Massachusetts ›Swansea

Country Gardens Health and Rehabilitation

2045 Grand Army Highway, Swansea, MA 02777 · Bristol County · 86 certified beds · avg 71 residents/day · certified since Feb 1, 1975

1/5
Health inspection rating (on-site)
0
Serious findings on record
$24,635
Fines, last 3 years
3.42
Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

All citations in the current public record (58)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

DateSeverityWhat the facility was cited for
Sep 10, 2025D · Potential for harm, one-offThe facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint
Sep 10, 2025D · Potential for harm, one-offThe facility did not prepare and serve food in a form that meets each resident's individual needs — for example, chopped, pureed, or softened food for residents with chewing or swallowing problems. · from a complaint
Sep 10, 2025D · Potential for harm, one-offThe facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint
Jun 23, 2025F · Potential for harm, facility-wideThe facility did not electronically submit complete and accurate staffing information to the government, based on payroll and other verifiable records.
Jun 23, 2025F · Potential for harm, facility-wideThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Jun 23, 2025E · Potential for harm, repeatedThe facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards.
Jun 23, 2025E · Potential for harm, repeatedThe facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them.
Jun 23, 2025E · Potential for harm, repeatedThe facility did not educate residents and staff about COVID-19 vaccination, offer the vaccine to those eligible after that education, or properly document everyone's vaccination status.
Jun 23, 2025D · Potential for harm, one-offThe facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights.
Jun 23, 2025D · Potential for harm, one-offThe facility did not keep residents' personal and medical information private and confidential.
Jun 23, 2025D · Potential for harm, one-offThe facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly.
Jun 23, 2025D · Potential for harm, one-offThe facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable.
Jun 23, 2025D · Potential for harm, one-offThe facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Jun 23, 2025D · Potential for harm, one-offThe facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Jun 23, 2025D · Potential for harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Jun 23, 2025D · Potential for harm, one-offThe facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time.
Apr 22, 2025D · Potential for harm, one-offThe facility did not treat residents with respect and dignity, or did not let them keep and use their own personal belongings. · from a complaint
Jul 1, 2024F · Potential for harm, facility-wideThe facility's activities program was not run by a qualified professional. The person directing recreation and social activities must have proper training or credentials.
Jul 1, 2024F · Potential for harm, facility-wideThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Jul 1, 2024F · Potential for harm, facility-wideThe facility's quality committee — the internal group responsible for finding and fixing care problems — did not have the required members or did not meet at least every three months.
Jul 1, 2024E · Potential for harm, repeatedThe facility did not honor residents' right to form and take part in resident or family groups, such as a resident council.
Jul 1, 2024E · Potential for harm, repeatedThe facility did not keep residents' personal and medical information private and confidential.
Jul 1, 2024E · Potential for harm, repeatedThe facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Jul 1, 2024E · Potential for harm, repeatedThe facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow.
Jul 1, 2024E · Potential for harm, repeatedThe facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle.
Jul 1, 2024E · Potential for harm, repeatedThe facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident.
Jul 1, 2024E · Potential for harm, repeatedThe facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason.
Jul 1, 2024E · Potential for harm, repeatedThe facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits.
Jul 1, 2024E · Potential for harm, repeatedThe facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Jul 1, 2024E · Potential for harm, repeatedThe facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards.
Jul 1, 2024E · Potential for harm, repeatedThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Jul 1, 2024E · Potential for harm, repeatedThe facility did not develop, carry out, or maintain an effective training program for all new and existing staff members.
Jul 1, 2024E · Potential for harm, repeatedThe facility did not develop or maintain an effective training program for its direct care staff, including training on how to communicate effectively with residents.
Jul 1, 2024E · Potential for harm, repeatedThe facility did not educate its staff on residents' rights and the facility's responsibilities toward residents. Staff can only respect rights they've been taught about.
Jul 1, 2024E · Potential for harm, repeatedThe facility did not give all staff the required training on its quality improvement program — the internal system for finding problems and making care better.
Jul 1, 2024E · Potential for harm, repeatedThe facility did not include required infection control training — with written standards, policies, and procedures — as part of its infection prevention program.
Jul 1, 2024E · Potential for harm, repeatedThe facility did not provide its staff with training in compliance and ethics — teaching employees the laws and ethical standards that govern how residents must be treated.
Jul 1, 2024E · Potential for harm, repeatedThe facility did not provide its staff with required training on behavioral health — caring for residents with conditions like dementia, depression, or other mental health needs.
Jul 1, 2024D · Potential for harm, one-offThe facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away.
Jul 1, 2024D · Potential for harm, one-offThe facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable.
Jul 1, 2024D · Potential for harm, one-offWhen a resident had a planned discharge, the facility did not make sure the necessary information was communicated to the resident and to the doctors or facility taking over their care.
Jul 1, 2024D · Potential for harm, one-offThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Jul 1, 2024D · Potential for harm, one-offThe facility did not safely and appropriately administer IV fluids (fluids given through a vein) for residents who needed them.
Jul 1, 2024D · Potential for harm, one-offThe facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it.
Jul 1, 2024D · Potential for harm, one-offThe facility did not have enough staff with the right skills to meet the mental and behavioral health needs of its residents, such as those living with dementia or depression.
Jul 1, 2024D · Potential for harm, one-offThe facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.
Jul 1, 2024D · Potential for harm, one-offThe facility did not train its staff on dementia care and on recognizing and reporting abuse, neglect, and exploitation.
Jul 1, 2024B · Minimal risk, repeatedThe facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
Mar 28, 2023F · Potential for harm, facility-wideThe facility did not perform required COVID-19 testing on residents and staff.
Mar 28, 2023E · Potential for harm, repeatedThe facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow.
Mar 28, 2023E · Potential for harm, repeatedThe facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it.
Mar 28, 2023E · Potential for harm, repeatedThe facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident.
Mar 28, 2023E · Potential for harm, repeatedThe facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time.
Mar 28, 2023E · Potential for harm, repeatedThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Mar 28, 2023D · Potential for harm, one-offThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Mar 28, 2023D · Potential for harm, one-offThe facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason.
Mar 28, 2023B · Minimal risk, repeatedThe facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
Mar 28, 2023B · Minimal risk, repeatedThe facility did not make sure resident assessments were done by a qualified health professional. Assessments guide all of a resident's care, so the person doing them must be properly trained.

Inspection trend by year

Citations from standard inspections decreased between the last two inspection cycles (31 → 13).

YearCitationsSerious (G–L)Worst severity that year
2023100F
2024310F
2025170F

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

4 fines totaling $24,635.

DateTypeAmount / length
Jul 1, 2024Fine$15,139
Feb 20, 2024Fine$2,659
Feb 12, 2024Fine$2,279
Jan 22, 2024Fine$4,558

Nurse staffing (from payroll records, adjusted for how much care residents need)

MeasureThis facilityMassachusetts avgU.S. avgWhere it stands
Total nurse staffing (hours per resident per day)3.423.893.95bottom 27% in Massachusetts; bottom 32% in the U.S.
Registered Nurse hours0.450.650.69bottom 22% in Massachusetts; bottom 30% in the U.S.
Weekend total nurse staffing3.243.513.50bottom 40% in Massachusetts; bottom 44% in the U.S.
Weekend RN hours (not acuity-adjusted)0.470.460.48top 35% in Massachusetts; top 37% in the U.S.
Total nursing staff turnover (%)0.038.245.8—
RN turnover (%)0.042.642.9—

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.36, RN 0.44, weekend 3.19. Staffing rating: 1/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 1/5 · long-stay residents: 2/5 · short-stay residents: 1/5

Who owns this facility

For profit - Limited Liability company

Owner / managerTypeRoleStakeSince
Ownership Data Not Available

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

Nearby facilities (within 20 miles)

FacilityDistanceCityOverallInspectionFlags
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The Dawn Hill Home for Rehab and Healthcare5.2 miBristol, RI★★★★☆4/5
Somerset Ridge Center5.4 miSomerset, MA★★★★☆4/5
Clifton Rehabilitation Nursing Center5.4 miSomerset, MA★★★★☆4/5
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Evergreen House Health Center5.5 miEast Providence, RI★★★★☆4/5
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Silver Creek Rehab and Healthcare Center5.8 miBristol, RI★★☆☆☆2/5

Compare this facility with the 3 closest →

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Facility data as of CMS processing date 2026-08-01. CCN 225185.