for more than minimal harm
2024-05-14
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 2024-05-31
F · Potential for more than minimal harm
2023-03-09
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-04-21
F · Potential for more than minimal harm
2023-03-09
F885 · Infection Control Deficiencies
Health
Report COVID19 data to residents and families.
Corrected 2023-04-21
E · Potential for more than minimal harm
2023-03-09
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 2023-04-21
D · Potential for more than minimal harm
2023-03-09
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 2023-04-21
D · Potential for more than minimal harm
2023-03-09
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-04-21
D · Potential for more than minimal harm
2023-03-09
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 2023-04-21
D · Potential for more than minimal harm
2023-03-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-21
D · Potential for more than minimal harm
2023-03-09
F909 · Environmental Deficiencies
Health
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Corrected 2023-04-21
Penalties and ownership
What sits behind the stars
Ownership
Woods, Thomas
5% Or Greater Direct Ownership Interest · Individual
Woods, Charles
5% Or Greater Direct Ownership Interest · Individual
Harrington, John
5% Or Greater Direct Ownership Interest · Individual
Sweeney, Matthew
5% Or Greater Direct Ownership Interest · Individual
Harrington, John
Corporate Officer · Individual
Harrington, John
W-2 Managing Employee · Individual
Sweeney, Matthew
Corporate Officer · Individual
Sweeney, Matthew
W-2 Managing Employee · Individual
Woods, Thomas
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Alliance Health At Maples
Wrentham, MA
3-star overall rating with 3-star inspections with $47,886 in total fines with 6 recent health deficiencies
#2
Cedarwood Gardens
Franklin, MA
3-star overall rating with 2-star inspections with $7,596 in total fines with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Foremost At Sharon LLC
Sharon, MA
2-star overall rating with 2-star inspections with $25,773 in total fines with 9 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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