Needham, MA

Briarwood Rehabilitation & Healthcare Center

4-star overall rating with 4-star inspections with $8,788 in total fines

150 Lincoln Street, Needham, MA

(781) 449-4040

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

120

Certified beds

Average residents

109

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Marquis Health Services

Operator or chain grouping

Approved since

1990-07-01

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

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

0.81

Registered nurse staffing · state 0.65 · national 0.68

LPN hours / resident day

0.79

Licensed practical nurse staffing · state 0.96 · national 0.87

Aide hours / resident day

2.38

Nurse aide staffing · state 2.26 · national 2.35

Total nurse hours

3.99

All reported nurse hours · state 3.86 · national 3.89

Licensed hours

1.61

RN + LPN hours · state 1.60 · national 1.54

Weekend hours

3.45

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

0.01

Reported PT staffing · state 0.08 · national 0.07

Adjusted RN hours

0.67

CMS adjusted RN staffing hours

Adjusted total hours

3.31

CMS adjusted total nurse staffing hours

Case-mix index

1.65

Higher values indicate more complex resident acuity

RN turnover

25%

Annual RN turnover · state 45% · national 45%

Total nurse turnover

20%

Annual nurse turnover · state 40% · national 46%

SNF VBP

Value-based purchasing

Program rank

4,023

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

41.67

Composite VBP score used to determine payment impact.

Payment multiplier

0.9946

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Baseline 20.60% · Performance 24.58% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

5.35

Baseline 6.81% · Performance 6.24% · Measure score 5.35 · Achievement 5.35 · Improvement 2.66

Total nurse turnover

Baseline 28.97% · Performance 24.73% · Measure score 10 · Achievement 10 · Improvement 9

Adjusted total nurse staffing

1.32

Baseline 4.16 hours · Performance 3.45 hours · Measure score 1.32 · Achievement 1.32 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	13.68%	10.72% 3 pts worse	No Different than the National Rate · Eligible stays 411 · Observed rate 15.33% · Lower 95% interval 10.7%
Discharge to community	50.14%	50.57% 0.4 pts worse	No Different than the National Rate · Eligible stays 398 · Observed rate 41.21% · Lower 95% interval 44.02%
Medicare spending per beneficiary	0.99	1.02 About the same
Drug regimen review with follow-up	99.63%	95.27% 4.4 pts better	Numerator 267 · Denominator 268
Falls with major injury	1.12%	0.77% 0.4 pts worse	Numerator 3 · Denominator 268
Discharge self-care score	61.75%	53.69% 8.1 pts better	Numerator 113 · Denominator 183
Discharge mobility score	68.31%	50.94% 17.4 pts better	Numerator 125 · Denominator 183
Pressure ulcers or injuries, new or worsened	0.75%	2.29% 1.5 pts better	Numerator 2 · Denominator 268 · Adjusted rate 0.54%
Healthcare-associated infections requiring hospitalization	6.24%	7.12% 0.9 pts better	No Different than the National Rate · Eligible stays 224 · Observed rate 6.7% · Lower 95% interval 3.79%
Staff COVID-19 vaccination coverage	11.69%	8.2% 3.5 pts better	Numerator 18 · Denominator 154
Staff flu vaccination coverage	73.05%	42% 31 pts better	Numerator 122 · Denominator 167
Discharge function score	68.31%	56.45% 11.9 pts better	Numerator 125 · Denominator 183
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 162 · Denominator 162
Transfer of health information to patient	100%	96.28% 3.7 pts better	Numerator 41 · Denominator 41
Resident COVID-19 vaccinations up to date	36.04%	25.2% 10.8 pts better	Numerator 40 · Denominator 111

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.7	1.9 0.2 pts better	1.9 0.2 pts better	Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.7 · Expected 2.0 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.1	1.5 0.4 pts better	1.8 0.7 pts better	Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.2 · Expected 1.7 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	97.2%	92.2% 5 pts better	93.4% 3.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 96.6% · Q2 97.8% · Q3 96.6% · Q4 97.6% · 4Q avg 97.2%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	93.9%	94.8% 0.9 pts worse	95.5% 1.6 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 93.9%
Percentage of long-stay residents experiencing one or more falls with major injury	2.8%	3.5% 0.7 pts better	3.3% 0.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 2.2% · Q3 3.4% · Q4 3.5% · 4Q avg 2.8% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	68.6%	12.0% 56.6 pts worse	11.4% 57.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 55.9% · Q2 74.6% · Q3 76.6% · Q4 68.1% · 4Q avg 68.6%
Percentage of long-stay residents who lose too much weight	3.1%	5.2% 2.1 pts better	5.4% 2.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 4.0% · Q3 5.6% · Q4 1.4% · 4Q avg 3.1%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	15.0%	19.2% 4.2 pts better	19.6% 4.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 15.2% · Q2 14.1% · Q3 17.1% · Q4 13.7% · 4Q avg 15.0%
Percentage of long-stay residents who received an antipsychotic medication	21.9%	22.5% 0.6 pts better	16.7% 5.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 27.4% · Q2 24.1% · Q3 17.5% · Q4 17.9% · 4Q avg 21.9% · 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	9.0%	17.7% 8.7 pts better	16.3% 7.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 10.8% · Q3 12.8% · Q4 5.6% · 4Q avg 9.0% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	7.2%	17.6% 10.4 pts better	14.9% 7.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 10.9% · Q2 1.6% · Q3 7.9% · Q4 8.1% · 4Q avg 7.2% · 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	5.1%	21.7% 16.6 pts better	19.8% 14.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 11.0% · Q3 1.4% · Q4 2.6% · 4Q avg 5.1%
Percentage of long-stay residents with pressure ulcers	6.2%	4.6% 1.6 pts worse	5.1% 1.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 4.9% · Q3 9.9% · Q4 5.8% · 4Q avg 6.2% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	95.1%	77.1% 18 pts better	81.7% 13.4 pts better	Short Stay · 2024Q4-2025Q3 · Q1 92.3% · Q2 97.2% · Q3 96.9% · Q4 94.3% · 4Q avg 95.1%
Percentage of short-stay residents who had an outpatient emergency department visit	13.6%	11.8% 1.8 pts worse	12.0% 1.6 pts worse	Short Stay · 20240701-20250630 · Adjusted 13.6% · Observed 14.8% · Expected 12.1% · 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 0.0% · Q2 0.9% · Q3 1.8% · 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	92.5%	77.7% 14.8 pts better	79.7% 12.8 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 92.5%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	26.5%	25.8% 0.7 pts worse	23.9% 2.6 pts worse	Short Stay · 20240701-20250630 · Adjusted 26.5% · Observed 29.6% · Expected 26.7% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-08-20 · Fire 2025-08-20

0 health deficiencies

No concentrated health issue counts in this cycle.

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 2 Health 2024-07-26 · Fire 2024-07-26

6 health deficiencies

Top issue: Resident Assessment and Care Planning (2 deficiencies)

10 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Cycle 3 Health 2023-05-12 · Fire 2023-05-12

17 health deficiencies

Top issue: Quality of Life and Care (5 deficiencies)

1 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2024-07-26

E20 · Emergency Preparedness Deficiencies

Fire Safety

Establish policies and procedures including evacuation.

Corrected 2024-09-20

E · Potential for more than minimal harm 2024-07-26

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 2024-09-20

E · Potential for more than minimal harm 2024-07-26

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-09-20

E · Potential for more than minimal harm 2024-07-26

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2024-09-20

E · Potential for more than minimal harm 2024-07-26

K711 · Miscellaneous Deficiencies

Fire Safety

Provide a written emergency evacuation plan.

Corrected 2024-09-20

E · Potential for more than minimal harm 2024-07-26

K911 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Meet requirements for the installation and maintenance of electrical systems.

Corrected 2024-09-20

D · Potential for more than minimal harm 2024-07-26

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2024-09-20

D · Potential for more than minimal harm 2024-07-26

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2024-09-20

D · Potential for more than minimal harm 2024-07-26

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2024-09-20

D · Potential for more than minimal harm 2024-07-26

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-09-20

F · Potential for more than minimal harm 2023-05-12

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2023-06-23

Inspection history

Recent health citations

G · Actual harm 2025-02-18

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2025-02-17

E · Potential for more than minimal harm 2024-07-26

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2024-08-07

E · Potential for more than minimal harm 2024-07-26

F698 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Corrected 2024-08-07

E · Potential for more than minimal harm 2024-07-26

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2024-08-07

E · Potential for more than minimal harm 2024-07-26

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-08-07

D · Potential for more than minimal harm 2024-07-26

F578 · Resident Rights Deficiencies

Health

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Corrected 2024-08-07

F · Potential for more than minimal harm 2023-05-12

F865 · Administration Deficiencies

Health

Have a plan that describes the process for conducting QAPI and QAA activities.

Corrected 2023-06-12

F · Potential for more than minimal harm 2023-05-12

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-06-12

E · Potential for more than minimal harm 2023-05-12

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 2023-06-12

E · Potential for more than minimal harm 2023-05-12