Cycle 1
Health 2024-12-10 · Fire 2024-12-10
5 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Westborough, MA
Beaumont Rehab & Skilled Nursing Ctr - Westboro
4-star overall rating with 4-star inspections with 5 recent health deficiencies
3 Lyman Street, Westborough, MA
(508) 366-9933
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
152
Certified beds
Average residents
142
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1983-12-28
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.53
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.17
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
1.87
Nurse aide staffing · state 2.26 · national 2.35
Total nurse hours
3.57
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.69
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
0.36
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.58
CMS adjusted RN staffing hours
Adjusted total hours
3.93
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
55%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
45%
Annual nurse turnover · state 40% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,646
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
39.13
Composite VBP score used to determine payment impact.
Payment multiplier
0.9921
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.07
Baseline 17.21% · Performance 20.01% · Measure score 3.07 · Achievement 3.07 · Improvement 0
Healthcare-associated infections
6.80
Baseline 4.26% · Performance 5.80% · Measure score 6.80 · Achievement 6.80 · Improvement 0
Total nurse turnover
3.84
Baseline 55.90% · Performance 48.00% · Measure score 3.84 · Achievement 3.84 · Improvement 2.04
Adjusted total nurse staffing
1.94
Baseline 3.63 hours · Performance 3.63 hours · Measure score 1.94 · Achievement 1.94 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.3% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 283 · Observed rate 9.89% · Lower 95% interval 7.78% |
| Discharge to community | 67.33% |
50.57%
16.8 pts better
|
Better than the National Rate · Eligible stays 252 · Observed rate 59.52% · Lower 95% interval 60.17% |
| Medicare spending per beneficiary | 0.72 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 99.44% |
95.27%
4.2 pts better
|
Numerator 178 · Denominator 179 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 179 |
| Discharge self-care score | 49.69% |
53.69%
4 pts worse
|
Numerator 81 · Denominator 163 |
| Discharge mobility score | 61.35% |
50.94%
10.4 pts better
|
Numerator 100 · Denominator 163 |
| Pressure ulcers or injuries, new or worsened | 1.12% |
2.29%
1.2 pts better
|
Numerator 2 · Denominator 179 · Adjusted rate 0.98% |
| Healthcare-associated infections requiring hospitalization | 5.8% |
7.12%
1.3 pts better
|
No Different than the National Rate · Eligible stays 178 · Observed rate 4.49% · Lower 95% interval 3.75% |
| Staff COVID-19 vaccination coverage | 12.5% |
8.2%
4.3 pts better
|
Numerator 23 · Denominator 184 |
| Staff flu vaccination coverage | 40.52% |
42%
1.5 pts worse
|
Numerator 62 · Denominator 153 |
| Discharge function score | 56.44% |
56.45%
About the same
|
Numerator 92 · Denominator 163 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 74 · Denominator 74 |
| Transfer of health information to patient | 94.92% |
96.28%
1.4 pts worse
|
Numerator 56 · Denominator 59 |
| Resident COVID-19 vaccinations up to date | 43.37% |
25.2%
18.2 pts better
|
Numerator 36 · Denominator 83 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.2 |
1.9
1.3 pts worse
|
1.9
1.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.2 · Observed 2.2 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
1.5
About the same
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.2 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.9% |
92.2%
4.7 pts better
|
93.4%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.4% · Q2 96.4% · Q3 97.5% · Q4 98.3% · 4Q avg 96.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.1% |
94.8%
4.3 pts better
|
95.5%
3.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.6% |
3.5%
3.1 pts worse
|
3.3%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 5.4% · Q3 5.8% · Q4 6.0% · 4Q avg 6.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.8% |
12.0%
7.2 pts better
|
11.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 5.1% · Q3 4.6% · Q4 6.4% · 4Q avg 4.8% |
| Percentage of long-stay residents who lose too much weight | 4.0% |
5.2%
1.2 pts better
|
5.4%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 6.1% · Q3 2.8% · Q4 3.9% · 4Q avg 4.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.1% |
19.2%
8.1 pts better
|
19.6%
8.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 11.9% · Q3 12.6% · Q4 11.5% · 4Q avg 11.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.7% |
22.5%
1.8 pts better
|
16.7%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.9% · Q2 22.9% · Q3 20.9% · Q4 20.2% · 4Q avg 20.7% · 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 | 15.5% |
17.7%
2.2 pts better
|
16.3%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.5% · Q2 21.3% · Q3 7.6% · Q4 17.0% · 4Q avg 15.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.2% |
17.6%
3.4 pts better
|
14.9%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.0% · Q2 16.1% · Q3 16.7% · Q4 9.7% · 4Q avg 14.2% · 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 2.4% · Q2 2.2% · Q3 1.4% · Q4 2.1% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.9% |
2.0%
1.1 pts better
|
1.7%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 1.9% · Q3 0.9% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.4% |
21.7%
1.3 pts better
|
19.8%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.2% · Q2 19.5% · Q3 22.3% · Q4 16.7% · 4Q avg 20.4% |
| Percentage of long-stay residents with pressure ulcers | 3.3% |
4.6%
1.3 pts better
|
5.1%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 3.4% · Q3 2.2% · Q4 4.0% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 89.5% |
77.1%
12.4 pts better
|
81.7%
7.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 88.9% · Q2 90.2% · Q3 91.5% · Q4 87.1% · 4Q avg 89.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.9% |
11.8%
0.1 pts worse
|
12.0%
0.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.9% · Observed 11.9% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.3%
0.7 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.7% · Q3 0.7% · Q4 0.8% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 90.3% |
77.7%
12.6 pts better
|
79.7%
10.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 32.6% |
25.8%
6.8 pts worse
|
23.9%
8.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 32.6% · Observed 31.0% · Expected 22.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-28 · Fire 2023-09-28
12 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2022-03-22 · Fire 2022-03-22
6 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2023-09-28
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-12-04
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-12-10
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 2025-01-20
D · Potential for more than minimal harm
2024-12-10
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 2025-01-20
D · Potential for more than minimal harm
2024-12-10
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2025-01-20
D · Potential for more than minimal harm
2024-12-10
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-01-20
B · Minimal harm
2024-12-10
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2025-01-20
F · Potential for more than minimal harm
2023-09-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-09
D · Potential for more than minimal harm
2023-09-28
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 2023-11-09
D · Potential for more than minimal harm
2023-09-28
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-11-09
D · Potential for more than minimal harm
2023-09-28
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2023-11-09
D · Potential for more than minimal harm
2023-09-28
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-11-09
D · Potential for more than minimal harm
2023-09-28
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2023-11-09
D · Potential for more than minimal harm
2023-09-28
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-11-09
D · Potential for more than minimal harm
2023-09-28
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-11-09
D · Potential for more than minimal harm
2023-09-28
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 2023-11-09
D · Potential for more than minimal harm
2023-09-28
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-11-09
B · Minimal harm
2023-09-28
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2023-11-09
B · Minimal harm
2023-09-28
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2023-11-09
E · Potential for more than minimal harm
2022-03-22
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 2022-04-22
D · Potential for more than minimal harm
2022-03-22
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-04-22
D · Potential for more than minimal harm
2022-03-22
F700 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2022-04-22
D · Potential for more than minimal harm
2022-03-22
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2022-04-22
D · Potential for more than minimal harm
2022-03-22
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2022-04-22
B · Minimal harm
2022-03-22
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2022-04-22
Penalties and ownership
What sits behind the stars
Ownership
Salmon, Daniel
5% Or Greater Direct Ownership Interest · Individual
Salmon, Dorothy
5% Or Greater Direct Ownership Interest · Individual
Tuffy, Robert
5% Or Greater Direct Ownership Interest · Individual
Continuing Care Management LLC
Operational/Managerial Control · Organization
Coppola, Lisa
Operational/Managerial Control · Individual
Sacon, Gary
Corporate Officer · Individual
Sacon, Gary
W-2 Managing Employee · Individual
Salmon, Matthew
Corporate Officer · Individual
Salmon, Matthew
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Westborough Healthcare
Westborough, MA
2-star overall rating with 2-star inspections with $28,772 in total fines with 17 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
Whittier Westborough Transitional Care Unit
Westborough, MA
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Beaumont Rehab & Skilled Nursing Ctr - Northboro
Northborough, MA
5-star overall rating with 4-star inspections with 3 recent health deficiencies
Jump out