| Hathorne Hill Rehabilitation and Healthcare Center | |
| 15 Kirkbride Drive, Danvers, Massachusetts 01923 | |
| (978) 716-3600 | |
| Name | Hathorne Hill Rehabilitation and Healthcare Center |
|---|---|
| Location | 15 Kirkbride Drive, Danvers, Massachusetts |
| Certified By | Medicare and Medicaid |
| No. of Certified Beds | 120 |
| Occupancy Rate | 95.67% |
| Medicare ID (CCN) | 225449 |
| Legal Business Name | Hathorne SNF Operations LLC |
| Ownership Type | For Profit - Corporation |
| Chain | Atlas Healthcare (29 nursing homes) |
| Chain Average Overall Rating | 3.6 out of 5 |
| NPI Number | 1023852167 |
| Match | Possible same name, address or phone number |
| Organization Name | Hathorne SNF Operations LLC |
| Address | 15 Kirkbride Dr, Danvers, MA 01923 |
| Phone Number | 978-716-3600 |
| Ratings from Surveys (Inspections): | |
| Ratings from Quality Measures: | |
| Ratings from Staffing Data: | |
| Overall Rating: |
|---|
| Staffing Measure | Provider | National Avg. |
|---|---|---|
| Total nurse staff hours per resident per day | 3.67 | 3.86 |
| Registered nurse (RN) hours per resident per day | 0.58 | 0.69 |
| Licensed practical nurse (LPN) hours per resident per day | 1.14 | 0.86 |
| Nurse aide hours per resident per day | 1.95 | 2.32 |
| Total nurse staff hours per resident per day on the weekend | 3.31 | 3.42 |
| RN hours per resident per day on the weekend | 0.4 | 0.48 |
| Physical therapist hours per resident per day | 0.06 | 0.07 |
| Total nursing staff turnover | 54% | 45.8% |
| Registered nurse turnover | 59.1% | 42.9% |
| Number of administrators who have left the nursing home | 0 | 0.5 |
| Cited for abuse, neglect or exploitation of residents (Care Compare abuse icon) | No |
| Number of Fines | 1 |
| Total Amount of Fines in Dollars | $242,785 |
| Number of Payment Denials | 0 |
| Total Number of Penalties | 1 |
| Date | Deficiency | Harm Level | Status |
|---|---|---|---|
| Dec 4, 2025 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. F0550, Resident Rights, Standard inspection | Potential for harm, isolated | Corrected by Dec 17, 2025 |
| Dec 4, 2025 | Provide care and assistance to perform activities of daily living for any resident who is unable. F0677, Quality of Life and Care, Standard inspection | Potential for harm, isolated | Corrected by Dec 17, 2025 |
| Dec 4, 2025 | 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. F0887, Infection Control, Standard inspection | Potential for harm, isolated | Corrected by Dec 17, 2025 |
| Dec 5, 2024 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. F0686, Quality of Life and Care, Standard inspection | Potential for harm, isolated | Corrected by Dec 31, 2024 |
| Dec 5, 2024 | Provide safe and appropriate respiratory care for a resident when needed. F0695, Quality of Life and Care, Standard inspection | Potential for harm, isolated | Corrected by Dec 31, 2024 |
| Dec 5, 2024 | Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. F0805, Nutrition and Dietary, Standard inspection | Potential for harm, isolated | Past non-compliance (already corrected) |
| Dec 5, 2024 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. F0842, Resident Assessment and Care Planning, Standard inspection | Potential for harm, isolated | Corrected by Dec 31, 2024 |
| Dec 15, 2023 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. F0686, Quality of Life and Care, Standard inspection | Immediate jeopardy, pattern | Corrected by Jan 10, 2024 |
| Dec 15, 2023 | 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. F0726, Nursing and Physician Services, Standard inspection | Immediate jeopardy, isolated | Corrected by Jan 26, 2024 |
| Dec 15, 2023 | Administer the facility in a manner that enables it to use its resources effectively and efficiently. F0835, Administration, Standard inspection | Immediate jeopardy, isolated | Corrected by Jan 10, 2024 |
| Dec 15, 2023 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted F0655, Resident Assessment and Care Planning, Standard inspection | Actual harm, isolated | Corrected by Jan 10, 2024 |
| Dec 15, 2023 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. F0689, Quality of Life and Care, Standard inspection | Actual harm, isolated | Corrected by Jan 10, 2024 |
| Dec 15, 2023 | Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. F0742, Quality of Life and Care, Standard inspection | Actual harm, isolated | Corrected by Jan 10, 2024 |
| Dec 15, 2023 | Provide safe, appropriate pain management for a resident who requires such services. F0697, Quality of Life and Care, Standard inspection | Potential for harm, pattern | Corrected by Jan 10, 2024 |
| Dec 15, 2023 | 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. F0761, Pharmacy Service, Standard inspection | Potential for harm, pattern | Corrected by Jan 26, 2024 |
| Dec 15, 2023 | Provide and implement an infection prevention and control program. F0880, Infection Control, Standard inspection | Potential for harm, pattern | Corrected by Jan 10, 2024 |
| Dec 15, 2023 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. F0550, Resident Rights, Standard inspection | Potential for harm, isolated | Corrected by Jan 10, 2024 |
| Dec 15, 2023 | Allow residents to self-administer drugs if determined clinically appropriate. F0554, Resident Rights, Standard inspection | Potential for harm, isolated | Corrected by Jan 10, 2024 |
| Dec 15, 2023 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. F0580, Resident Rights, Standard inspection | Potential for harm, isolated | Corrected by Jan 10, 2024 |
| Dec 15, 2023 | Provide care and assistance to perform activities of daily living for any resident who is unable. F0677, Quality of Life and Care, Standard inspection | Potential for harm, isolated | Corrected by Jan 10, 2024 |
| Dec 15, 2023 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. F0684, Quality of Life and Care, Standard inspection | Potential for harm, isolated | Corrected by Jan 10, 2024 |
| Dec 15, 2023 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. F0690, Quality of Life and Care, Standard inspection | Potential for harm, isolated | Corrected by Jan 10, 2024 |
| Dec 15, 2023 | Provide care or services that was trauma informed and/or culturally competent. F0699, Quality of Life and Care, Standard inspection | Potential for harm, isolated | Corrected by Jan 10, 2024 |
| Dec 15, 2023 | Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. F0700, Quality of Life and Care, Standard inspection | Potential for harm, isolated | Corrected by Jan 10, 2024 |
| Dec 15, 2023 | 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. F0758, Pharmacy Service, Standard inspection | Potential for harm, isolated | Corrected by Jan 10, 2024 |
| Dec 15, 2023 | Ensure medication error rates are not 5 percent or greater. F0759, Pharmacy Service, Standard inspection | Potential for harm, isolated | Corrected by Jan 10, 2024 |
| Dec 15, 2023 | Ensure that residents are free from significant medication errors. F0760, Pharmacy Service, Standard inspection | Potential for harm, isolated | Corrected by Jan 26, 2024 |
| Dec 15, 2023 | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. F0806, Nutrition and Dietary, Standard inspection | Potential for harm, isolated | Corrected by Jan 10, 2024 |
| Dec 15, 2023 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. F0842, Resident Assessment and Care Planning, Standard inspection | Potential for harm, isolated | Corrected by Jan 26, 2024 |
| Quality Measure | Provider | National Avg. |
|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.67 | 13.87 |
| Percentage of long-stay residents who lose too much weight | 5.65 | 5.19 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.2 | 0.82 |
| Percentage of long-stay residents with a urinary tract infection | 0.66 | 1.59 |
| Percentage of long-stay residents who have depressive symptoms | 79.93 | 12.8 |
| Percentage of long-stay residents who were physically restrained | 0 | 0.13 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.27 | 3.23 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 79.31 | 93.55 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 64.03 | 82.04 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.4 | 1.56 |
| Percentage of long-stay residents whose ability to walk independently worsened | 15.1 | 14.07 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.59 | 19.52 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 72.94 | 95.46 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 68 | 79.75 |
| Percentage of long-stay residents with pressure ulcers | 4.87 | 4.62 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 36.13 | 19.01 |
| Percentage of long-stay residents who received an antipsychotic medication | 28.79 | 15.38 |
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