Cycle 1
Health 2025-12-17 · Fire 2025-12-17
7 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
5 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Beverly, MA
Blueberry Hill Rehabilitation And Healthcare Ctr
1-star overall rating with 1-star inspections with $231,459 in total fines with 7 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
75 Brimbal Avenue, Beverly, MA
(978) 927-2020
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
132
Certified beds
Average residents
117
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Marquis Health Services
Operator or chain grouping
Approved since
1967-06-30
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
81 facilities
Chain averages 3 overall / 3 health / 2 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
0.54
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
0.89
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.16
Nurse aide staffing · state 2.26 · national 2.35
Total nurse hours
3.58
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.43
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.31
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.41
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.49
CMS adjusted RN staffing hours
Adjusted total hours
3.27
CMS adjusted total nurse staffing hours
Case-mix index
1.50
Higher values indicate more complex resident acuity
RN turnover
63%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
39%
Annual nurse turnover · state 40% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,080
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
18.11
Composite VBP score used to determine payment impact.
Payment multiplier
0.9819
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.42
Baseline 19.08% · Performance 20.31% · Measure score 2.42 · Achievement 2.42 · Improvement 0
Healthcare-associated infections
3.02
Baseline 8.76% · Performance 7.43% · Measure score 3.02 · Achievement 1.35 · Improvement 3.02
Total nurse turnover
1.80
Baseline 47.59% · Performance 56.31% · Measure score 1.80 · Achievement 1.80 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.42 hours · Performance 2.56 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.89% |
10.72%
1.2 pts worse
|
No Different than the National Rate · Eligible stays 143 · Observed rate 12.59% · Lower 95% interval 8.5% |
| Discharge to community | 39.3% |
50.57%
11.3 pts worse
|
Worse than the National Rate · Eligible stays 108 · Observed rate 30.56% · Lower 95% interval 30.69% |
| Medicare spending per beneficiary | 0.95 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 98.92% |
95.27%
3.7 pts better
|
Numerator 92 · Denominator 93 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 93 |
| Discharge self-care score | 40.68% |
53.69%
13 pts worse
|
Numerator 24 · Denominator 59 |
| Discharge mobility score | 49.15% |
50.94%
1.8 pts worse
|
Numerator 29 · Denominator 59 |
| Pressure ulcers or injuries, new or worsened | 3.23% |
2.29%
0.9 pts worse
|
Numerator 3 · Denominator 93 · Adjusted rate 3.1% |
| Healthcare-associated infections requiring hospitalization | 7.43% |
7.12%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 66 · Observed rate 9.09% · Lower 95% interval 4.51% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 134 |
| Staff flu vaccination coverage | 42.97% |
42%
1 pts better
|
Numerator 55 · Denominator 128 |
| Discharge function score | 52.54% |
56.45%
3.9 pts worse
|
Numerator 31 · Denominator 59 |
| Transfer of health information to provider | 96.15% |
95.95%
0.2 pts better
|
Numerator 25 · Denominator 26 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 13.73% |
25.2%
11.5 pts worse
|
Numerator 7 · Denominator 51 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.9 |
1.9
1 pts worse
|
1.9
1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.9 · Observed 3.2 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.0 |
1.5
0.5 pts worse
|
1.8
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 2.0 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.5% |
92.2%
5.3 pts better
|
93.4%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.3% · Q2 96.1% · Q3 99.1% · Q4 97.2% · 4Q avg 97.5% |
| 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 | 3.9% |
3.5%
0.4 pts worse
|
3.3%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 4.9% · Q3 3.6% · Q4 2.8% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 93.1% |
12.0%
81.1 pts worse
|
11.4%
81.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 71.9% · Q3 98.0% · Q4 100.0% · 4Q avg 93.1% |
| Percentage of long-stay residents who lose too much weight | 14.6% |
5.2%
9.4 pts worse
|
5.4%
9.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 14.7% · Q3 25.8% · Q4 11.5% · 4Q avg 14.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 29.5% |
19.2%
10.3 pts worse
|
19.6%
9.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.4% · Q2 32.0% · Q3 27.5% · Q4 29.4% · 4Q avg 29.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 22.1% |
22.5%
0.4 pts better
|
16.7%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.9% · Q2 24.6% · Q3 24.6% · Q4 22.4% · 4Q avg 22.1% · 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 | 5.0% |
17.7%
12.7 pts better
|
16.3%
11.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 6.1% · Q3 6.4% · Q4 1.5% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.0% |
17.6%
4.6 pts better
|
14.9%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.7% · Q2 12.2% · Q3 20.0% · Q4 9.0% · 4Q avg 13.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
1.0%
0.4 pts better
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 0.9% · Q3 0.7% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.5% |
2.0%
1.5 pts better
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 1.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.5% |
21.7%
3.2 pts better
|
19.8%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 23.5% · Q3 20.7% · Q4 21.2% · 4Q avg 18.5% |
| Percentage of long-stay residents with pressure ulcers | 4.3% |
4.6%
0.3 pts better
|
5.1%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 4.4% · Q3 5.1% · Q4 5.0% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 82.0% |
77.1%
4.9 pts better
|
81.7%
0.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 87.9% · Q2 77.6% · Q3 81.5% · Q4 84.2% · 4Q avg 82.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.2% |
11.8%
3.6 pts better
|
12.0%
3.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.2% · Observed 9.3% · Expected 12.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.7% |
1.3%
1.4 pts worse
|
1.6%
1.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q2 4.3% · Q3 0.0% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 73.5% |
77.7%
4.2 pts worse
|
79.7%
6.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 73.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.5% |
25.8%
4.3 pts better
|
23.9%
2.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.5% · Observed 22.7% · Expected 25.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-11-12 · Fire 2024-11-12
34 health deficiencies
Top issue: Quality of Life and Care (11 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2023-10-26 · Fire 2023-10-26
31 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-12-17
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 2026-01-23
F · Potential for more than minimal harm
2025-12-17
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2026-01-23
F · Potential for more than minimal harm
2025-12-17
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2026-01-23
F · Potential for more than minimal harm
2025-12-17
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2026-01-23
F · Potential for more than minimal harm
2025-12-17
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2026-01-23
F · Potential for more than minimal harm
2024-11-12
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2025-01-02
F · Potential for more than minimal harm
2024-11-12
K227 · Egress Deficiencies
Fire Safety
Have ramps, exits, fire escape ladders, steps, and areas of refuge that meet safety requirements.
Corrected 2025-01-02
E · Potential for more than minimal harm
2024-11-12
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-01-02
E · Potential for more than minimal harm
2024-11-12
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-01-02
E · Potential for more than minimal harm
2024-11-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-01-02
E · Potential for more than minimal harm
2024-11-12
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-01-02
E · Potential for more than minimal harm
2024-11-12
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-01-02
D · Potential for more than minimal harm
2024-11-12
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-01-02
F · Potential for more than minimal harm
2023-10-26
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-11-14
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-12-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-01-12
D · Potential for more than minimal harm
2025-12-17
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2026-01-12
D · Potential for more than minimal harm
2025-12-17
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2026-01-12
D · Potential for more than minimal harm
2025-12-17
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2026-01-12
D · Potential for more than minimal harm
2025-12-17
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 2026-01-12
D · Potential for more than minimal harm
2025-12-17
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 2026-01-12
D · Potential for more than minimal harm
2025-12-17
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2026-01-12
G · Actual harm
2025-02-19
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-03-24
D · Potential for more than minimal harm
2025-02-19
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 2025-03-24
K · Immediate jeopardy
2024-11-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-12-11
J · Immediate jeopardy
2024-11-12
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 2024-12-11
J · Immediate jeopardy
2024-11-12
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-12-11
J · Immediate jeopardy
2024-11-12
F710 · Nursing and Physician Services Deficiencies
Health
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Corrected 2024-12-11
G · Actual harm
2024-11-12
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-12-11
G · Actual harm
2024-11-12
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-12-11
F · Potential for more than minimal harm
2024-11-12
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-12-11
E · Potential for more than minimal harm
2024-11-12
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-12-11
E · Potential for more than minimal harm
2024-11-12
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-12-11
E · Potential for more than minimal harm
2024-11-12
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-12-11
E · Potential for more than minimal harm
2024-11-12
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-12-11
E · Potential for more than minimal harm
2024-11-12
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-12-11
E · Potential for more than minimal harm
2024-11-12
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 2024-12-11
E · Potential for more than minimal harm
2024-11-12
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2024-12-11
E · Potential for more than minimal harm
2024-11-12
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-12-11
E · Potential for more than minimal harm
2024-11-12
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 2024-12-11
E · Potential for more than minimal harm
2024-11-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-11
D · Potential for more than minimal harm
2024-11-12
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-12-11
D · Potential for more than minimal harm
2024-11-12
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2024-12-11
D · Potential for more than minimal harm
2024-11-12
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2024-12-11
D · Potential for more than minimal harm
2024-11-12
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-12-11
D · Potential for more than minimal harm
2024-11-12
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-12-11
D · Potential for more than minimal harm
2024-11-12
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 2024-12-11
D · Potential for more than minimal harm
2024-11-12
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-12-11
D · Potential for more than minimal harm
2024-11-12
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-12-11
D · Potential for more than minimal harm
2024-11-12
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-12-11
D · Potential for more than minimal harm
2024-11-12
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-12-11
D · Potential for more than minimal harm
2024-11-12
F726 · Nursing and Physician Services Deficiencies
Health
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.
Corrected 2024-12-11
D · Potential for more than minimal harm
2024-11-12
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 2024-12-11
D · Potential for more than minimal harm
2024-11-12
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-12-11
D · Potential for more than minimal harm
2024-11-12
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 2024-12-11
D · Potential for more than minimal harm
2024-11-12
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2024-12-11
D · Potential for more than minimal harm
2024-01-23
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-02-12
G · Actual harm
2023-10-26
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-12-11
G · Actual harm
2023-10-26
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 2023-12-11
F · Potential for more than minimal harm
2023-10-26
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-12-11
F · Potential for more than minimal harm
2023-10-26
F726 · Nursing and Physician Services Deficiencies
Health
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.
Corrected 2023-12-11
F · Potential for more than minimal harm
2023-10-26
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2023-12-11
F · Potential for more than minimal harm
2023-10-26
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 2023-12-11
F · Potential for more than minimal harm
2023-10-26
F841 · Nursing and Physician Services Deficiencies
Health
Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.
Corrected 2023-12-11
F · Potential for more than minimal harm
2023-10-26
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2023-12-11
F · Potential for more than minimal harm
2023-10-26
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2023-12-11
E · Potential for more than minimal harm
2023-10-26
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-12-11
E · Potential for more than minimal harm
2023-10-26
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-12-11
E · Potential for more than minimal harm
2023-10-26
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 2023-12-11
E · Potential for more than minimal harm
2023-10-26
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 2023-12-11
E · Potential for more than minimal harm
2023-10-26
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2023-12-11
E · Potential for more than minimal harm
2023-10-26
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-12-11
D · Potential for more than minimal harm
2023-10-26
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2023-12-11
D · Potential for more than minimal harm
2023-10-26
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-12-11
D · Potential for more than minimal harm
2023-10-26
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-12-11
D · Potential for more than minimal harm
2023-10-26
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-12-11
D · Potential for more than minimal harm
2023-10-26
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-12-11
D · Potential for more than minimal harm
2023-10-26
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 2023-12-11
D · Potential for more than minimal harm
2023-10-26
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2023-12-11
D · Potential for more than minimal harm
2023-10-26
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-12-11
D · Potential for more than minimal harm
2023-10-26
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 2023-12-11
D · Potential for more than minimal harm
2023-10-26
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-12-11
D · Potential for more than minimal harm
2023-10-26
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2023-12-11
D · Potential for more than minimal harm
2023-10-26
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 2023-12-11
D · Potential for more than minimal harm
2023-10-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-11
D · Potential for more than minimal harm
2023-03-16
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-04-17
D · Potential for more than minimal harm
2023-03-16
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 2023-04-17
Penalties and ownership
What sits behind the stars
$12,935
2025-02-19
Fine
Fine · fine $12,935
Fine
$157,749
2024-11-12
Fine
Fine · fine $157,749
Fine
$60,775
2023-10-26
Fine
Fine · fine $60,775
Fine
Ownership
Quinto Guardian LLC
5% Or Greater Direct Ownership Interest · Organization
Ukr Consulting LLC
5% Or Greater Direct Ownership Interest · Organization
Cibc Bank Usa
5% Or Greater Security Interest · Organization
Kohn Fam Tr Gst Exempt Uad 3-25-13
5% Or Greater Indirect Ownership Interest · Organization
Nfr 2020 Irrv Tr
5% Or Greater Indirect Ownership Interest · Organization
Posen, Mindee
Corporate Officer · Individual
Rsbrmk Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Sk 2013 Investment Tr Ua 03252013
5% Or Greater Indirect Ownership Interest · Organization
Tormey, Greg
Corporate Director · Individual
Tormey, Greg
W-2 Managing Employee · Individual
Tryko Guardian Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Uak 2020 Irrv Tr
5% Or Greater Indirect Ownership Interest · Organization
Yr 2013 Investment Trust U/A/D 3/25/13
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Ledgewood Rehabilitation And Nursing Center
Beverly, MA
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Care One At Essex Park
Beverly, MA
5-star overall rating with 4-star inspections with $35,968 in total fines with 7 fire-safety deficiencies in the latest cycle
#3
Brentwood Rehabilitation And Healthcare Ctr (The)
Danvers, MA
3-star overall rating with 3-star inspections with 12 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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