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
Staffing
Hours and turnover
RN hours / resident day
0.30
Registered nurse staffing
LPN hours / resident day
1.00
Licensed practical nurse staffing
Aide hours / resident day
1.93
Nurse aide staffing
Weekend hours
2.90
Weekend nurse staffing
RN turnover
50%
Annual RN turnover
Total nurse turnover
41%
Annual nurse turnover
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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
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
Nearby options
Other facilities in reach
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4-star overall rating with 4-star inspections with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Webster Manor Rehabilitation & Health Care Center
Webster, MA
2-star overall rating with 2-star inspections with 13 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#3
Lanessa Extended Care
Webster, MA
1-star overall rating with 1-star inspections with $119,962 in total fines with 26 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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