Cycle 1
Health 2024-12-04 · Fire 2024-12-04
0 health deficiencies
No concentrated health issue counts in this cycle.
11 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Norwell, MA
Southwood At Norwell Nursing Ctr
5-star overall rating with 5-star inspections with 11 fire-safety deficiencies in the latest cycle
501 Cordwainer Drive, Norwell, MA
(781) 982-7450
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
142
Certified beds
Average residents
127
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1993-10-28
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
0.71
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
0.63
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.46
Nurse aide staffing · state 2.26 · national 2.35
Total nurse hours
3.79
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.34
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.42
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.48
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.78
CMS adjusted RN staffing hours
Adjusted total hours
4.16
CMS adjusted total nurse staffing hours
Case-mix index
1.25
Higher values indicate more complex resident acuity
RN turnover
48%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
27%
Annual nurse turnover · state 40% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,308
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
50.31
Composite VBP score used to determine payment impact.
Payment multiplier
1.0044
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.51
Baseline 18.75% · Performance 19.34% · Measure score 4.51 · Achievement 4.51 · Improvement 0
Healthcare-associated infections
2.93
Baseline 5.31% · Performance 6.96% · Measure score 2.93 · Achievement 2.93 · Improvement 0
Total nurse turnover
9.30
Baseline 39.80% · Performance 25.69% · Measure score 9.30 · Achievement 9.30 · Improvement 8.94
Adjusted total nurse staffing
3.39
Baseline 3.76 hours · Performance 4.04 hours · Measure score 3.39 · Achievement 3.39 · Improvement 0.88
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.2% |
10.72%
2.5 pts worse
|
No Different than the National Rate · Eligible stays 479 · Observed rate 12.73% · Lower 95% interval 10.53% |
| Discharge to community | 60.86% |
50.57%
10.3 pts better
|
Better than the National Rate · Eligible stays 461 · Observed rate 56.83% · Lower 95% interval 55.83% |
| Medicare spending per beneficiary | 0.96 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 340 · Denominator 340 |
| Falls with major injury | 0.29% |
0.77%
0.5 pts better
|
Numerator 1 · Denominator 340 |
| Discharge self-care score | 56.07% |
53.69%
2.4 pts better
|
Numerator 157 · Denominator 280 |
| Discharge mobility score | 44.29% |
50.94%
6.6 pts worse
|
Numerator 124 · Denominator 280 |
| Pressure ulcers or injuries, new or worsened | 0.88% |
2.29%
1.4 pts better
|
Numerator 3 · Denominator 340 · Adjusted rate 0.82% |
| Healthcare-associated infections requiring hospitalization | 6.96% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 310 · Observed rate 5.81% · Lower 95% interval 4.59% |
| Staff COVID-19 vaccination coverage | 2.69% |
8.2%
5.5 pts worse
|
Numerator 5 · Denominator 186 |
| Staff flu vaccination coverage | 68.72% |
42%
26.7 pts better
|
Numerator 134 · Denominator 195 |
| Discharge function score | 53.21% |
56.45%
3.2 pts worse
|
Numerator 149 · Denominator 280 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 58 · Denominator 58 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 223 · Denominator 223 |
| Resident COVID-19 vaccinations up to date | 40.41% |
25.2%
15.2 pts better
|
Numerator 78 · Denominator 193 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.8 |
1.9
1.1 pts better
|
1.9
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.6 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.4 |
1.5
1.1 pts better
|
1.8
1.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.4 · Observed 0.4 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
92.2%
7.8 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 | 3.3% |
3.5%
0.2 pts better
|
3.3%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 3.1% · Q3 4.2% · Q4 2.1% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.3% |
12.0%
11.7 pts better
|
11.4%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% |
| Percentage of long-stay residents who lose too much weight | 3.0% |
5.2%
2.2 pts better
|
5.4%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 1.2% · Q3 4.8% · Q4 4.9% · 4Q avg 3.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.5% |
19.2%
0.3 pts worse
|
19.6%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 24.4% · Q2 19.8% · Q3 18.2% · Q4 15.9% · 4Q avg 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.6% |
22.5%
10.9 pts better
|
16.7%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.7% · Q2 9.7% · Q3 12.2% · Q4 10.0% · 4Q avg 11.6% · 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 | 14.4% |
17.7%
3.3 pts better
|
16.3%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.3% · Q2 7.6% · Q3 14.3% · Q4 19.5% · 4Q avg 14.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.1% |
17.6%
6.5 pts better
|
14.9%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 7.6% · Q3 16.2% · Q4 13.2% · 4Q avg 11.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.0%
1 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.6% |
2.0%
1.6 pts worse
|
1.7%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 5.2% · Q3 6.5% · Q4 2.1% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 10.2% |
21.7%
11.5 pts better
|
19.8%
9.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.9% · Q2 2.9% · Q3 14.1% · Q4 12.4% · 4Q avg 10.2% |
| 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 3.8% · Q2 2.3% · Q3 4.3% · Q4 5.0% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.3% |
77.1%
22.2 pts better
|
81.7%
17.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.3% · Q3 99.0% · Q4 100.0% · 4Q avg 99.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.4% |
11.8%
7.4 pts better
|
12.0%
7.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.4% · Observed 4.2% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.3%
0.9 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.8% · Q3 0.7% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.9% |
77.7%
21.2 pts better
|
79.7%
19.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.3% |
25.8%
6.5 pts better
|
23.9%
4.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.3% · Observed 17.2% · Expected 21.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-29 · Fire 2023-09-29
7 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2021-04-16 · Fire 2021-04-16
4 health deficiencies
Top issue: Pharmacy Service (2 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
2024-12-04
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2025-01-31
F · Potential for more than minimal harm
2024-12-04
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2025-01-31
F · Potential for more than minimal harm
2024-12-04
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2025-01-31
F · Potential for more than minimal harm
2024-12-04
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-01-31
F · Potential for more than minimal harm
2024-12-04
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-01-31
F · Potential for more than minimal harm
2024-12-04
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-01-31
E · Potential for more than minimal harm
2024-12-04
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2025-01-31
E · Potential for more than minimal harm
2024-12-04
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-01-31
D · Potential for more than minimal harm
2024-12-04
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-01-31
D · Potential for more than minimal harm
2024-12-04
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2025-01-31
D · Potential for more than minimal harm
2024-12-04
K361 · Smoke Deficiencies
Fire Safety
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
Corrected 2025-01-31
Inspection history
Recent health citations
E · Potential for more than minimal harm
2023-09-29
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-11-06
E · Potential for more than minimal harm
2023-09-29
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 2023-11-06
E · Potential for more than minimal harm
2023-09-29
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2023-11-06
D · Potential for more than minimal harm
2023-09-29
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-11-06
D · Potential for more than minimal harm
2023-09-29
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 2023-11-06
D · Potential for more than minimal harm
2023-09-29
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-11-06
D · Potential for more than minimal harm
2023-09-29
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-11-06
D · Potential for more than minimal harm
2023-09-29
F849 · Administration Deficiencies
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 2023-11-06
E · Potential for more than minimal harm
2021-04-16
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 2021-05-21
D · Potential for more than minimal harm
2021-04-16
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 2021-05-21
D · Potential for more than minimal harm
2021-04-16
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 2021-05-21
Penalties and ownership
What sits behind the stars
Ownership
Starr, Richard
5% Or Greater Direct Ownership Interest · Individual
Southwood At Norwell Nursing Center
Limited Partnership Interest · Organization
Southwood At Norwell Nursing Center, Inc.
General Partnership Interest · Organization
Starr Healthgroup, LLC
Operational/Managerial Control · Organization
Starr, Lindsey
Operational/Managerial Control · Individual
Starr, Richard
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Royal Norwell Nursing & Rehabilitation Center LLC
Norwell, MA
3-star overall rating with 3-star inspections with $114,868 in total fines with 3 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
Queen Anne Nursing Home, Inc
Hingham, MA
5-star overall rating with 5-star inspections
#3
Linden Ponds
Hingham, MA
5-star overall rating with 5-star inspections with 2 recent health deficiencies
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