Cycle 1
Health 2025-03-06 · Fire 2025-03-06
17 health deficiencies
Top issue: Resident Assessment and Care Planning (5 deficiencies)
6 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Holliston, MA
Timothy Daniels House
3-star overall rating with 2-star inspections with 17 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
84 Elm Street, Holliston, MA
(508) 429-4566
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
40
Certified beds
Average residents
33
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Rehabilitation Associates
Operator or chain grouping
Approved since
1996-08-01
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
0.97
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
0.46
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.61
Nurse aide staffing · state 2.26 · national 2.35
Total nurse hours
4.04
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.43
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.72
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.70
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
1.08
CMS adjusted RN staffing hours
Adjusted total hours
4.49
CMS adjusted total nurse staffing hours
Case-mix index
1.23
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
38%
Annual nurse turnover · state 40% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,941
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
38.04
Composite VBP score used to determine payment impact.
Payment multiplier
0.9912
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
0.99
Baseline 8.23% · Performance 7.75% · Measure score 0.99 · Achievement 0 · Improvement 0.99
Total nurse turnover
5
Baseline 31.25% · Performance 43.24% · Measure score 5 · Achievement 5 · Improvement 0
Adjusted total nurse staffing
5.43
Baseline 5.29 hours · Performance 4.62 hours · Measure score 5.43 · Achievement 5.43 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.21% |
10.72%
0.5 pts better
|
No Different than the National Rate · Eligible stays 53 · Observed rate 7.55% · Lower 95% interval 5.77% |
| Discharge to community | 70.64% |
50.57%
20.1 pts better
|
Better than the National Rate · Eligible stays 37 · Observed rate 75.68% · Lower 95% interval 58.46% |
| Medicare spending per beneficiary | 0.86 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 94.44% |
95.27%
0.8 pts worse
|
Numerator 34 · Denominator 36 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 36 |
| Discharge self-care score | 48.28% |
53.69%
5.4 pts worse
|
Numerator 14 · Denominator 29 |
| Discharge mobility score | 41.38% |
50.94%
9.6 pts worse
|
Numerator 12 · Denominator 29 |
| Pressure ulcers or injuries, new or worsened | 8.33% |
2.29%
6 pts worse
|
Numerator 3 · Denominator 36 · Adjusted rate 6.13% |
| Healthcare-associated infections requiring hospitalization | 7.75% |
7.12%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 30 · Observed rate 13.33% · Lower 95% interval 4% |
| Staff COVID-19 vaccination coverage | 6.25% |
8.2%
1.9 pts worse
|
Numerator 3 · Denominator 48 |
| Staff flu vaccination coverage | 54.17% |
42%
12.2 pts better
|
Numerator 26 · Denominator 48 |
| Discharge function score | 55.17% |
56.45%
1.3 pts worse
|
Numerator 16 · Denominator 29 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 24% |
25.2%
1.2 pts worse
|
Numerator 6 · Denominator 25 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.3 |
1.9
0.4 pts worse
|
1.9
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.1 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.2 |
1.5
1.7 pts worse
|
1.8
1.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.2 · Observed 2.8 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 88.1% |
92.2%
4.1 pts worse
|
93.4%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 80.0% · Q2 96.3% · Q3 85.7% · Q4 89.7% · 4Q avg 88.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 92.9% |
94.8%
1.9 pts worse
|
95.5%
2.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 92.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.7% |
3.5%
0.2 pts worse
|
3.3%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 7.4% · Q3 3.6% · Q4 0.0% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.7% |
12.0%
8.3 pts better
|
11.4%
7.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 4.8% · Q3 4.5% · Q4 0.0% · 4Q avg 3.7% |
| Percentage of long-stay residents who lose too much weight | 4.5% |
5.2%
0.7 pts better
|
5.4%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 4.8% · Q3 4.0% · Q4 0.0% · 4Q avg 4.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.1% |
19.2%
1.1 pts better
|
19.6%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 13.0% · Q3 20.0% · Q4 26.9% · 4Q avg 18.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 23.0% |
22.5%
0.5 pts worse
|
16.7%
6.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 20.0% · Q4 25.0% · 4Q avg 23.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.9% |
0.1%
0.8 pts worse
|
0.1%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% |
| Percentage of long-stay residents whose ability to walk independently worsened | 16.4% |
17.7%
1.3 pts better
|
16.3%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 16.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.2% |
17.6%
1.6 pts worse
|
14.9%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 5.0% · Q3 23.8% · Q4 23.8% · 4Q avg 19.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
1.0%
0.3 pts better
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.7% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.0% |
2.0%
1 pts better
|
1.7%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 10.6% |
21.7%
11.1 pts better
|
19.8%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 18.4% · Q3 7.3% · Q4 12.3% · 4Q avg 10.6% |
| Percentage of long-stay residents with pressure ulcers | 5.8% |
4.6%
1.2 pts worse
|
5.1%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 7.8% · Q3 3.1% · Q4 6.5% · 4Q avg 5.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 49.0% |
77.1%
28.1 pts worse
|
81.7%
32.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 50.0% · Q2 45.8% · Q3 59.1% · Q4 42.9% · 4Q avg 49.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 18.1% |
11.8%
6.3 pts worse
|
12.0%
6.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 18.1% · Observed 16.7% · Expected 10.3% · 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 · 4Q avg 1.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 76.9% |
77.7%
0.8 pts worse
|
79.7%
2.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 76.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 15.5% |
25.8%
10.3 pts better
|
23.9%
8.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 15.5% · Observed 12.5% · Expected 19.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-16 · Fire 2024-02-16
9 health deficiencies
Top issue: Infection Control (4 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2022-08-02 · Fire 2022-08-02
9 health deficiencies
Top issue: Administration (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
2025-03-06
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2025-03-31
F · Potential for more than minimal harm
2025-03-06
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2025-03-31
F · Potential for more than minimal harm
2025-03-06
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2025-03-31
F · Potential for more than minimal harm
2025-03-06
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-03-31
F · Potential for more than minimal harm
2025-03-06
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-04-11
D · Potential for more than minimal harm
2025-03-06
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-04-11
D · Potential for more than minimal harm
2024-02-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-05
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-25
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 2025-12-19
F · Potential for more than minimal harm
2025-03-06
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2025-04-05
F · Potential for more than minimal harm
2025-03-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-05
E · Potential for more than minimal harm
2025-03-06
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2025-04-05
E · Potential for more than minimal harm
2025-03-06
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 2025-04-05
E · Potential for more than minimal harm
2025-03-06
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 2025-04-05
E · Potential for more than minimal harm
2025-03-06
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2025-04-05
E · Potential for more than minimal harm
2025-03-06
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 2025-04-05
E · Potential for more than minimal harm
2025-03-06
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2025-04-05
D · Potential for more than minimal harm
2025-03-06
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-04-05
D · Potential for more than minimal harm
2025-03-06
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-04-05
D · Potential for more than minimal harm
2025-03-06
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 2025-04-05
D · Potential for more than minimal harm
2025-03-06
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 2025-04-05
D · Potential for more than minimal harm
2025-03-06
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-04-05
D · Potential for more than minimal harm
2025-03-06
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-04-05
D · Potential for more than minimal harm
2025-03-06
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 2025-04-05
B · Minimal harm
2025-03-06
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2025-03-25
F · Potential for more than minimal harm
2024-02-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-28
E · Potential for more than minimal harm
2024-02-16
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 2024-03-26
E · Potential for more than minimal harm
2024-02-16
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2024-03-15
E · Potential for more than minimal harm
2024-02-16
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-03-26
E · Potential for more than minimal harm
2024-02-16
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-03-28
E · Potential for more than minimal harm
2024-02-16
F887 · Infection Control Deficiencies
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 2024-03-28
D · Potential for more than minimal harm
2024-02-16
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 2024-03-28
D · Potential for more than minimal harm
2024-02-16
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 2024-03-22
B · Minimal harm
2024-02-16
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-03-26
F · Potential for more than minimal harm
2022-08-02
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 2022-09-16
F · Potential for more than minimal harm
2022-08-02
F838 · Administration Deficiencies
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 2022-09-16
F · Potential for more than minimal harm
2022-08-02
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2022-09-16
E · Potential for more than minimal harm
2022-08-02
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 2022-09-16
E · Potential for more than minimal harm
2022-08-02
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2022-09-16
D · Potential for more than minimal harm
2022-08-02
F657 · Resident Assessment and Care Planning Deficiencies
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 2022-09-16
D · Potential for more than minimal harm
2022-08-02
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-09-16
D · Potential for more than minimal harm
2022-08-02
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 2022-09-16
D · Potential for more than minimal harm
2022-08-02
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-09-16
Penalties and ownership
What sits behind the stars
$0
2024-02-16
Payment Denial
Payment Denial · denial start 2024-03-28 · 18 days
18 day denial
Ownership
Thisse, Marion
5% Or Greater Direct Ownership Interest · Individual
Bunker, Thomas
Operational/Managerial Control · Individual
Rehabilitation Associates Inc
Operational/Managerial Control · Organization
Thisse, Peter
Corporate Director · Individual
Nearby options
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Medway Country Manor Skilled Nursing & Rehabilitat
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1-star overall rating with 1-star inspections with Special Focus status with $191,151 in total fines with 20 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Waterview Lodge LLC, Rehabilitation & Healthcare
Ashland, MA
3-star overall rating with 2-star inspections with 13 recent health deficiencies with 28 fire-safety deficiencies in the latest cycle
#3
Bethany Skilled Nursing Facility
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5-star overall rating with 5-star inspections with $9,318 in total fines with 4 fire-safety deficiencies in the latest cycle
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