Cycle 1
Health 2024-12-18 · Fire 2024-12-18
13 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Southbridge, MA
Southbridge Rehabilitation & Health Care Center
1-star overall rating with 2-star inspections with $14,675 in total fines with 13 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
84 Chapin Street, Southbridge, MA
(508) 765-9133
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
144
Certified beds
Average residents
135
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Athena Healthcare Systems
Operator or chain grouping
Approved since
1987-01-02
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
0.30
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.00
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
1.93
Nurse aide staffing · state 2.26 · national 2.35
Total nurse hours
3.23
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.30
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
2.90
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.27
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
0.30
CMS adjusted RN staffing hours
Adjusted total hours
3.26
CMS adjusted total nurse staffing hours
Case-mix index
1.36
Higher values indicate more complex resident acuity
RN turnover
50%
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
7,271
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
30.22
Composite VBP score used to determine payment impact.
Payment multiplier
0.9858
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.94
Baseline 18.48% · Performance 19.60% · Measure score 3.94 · Achievement 3.94 · Improvement 0
Healthcare-associated infections
1.41
Baseline 5.94% · Performance 7.41% · Measure score 1.41 · Achievement 1.41 · Improvement 0
Total nurse turnover
6.21
Baseline 41.74% · Performance 38.30% · Measure score 6.21 · Achievement 6.21 · Improvement 1.54
Adjusted total nurse staffing
0.53
Baseline 3.26 hours · Performance 3.23 hours · Measure score 0.53 · Achievement 0.53 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.6% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 109 · Observed rate 12.84% · Lower 95% interval 7.18% |
| Discharge to community | 43.27% |
50.57%
7.3 pts worse
|
No Different than the National Rate · Eligible stays 81 · Observed rate 34.57% · Lower 95% interval 33.86% |
| Medicare spending per beneficiary | 0.87 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 98.51% |
95.27%
3.2 pts better
|
Numerator 66 · Denominator 67 |
| Falls with major injury | 1.49% |
0.77%
0.7 pts worse
|
Numerator 1 · Denominator 67 |
| Discharge self-care score | 13.95% |
53.69%
39.7 pts worse
|
Numerator 6 · Denominator 43 |
| Discharge mobility score | 11.63% |
50.94%
39.3 pts worse
|
Numerator 5 · Denominator 43 |
| Pressure ulcers or injuries, new or worsened | 2.99% |
2.29%
0.7 pts worse
|
Numerator 2 · Denominator 67 · Adjusted rate 2.81% |
| Healthcare-associated infections requiring hospitalization | 7.41% |
7.12%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 56 · Observed rate 8.93% · Lower 95% interval 4.34% |
| Staff COVID-19 vaccination coverage | 23.38% |
8.2%
15.2 pts better
|
Numerator 36 · Denominator 154 |
| Staff flu vaccination coverage | 52.58% |
42%
10.6 pts better
|
Numerator 102 · Denominator 194 |
| Discharge function score | 25.58% |
56.45%
30.9 pts worse
|
Numerator 11 · Denominator 43 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 15 · 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 | 12.5% |
25.2%
12.7 pts worse
|
Numerator 4 · Denominator 32 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
1.9
0.5 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.3 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.9 |
1.5
1.4 pts worse
|
1.8
1.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.9 · Observed 2.9 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 83.5% |
92.2%
8.7 pts worse
|
93.4%
9.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 75.7% · Q2 84.9% · Q3 86.6% · Q4 86.3% · 4Q avg 83.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 84.5% |
94.8%
10.3 pts worse
|
95.5%
11 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 84.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.3% |
3.5%
1.2 pts better
|
3.3%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 3.4% · Q3 2.4% · Q4 0.8% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 9.0% |
12.0%
3 pts better
|
11.4%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.5% · Q3 20.4% · Q4 10.8% · 4Q avg 9.0% |
| Percentage of long-stay residents who lose too much weight | 8.2% |
5.2%
3 pts worse
|
5.4%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 12.4% · Q3 8.6% · Q4 6.0% · 4Q avg 8.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.2% |
19.2%
5 pts worse
|
19.6%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.2% · Q2 25.4% · Q3 22.7% · Q4 26.5% · 4Q avg 24.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 28.9% |
22.5%
6.4 pts worse
|
16.7%
12.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.4% · Q2 28.0% · Q3 28.6% · Q4 28.6% · 4Q avg 28.9% · 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 | 15.2% |
17.7%
2.5 pts better
|
16.3%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 24.2% · Q3 14.3% · Q4 14.9% · 4Q avg 15.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.6% |
17.6%
4 pts better
|
14.9%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 20.4% · Q3 13.9% · Q4 12.1% · 4Q avg 13.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.4% |
1.0%
1.4 pts worse
|
1.0%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 2.5% · Q3 2.8% · Q4 1.4% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.2% |
2.0%
2.2 pts worse
|
1.7%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 5.9% · Q3 4.8% · Q4 1.6% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.5% |
21.7%
6.8 pts worse
|
19.8%
8.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.8% · Q2 28.1% · Q3 22.5% · Q4 37.5% · 4Q avg 28.5% |
| Percentage of long-stay residents with pressure ulcers | 5.3% |
4.6%
0.7 pts worse
|
5.1%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 6.4% · Q3 3.4% · Q4 4.3% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 55.8% |
77.1%
21.3 pts worse
|
81.7%
25.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 50.8% · Q2 54.5% · Q3 55.4% · Q4 64.7% · 4Q avg 55.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 22.0% |
11.8%
10.2 pts worse
|
12.0%
10 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 22.0% · Observed 27.8% · Expected 14.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.2% |
1.3%
1.9 pts worse
|
1.6%
1.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 3.8% · Q3 2.2% · Q4 0.0% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 46.0% |
77.7%
31.7 pts worse
|
79.7%
33.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 46.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 32.3% |
25.8%
6.5 pts worse
|
23.9%
8.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 32.3% · Observed 35.2% · Expected 26.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-25 · Fire 2023-10-25
13 health deficiencies
Top issue: Resident Rights (5 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2022-09-23 · Fire 2022-09-23
18 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
4 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-12-18
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2025-02-10
F · Potential for more than minimal harm
2024-12-18
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-02-10
F · Potential for more than minimal harm
2024-12-18
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-02-10
F · Potential for more than minimal harm
2024-12-18
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-02-10
F · Potential for more than minimal harm
2024-12-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-02-10
F · Potential for more than minimal harm
2024-12-18
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-02-10
D · Potential for more than minimal harm
2024-12-18
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-02-10
D · Potential for more than minimal harm
2024-12-18
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-02-10
D · Potential for more than minimal harm
2024-12-18
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-02-10
E · Potential for more than minimal harm
2023-10-25
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-12-17
E · Potential for more than minimal harm
2023-10-25
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-12-17
E · Potential for more than minimal harm
2023-10-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-12-17
E · Potential for more than minimal harm
2023-10-25
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-12-17
D · Potential for more than minimal harm
2023-10-25
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-12-17
D · Potential for more than minimal harm
2023-10-25
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 2023-12-17
F · Potential for more than minimal harm
2022-09-23
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2022-10-28
F · Potential for more than minimal harm
2022-09-23
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-10-28
E · Potential for more than minimal harm
2022-09-23
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-10-28
D · Potential for more than minimal harm
2022-09-23
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2022-10-28
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-12-18
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 2025-01-27
E · Potential for more than minimal harm
2024-12-18
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 2025-01-27
E · Potential for more than minimal harm
2024-12-18
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 2025-01-27
D · Potential for more than minimal harm
2024-12-18
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 2025-01-27
D · Potential for more than minimal harm
2024-12-18
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 2025-01-27
D · Potential for more than minimal harm
2024-12-18
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-01-27
D · Potential for more than minimal harm
2024-12-18
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-01-27
D · Potential for more than minimal harm
2024-12-18
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 2025-01-27
D · Potential for more than minimal harm
2024-12-18
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2025-01-27
D · Potential for more than minimal harm
2024-12-18
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-01-27
D · Potential for more than minimal harm
2024-12-18
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 2025-01-27
B · Minimal harm
2024-12-18
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-01-27
B · Minimal harm
2024-12-18
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-01-27
D · Potential for more than minimal harm
2024-12-03
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 2025-01-10
E · Potential for more than minimal harm
2023-10-25
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-12-03
E · Potential for more than minimal harm
2023-10-25
F712 · Nursing and Physician Services Deficiencies
Health
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected 2023-12-03
E · Potential for more than minimal harm
2023-10-25
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 2023-12-03
D · Potential for more than minimal harm
2023-10-25
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-12-03
D · Potential for more than minimal harm
2023-10-25
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2023-12-03
D · Potential for more than minimal harm
2023-10-25
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 2023-12-03
D · Potential for more than minimal harm
2023-10-25
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 2023-12-03
D · Potential for more than minimal harm
2023-10-25
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2023-12-03
D · Potential for more than minimal harm
2023-10-25
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-12-03
D · Potential for more than minimal harm
2023-10-25
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 2023-12-03
D · Potential for more than minimal harm
2023-10-25
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 2023-12-03
D · Potential for more than minimal harm
2023-10-25
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 2023-12-03
G · Actual harm
2023-05-10
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 2023-05-05
E · Potential for more than minimal harm
2022-09-23
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 2022-11-07
E · Potential for more than minimal harm
2022-09-23
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 2022-11-07
E · Potential for more than minimal harm
2022-09-23
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 2022-11-07
E · Potential for more than minimal harm
2022-09-23
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2022-11-07
E · Potential for more than minimal harm
2022-09-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-11-07
D · Potential for more than minimal harm
2022-09-23
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 2022-11-07
D · Potential for more than minimal harm
2022-09-23
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2022-11-07
D · Potential for more than minimal harm
2022-09-23
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2022-11-07
D · Potential for more than minimal harm
2022-09-23
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 2022-11-07
D · Potential for more than minimal harm
2022-09-23
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2022-11-07
D · Potential for more than minimal harm
2022-09-23
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-11-07
D · Potential for more than minimal harm
2022-09-23
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2022-11-07
D · Potential for more than minimal harm
2022-09-23
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2022-11-07
D · Potential for more than minimal harm
2022-09-23
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2022-11-07
D · Potential for more than minimal harm
2022-09-23
F772 · Administration Deficiencies
Health
Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided.
Corrected 2022-11-07
D · Potential for more than minimal harm
2022-09-23
F886 · Infection Control Deficiencies
Health
Perform COVID19 testing on residents and staff.
Corrected 2022-11-07
D · Potential for more than minimal harm
2022-09-23
F888 · Infection Control Deficiencies
Health
Ensure staff are vaccinated for COVID-19
Corrected 2022-11-07
Penalties and ownership
What sits behind the stars
$14,675
2023-05-10
Fine
Fine · fine $14,675
Fine
Ownership
Athena Health Care Systems Ma R LLC
5% Or Greater Direct Ownership Interest · Organization
Santilli, Lawrence
5% Or Greater Indirect Ownership Interest · Individual
Mosier, Michael
5% Or Greater Indirect Ownership Interest · Individual
Chakalos-Santilli, Valerie
5% Or Greater Indirect Ownership Interest · Individual
Athena Health Care Associates, Inc.
Operational/Managerial Control · Organization
Curtis, Diane
5% Or Greater Indirect Ownership Interest · Individual
Mosier, Michael
W-2 Managing Employee · Individual
Rezendes, Lorrie
5% Or Greater Indirect Ownership Interest · Individual
Santilli, Lawrence
Operational/Managerial Control · Individual
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