D-
43/100Country Gardens Health and Rehabilitation Inspection Report, Violations & Safety Grade (SWANSEA, Massachusetts)
2045 GRAND ARMY HIGHWAY, SWANSEA, Massachusetts 02777
Phone: 5083799700
CMS Overall:1/5
Overview & Bed Count
Certified Beds
86
Avg Residents/Day
68.5
Ownership
For profit - Limited Liability company
Provider Type
Medicare and Medicaid
County
Bristol
Sprinkler Systems
Yes
Special Focus
SFF Candidate
Abuse Icon
No
CMS Star Ratings
Overall1/5
Health1/5
Staffing2/5
Quality1/5
Nurse Staffing Check
| Metric | This Facility | Massachusetts Avg | Difference |
|---|---|---|---|
| RN Hours per Resident per Day | 0.56 | 0.66 | -0.09 |
| Total Nurse Hours per Resident per Day | 3.62 | 3.94 | -0.32 |
| CMS Staffing Rating | 2/5 | 3.1/5 | - |
| Nursing Staff Turnover | N/A | 37.6% | - |
Health Citation History
58 health citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2025-09-10 | Resident Rights Deficiencies | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | D – Moderate Harm Potential |
| 2025-09-10 | Nutrition and Dietary Deficiencies | Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | D – Moderate Harm Potential |
| 2025-09-10 | Resident Assessment and Care Planning Deficiencies | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | D – Moderate Harm Potential |
| 2025-06-23 | Administration Deficiencies | Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | F – Moderate Harm Potential |
| 2025-06-23 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | F – Moderate Harm Potential |
| 2025-06-23 | Resident Assessment and Care Planning Deficiencies | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | E – Moderate Harm Potential |
| 2025-06-23 | Administration Deficiencies | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | E – Moderate Harm Potential |
| 2025-06-23 | Infection Control Deficiencies | 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. | E – Moderate Harm Potential |
| 2025-06-23 | Resident Rights Deficiencies | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | D – Moderate Harm Potential |
| 2025-06-23 | Resident Rights Deficiencies | Keep residents' personal and medical records private and confidential. | D – Moderate Harm Potential |
| 2025-06-23 | Resident Rights Deficiencies | 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. | D – Moderate Harm Potential |
| 2025-06-23 | Resident Assessment and Care Planning Deficiencies | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | D – Moderate Harm Potential |
| 2025-06-23 | Resident Assessment and Care Planning Deficiencies | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D – Moderate Harm Potential |
| 2025-06-23 | Quality of Life and Care Deficiencies | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | D – Moderate Harm Potential |
| 2025-06-23 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D – Moderate Harm Potential |
| 2025-06-23 | Pharmacy Service Deficiencies | Ensure medication error rates are not 5 percent or greater. | D – Moderate Harm Potential |
| 2025-04-22 | Resident Rights Deficiencies | Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | D – Moderate Harm Potential |
| 2024-07-01 | Quality of Life and Care Deficiencies | Ensure the activities program is directed by a qualified professional. | F – Moderate Harm Potential |
| 2024-07-01 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F – Moderate Harm Potential |
| 2024-07-01 | Administration Deficiencies | Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | F – Moderate Harm Potential |
| 2024-07-01 | Resident Rights Deficiencies | Honor the resident's right to organize and participate in resident/family groups in the facility. | E – Moderate Harm Potential |
| 2024-07-01 | Resident Rights Deficiencies | Keep residents' personal and medical records private and confidential. | E – Moderate Harm Potential |
| 2024-07-01 | Resident Assessment and Care Planning Deficiencies | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | E – Moderate Harm Potential |
| 2024-07-01 | Resident Assessment and Care Planning Deficiencies | Ensure services provided by the nursing facility meet professional standards of quality. | E – Moderate Harm Potential |
| 2024-07-01 | Quality of Life and Care Deficiencies | Provide activities to meet all resident's needs. | E – Moderate Harm Potential |
| 2024-07-01 | Nursing and Physician Services Deficiencies | Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | E – Moderate Harm Potential |
| 2024-07-01 | Pharmacy Service Deficiencies | Ensure each resident’s drug regimen must be free from unnecessary drugs. | E – Moderate Harm Potential |
| 2024-07-01 | Pharmacy Service Deficiencies | 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. | E – Moderate Harm Potential |
| 2024-07-01 | Pharmacy Service Deficiencies | 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. | E – Moderate Harm Potential |
| 2024-07-01 | Resident Assessment and Care Planning Deficiencies | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | E – Moderate Harm Potential |
| 2024-07-01 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | E – Moderate Harm Potential |
| 2024-07-01 | Administration Deficiencies | Develop, implement, and/or maintain an effective training program for all new and existing staff members. | E – Moderate Harm Potential |
| 2024-07-01 | Administration Deficiencies | Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. | E – Moderate Harm Potential |
| 2024-07-01 | Resident Rights Deficiencies | Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. | E – Moderate Harm Potential |
| 2024-07-01 | Administration Deficiencies | Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. | E – Moderate Harm Potential |
| 2024-07-01 | Infection Control Deficiencies | Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program. | E – Moderate Harm Potential |
| 2024-07-01 | Administration Deficiencies | Provide training in compliance and ethics. | E – Moderate Harm Potential |
| 2024-07-01 | Administration Deficiencies | Provide behavior health training consistent with the requirements and as determined by a facility assessment. | E – Moderate Harm Potential |
| 2024-07-01 | Resident Rights Deficiencies | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | D – Moderate Harm Potential |
| 2024-07-01 | Resident Assessment and Care Planning Deficiencies | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | D – Moderate Harm Potential |
| 2024-07-01 | Resident Assessment and Care Planning Deficiencies | Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | D – Moderate Harm Potential |
| 2024-07-01 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D – Moderate Harm Potential |
| 2024-07-01 | Quality of Life and Care Deficiencies | Provide for the safe, appropriate administration of IV fluids for a resident when needed. | D – Moderate Harm Potential |
| 2024-07-01 | Quality of Life and Care Deficiencies | Provide safe and appropriate respiratory care for a resident when needed. | D – Moderate Harm Potential |
| 2024-07-01 | Quality of Life and Care Deficiencies | Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | D – Moderate Harm Potential |
| 2024-07-01 | Pharmacy Service Deficiencies | Ensure that residents are free from significant medication errors. | D – Moderate Harm Potential |
| 2024-07-01 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | D – Moderate Harm Potential |
| 2024-07-01 | Resident Assessment and Care Planning Deficiencies | Ensure each resident receives an accurate assessment. | B – Minimal Harm Potential |
| 2023-03-28 | Infection Control Deficiencies | Perform COVID19 testing on residents and staff. | F – Moderate Harm Potential |
| 2023-03-28 | Resident Assessment and Care Planning Deficiencies | Ensure services provided by the nursing facility meet professional standards of quality. | E – Moderate Harm Potential |
Showing 50 of 58 citations.
Fire Safety Citation History
3 fire safety citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2025-06-23 | Smoke Deficiencies | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | C – Minimal Harm Potential |
| 2025-06-23 | Miscellaneous Deficiencies | Provide properly sized and located linen or trash receptacles. | C – Minimal Harm Potential |
| 2023-03-28 | Gas, Vacuum, and Electrical Systems Deficiencies | Meet requirements for the installation and maintenance of electrical systems. | F – Moderate Harm Potential |
Total Penalties & Fines
$24,635
Total Fine Amount (CMS)
4
Number of Fines
4
Total Penalties
| Date | Type | Fine Amount | Payment Denial |
|---|---|---|---|
| 2024-07-01 | Fine | $15,139 | - |
| 2024-02-20 | Fine | $2,659 | - |
| 2024-02-12 | Fine | $2,279 | - |
| 2024-01-22 | Fine | $4,558 | - |
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Need Help Finding Safe Care?
Our family advisors can help you find vetted, top-rated facilities in the SWANSEA area at no cost.
Find Safe, Vetted Facilities Near SWANSEA
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.