Cycle 1
Health 2024-10-18 · Fire 2024-10-18
7 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
9 fire-safety deficiencies
Top issue: Egress (5 deficiencies)
Medfield, MA
Thomas Upham House
3-star overall rating with 3-star inspections with 7 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
519 Main Street, Medfield, MA
(508) 359-6050
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
42
Certified beds
Average residents
36
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Rehabilitation Associates
Operator or chain grouping
Approved since
1994-09-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
6 facilities
Chain averages 3 overall / 3 health / 4 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
0.93
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
0.73
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.84
Nurse aide staffing · state 2.26 · national 2.35
Total nurse hours
4.50
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.66
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.92
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.53
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.14
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
1.12
CMS adjusted RN staffing hours
Adjusted total hours
5.44
CMS adjusted total nurse staffing hours
Case-mix index
1.13
Higher values indicate more complex resident acuity
RN turnover
57%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
56%
Annual nurse turnover · state 40% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,258
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
50.63
Composite VBP score used to determine payment impact.
Payment multiplier
1.0048
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.27
Baseline 18.46% · Performance 20.38% · Measure score 2.27 · Achievement 2.27 · Improvement 0
Healthcare-associated infections
4.03
Baseline 5.73% · Performance 6.63% · Measure score 4.03 · Achievement 4.03 · Improvement 0
Total nurse turnover
4.79
Baseline 16.67% · Performance 44.12% · Measure score 4.79 · Achievement 4.79 · Improvement 0
Adjusted total nurse staffing
9.17
Baseline 5.24 hours · Performance 5.69 hours · Measure score 9.17 · Achievement 9.17 · Improvement 7.76
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.18% |
10.72%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 67 · Observed rate 10.45% · Lower 95% interval 7.32% |
| Discharge to community | 49.49% |
50.57%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 63 · Observed rate 46.03% · Lower 95% interval 37.64% |
| Medicare spending per beneficiary | 0.92 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 95.83% |
95.27%
0.6 pts better
|
Numerator 46 · Denominator 48 |
| Falls with major injury | 2.08% |
0.77%
1.3 pts worse
|
Numerator 1 · Denominator 48 |
| Discharge self-care score | 75% |
53.69%
21.3 pts better
|
Numerator 27 · Denominator 36 |
| Discharge mobility score | 75% |
50.94%
24.1 pts better
|
Numerator 27 · Denominator 36 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 48 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.63% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 33 · Observed rate 3.03% · Lower 95% interval 2.93% |
| Staff COVID-19 vaccination coverage | 15.15% |
8.2%
7 pts better
|
Numerator 10 · Denominator 66 |
| Staff flu vaccination coverage | 77.78% |
42%
35.8 pts better
|
Numerator 42 · Denominator 54 |
| Discharge function score | 83.33% |
56.45%
26.9 pts better
|
Numerator 30 · Denominator 36 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 95.45% |
96.28%
0.8 pts worse
|
Numerator 21 · Denominator 22 |
| Resident COVID-19 vaccinations up to date | 56.25% |
25.2%
31.1 pts better
|
Numerator 18 · Denominator 32 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.1 |
1.9
0.2 pts worse
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 1.9 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
1.5
0.6 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.9 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.0% |
92.2%
0.8 pts better
|
93.4%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 93.5% · Q2 96.9% · Q3 81.2% · Q4 100.0% · 4Q avg 93.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.1% |
94.8%
0.7 pts worse
|
95.5%
1.4 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.9% |
3.5%
0.4 pts worse
|
3.3%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 3.1% · Q3 6.2% · Q4 3.0% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.6% |
12.0%
8.4 pts better
|
11.4%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 4.0% · Q3 3.4% · Q4 0.0% · 4Q avg 3.6% |
| 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 10.0% · Q2 10.7% · Q3 0.0% · Q4 3.1% · 4Q avg 5.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.4% |
19.2%
3.8 pts better
|
19.6%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.9% · Q2 24.1% · Q3 16.1% · Q4 9.4% · 4Q avg 15.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 24.2% |
22.5%
1.7 pts worse
|
16.7%
7.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 21.7% · Q3 23.1% · Q4 29.6% · 4Q avg 24.2% · 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 | 19.6% |
17.7%
1.9 pts worse
|
16.3%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q4 10.6% · 4Q avg 19.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.0% |
17.6%
3.4 pts worse
|
14.9%
6.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.6% · Q2 28.6% · Q3 23.3% · Q4 6.2% · 4Q avg 21.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 4.0% |
1.0%
3 pts worse
|
1.0%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 4.3% · Q3 3.5% · Q4 4.3% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.8% |
2.0%
2.8 pts worse
|
1.7%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 3.3% · Q3 9.7% · Q4 0.0% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.3% |
21.7%
3.4 pts better
|
19.8%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 28.6% · Q2 10.0% · Q3 18.0% · Q4 17.2% · 4Q avg 18.3% |
| Percentage of long-stay residents with pressure ulcers | 6.3% |
4.6%
1.7 pts worse
|
5.1%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 12.0% · Q3 0.0% · Q4 7.0% · 4Q avg 6.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 52.1% |
77.1%
25 pts worse
|
81.7%
29.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q2 50.0% · Q3 29.2% · Q4 52.0% · 4Q avg 52.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.6% |
11.8%
1.2 pts better
|
12.0%
1.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.6% · Observed 9.8% · Expected 10.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 84.6% |
77.7%
6.9 pts better
|
79.7%
4.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 84.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 33.3% |
25.8%
7.5 pts worse
|
23.9%
9.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 33.3% · Observed 29.3% · Expected 21.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-07-10 · Fire 2023-07-10
1 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
6 fire-safety deficiencies
Top issue: Egress (4 deficiencies)
Cycle 3
Health 2021-04-14 · Fire 2021-04-14
4 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
6 fire-safety deficiencies
Top issue: Egress (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-18
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-12-20
F · Potential for more than minimal harm
2024-10-18
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-12-31
F · Potential for more than minimal harm
2024-10-18
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-12-31
F · Potential for more than minimal harm
2024-10-18
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2024-12-31
F · Potential for more than minimal harm
2024-10-18
K241 · Egress Deficiencies
Fire Safety
Have correct number of accessible exits for each story.
Corrected 2024-12-31
F · Potential for more than minimal harm
2024-10-18
K252 · Egress Deficiencies
Fire Safety
Provide at least two remote exits on each floor or fire section of the building.
Corrected 2024-12-31
F · Potential for more than minimal harm
2024-10-18
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-12-20
F · Potential for more than minimal harm
2024-10-18
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2024-12-31
F · Potential for more than minimal harm
2024-10-18
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-12-20
F · Potential for more than minimal harm
2023-07-10
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2023-07-18
F · Potential for more than minimal harm
2023-07-10
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-07-18
F · Potential for more than minimal harm
2023-07-10
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2023-07-18
F · Potential for more than minimal harm
2023-07-10
K241 · Egress Deficiencies
Fire Safety
Have correct number of accessible exits for each story.
Corrected 2023-07-18
F · Potential for more than minimal harm
2023-07-10
K252 · Egress Deficiencies
Fire Safety
Provide at least two remote exits on each floor or fire section of the building.
Corrected 2023-07-18
F · Potential for more than minimal harm
2023-07-10
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2023-07-18
F · Potential for more than minimal harm
2021-04-14
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2021-05-04
F · Potential for more than minimal harm
2021-04-14
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2021-05-04
F · Potential for more than minimal harm
2021-04-14
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2021-05-04
F · Potential for more than minimal harm
2021-04-14
K241 · Egress Deficiencies
Fire Safety
Have correct number of accessible exits for each story.
Corrected 2021-05-04
F · Potential for more than minimal harm
2021-04-14
K252 · Egress Deficiencies
Fire Safety
Provide at least two remote exits on each floor or fire section of the building.
Corrected 2021-05-04
F · Potential for more than minimal harm
2021-04-14
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2021-05-04
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-10-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-15
E · Potential for more than minimal harm
2024-10-18
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 2024-11-15
E · Potential for more than minimal harm
2024-10-18
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-11-15
E · Potential for more than minimal harm
2024-10-18
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 2024-11-15
D · Potential for more than minimal harm
2024-10-18
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 2024-11-15
D · Potential for more than minimal harm
2024-10-18
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-10-18
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-11-15
D · Potential for more than minimal harm
2023-07-10
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 2023-07-13
F · Potential for more than minimal harm
2021-04-14
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 2021-05-06
E · Potential for more than minimal harm
2021-04-14
F800 · Nutrition and Dietary Deficiencies
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2021-05-06
D · Potential for more than minimal harm
2021-04-14
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 2021-05-06
D · Potential for more than minimal harm
2021-04-14
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 2021-05-06
Penalties and ownership
What sits behind the stars
Ownership
Thisse, Nicholas
5% Or Greater Direct Ownership Interest · Individual
Allen, Denise
Operational/Managerial Control · Individual
Rehabilitation Associates Inc
Operational/Managerial Control · Organization
Thisse, Nicholas
Corporate Director · Individual
Thisse, Peter
Corporate Director · Individual
Thisse, Peter
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Premier Healthcare at Harrington House
Walpole, MA
1-star overall rating with 1-star inspections with $43,891 in total fines with 19 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Charlwell House Health And Rehabilitation
Norwood, MA
1-star overall rating with 2-star inspections with 13 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Victoria Haven Nursing Facility
Norwood, MA
1-star overall rating with 2-star inspections with $40,641 in total fines with 10 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
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