Cycle 1
Health 2025-01-07 · Fire 2025-01-07
7 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Wareham, MA
Tremont Rehabilitation & Skilled Care Center
3-star overall rating with 3-star inspections with $285,936 in total fines with 7 recent health deficiencies
605 Main Street, Wareham, MA
(508) 295-1040
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
104
Certified beds
Average residents
100
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Athena Healthcare Systems
Operator or chain grouping
Approved since
1990-07-01
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
Hours and turnover
RN hours / resident day
0.56
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
0.53
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
1.63
Nurse aide staffing · state 2.26 · national 2.35
Total nurse hours
2.72
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.09
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
2.45
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.29
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.62
CMS adjusted RN staffing hours
Adjusted total hours
2.98
CMS adjusted total nurse staffing hours
Case-mix index
1.25
Higher values indicate more complex resident acuity
RN turnover
39%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
32%
Annual nurse turnover · state 40% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,639
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
35.46
Composite VBP score used to determine payment impact.
Payment multiplier
0.9891
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.68
Baseline 21.99% · Performance 19.42% · Measure score 4.68 · Achievement 4.35 · Improvement 4.68
Healthcare-associated infections
4.44
Performance 6.51% · Measure score 4.44 · Achievement 4.44 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
3.64
Baseline 43.10% · Performance 48.81% · Measure score 3.64 · Achievement 3.64 · Improvement 0
Adjusted total nurse staffing
1.42
Baseline 2.86 hours · Performance 3.42 hours · Measure score 1.42 · Achievement 1.19 · Improvement 1.42
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.69% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 58 · Observed rate 10.34% · Lower 95% interval 7.24% |
| Discharge to community | 45.26% |
50.57%
5.3 pts worse
|
No Different than the National Rate · Eligible stays 36 · Observed rate 38.89% · Lower 95% interval 31.66% |
| Medicare spending per beneficiary | 1.01 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 97.37% |
95.27%
2.1 pts better
|
Numerator 37 · Denominator 38 |
| Falls with major injury | 2.63% |
0.77%
1.9 pts worse
|
Numerator 1 · Denominator 38 |
| Discharge self-care score | 10% |
53.69%
43.7 pts worse
|
Numerator 3 · Denominator 30 |
| Discharge mobility score | 16.67% |
50.94%
34.3 pts worse
|
Numerator 5 · Denominator 30 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 38 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.51% |
7.12%
0.6 pts better
|
No Different than the National Rate · Eligible stays 32 · Observed rate 6.25% · Lower 95% interval 3.86% |
| Staff COVID-19 vaccination coverage | 7.26% |
8.2%
0.9 pts worse
|
Numerator 9 · Denominator 124 |
| Staff flu vaccination coverage | 38.33% |
42%
3.7 pts worse
|
Numerator 46 · Denominator 120 |
| Discharge function score | 23.33% |
56.45%
33.1 pts worse
|
Numerator 7 · Denominator 30 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 28.57% |
25.2%
3.4 pts better
|
Numerator 6 · Denominator 21 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
1.9
0.1 pts worse
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.9 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.7 |
1.5
1.2 pts worse
|
1.8
0.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 2.9 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.3% |
92.2%
1.1 pts better
|
93.4%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 98.8% · Q2 92.2% · Q3 92.2% · Q4 90.5% · 4Q avg 93.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.8% |
94.8%
About the same
|
95.5%
0.7 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.5% |
3.5%
1 pts better
|
3.3%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 2.2% · Q3 2.2% · Q4 3.2% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.8% |
12.0%
9.2 pts better
|
11.4%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.4% · Q3 2.4% · Q4 5.9% · 4Q avg 2.8% |
| Percentage of long-stay residents who lose too much weight | 3.7% |
5.2%
1.5 pts better
|
5.4%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 2.7% · Q3 1.4% · Q4 8.8% · 4Q avg 3.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.7% |
19.2%
1.5 pts worse
|
19.6%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.1% · Q2 20.8% · Q3 22.4% · Q4 22.4% · 4Q avg 20.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 47.7% |
22.5%
25.2 pts worse
|
16.7%
31 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 48.1% · Q2 45.5% · Q3 49.0% · Q4 48.2% · 4Q avg 47.7% · 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 | 10.8% |
17.7%
6.9 pts better
|
16.3%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.6% · Q2 7.7% · Q3 11.3% · Q4 8.3% · 4Q avg 10.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.7% |
17.6%
3.1 pts worse
|
14.9%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.6% · Q2 26.0% · Q3 16.7% · Q4 16.7% · 4Q avg 20.7% · 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 | 1.1% |
2.0%
0.9 pts better
|
1.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.1% · Q4 3.2% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.5% |
21.7%
1.2 pts better
|
19.8%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.0% · Q2 22.4% · Q3 24.2% · Q4 19.1% · 4Q avg 20.5% |
| Percentage of long-stay residents with pressure ulcers | 2.3% |
4.6%
2.3 pts better
|
5.1%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 2.3% · Q3 2.2% · Q4 2.0% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 69.4% |
77.1%
7.7 pts worse
|
81.7%
12.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 75.5% · Q2 68.8% · Q3 71.4% · Q4 52.4% · 4Q avg 69.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.3% |
11.8%
2.5 pts worse
|
12.0%
2.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.3% · Observed 17.1% · Expected 13.4% · 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 · Q1 0.0% · Q2 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 48.0% |
77.7%
29.7 pts worse
|
79.7%
31.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 48.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.6% |
25.8%
3.2 pts better
|
23.9%
1.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.6% · Observed 24.4% · Expected 25.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-05 · Fire 2024-08-05
9 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2024-03-05 · Fire 2024-03-05
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-01-07
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2025-02-04
E · Potential for more than minimal harm
2025-01-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-04
D · Potential for more than minimal harm
2025-01-07
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-02-04
D · Potential for more than minimal harm
2025-01-07
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 2025-02-04
D · Potential for more than minimal harm
2025-01-07
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 2025-02-04
D · Potential for more than minimal harm
2025-01-07
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 2025-02-04
D · Potential for more than minimal harm
2025-01-07
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2025-02-04
E · Potential for more than minimal harm
2024-08-05
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-09-10
E · Potential for more than minimal harm
2024-08-05
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 2024-09-10
E · Potential for more than minimal harm
2024-08-05
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 2024-09-10
E · Potential for more than minimal harm
2024-08-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-10
D · Potential for more than minimal harm
2024-08-05
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 2024-09-10
D · Potential for more than minimal harm
2024-08-05
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 2024-09-10
D · Potential for more than minimal harm
2024-08-05
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 2024-09-10
D · Potential for more than minimal harm
2024-08-05
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 2024-09-10
C · Minimal harm
2024-08-05
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 2024-09-10
G · Actual harm
2024-03-05
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 2024-04-16
E · Potential for more than minimal harm
2024-03-05
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-04-16
D · Potential for more than minimal harm
2024-03-05
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 2024-04-16
D · Potential for more than minimal harm
2024-03-05
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-04-16
D · Potential for more than minimal harm
2024-03-05
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-04-16
D · Potential for more than minimal harm
2024-03-05
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 2024-04-16
Penalties and ownership
What sits behind the stars
$15,569
2024-03-05
Fine
Fine · fine $15,569
Fine
$270,367
2023-10-26
Fine
Fine · fine $270,367
Fine
Ownership
Athena Health Care Systems Ma 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
Athena Health Care Associates, Inc.
Operational/Managerial Control · Organization
Mosier, Michael
W-2 Managing Employee · Individual
Santilli, Lawrence
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Sippican Rehabilitation And Healthcare Center
Marion, MA
3-star overall rating with 3-star inspections with $8,788 in total fines with 9 recent health deficiencies
#2
Royal Cape Cod Nursing & Rehabilitation Center
Buzzards Bay, MA
4-star overall rating with 4-star inspections with $9,004 in total fines with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Bourne Manor Extended Care Facility
Bourne, MA
1-star overall rating with 2-star inspections with $48,575 in total fines with 3 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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