Cycle 1
Health 2025-09-09 · Fire 2025-09-09
6 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Northborough, MA
Alliance Health at Coleman
4-star overall rating with 4-star inspections with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
112 West Main Street, Northborough, MA
(508) 351-9355
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
45
Certified beds
Average residents
44
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
0.69
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
0.99
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
1.98
Nurse aide staffing · state 2.26 · national 2.35
Total nurse hours
3.66
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.68
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.13
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.50
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.76
CMS adjusted RN staffing hours
Adjusted total hours
4.01
CMS adjusted total nurse staffing hours
Case-mix index
1.25
Higher values indicate more complex resident acuity
RN turnover
43%
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
5,866
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
34.78
Composite VBP score used to determine payment impact.
Payment multiplier
0.9886
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
3.66
Baseline 32.43% · Performance 48.72% · Measure score 3.66 · Achievement 3.66 · Improvement 0
Adjusted total nurse staffing
3.30
Baseline 3.62 hours · Performance 4.02 hours · Measure score 3.30 · Achievement 3.30 · Improvement 1.34
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 15 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 7 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 9 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 9 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 45.12% |
8.2%
36.9 pts better
|
Numerator 37 · Denominator 82 |
| Staff flu vaccination coverage | 45.12% |
42%
3.1 pts better
|
Numerator 37 · Denominator 82 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
1.9
0.4 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.0 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
1.5
0.7 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.6 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
92.2%
7.8 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.8%
5.2 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.8% |
3.5%
1.7 pts better
|
3.3%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 2.5% · Q3 2.3% · Q4 0.0% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
12.0%
12 pts better
|
11.4%
11.4 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 who lose too much weight | 2.9% |
5.2%
2.3 pts better
|
5.4%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 6.2% · Q3 0.0% · Q4 2.8% · 4Q avg 2.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.8% |
19.2%
8.4 pts better
|
19.6%
8.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 6.2% · Q3 13.5% · Q4 11.1% · 4Q avg 10.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 23.4% |
22.5%
0.9 pts worse
|
16.7%
6.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.6% · Q2 27.6% · Q3 22.2% · Q4 21.9% · 4Q avg 23.4% · 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 | 9.3% |
17.7%
8.4 pts better
|
16.3%
7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 3.7% · 4Q avg 9.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.8% |
17.6%
5.8 pts better
|
14.9%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.6% · Q2 26.7% · Q3 3.1% · Q4 3.0% · 4Q avg 11.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.0% |
1.0%
1 pts worse
|
1.0%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 1.9% · Q3 1.7% · Q4 1.9% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.0% |
2.0%
1 pts worse
|
1.7%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 2.5% · Q3 4.5% · Q4 0.0% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 9.5% |
21.7%
12.2 pts better
|
19.8%
10.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.0% · Q2 15.3% · Q3 4.4% · Q4 6.8% · 4Q avg 9.5% |
| Percentage of long-stay residents with pressure ulcers | 4.8% |
4.6%
0.2 pts worse
|
5.1%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 2.3% · Q3 6.4% · Q4 2.2% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 84.4% |
77.1%
7.3 pts better
|
81.7%
2.7 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 84.4% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-03 · Fire 2024-07-03
0 health deficiencies
No concentrated health issue counts in this cycle.
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2023-04-19 · Fire 2023-04-19
6 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
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
2025-09-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-10-16
F · Potential for more than minimal harm
2025-09-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-10-20
D · Potential for more than minimal harm
2024-07-03
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-07-18
D · Potential for more than minimal harm
2024-07-03
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2024-08-16
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-09-09
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2025-10-16
E · Potential for more than minimal harm
2025-09-09
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2025-10-16
D · Potential for more than minimal harm
2025-09-09
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2025-10-16
D · Potential for more than minimal harm
2025-09-09
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 2025-10-16
D · Potential for more than minimal harm
2025-09-09
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 2025-10-16
B · Minimal harm
2025-09-09
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-10-16
E · Potential for more than minimal harm
2023-04-19
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-05-25
D · Potential for more than minimal harm
2023-04-19
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-05-25
D · Potential for more than minimal harm
2023-04-19
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-05-25
D · Potential for more than minimal harm
2023-04-19
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-05-25
D · Potential for more than minimal harm
2023-04-19
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-05-25
D · Potential for more than minimal harm
2023-04-19
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-05-25
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
Chaudhary, Saqib
Operational/Managerial Control · Individual
Corridan, Linda
Corporate Director · Individual
Grady, Francis
Corporate Director · Individual
Grady, Francis
Corporate Officer · Individual
Gray, Alfred
Corporate Director · Individual
Hunter, Linda
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
Lozoya, Katherine
Operational/Managerial Control · 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
Beaumont Rehab & Skilled Nursing Ctr - Northboro
Northborough, MA
5-star overall rating with 4-star inspections with 3 recent health deficiencies
#2
Shrewsbury Rehabilitation And Nursing At Southgate
Shrewsbury, MA
5-star overall rating with 4-star inspections with $7,901 in total fines with 9 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#3
Beaumont Rehab & Skilled Nursing Ctr - Westboro
Westborough, MA
4-star overall rating with 4-star inspections with 5 recent health deficiencies
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