Cycle 1
Health 2024-11-27 · Fire 2024-11-27
9 health deficiencies
Top issue: Resident Assessment and Care Planning (5 deficiencies)
10 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Shrewsbury, MA
Shrewsbury Rehabilitation And Nursing At Southgate
5-star overall rating with 4-star inspections with $7,901 in total fines with 9 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
40 Julio Drive, Shrewsbury, MA
(508) 845-6786
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
99
Certified beds
Average residents
94
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Atlas Healthcare
Operator or chain grouping
Approved since
1990-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
28 facilities
Chain averages 4 overall / 3 health / 2 staffing / 4 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
0.55
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.29
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.17
Nurse aide staffing · state 2.26 · national 2.35
Total nurse hours
4.01
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.84
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.68
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.47
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.50
CMS adjusted RN staffing hours
Adjusted total hours
3.71
CMS adjusted total nurse staffing hours
Case-mix index
1.48
Higher values indicate more complex resident acuity
RN turnover
45%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
45%
Annual nurse turnover · state 40% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,371
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
33.13
Composite VBP score used to determine payment impact.
Payment multiplier
0.9875
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 17.33% · Performance 21.45% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
7.40
Baseline 5.51% · Performance 5.62% · Measure score 7.40 · Achievement 7.40 · Improvement 0
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
2.54
Baseline 4.28 hours · Performance 3.8 hours · Measure score 2.54 · Achievement 2.54 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.93% |
10.72%
1.8 pts better
|
No Different than the National Rate · Eligible stays 176 · Observed rate 6.82% · Lower 95% interval 6.02% |
| Discharge to community | 62.21% |
50.57%
11.6 pts better
|
Better than the National Rate · Eligible stays 162 · Observed rate 54.94% · Lower 95% interval 52.78% |
| Medicare spending per beneficiary | 0.8 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 99.41% |
95.27%
4.1 pts better
|
Numerator 169 · Denominator 170 |
| Falls with major injury | 0.59% |
0.77%
0.2 pts better
|
Numerator 1 · Denominator 170 |
| Discharge self-care score | 50% |
53.69%
3.7 pts worse
|
Numerator 66 · Denominator 132 |
| Discharge mobility score | 43.94% |
50.94%
7 pts worse
|
Numerator 58 · Denominator 132 |
| Pressure ulcers or injuries, new or worsened | 1.76% |
2.29%
0.5 pts better
|
Numerator 3 · Denominator 170 · Adjusted rate 1.85% |
| Healthcare-associated infections requiring hospitalization | 5.62% |
7.12%
1.5 pts better
|
No Different than the National Rate · Eligible stays 121 · Observed rate 3.31% · Lower 95% interval 3.3% |
| Staff COVID-19 vaccination coverage | 86.86% |
8.2%
78.7 pts better
|
Numerator 119 · Denominator 137 |
| Staff flu vaccination coverage | 83.69% |
42%
41.7 pts better
|
Numerator 118 · Denominator 141 |
| Discharge function score | 49.24% |
56.45%
7.2 pts worse
|
Numerator 65 · Denominator 132 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 33 · Denominator 33 |
| Transfer of health information to patient | 98.91% |
96.28%
2.6 pts better
|
Numerator 91 · Denominator 92 |
| Resident COVID-19 vaccinations up to date | 31.58% |
25.2%
6.4 pts better
|
Numerator 30 · Denominator 95 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.7 |
1.9
1.2 pts better
|
1.9
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.8 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.7 |
1.5
0.2 pts worse
|
1.8
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.7 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.9% |
92.2%
6.7 pts better
|
93.4%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.6% · Q2 100.0% · Q3 100.0% · Q4 97.2% · 4Q avg 98.9% |
| 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 | 0.4% |
3.5%
3.1 pts better
|
3.3%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.4% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 24.9% |
12.0%
12.9 pts worse
|
11.4%
13.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 33.9% · Q3 38.0% · Q4 32.2% · 4Q avg 24.9% |
| Percentage of long-stay residents who lose too much weight | 6.7% |
5.2%
1.5 pts worse
|
5.4%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 5.6% · Q3 12.5% · Q4 3.4% · 4Q avg 6.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.8% |
19.2%
7.4 pts better
|
19.6%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 15.0% · Q3 15.3% · Q4 9.7% · 4Q avg 11.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.2% |
22.5%
11.3 pts better
|
16.7%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 15.6% · Q3 10.2% · Q4 11.1% · 4Q avg 11.2% · 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 | 16.9% |
17.7%
0.8 pts better
|
16.3%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 28.4% · Q3 3.5% · Q4 23.0% · 4Q avg 16.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.5% |
17.6%
0.1 pts better
|
14.9%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 25.9% · Q3 7.7% · Q4 16.4% · 4Q avg 17.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
1.0%
0.5 pts better
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 1.1% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.7% |
2.0%
1.3 pts better
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.5% · Q3 1.5% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.6% |
21.7%
6.9 pts worse
|
19.8%
8.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.0% · Q2 29.7% · Q3 21.6% · Q4 35.7% · 4Q avg 28.6% |
| Percentage of long-stay residents with pressure ulcers | 4.4% |
4.6%
0.2 pts better
|
5.1%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 4.9% · Q3 1.9% · Q4 3.3% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.1% |
77.1%
19 pts better
|
81.7%
14.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.8% · Q2 91.8% · Q3 97.0% · Q4 98.7% · 4Q avg 96.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.8% |
11.8%
2 pts better
|
12.0%
2.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.8% · Observed 9.9% · Expected 11.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.3% |
1.3%
1 pts better
|
1.6%
1.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.9% |
77.7%
18.2 pts better
|
79.7%
16.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.4% |
25.8%
2.4 pts better
|
23.9%
0.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.4% · Observed 23.2% · Expected 23.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-19 · Fire 2023-09-19
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-03-11 · Fire 2022-03-11
9 health deficiencies
Top issue: Infection Control (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-11-27
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2025-01-25
F · Potential for more than minimal harm
2024-11-27
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2025-01-25
F · Potential for more than minimal harm
2024-11-27
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2025-01-25
F · Potential for more than minimal harm
2024-11-27
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2025-01-25
F · Potential for more than minimal harm
2024-11-27
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-01-25
E · Potential for more than minimal harm
2024-11-27
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2025-01-25
E · Potential for more than minimal harm
2024-11-27
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-01-25
D · Potential for more than minimal harm
2024-11-27
K254 · Egress Deficiencies
Fire Safety
Provide hallway or ground-level exits in all residents' rooms.
Corrected 2025-01-25
D · Potential for more than minimal harm
2024-11-27
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2025-01-25
D · Potential for more than minimal harm
2024-11-27
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-01-25
E · Potential for more than minimal harm
2023-09-19
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-11-19
D · Potential for more than minimal harm
2023-09-19
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2023-10-25
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-04
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-11-28
D · Potential for more than minimal harm
2024-11-27
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2025-01-11
D · Potential for more than minimal harm
2024-11-27
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-01-11
D · Potential for more than minimal harm
2024-11-27
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-01-11
D · Potential for more than minimal harm
2024-11-27
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 2025-01-11
D · Potential for more than minimal harm
2024-11-27
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 2025-01-11
D · Potential for more than minimal harm
2024-11-27
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 2025-01-11
B · Minimal harm
2024-11-27
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-01-11
B · Minimal harm
2024-11-27
F646 · Resident Assessment and Care Planning Deficiencies
Health
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
Corrected 2025-01-11
E · Potential for more than minimal harm
2023-12-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-07
G · Actual harm
2023-09-19
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 2023-10-20
D · Potential for more than minimal harm
2023-09-19
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-10-20
D · Potential for more than minimal harm
2023-09-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-20
D · Potential for more than minimal harm
2023-08-03
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-08-25
E · Potential for more than minimal harm
2022-03-11
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 2022-03-25
E · Potential for more than minimal harm
2022-03-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-03-25
D · Potential for more than minimal harm
2022-03-11
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2022-03-25
D · Potential for more than minimal harm
2022-03-11
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2022-03-25
D · Potential for more than minimal harm
2022-03-11
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 2022-03-25
D · Potential for more than minimal harm
2022-03-11
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 2022-03-25
B · Minimal harm
2022-03-11
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2022-03-25
Penalties and ownership
What sits behind the stars
$7,901
2023-09-19
Fine
Fine · fine $7,901
Fine
Ownership
Shrewsbury Operations Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Demma, Heather
W-2 Managing Employee · Individual
Herzka, David
5% Or Greater Indirect Ownership Interest · Individual
Jmh Family LLC
5% Or Greater Indirect Ownership Interest · Organization
Jmh Family Trust
5% Or Greater Indirect Ownership Interest · Organization
Levy, Michael
5% Or Greater Indirect Ownership Interest · Individual
Levy, Michael
Corporate Officer · Individual
Mls Family LLC
5% Or Greater Indirect Ownership Interest · Organization
Mls Family Trust
5% Or Greater Indirect Ownership Interest · Organization
Sgs Family LLC
5% Or Greater Indirect Ownership Interest · Organization
Sgs Family Trust
5% Or Greater Indirect Ownership Interest · Organization
Sheikh, Zahra
Contracted Managing Employee · Individual
Nearby options
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5-star overall rating with 4-star inspections with 3 recent health deficiencies
#2
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4-star overall rating with 4-star inspections with 3 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Alliance Health at Coleman
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4-star overall rating with 4-star inspections with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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