28 health deficiencies
Top issue: Resident Rights (5 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
North Easton, MA
1-star overall rating with 1-star inspections with $11,947 in total fines with 28 recent health deficiencies
184 Lincoln Street, North Easton, MA
(508) 238-7053
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Beds
171
Certified beds
Average residents
154
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Athena Healthcare Systems
Operator or chain grouping
Approved since
1975-03-04
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
RN hours / resident day
0.43
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
0.93
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
1.87
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
1.36
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
2.82
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.20
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
0.43
CMS adjusted RN staffing hours
Adjusted total hours
3.22
CMS adjusted total nurse staffing hours
Case-mix index
1.37
Higher values indicate more complex resident acuity
RN turnover
54%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
24%
Annual nurse turnover · state 40% · national 46%
SNF VBP
Program rank
8,327
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
27.10
Composite VBP score used to determine payment impact.
Payment multiplier
0.9844
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
0
Baseline 19.58% · Performance 22.83% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 7.58% · Performance 8.15% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
9.41
Baseline 20.32% · Performance 25.23% · Measure score 9.41 · Achievement 9.41 · Improvement 0
Adjusted total nurse staffing
1.44
Baseline 3.91 hours · Performance 3.49 hours · Measure score 1.44 · Achievement 1.44 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.48% |
10.72%
2.8 pts worse
|
No Different than the National Rate · Eligible stays 142 · Observed rate 18.31% · Lower 95% interval 9.67% |
| Discharge to community | 45.32% |
50.57%
5.2 pts worse
|
No Different than the National Rate · Eligible stays 115 · Observed rate 36.52% · Lower 95% interval 37.99% |
| Medicare spending per beneficiary | 0.9 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 98.8% |
95.27%
3.5 pts better
|
Numerator 82 · Denominator 83 |
| Falls with major injury | 1.2% |
0.77%
0.4 pts worse
|
Numerator 1 · Denominator 83 |
| Discharge self-care score | 44.64% |
53.69%
9 pts worse
|
Numerator 25 · Denominator 56 |
| Discharge mobility score | 37.5% |
50.94%
13.4 pts worse
|
Numerator 21 · Denominator 56 |
| Pressure ulcers or injuries, new or worsened | 6.02% |
2.29%
3.7 pts worse
|
Numerator 5 · Denominator 83 · Adjusted rate 4.49% |
| Healthcare-associated infections requiring hospitalization | 8.15% |
7.12%
1 pts worse
|
No Different than the National Rate · Eligible stays 84 · Observed rate 10.71% · Lower 95% interval 5.03% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 218 |
| Staff flu vaccination coverage | 17.76% |
42%
24.2 pts worse
|
Numerator 38 · Denominator 214 |
| Discharge function score | 48.21% |
56.45%
8.2 pts worse
|
Numerator 27 · Denominator 56 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 27 · Denominator 27 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 26 · Denominator 26 |
| Resident COVID-19 vaccinations up to date | 7.5% |
25.2%
17.7 pts worse
|
Numerator 3 · Denominator 40 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
1.9
0.2 pts better
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.5 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
1.5
0.4 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.2 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 91.0% |
92.2%
1.2 pts worse
|
93.4%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 92.6% · Q2 89.0% · Q3 90.3% · Q4 92.1% · 4Q avg 91.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 75.7% |
94.8%
19.1 pts worse
|
95.5%
19.8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 75.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.5% |
3.5%
About the same
|
3.3%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 2.8% · Q3 3.4% · Q4 4.3% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.0% |
12.0%
7 pts better
|
11.4%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 3.3% · Q3 5.3% · Q4 10.2% · 4Q avg 5.0% |
| Percentage of long-stay residents who lose too much weight | 5.8% |
5.2%
0.6 pts worse
|
5.4%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 11.0% · Q3 6.3% · Q4 0.0% · 4Q avg 5.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.3% |
19.2%
2.1 pts worse
|
19.6%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.5% · Q2 21.7% · Q3 21.5% · Q4 22.1% · 4Q avg 21.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 36.4% |
22.5%
13.9 pts worse
|
16.7%
19.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.8% · Q2 35.9% · Q3 38.2% · Q4 36.8% · 4Q avg 36.4% · 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 | 30.4% |
17.7%
12.7 pts worse
|
16.3%
14.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.3% · Q2 31.5% · Q3 34.0% · Q4 20.5% · 4Q avg 30.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 29.5% |
17.6%
11.9 pts worse
|
14.9%
14.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.5% · Q2 26.8% · Q3 26.7% · Q4 30.3% · 4Q avg 29.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
1.0%
0.1 pts better
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 1.1% · Q3 1.1% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.5% |
2.0%
0.5 pts worse
|
1.7%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 4.2% · Q3 3.5% · Q4 0.0% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.3% |
21.7%
4.6 pts worse
|
19.8%
6.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.8% · Q2 30.6% · Q3 21.4% · Q4 24.6% · 4Q avg 26.3% |
| Percentage of long-stay residents with pressure ulcers | 3.8% |
4.6%
0.8 pts better
|
5.1%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 2.6% · Q3 5.7% · Q4 2.9% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 69.8% |
77.1%
7.3 pts worse
|
81.7%
11.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 78.2% · Q2 69.6% · Q3 62.5% · Q4 68.1% · 4Q avg 69.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.8% |
11.8%
About the same
|
12.0%
0.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.8% · Observed 14.9% · Expected 14.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.8% |
1.3%
0.5 pts worse
|
1.6%
0.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 1.6% · Q3 1.7% · Q4 2.3% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 41.1% |
77.7%
36.6 pts worse
|
79.7%
38.6 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 41.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.0% |
25.8%
0.8 pts better
|
23.9%
1.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.0% · Observed 26.4% · Expected 25.2% · Used in QM five-star |
Survey summary
Top issue: Resident Rights (5 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Top issue: Resident Rights (5 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Top issue: Freedom from Abuse and Neglect and Exploitation (6 deficiencies)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Fire safety
Fire Safety
Implement emergency and standby power systems.
Corrected 2022-11-17
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-11-17
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-11-17
Inspection history
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2025-09-12
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 2025-09-12
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-09-12
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-09-12
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-09-12
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-09-12
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 2025-09-12
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2025-09-12
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2025-09-12
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-09-12
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2025-09-12
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-12
Health
Implement a program that monitors antibiotic use.
Corrected 2025-09-12
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-09-12
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 2025-09-12
Health
Give the resident's representative the ability to exercise the resident's rights.
Corrected 2025-09-12
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-09-12
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-09-12
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-09-12
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2025-09-12
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-09-12
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-09-12
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2025-09-12
Health
Follow rules about disclosure of ownership requirements and tell the state agency about changes in ownership and/or administrative personnel.
Corrected 2025-09-12
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2025-09-12
Health
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected 2025-09-12
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2025-09-12
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-06-26
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-06-16
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-06-16
Health
Keep all essential equipment working safely.
Corrected 2024-06-16
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-06-16
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-06-16
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-06-16
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-06-16
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-16
Health
Implement a program that monitors antibiotic use.
Corrected 2024-06-16
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-06-16
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 2024-06-16
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-04-18
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2024-04-18
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-12-28
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-12-28
Health
Respond appropriately to all alleged violations.
Corrected 2023-10-16
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2022-10-24
Health
Respond appropriately to all alleged violations.
Corrected 2022-10-24
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2022-11-01
Health
Provide and implement an infection prevention and control program.
Corrected 2022-11-01
Health
Report COVID19 data to residents and families.
Corrected 2022-11-01
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2022-11-01
Health
Keep all essential equipment working safely.
Corrected 2022-11-21
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2022-11-21
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2022-10-24
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-11-01
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 2022-11-01
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-11-01
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-11-01
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 2022-11-01
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-11-01
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2022-11-01
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2022-11-01
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2022-11-01
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2022-11-01
Health
Post nurse staffing information every day.
Corrected 2022-11-01
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2022-11-01
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2022-11-01
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2022-11-01
Penalties and ownership
Fine · fine $11,947
Fine
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Individual
Operational/Managerial Control · Organization
W-2 Managing Employee · Individual
5% Or Greater Indirect Ownership Interest · Individual
Corporate Officer · Individual
Nearby options
Stoughton, MA
5-star overall rating with 4-star inspections with $10,517 in total fines with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
Brockton, MA
4-star overall rating with 4-star inspections with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
Stoughton, MA
2-star overall rating with 2-star inspections with abuse icon flag with $12,735 in total fines with 1 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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