8 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
South Yarmouth, MA
1-star overall rating with 2-star inspections with $12,386 in total fines with 8 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
265 N Main St, South Yarmouth, MA
(413) 544-3329
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Beds
120
Certified beds
Average residents
88
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Integritus Healthcare
Operator or chain grouping
Approved since
1989-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
15 facilities
Chain averages 3 overall / 3 health / 3 staffing / 2 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
0.61
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
0.88
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.44
Nurse aide staffing · state 2.26 · national 2.35
Total nurse hours
3.93
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.49
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.41
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.34
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.58
CMS adjusted RN staffing hours
Adjusted total hours
3.75
CMS adjusted total nurse staffing hours
Case-mix index
1.43
Higher values indicate more complex resident acuity
RN turnover
47%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
49%
Annual nurse turnover · state 40% · national 46%
SNF VBP
Program rank
11,020
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
18.31
Composite VBP score used to determine payment impact.
Payment multiplier
0.9819
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
0
Baseline 20.05% · Performance 23.04% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
4.79
Baseline 6.51% · Performance 6.40% · Measure score 4.79 · Achievement 4.79 · Improvement 0.24
Total nurse turnover
0
Baseline 48.72% · Performance 71.11% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
2.53
Baseline 3.48 hours · Performance 3.80 hours · Measure score 2.53 · Achievement 2.53 · Improvement 0.88
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.67% |
10.72%
2.1 pts better
|
No Different than the National Rate · Eligible stays 175 · Observed rate 5.14% · Lower 95% interval 5.83% |
| Discharge to community | 48.16% |
50.57%
2.4 pts worse
|
No Different than the National Rate · Eligible stays 149 · Observed rate 43.62% · Lower 95% interval 40% |
| Medicare spending per beneficiary | 0.89 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 85.47% |
95.27%
9.8 pts worse
|
Numerator 100 · Denominator 117 |
| Falls with major injury | 0.85% |
0.77%
0.1 pts worse
|
Numerator 1 · Denominator 117 |
| Discharge self-care score | 29.51% |
53.69%
24.2 pts worse
|
Numerator 18 · Denominator 61 |
| Discharge mobility score | 32.79% |
50.94%
18.1 pts worse
|
Numerator 20 · Denominator 61 |
| Pressure ulcers or injuries, new or worsened | 3.42% |
2.29%
1.1 pts worse
|
Numerator 4 · Denominator 117 · Adjusted rate 4.59% |
| Healthcare-associated infections requiring hospitalization | 6.4% |
7.12%
0.7 pts better
|
No Different than the National Rate · Eligible stays 106 · Observed rate 4.72% · Lower 95% interval 4.22% |
| Staff COVID-19 vaccination coverage | 2.91% |
8.2%
5.3 pts worse
|
Numerator 3 · Denominator 103 |
| Staff flu vaccination coverage | 50.62% |
42%
8.6 pts better
|
Numerator 41 · Denominator 81 |
| Discharge function score | 22.95% |
56.45%
33.5 pts worse
|
Numerator 14 · Denominator 61 |
| Transfer of health information to provider | 98% |
95.95%
2 pts better
|
Numerator 49 · Denominator 50 |
| Transfer of health information to patient | 97.67% |
96.28%
1.4 pts better
|
Numerator 42 · Denominator 43 |
| Resident COVID-19 vaccinations up to date | 42.03% |
25.2%
16.8 pts better
|
Numerator 29 · Denominator 69 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
1.9
About the same
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.3 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.0 |
1.5
0.5 pts worse
|
1.8
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.6 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.8% |
92.2%
5.6 pts better
|
93.4%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.8% · Q2 100.0% · Q3 97.4% · Q4 95.1% · 4Q avg 97.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 80.7% |
94.8%
14.1 pts worse
|
95.5%
14.8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 80.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.8% |
3.5%
0.7 pts better
|
3.3%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 2.4% · Q3 2.6% · Q4 3.7% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 16.8% |
12.0%
4.8 pts worse
|
11.4%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 6.8% · Q3 31.5% · Q4 24.7% · 4Q avg 16.8% |
| Percentage of long-stay residents who lose too much weight | 6.0% |
5.2%
0.8 pts worse
|
5.4%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 5.3% · Q3 9.3% · Q4 5.6% · 4Q avg 6.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.2% |
19.2%
1 pts better
|
19.6%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.9% · Q2 21.8% · Q3 18.4% · Q4 18.7% · 4Q avg 18.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.6% |
22.5%
2.9 pts better
|
16.7%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.4% · Q2 16.3% · Q3 18.3% · Q4 19.4% · 4Q avg 19.6% · 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 | 24.4% |
17.7%
6.7 pts worse
|
16.3%
8.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.1% · Q2 17.0% · Q3 16.4% · Q4 31.7% · 4Q avg 24.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.8% |
17.6%
3.2 pts worse
|
14.9%
5.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 20.3% · Q3 20.6% · Q4 17.4% · 4Q avg 20.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
1.0%
0.4 pts better
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.9% |
2.0%
0.1 pts better
|
1.7%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 0.0% · Q3 2.6% · Q4 2.6% · 4Q avg 1.9% · 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 6.8% · Q2 10.0% · Q3 12.7% · Q4 11.2% · 4Q avg 10.2% |
| Percentage of long-stay residents with pressure ulcers | 4.7% |
4.6%
0.1 pts worse
|
5.1%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 4.4% · Q3 5.7% · Q4 4.1% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 89.5% |
77.1%
12.4 pts better
|
81.7%
7.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 87.5% · Q2 92.7% · Q3 90.0% · Q4 86.9% · 4Q avg 89.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.3% |
11.8%
0.5 pts better
|
12.0%
0.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.3% · Observed 12.0% · Expected 11.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.3%
0.8 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.9% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 80.4% |
77.7%
2.7 pts better
|
79.7%
0.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 80.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.6% |
25.8%
3.8 pts worse
|
23.9%
5.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.6% · Observed 32.4% · Expected 26.1% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Top issue: Quality of Life and Care (4 deficiencies)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
6 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Fire safety
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2025-02-19
Fire Safety
Provide emergency officials' contact information.
Corrected 2025-02-03
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2025-01-24
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-02-19
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-11-13
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-11-13
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-11-13
Fire Safety
Implement emergency and standby power systems.
Corrected 2021-05-31
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2021-05-31
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-05-31
Fire Safety
List the names and contact information of those in the facility.
Corrected 2021-05-31
Fire Safety
Conduct testing and exercise requirements.
Corrected 2021-05-31
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2021-05-31
Inspection history
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 2025-02-19
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2025-02-19
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 2025-02-19
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-02-19
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-02-19
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 2025-02-19
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-02-19
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-02-19
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-11-22
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2023-11-22
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 2023-11-22
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2023-11-22
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-11-22
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-11-22
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-11-22
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 2023-11-22
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-11-22
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2023-11-22
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-06-30
Health
Perform COVID19 testing on residents and staff.
Corrected 2023-03-22
Health
Provide and implement an infection prevention and control program.
Corrected 2023-03-22
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2021-06-01
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2021-06-01
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 2021-06-11
Health
Provide and implement an infection prevention and control program.
Corrected 2021-06-01
Health
Implement a program that monitors antibiotic use.
Corrected 2021-06-01
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 2021-06-01
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2021-06-01
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2021-06-01
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 2021-06-01
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2021-06-15
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2021-06-15
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2021-06-01
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2021-06-01
Health
Respond appropriately to all alleged violations.
Corrected 2021-06-01
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2021-06-01
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2021-06-01
Health
Provide appropriate foot care.
Corrected 2021-06-01
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-06-01
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2021-06-01
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 2021-06-01
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2021-06-01
Penalties and ownership
Fine · fine $12,386
Fine
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
W-2 Managing Employee · Individual
Corporate Officer · Individual
Operational/Managerial Control · Organization
Operational/Managerial Control · Organization
Corporate Officer · Individual
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