Cycle 1
Health 2024-12-23 · Fire 2024-12-23
11 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Peabody, MA
Continuing Care At Brooksby Village
3-star overall rating with 2-star inspections with $167,099 in total fines with 11 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
400 Brooksby Village Drive, Peabody, MA
(978) 536-7939
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
104
Certified beds
Average residents
57
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Erickson Senior Living
Operator or chain grouping
Approved since
2004-03-05
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
17 facilities
Chain averages 4 overall / 3 health / 5 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
1.43
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
0.76
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.88
Nurse aide staffing · state 2.26 · national 2.35
Total nurse hours
5.07
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
2.19
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
4.56
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.62
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
1.52
CMS adjusted RN staffing hours
Adjusted total hours
5.36
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
55%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
46%
Annual nurse turnover · state 40% · national 46%
SNF VBP
Value-based purchasing
Program rank
696
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
65.19
Composite VBP score used to determine payment impact.
Payment multiplier
1.0195
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.19
Baseline 17.15% · Performance 19.03% · Measure score 5.19 · Achievement 5.19 · Improvement 0
Healthcare-associated infections
10
Baseline 4.80% · Performance 4.21% · Measure score 10 · Achievement 10 · Improvement 9
Total nurse turnover
3.76
Baseline 33.33% · Performance 48.32% · Measure score 3.76 · Achievement 3.76 · Improvement 0
Adjusted total nurse staffing
7.13
Baseline 4.42 hours · Performance 5.11 hours · Measure score 7.13 · Achievement 7.13 · Improvement 4.53
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.72% |
10.72%
1 pts worse
|
No Different than the National Rate · Eligible stays 387 · Observed rate 10.59% · Lower 95% interval 8.96% |
| Discharge to community | 64.28% |
50.57%
13.7 pts better
|
Better than the National Rate · Eligible stays 362 · Observed rate 59.67% · Lower 95% interval 58.95% |
| Medicare spending per beneficiary | 0.69 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 200 · Denominator 200 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 200 |
| Discharge self-care score | 58.29% |
53.69%
4.6 pts better
|
Numerator 102 · Denominator 175 |
| Discharge mobility score | 41.14% |
50.94%
9.8 pts worse
|
Numerator 72 · Denominator 175 |
| Pressure ulcers or injuries, new or worsened | 1.5% |
2.29%
0.8 pts better
|
Numerator 3 · Denominator 200 · Adjusted rate 1.78% |
| Healthcare-associated infections requiring hospitalization | 4.21% |
7.12%
2.9 pts better
|
Better than the National Rate · Eligible stays 216 · Observed rate 0.93% · Lower 95% interval 2.28% |
| Staff COVID-19 vaccination coverage | 19.34% |
8.2%
11.1 pts better
|
Numerator 47 · Denominator 243 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 73.71% |
56.45%
17.3 pts better
|
Numerator 129 · Denominator 175 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 26 · Denominator 26 |
| Transfer of health information to patient | 99.17% |
96.28%
2.9 pts better
|
Numerator 119 · Denominator 120 |
| Resident COVID-19 vaccinations up to date | 45.45% |
25.2%
20.3 pts better
|
Numerator 40 · Denominator 88 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
1.9
0.5 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.1 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.6 |
1.5
0.9 pts better
|
1.8
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.5 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 78.0% |
92.2%
14.2 pts worse
|
93.4%
15.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 90.0% · Q2 80.0% · Q3 70.7% · Q4 72.3% · 4Q avg 78.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 88.4% |
94.8%
6.4 pts worse
|
95.5%
7.1 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 88.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.6% |
3.5%
0.1 pts worse
|
3.3%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 5.0% · Q3 4.9% · Q4 2.1% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.5% |
12.0%
8.5 pts better
|
11.4%
7.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q3 3.1% · Q4 7.0% · 4Q avg 3.5% |
| Percentage of long-stay residents who lose too much weight | 5.2% |
5.2%
About the same
|
5.4%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 5.0% · Q3 7.7% · Q4 3.4% · 4Q avg 5.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.0% |
19.2%
2.2 pts better
|
19.6%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.7% · Q2 22.7% · Q3 15.4% · Q4 10.3% · 4Q avg 17.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 39.1% |
22.5%
16.6 pts worse
|
16.7%
22.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 39.1% · 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 | 33.4% |
17.7%
15.7 pts worse
|
16.3%
17.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 33.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 29.0% |
17.6%
11.4 pts worse
|
14.9%
14.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.4% · Q2 19.0% · Q3 25.0% · Q4 34.6% · 4Q avg 29.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
1.0%
0.6 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.3% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.0% |
2.0%
1 pts worse
|
1.7%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 4.9% · Q4 6.4% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 34.0% |
21.7%
12.3 pts worse
|
19.8%
14.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 44.3% · Q2 31.8% · Q3 26.1% · Q4 34.2% · 4Q avg 34.0% |
| Percentage of long-stay residents with pressure ulcers | 8.4% |
4.6%
3.8 pts worse
|
5.1%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 4.3% · Q3 8.7% · Q4 11.7% · 4Q avg 8.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 53.9% |
77.1%
23.2 pts worse
|
81.7%
27.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 71.1% · Q2 57.3% · Q3 48.4% · Q4 32.6% · 4Q avg 53.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.6% |
11.8%
3.2 pts better
|
12.0%
3.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.6% · Observed 7.7% · Expected 10.0% · 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 2.4% · Q2 1.2% · Q3 0.0% · Q4 1.7% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 86.0% |
77.7%
8.3 pts better
|
79.7%
6.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 86.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.4% |
25.8%
1.4 pts better
|
23.9%
0.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.4% · Observed 19.2% · Expected 18.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-06 · Fire 2023-12-06
1 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-11-17 · Fire 2022-11-17
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-12-23
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2025-02-16
F · Potential for more than minimal harm
2024-12-23
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 2025-02-16
F · Potential for more than minimal harm
2024-12-23
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-02-16
F · Potential for more than minimal harm
2024-12-23
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-02-16
E · Potential for more than minimal harm
2024-12-23
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2025-02-16
E · Potential for more than minimal harm
2024-12-23
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-02-16
E · Potential for more than minimal harm
2024-12-23
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-02-16
D · Potential for more than minimal harm
2024-12-23
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-02-16
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-06-18
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2025-08-08
D · Potential for more than minimal harm
2025-01-07
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-02-14
H · Actual harm
2024-12-23
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-02-02
F · Potential for more than minimal harm
2024-12-23
F944 · Administration Deficiencies
Health
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Corrected 2025-02-02
E · Potential for more than minimal harm
2024-12-23
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 2025-02-02
E · Potential for more than minimal harm
2024-12-23
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-02-02
E · Potential for more than minimal harm
2024-12-23
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 2025-02-02
E · Potential for more than minimal harm
2024-12-23
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 2025-02-02
D · Potential for more than minimal harm
2024-12-23
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 2025-02-02
D · Potential for more than minimal harm
2024-12-23
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 2025-02-02
D · Potential for more than minimal harm
2024-12-23
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-02-02
D · Potential for more than minimal harm
2024-12-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-02
Penalties and ownership
What sits behind the stars
$167,099
2024-12-23
Fine
Fine · fine $167,099
Fine
Ownership
National Senior Communities, Inc
5% Or Greater Direct Ownership Interest · Organization
Arnold, Courtney
Operational/Managerial Control · Individual
Brown, Ian
Corporate Director · Individual
Brown, Patricia
Corporate Director · Individual
Butler, Richard
Operational/Managerial Control · Individual
Clupper, Katherine
Corporate Director · Individual
Colins, Mary
Corporate Director · Individual
Colins, Mary
Corporate Officer · Individual
Embley, Mark
Operational/Managerial Control · Individual
Embley, Mark
Corporate Officer · Individual
Erickson Senior Living LLC
Operational/Managerial Control · Organization
Erstad, Eileen
Corporate Director · Individual
Erstad, Eileen
Corporate Officer · Individual
Gantert, Neal
Operational/Managerial Control · Individual
Gantert, Neal
Corporate Officer · Individual
Hall, John
Operational/Managerial Control · Individual
Hall, John
Corporate Officer · Individual
Jacque, Zina
Corporate Director · Individual
Leonard, Monty
Corporate Director · Individual
Moscato, Mary
Corporate Director · Individual
Moscato, Mary
Corporate Officer · Individual
National Senior Communities, Inc
Operational/Managerial Control · Organization
Paulk, Pamela
Corporate Director · Individual
Pomeranz, William
Corporate Director · Individual
Reel, Stephanie
Corporate Director · Individual
Reizun, Catherine
Operational/Managerial Control · Individual
Roskiewicz, Michael
Corporate Director · Individual
Sawicki, Scott
Corporate Officer · Individual
Sharp, Russel
Corporate Director · Individual
Stiner, Pamela
Operational/Managerial Control · Individual
Stiner, Pamela
Corporate Officer · Individual
Sweetser, Christian
Operational/Managerial Control · Individual
Tyler, Daniel
Corporate Officer · Individual
Wallick, Daniel
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Alliance Health At Rosewood
Peabody, MA
3-star overall rating with 3-star inspections with $8,824 in total fines with 9 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Care One At Peabody
Peabody, MA
4-star overall rating with 4-star inspections with 4 recent health deficiencies
#3
Pilgrim Rehabilitation & Skilled Nursing Center
Peabody, MA
4-star overall rating with 4-star inspections with 6 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
Jump out