Cycle 1
Health 2024-09-12 · Fire 2024-09-12
35 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
20 fire-safety deficiencies
Top issue: Emergency Preparedness (10 deficiencies)
Newburyport, MA
Brigham Health And Rehabilitation Center
1-star overall rating with 1-star inspections with $152,988 in total fines with 35 recent health deficiencies with 20 fire-safety deficiencies in the latest cycle
77 High Street, Newburyport, MA
(978) 462-4221
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
64
Certified beds
Average residents
43
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Alpha SNF Ma
Operator or chain grouping
Approved since
1992-02-24
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
5 facilities
Chain averages 2 overall / 1 health / 2 staffing / 3 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
0.55
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
0.72
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.11
Nurse aide staffing · state 2.26 · national 2.35
Total nurse hours
3.38
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.27
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.23
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.51
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.59
CMS adjusted RN staffing hours
Adjusted total hours
3.63
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
13,726
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
0
Composite VBP score used to determine payment impact.
Payment multiplier
0.9803
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.29% · Performance 21.83% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 5.91% · Performance 7.90% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0
Baseline 37.74% · Performance 77.19% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
0
Baseline 4.02 hours · Performance 2.82 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.39% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 134 · Observed rate 8.96% · Lower 95% interval 6.84% |
| Discharge to community | 54.44% |
50.57%
3.9 pts better
|
No Different than the National Rate · Eligible stays 105 · Observed rate 48.57% · Lower 95% interval 45.23% |
| Medicare spending per beneficiary | 0.99 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 66 · Denominator 66 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 66 |
| Discharge self-care score | 57.14% |
53.69%
3.5 pts better
|
Numerator 20 · Denominator 35 |
| Discharge mobility score | 62.86% |
50.94%
11.9 pts better
|
Numerator 22 · Denominator 35 |
| Pressure ulcers or injuries, new or worsened | 1.52% |
2.29%
0.8 pts better
|
Numerator 1 · Denominator 66 · Adjusted rate 1.77% |
| Healthcare-associated infections requiring hospitalization | 7.9% |
7.12%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 84 · Observed rate 8.33% · Lower 95% interval 4.52% |
| Staff COVID-19 vaccination coverage | 20.29% |
8.2%
12.1 pts better
|
Numerator 14 · Denominator 69 |
| Staff flu vaccination coverage | 43.64% |
42%
1.6 pts better
|
Numerator 24 · Denominator 55 |
| Discharge function score | 60% |
56.45%
3.5 pts better
|
Numerator 21 · Denominator 35 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 25 · Denominator 25 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 25% |
25.2%
0.2 pts worse
|
Numerator 7 · Denominator 28 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.5 |
1.9
1.6 pts worse
|
1.9
1.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.5 · Observed 3.0 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.3 |
1.5
0.8 pts worse
|
1.8
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.0 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.6% |
92.2%
4.4 pts better
|
93.4%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.3% · Q2 90.9% · Q3 97.1% · Q4 100.0% · 4Q avg 96.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 87.2% |
94.8%
7.6 pts worse
|
95.5%
8.3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 87.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.8% |
3.5%
1.3 pts worse
|
3.3%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 3.0% · Q3 2.9% · Q4 7.0% · 4Q avg 4.8% · 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 | 2.3% |
5.2%
2.9 pts better
|
5.4%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 0.0% · Q3 3.1% · Q4 2.6% · 4Q avg 2.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 26.7% |
19.2%
7.5 pts worse
|
19.6%
7.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.3% · Q2 29.0% · Q3 28.1% · Q4 20.5% · 4Q avg 26.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 25.8% |
22.5%
3.3 pts worse
|
16.7%
9.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.6% · Q3 25.0% · Q4 23.1% · 4Q avg 25.8% · 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 | 28.8% |
17.7%
11.1 pts worse
|
16.3%
12.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 28.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 28.7% |
17.6%
11.1 pts worse
|
14.9%
13.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.0% · Q2 21.4% · Q3 27.6% · Q4 35.3% · 4Q avg 28.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 4.5% |
1.0%
3.5 pts worse
|
1.0%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 2.7% · Q3 9.7% · Q4 3.5% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.4% |
2.0%
0.6 pts better
|
1.7%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.9% · Q4 2.4% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.1% |
21.7%
6.4 pts worse
|
19.8%
8.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.3% · Q2 19.3% · Q3 18.3% · Q4 43.8% · 4Q avg 28.1% |
| Percentage of long-stay residents with pressure ulcers | 5.5% |
4.6%
0.9 pts worse
|
5.1%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 6.9% · Q3 2.8% · Q4 6.7% · 4Q avg 5.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 76.9% |
77.1%
0.2 pts worse
|
81.7%
4.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 60.6% · Q2 77.5% · Q3 87.9% · 4Q avg 76.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.1% |
11.8%
4.3 pts worse
|
12.0%
4.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.1% · Observed 16.9% · Expected 11.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.3% |
1.3%
About the same
|
1.6%
0.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 5.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 30.8% |
77.7%
46.9 pts worse
|
79.7%
48.9 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 30.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 32.8% |
25.8%
7 pts worse
|
23.9%
8.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 32.8% · Observed 35.6% · Expected 25.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-05 · Fire 2023-09-05
21 health deficiencies
Top issue: Resident Assessment and Care Planning (6 deficiencies)
6 fire-safety deficiencies
Top issue: Egress (4 deficiencies)
Cycle 3
Health 2022-08-04 · Fire 2022-08-04
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
10 fire-safety deficiencies
Top issue: Egress (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-09-12
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2024-11-11
F · Potential for more than minimal harm
2024-09-12
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2024-11-11
F · Potential for more than minimal harm
2024-09-12
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2024-11-11
F · Potential for more than minimal harm
2024-09-12
E25 · Emergency Preparedness Deficiencies
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2024-11-11
F · Potential for more than minimal harm
2024-09-12
E33 · Emergency Preparedness Deficiencies
Fire Safety
Establish methods for sharing information.
Corrected 2024-11-11
F · Potential for more than minimal harm
2024-09-12
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2024-11-11
F · Potential for more than minimal harm
2024-09-12
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-11-11
F · Potential for more than minimal harm
2024-09-12
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-11-11
F · Potential for more than minimal harm
2024-09-12
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-11-11
F · Potential for more than minimal harm
2024-09-12
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-09-12
F · Potential for more than minimal harm
2024-09-12
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-12-02
F · Potential for more than minimal harm
2024-09-12
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-12-02
F · Potential for more than minimal harm
2024-09-12
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2024-12-02
F · Potential for more than minimal harm
2024-09-12
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2024-12-02
F · Potential for more than minimal harm
2024-09-12
K254 · Egress Deficiencies
Fire Safety
Provide hallway or ground-level exits in all residents' rooms.
Corrected 2024-12-02
F · Potential for more than minimal harm
2024-09-12
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2024-12-02
F · Potential for more than minimal harm
2024-09-12
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-11-11
F · Potential for more than minimal harm
2024-09-12
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-11-11
F · Potential for more than minimal harm
2024-09-12
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-11-11
F · Potential for more than minimal harm
2024-09-12
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-11-11
F · Potential for more than minimal harm
2023-09-05
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2023-10-10
F · Potential for more than minimal harm
2023-09-05
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-10-10
F · Potential for more than minimal harm
2023-09-05
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2023-10-10
F · Potential for more than minimal harm
2023-09-05
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2023-10-10
F · Potential for more than minimal harm
2023-09-05
K254 · Egress Deficiencies
Fire Safety
Provide hallway or ground-level exits in all residents' rooms.
Corrected 2023-10-10
F · Potential for more than minimal harm
2023-09-05
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2023-10-10
F · Potential for more than minimal harm
2022-08-04
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2022-10-13
F · Potential for more than minimal harm
2022-08-04
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2022-09-06
F · Potential for more than minimal harm
2022-08-04
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-09-06
F · Potential for more than minimal harm
2022-08-04
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2022-09-06
F · Potential for more than minimal harm
2022-08-04
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2022-09-06
F · Potential for more than minimal harm
2022-08-04
K254 · Egress Deficiencies
Fire Safety
Provide hallway or ground-level exits in all residents' rooms.
Corrected 2022-09-06
F · Potential for more than minimal harm
2022-08-04
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2022-09-06
F · Potential for more than minimal harm
2022-08-04
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-10-13
F · Potential for more than minimal harm
2022-08-04
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-10-13
F · Potential for more than minimal harm
2022-08-04
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-10-13
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-11-05
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 2024-11-29
D · Potential for more than minimal harm
2024-11-05
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-11-29
F · Potential for more than minimal harm
2024-09-12
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2024-10-24
E · Potential for more than minimal harm
2024-09-12
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 2024-10-24
E · Potential for more than minimal harm
2024-09-12
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 2024-10-24
E · Potential for more than minimal harm
2024-09-12
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-10-24
E · Potential for more than minimal harm
2024-09-12
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 2024-10-24
E · Potential for more than minimal harm
2024-09-12
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 2024-10-24
E · Potential for more than minimal harm
2024-09-12
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 2024-10-24
E · Potential for more than minimal harm
2024-09-12
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 2024-10-24
E · Potential for more than minimal harm
2024-09-12
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2024-10-24
E · Potential for more than minimal harm
2024-09-12
F802 · Nutrition and Dietary Deficiencies
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2024-10-24
E · Potential for more than minimal harm
2024-09-12
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2024-10-24
E · Potential for more than minimal harm
2024-09-12
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2024-10-24
E · Potential for more than minimal harm
2024-09-12
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 2024-10-24
E · Potential for more than minimal harm
2024-09-12
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 2024-10-24
D · Potential for more than minimal harm
2024-09-12
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 2024-10-24
D · Potential for more than minimal harm
2024-09-12
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 2024-10-24
D · Potential for more than minimal harm
2024-09-12
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2024-10-24
D · Potential for more than minimal harm
2024-09-12
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-10-24
D · Potential for more than minimal harm
2024-09-12
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-10-24
D · Potential for more than minimal harm
2024-09-12
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 2024-10-24
D · Potential for more than minimal harm
2024-09-12
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-10-24
D · Potential for more than minimal harm
2024-09-12
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 2024-10-24
D · Potential for more than minimal harm
2024-09-12
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 2024-10-24
D · Potential for more than minimal harm
2024-09-12
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-10-24
D · Potential for more than minimal harm
2024-09-12
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 2024-10-24
D · Potential for more than minimal harm
2024-09-12
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-10-24
D · Potential for more than minimal harm
2024-09-12
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-10-24
D · Potential for more than minimal harm
2024-09-12
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 2024-10-24
D · Potential for more than minimal harm
2024-09-12
F808 · Nutrition and Dietary Deficiencies
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2024-10-24
D · Potential for more than minimal harm
2024-09-12
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2024-10-24
C · Minimal harm
2024-09-12
F844 · Administration Deficiencies
Health
Follow rules about disclosure of ownership requirements and tell the state agency about changes in ownership and/or administrative personnel.
Corrected 2024-10-24
B · Minimal harm
2024-09-12
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-10-24
B · Minimal harm
2024-09-12
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 2024-10-24
B · Minimal harm
2024-09-12
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-10-24
B · Minimal harm
2024-09-12
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-10-24
E · Potential for more than minimal harm
2024-09-03
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2024-09-25
E · Potential for more than minimal harm
2024-09-03
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-09-25
D · Potential for more than minimal harm
2024-09-03
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 2024-09-25
D · Potential for more than minimal harm
2024-07-17
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 2024-08-16
D · Potential for more than minimal harm
2024-03-26
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2024-05-01
D · Potential for more than minimal harm
2024-03-26
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 2024-05-01
F · Potential for more than minimal harm
2024-02-01
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 2024-03-13
J · Immediate jeopardy
2023-09-05
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 2023-09-13
J · Immediate jeopardy
2023-09-05
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 2023-09-13
E · Potential for more than minimal harm
2023-09-05
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 2023-09-13
E · Potential for more than minimal harm
2023-09-05
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 2023-09-13
E · Potential for more than minimal harm
2023-09-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-13
D · Potential for more than minimal harm
2023-09-05
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 2023-09-13
D · Potential for more than minimal harm
2023-09-05
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-09-13
D · Potential for more than minimal harm
2023-09-05
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 2023-09-13
D · Potential for more than minimal harm
2023-09-05
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2023-09-13
D · Potential for more than minimal harm
2023-09-05
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-09-13
D · Potential for more than minimal harm
2023-09-05
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-09-13
D · Potential for more than minimal harm
2023-09-05
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 2023-09-13
B · Minimal harm
2023-09-05
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-09-13
E · Potential for more than minimal harm
2022-08-04
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 2022-09-15
Penalties and ownership
What sits behind the stars
$152,988
2023-08-22
Fine
Fine · fine $152,988
Fine
$0
2023-08-22
Payment Denial
Payment Denial · denial start 2023-12-05 · 148 days
148 day denial
Ownership
Alpha SNF Ma LLC
5% Or Greater Direct Ownership Interest · Organization
Segal, William
5% Or Greater Indirect Ownership Interest · Individual
Das Munshi, Uma
W-2 Managing Employee · Individual
Segal, William
General Partnership Interest · Individual
Segal, William
Operational/Managerial Control · Individual
Segal, William
Corporate Officer · Individual
Nearby options
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3-star overall rating with 3-star inspections with 8 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Adviniacare Newburyport
Newburyport, MA
3-star overall rating with 3-star inspections with $322,104 in total fines with 4 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Maplewood Center
Amesbury, MA
1-star overall rating with 1-star inspections with Special Focus status with $226,445 in total fines with 29 recent health deficiencies with 15 fire-safety deficiencies in the latest cycle
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