Cycle 1
Health 2025-03-13 · Fire 2025-03-13
12 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Danvers, MA
Brentwood Rehabilitation And Healthcare Ctr (The)
3-star overall rating with 3-star inspections with 12 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
56 Liberty Street, Danvers, MA
(978) 777-2700
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
159
Certified beds
Average residents
135
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Marquis Health Services
Operator or chain grouping
Approved since
1982-10-29
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
0.46
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.02
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.00
Nurse aide staffing · state 2.26 · national 2.35
Total nurse hours
3.48
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.48
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.19
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.43
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.42
CMS adjusted RN staffing hours
Adjusted total hours
3.20
CMS adjusted total nurse staffing hours
Case-mix index
1.49
Higher values indicate more complex resident acuity
RN turnover
38%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
29%
Annual nurse turnover · state 40% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,526
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
11.82
Composite VBP score used to determine payment impact.
Payment multiplier
0.9810
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.33% · Performance 24.02% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 6.99% · Performance 9.32% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
4.73
Baseline 45.53% · Performance 44.35% · Measure score 4.73 · Achievement 4.73 · Improvement 0.07
Adjusted total nurse staffing
0
Baseline 3.60 hours · Performance 3.21 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.89% |
10.72%
2.2 pts worse
|
No Different than the National Rate · Eligible stays 226 · Observed rate 18.14% · Lower 95% interval 10.23% |
| Discharge to community | 47.8% |
50.57%
2.8 pts worse
|
No Different than the National Rate · Eligible stays 237 · Observed rate 34.6% · Lower 95% interval 41.37% |
| Medicare spending per beneficiary | 1.17 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 209 · Denominator 209 |
| Falls with major injury | 0.96% |
0.77%
0.2 pts worse
|
Numerator 2 · Denominator 209 |
| Discharge self-care score | 65.6% |
53.69%
11.9 pts better
|
Numerator 82 · Denominator 125 |
| Discharge mobility score | 57.6% |
50.94%
6.7 pts better
|
Numerator 72 · Denominator 125 |
| Pressure ulcers or injuries, new or worsened | 0.96% |
2.29%
1.3 pts better
|
Numerator 2 · Denominator 209 · Adjusted rate 0.98% |
| Healthcare-associated infections requiring hospitalization | 9.32% |
7.12%
2.2 pts worse
|
No Different than the National Rate · Eligible stays 158 · Observed rate 14.56% · Lower 95% interval 6.51% |
| Staff COVID-19 vaccination coverage | 5% |
8.2%
3.2 pts worse
|
Numerator 6 · Denominator 120 |
| Staff flu vaccination coverage | 94.67% |
42%
52.7 pts better
|
Numerator 142 · Denominator 150 |
| Discharge function score | 67.2% |
56.45%
10.8 pts better
|
Numerator 84 · Denominator 125 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 110 · Denominator 110 |
| Transfer of health information to patient | 97.83% |
96.28%
1.5 pts better
|
Numerator 45 · Denominator 46 |
| Resident COVID-19 vaccinations up to date | 14.41% |
25.2%
10.8 pts worse
|
Numerator 16 · Denominator 111 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.1 |
1.9
0.2 pts worse
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 1.8 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.9 |
1.5
0.4 pts worse
|
1.8
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.7 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.0% |
92.2%
4.8 pts better
|
93.4%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.5% · Q2 94.3% · Q3 99.0% · Q4 99.1% · 4Q avg 97.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.2% |
94.8%
3.4 pts better
|
95.5%
2.7 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.2% |
3.5%
2.3 pts better
|
3.3%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.9% · Q3 2.0% · Q4 0.9% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 39.7% |
12.0%
27.7 pts worse
|
11.4%
28.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 65.7% · Q2 37.5% · Q3 27.7% · Q4 25.0% · 4Q avg 39.7% |
| Percentage of long-stay residents who lose too much weight | 0.5% |
5.2%
4.7 pts better
|
5.4%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.1% · Q4 1.0% · 4Q avg 0.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.5% |
19.2%
1.3 pts worse
|
19.6%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.5% · Q2 20.8% · Q3 21.2% · Q4 16.7% · 4Q avg 20.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.4% |
22.5%
8.1 pts better
|
16.7%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.1% · Q2 15.9% · Q3 12.0% · Q4 12.0% · 4Q avg 14.4% · 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 | 6.4% |
17.7%
11.3 pts better
|
16.3%
9.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 5.2% · Q3 13.3% · Q4 3.3% · 4Q avg 6.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.9% |
17.6%
8.7 pts better
|
14.9%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 5.2% · Q3 15.6% · Q4 9.6% · 4Q avg 8.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.0%
1 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
2.0%
2 pts better
|
1.7%
1.7 pts better
|
Long 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 long-stay residents with new or worsened bowel or bladder incontinence | 23.6% |
21.7%
1.9 pts worse
|
19.8%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.0% · Q2 27.1% · Q3 27.8% · Q4 21.1% · 4Q avg 23.6% |
| Percentage of long-stay residents with pressure ulcers | 2.1% |
4.6%
2.5 pts better
|
5.1%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 1.5% · Q3 3.1% · Q4 2.4% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.2% |
77.1%
15.1 pts better
|
81.7%
10.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 83.7% · Q2 89.9% · Q3 97.4% · Q4 97.2% · 4Q avg 92.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.3% |
11.8%
4.5 pts worse
|
12.0%
4.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.3% · Observed 21.5% · Expected 14.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.3%
0.6 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 1.2% · Q3 0.7% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 85.8% |
77.7%
8.1 pts better
|
79.7%
6.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 85.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.1% |
25.8%
1.3 pts worse
|
23.9%
3.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.1% · Observed 37.9% · Expected 33.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-28 · Fire 2024-03-28
8 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-01-12 · Fire 2023-01-12
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-13
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 2025-04-18
E · Potential for more than minimal harm
2023-01-12
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-03-10
E · Potential for more than minimal harm
2023-01-12
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 2023-03-10
E · Potential for more than minimal harm
2023-01-12
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-03-10
D · Potential for more than minimal harm
2023-01-12
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 2023-03-10
D · Potential for more than minimal harm
2023-01-12
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2023-03-10
D · Potential for more than minimal harm
2023-01-12
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2023-03-10
D · Potential for more than minimal harm
2023-01-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-03-10
D · Potential for more than minimal harm
2023-01-12
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-03-10
D · Potential for more than minimal harm
2023-01-12
K751 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of flammable curtains.
Corrected 2023-03-10
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-03-13
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-04-18
E · Potential for more than minimal harm
2025-03-13
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 2025-04-18
D · Potential for more than minimal harm
2025-03-13
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 2025-04-18
D · Potential for more than minimal harm
2025-03-13
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2025-04-18
D · Potential for more than minimal harm
2025-03-13
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-04-18
D · Potential for more than minimal harm
2025-03-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-18
D · Potential for more than minimal harm
2025-03-13
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-04-18
D · Potential for more than minimal harm
2025-03-13
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-04-18
D · Potential for more than minimal harm
2025-03-13
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2025-04-18
D · Potential for more than minimal harm
2025-03-13
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-04-18
D · Potential for more than minimal harm
2025-03-13
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 2025-04-18
D · Potential for more than minimal harm
2025-03-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-18
E · Potential for more than minimal harm
2024-03-28
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 2024-04-17
E · Potential for more than minimal harm
2024-03-28
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 2024-04-17
E · Potential for more than minimal harm
2024-03-28
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-04-17
E · Potential for more than minimal harm
2024-03-28
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 2024-04-17
D · Potential for more than minimal harm
2024-03-28
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 2024-04-17
D · Potential for more than minimal harm
2024-03-28
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-04-17
D · Potential for more than minimal harm
2024-03-28
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 2024-04-17
B · Minimal harm
2024-03-28
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-04-17
D · Potential for more than minimal harm
2023-01-12
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 2023-02-01
D · Potential for more than minimal harm
2023-01-12
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 2023-02-01
D · Potential for more than minimal harm
2023-01-12
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 2023-02-01
D · Potential for more than minimal harm
2023-01-12
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 2023-02-01
D · Potential for more than minimal harm
2023-01-12
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 2023-02-01
D · Potential for more than minimal harm
2023-01-12
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-02-01
D · Potential for more than minimal harm
2023-01-12
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-02-01
D · Potential for more than minimal harm
2023-01-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-02-01
Penalties and ownership
What sits behind the stars
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
Doyle, Stephen
Corporate Director · Individual
Doyle, Stephen
W-2 Managing Employee · Individual
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
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
Twin Oaks Center
Danvers, MA
1-star overall rating with 1-star inspections with $141,733 in total fines with 19 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
#2
New England Homes For The Deaf, Inc
Danvers, MA
4-star overall rating with 3-star inspections with $3,174 in total fines with 9 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#3
Hunt Nursing & Rehab Center
Danvers, MA
3-star overall rating with 3-star inspections with $10,517 in total fines with 5 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
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