Cycle 1
Health 2026-01-05 · Fire 2026-01-05
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Baldwinville, MA
Alliance Health At Baldwinville
4-star overall rating with 4-star inspections with 6 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
51 Hospital Road, Baldwinville, MA
(978) 939-2196
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
94
Certified beds
Average residents
84
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Alliance Health & Human Services
Operator or chain grouping
Approved since
1990-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
8 facilities
Chain averages 4 overall / 4 health / 4 staffing / 4 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
Hours and turnover
RN hours / resident day
0.70
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
0.76
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.35
Nurse aide staffing · state 2.26 · national 2.35
Total nurse hours
3.82
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.46
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.14
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.48
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.71
CMS adjusted RN staffing hours
Adjusted total hours
3.87
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
39%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
38%
Annual nurse turnover · state 40% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,619
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
55.23
Composite VBP score used to determine payment impact.
Payment multiplier
1.0102
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.81
Baseline 19.94% · Performance 19.67% · Measure score 3.81 · Achievement 3.81 · Improvement 0.42
Healthcare-associated infections
7.67
Baseline 7.87% · Performance 5.54% · Measure score 7.67 · Achievement 7.67 · Improvement 7.60
Total nurse turnover
6.37
Baseline 46.51% · Performance 37.65% · Measure score 6.37 · Achievement 6.37 · Improvement 3.59
Adjusted total nurse staffing
4.24
Baseline 3.79 hours · Performance 4.29 hours · Measure score 4.24 · Achievement 4.24 · Improvement 1.98
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.63% |
10.72%
1.9 pts worse
|
No Different than the National Rate · Eligible stays 163 · Observed rate 13.5% · Lower 95% interval 9.64% |
| Discharge to community | 54.37% |
50.57%
3.8 pts better
|
No Different than the National Rate · Eligible stays 136 · Observed rate 50.74% · Lower 95% interval 47.48% |
| Medicare spending per beneficiary | 0.61 |
1.02
0.4 pts better
|
|
| Drug regimen review with follow-up | 98.98% |
95.27%
3.7 pts better
|
Numerator 97 · Denominator 98 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 98 |
| Discharge self-care score | 36.25% |
53.69%
17.4 pts worse
|
Numerator 29 · Denominator 80 |
| Discharge mobility score | 30% |
50.94%
20.9 pts worse
|
Numerator 24 · Denominator 80 |
| Pressure ulcers or injuries, new or worsened | 2.04% |
2.29%
0.2 pts better
|
Numerator 2 · Denominator 98 · Adjusted rate 2.38% |
| Healthcare-associated infections requiring hospitalization | 5.54% |
7.12%
1.6 pts better
|
No Different than the National Rate · Eligible stays 100 · Observed rate 2% · Lower 95% interval 3.15% |
| Staff COVID-19 vaccination coverage | 19.49% |
8.2%
11.3 pts better
|
Numerator 23 · Denominator 118 |
| Staff flu vaccination coverage | 63.39% |
42%
21.4 pts better
|
Numerator 71 · Denominator 112 |
| Discharge function score | 47.5% |
56.45%
9 pts worse
|
Numerator 38 · Denominator 80 |
| Transfer of health information to provider | 97.3% |
95.95%
1.3 pts better
|
Numerator 36 · Denominator 37 |
| Transfer of health information to patient | 96.55% |
96.28%
0.3 pts better
|
Numerator 28 · Denominator 29 |
| Resident COVID-19 vaccinations up to date | 44.9% |
25.2%
19.7 pts better
|
Numerator 22 · Denominator 49 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.8 |
1.9
1.1 pts better
|
1.9
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.8 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
1.5
0.1 pts better
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.3 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 87.5% |
92.2%
4.7 pts worse
|
93.4%
5.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 86.4% · Q2 90.2% · Q3 88.1% · Q4 85.7% · 4Q avg 87.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 89.4% |
94.8%
5.4 pts worse
|
95.5%
6.1 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 89.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.1% |
3.5%
1.6 pts worse
|
3.3%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 6.6% · Q3 3.4% · Q4 4.3% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.4% |
12.0%
11.6 pts better
|
11.4%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% |
| Percentage of long-stay residents who lose too much weight | 1.3% |
5.2%
3.9 pts better
|
5.4%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 1.8% · Q3 0.0% · Q4 1.5% · 4Q avg 1.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.1% |
19.2%
3.9 pts worse
|
19.6%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.4% · Q2 30.9% · Q3 21.1% · Q4 19.7% · 4Q avg 23.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.4% |
22.5%
2.1 pts better
|
16.7%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.8% · Q2 19.1% · Q3 20.0% · Q4 21.4% · 4Q avg 20.4% · 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 | 18.6% |
17.7%
0.9 pts worse
|
16.3%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.1% · Q2 15.2% · Q3 27.2% · Q4 13.6% · 4Q avg 18.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 24.8% |
17.6%
7.2 pts worse
|
14.9%
9.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.4% · Q2 25.5% · Q3 24.5% · Q4 20.6% · 4Q avg 24.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.7% |
1.0%
0.7 pts worse
|
1.0%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 0.0% · Q3 0.0% · Q4 1.2% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 7.5% |
2.0%
5.5 pts worse
|
1.7%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.6% · Q2 9.8% · Q3 3.4% · Q4 8.7% · 4Q avg 7.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.4% |
21.7%
3.7 pts worse
|
19.8%
5.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.3% · Q2 25.4% · Q3 18.0% · Q4 31.9% · 4Q avg 25.4% |
| Percentage of long-stay residents with pressure ulcers | 3.4% |
4.6%
1.2 pts better
|
5.1%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 3.3% · Q3 1.8% · Q4 3.6% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.2% |
77.1%
22.1 pts better
|
81.7%
17.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 99.0% · Q3 99.1% · Q4 98.9% · 4Q avg 99.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.6% |
11.8%
0.2 pts better
|
12.0%
0.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.6% · Observed 10.0% · Expected 9.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 87.9% |
77.7%
10.2 pts better
|
79.7%
8.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 87.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.7% |
25.8%
4.1 pts better
|
23.9%
2.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.7% · Observed 21.2% · Expected 23.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-09-19 · Fire 2024-09-19
4 health deficiencies
Top issue: Infection Control (3 deficiencies)
4 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Cycle 3
Health 2023-06-08 · Fire 2023-06-08
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2026-01-05
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2026-02-20
F · Potential for more than minimal harm
2026-01-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2026-02-20
D · Potential for more than minimal harm
2026-01-05
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2026-02-20
D · Potential for more than minimal harm
2026-01-05
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2026-02-20
D · Potential for more than minimal harm
2024-09-19
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2024-10-31
D · Potential for more than minimal harm
2024-09-19
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2024-10-31
D · Potential for more than minimal harm
2024-09-19
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2024-10-31
D · Potential for more than minimal harm
2024-09-19
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2024-10-31
Inspection history
Recent health citations
E · Potential for more than minimal harm
2026-01-05
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2026-02-13
D · Potential for more than minimal harm
2026-01-05
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2026-02-13
D · Potential for more than minimal harm
2026-01-05
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2026-02-13
D · Potential for more than minimal harm
2026-01-05
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2026-02-13
B · Minimal harm
2026-01-05
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2026-02-13
B · Minimal harm
2026-01-05
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2026-02-13
D · Potential for more than minimal harm
2024-10-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-29
E · Potential for more than minimal harm
2024-09-19
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-10-29
D · Potential for more than minimal harm
2024-09-19
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-10-29
D · Potential for more than minimal harm
2024-09-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-29
Penalties and ownership
What sits behind the stars
Ownership
Alliance Health Inc
5% Or Greater Direct Ownership Interest · Organization
Alliance Health Management Services LLC
Operational/Managerial Control · Organization
Brunetti, Tammy
Corporate Director · Individual
Calkins, Andrew
Corporate Director · Individual
Corridan, Linda
Corporate Director · Individual
Gillissen, Christopher
Operational/Managerial Control · Individual
Grady, Francis
Corporate Director · Individual
Grady, Francis
Corporate Officer · Individual
Gray, Alfred
Corporate Director · Individual
Havlin, David
Operational/Managerial Control · Individual
Janisko, Jerome
Corporate Director · Individual
Jennings, Michael
Corporate Director · Individual
Jones, Erik
Corporate Director · Individual
Kemp, Paul
Corporate Officer · Individual
Lavallee, Thomas
Corporate Officer · Individual
Lument Real Estate Capital LLC
5% Or Greater Mortgage Interest · Organization
Mourtzinos, Arthur
Corporate Director · Individual
Riley, James
Corporate Director · Individual
Robbins, Christopher
Corporate Director · Individual
Zampine, Peter
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Wachusett Manor
Gardner, MA
2-star overall rating with 3-star inspections with $26,756 in total fines with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Gardner Rehabilitation And Nursing Center
Gardner, MA
2-star overall rating with 2-star inspections with 16 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Quabbin Valley Healthcare
Athol, MA
1-star overall rating with 2-star inspections with $62,250 in total fines with 17 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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