Your report for Country Gardens Health and Rehabilitation Center
Overall Score
CMS Five-Star Quality RatingMuch below averageCMS Five-Star overall rating
- Much below average
- Below average
- Average
- Above average
- Much above average
Where it ranks
- MassachusettsLowest tier among peers338 rated homes · average 3.0★
- Bristol CountyLowest tier among peers27 rated homes · average 2.6★
- United StatesLowest tier among peers14,574 rated homes · average 3.0★
How the rating is built
- Health inspectionsStarting point1★−1.9 vs MA avg
- StaffingCan add or remove a star1★−1.9 vs MA avg
- Quality measuresCan add or remove a star3★−0.3 vs MA avg
CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.
Ratings & measures
Tap a row to see what it meansHealth inspection ratingCMS stars from the last three on-site inspection cycles1★Lowest tier among peersMA avg2.9★U.S. avg2.8★
What is health inspection rating?
Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.
Why it matters
It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.
Staffing ratingCMS stars from payroll-reported hours and turnover1★Lowest tier among peersMA avg2.9★U.S. avg2.9★
What is staffing rating?
Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.
Why it matters
More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.
Quality measures ratingCMS stars from clinical outcomes and resident assessments3★Above only 27% of peersMA avg3.3★U.S. avg3.6★
What is quality measures rating?
Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.
Why it matters
It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.
Total nurse hoursPer resident per day, all nursing staff3.24hrsAbove only 10% of peersMA avg3.86Benchmark4.10
What is total nurse hours?
All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.
Why it matters
Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.
RN hoursPer resident per day, registered nurses only0.42hrsAbove only 15% of peersMA avg0.65Benchmark0.75
What is rn hours?
Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.
Why it matters
RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.
Nursing staff turnoverShare of nursing staff who left within a year · lower is better—No dataMA avg39%RN turnover—
What is nursing staff turnover?
The share of nursing staff who left within the past year, from the same payroll data.
Why it matters
High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.
Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$24,635Above only 32% of peersMA avg$39,993Fines · denials4 · 0
What is fines in the last three years?
Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.
Why it matters
Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.
Inspection history
Last three inspection cycles59citations
6inspection dates
0actual harm (G–I)
0immediate jeopardy (J–L)
Sep 10, 2025most recent
Citations by monthMar 2023 – Sep 2025
- No actual harm (D–F)
- Actual harm (G–I)
- Immediate jeopardy (J–L)
- $Fine or payment denial
Click to filter the findings below
Showing
Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.
Sep 10, 2025Cycle 1worst D · no actual harm
- F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsD · isolatedCorrected Oct 16, 2025
- F805Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.Nutrition and DietaryD · isolatedCorrected Oct 16, 2025
- F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningD · isolatedCorrected Oct 16, 2025
Jun 23, 2025Cycle 1worst F · no actual harm
- F887Educate 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.Infection ControlE · patternCorrected Jul 21, 2025
- F880Provide and implement an infection prevention and control program.Infection ControlF · widespreadCorrected Jul 21, 2025
- F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningE · patternCorrected Jul 21, 2025
- F851Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.AdministrationF · widespreadCorrected Jul 21, 2025
- F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.AdministrationE · patternCorrected Jul 21, 2025
- F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceD · isolatedCorrected Jul 21, 2025
- F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsD · isolatedCorrected Jul 21, 2025
- F583Keep residents' personal and medical records private and confidential.Resident RightsD · isolatedCorrected Jul 21, 2025
- F585Honor 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.Resident RightsD · isolatedCorrected Jul 21, 2025
- F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedResident Assessment and Care PlanningD · isolatedCorrected Jul 21, 2025
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Jul 21, 2025
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareD · isolatedCorrected Jul 21, 2025
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Jul 21, 2025
Apr 22, 2025Cycle 1worst D · no actual harm
- F557Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.Resident RightsD · isolatedCorrected Apr 7, 2025
Jul 1, 2024Cycle 2worst F · no actual harm$15,139
- F758Implement 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.Pharmacy ServiceE · patternCorrected Aug 9, 2024
- Ensure each residentâs drug regimen must be free from unnecessary drugs.Pharmacy ServiceE · patternCorrected Sep 10, 2024
- Conduct mandatory training, for all staff, on the facilityâs Quality Assurance and Performance Improvement Program.AdministrationE · patternCorrected Aug 9, 2024
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Aug 9, 2024
- F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningE · patternCorrected Sep 10, 2024
- F868Have the Quality Assessment and Assurance group have the required members and meet at least quarterlyAdministrationF · widespreadCorrected Aug 9, 2024
- F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Aug 9, 2024
- F940Develop, implement, and/or maintain an effective training program for all new and existing staff members.AdministrationE · patternCorrected Aug 9, 2024
- F941Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.AdministrationE · patternCorrected Aug 9, 2024
- F942Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.Resident RightsE · patternCorrected Aug 9, 2024
- F943Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Aug 9, 2024
- F945Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.Infection ControlE · patternCorrected Aug 9, 2024
- F946Provide training in compliance and ethics.AdministrationE · patternCorrected Aug 9, 2024
- F949Provide behavior health training consistent with the requirements and as determined by a facility assessment.AdministrationE · patternCorrected Aug 9, 2024
- F565Honor the resident's right to organize and participate in resident/family groups in the facility.Resident RightsE · patternCorrected Aug 9, 2024
- F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsD · isolatedCorrected Sep 10, 2024
- F583Keep residents' personal and medical records private and confidential.Resident RightsE · patternCorrected Sep 10, 2024
- F641Ensure each resident receives an accurate assessment.Resident Assessment and Care PlanningB · patternCorrected Aug 9, 2024
- F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedResident Assessment and Care PlanningD · isolatedCorrected Aug 9, 2024
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningE · patternCorrected Sep 10, 2024
- F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningE · patternCorrected Sep 10, 2024
- F661Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.Resident Assessment and Care PlanningD · isolatedCorrected Aug 9, 2024
- F679Provide activities to meet all resident's needs.Quality of Life and CareE · patternCorrected Aug 9, 2024
- F680Ensure the activities program is directed by a qualified professional.Quality of Life and CareF · widespreadCorrected Aug 9, 2024
- F694Provide for the safe, appropriate administration of IV fluids for a resident when needed.Quality of Life and CareD · isolatedCorrected Aug 9, 2024
- F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareD · isolatedCorrected Aug 9, 2024
- F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Nursing and Physician ServicesE · patternCorrected Aug 9, 2024
- F741Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.Quality of Life and CareD · isolatedCorrected Aug 9, 2024
- Provide appropriate treatment and care according to orders, residentâs preferences and goals.Quality of Life and CareD · isolatedCorrected Aug 9, 2024
- F760Ensure that residents are free from significant medication errors.Pharmacy ServiceD · isolatedCorrected Sep 10, 2024
- F761Ensure 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.Pharmacy ServiceE · patternCorrected Sep 10, 2024
Jun 22, 2023Cycle 3worst E · no actual harm
- F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Infection ControlE · patternCorrected Jul 26, 2023
Mar 28, 2023Cycle 3worst F · no actual harm
- Provide appropriate treatment and care according to orders, residentâs preferences and goals.Quality of Life and CareD · isolatedCorrected May 8, 2023
- F886Perform COVID19 testing on residents and staff.Infection ControlF · widespreadCorrected May 8, 2023
- F641Ensure each resident receives an accurate assessment.Resident Assessment and Care PlanningB · patternCorrected May 8, 2023
- F642Ensure a qualified health professional conducts resident assessments.Resident Assessment and Care PlanningB · patternCorrected May 8, 2023
- F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningE · patternCorrected May 8, 2023
- F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareE · patternCorrected May 8, 2023
- F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Nursing and Physician ServicesE · patternCorrected May 8, 2023
- F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceE · patternCorrected May 8, 2023
- Ensure each residentâs drug regimen must be free from unnecessary drugs.Pharmacy ServiceD · isolatedCorrected May 8, 2023
- F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected May 8, 2023
Staffing
From quarterly payroll reportsHours per resident per day
- All nursing staffRNs, LPNs and aides combined3.24hrs
- Registered nursesRN hours only0.42hrs
- Licensed practical nursesLPN hours0.78hrs
- Nurse aidesCNA hours2.04hrs
- Weekend nursingAll staff on Saturdays and Sundays2.92hrs
- Massachusetts average
- Research benchmark (4.10 total, 0.75 RN)
Turnover & capacity
- Nursing staff turnoverShare who left within a year · lower is better—MA avg 39%
- RN turnoverRegistered nurses only—Not ranked by CMS
- Administrators who leftIn the past year—
- Occupancy86 certified beds · ~71 residents a day83%Above only 41% of peersMA avg 81%
Fines & penalties
Roughly the past three yearsEnforcement summary
- $24,635In fines
- 4Fines
- 0Payment denials
- $39,993MA avg in fines
Above only 32% of peersFewer fines than 32% of rated homes in Massachusetts
Actions on record
- Jul 1, 2024Civil money penalty$15,139
- Feb 20, 2024Civil money penalty$2,659
- Feb 12, 2024Civil money penalty$2,279
- Jan 22, 2024Civil money penalty$4,558
Ownership
As filed with CMSStructure
- Ownership type
- For profit - Limited Liability company
- Chain
- Alpha SNF Ma5 facilities in the chain1.8★ chain average
- Certification
- Medicare and Medicaid
- Location type
- Urban
- Ownership change
- None in the last 12 months
People and entities on file
Direct owners (5%+)
- Alpha SNF Ma LLC
Indirect owners (5%+)
- William Segal
General Partnership Interest
- William Segal
Operational or managerial control
- William Segal
Corporate officers
- William Segal
Managing employees
- Uma Das Munshi
Person Organization
Sources & notes
Public data, updated quarterlyData sources
- CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
- CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
- CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.
Notes
- CMS Certification Number 225185 · 2045 GRAND ARMY HIGHWAY, SWANSEA, MA, 02777.
- Percentiles compare this facility with every rated nursing home in Massachusetts and Bristol County. Turnover and fines are inverted so a high percentile is always good.
- This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.
