Cycle 1
Health 2025-07-25 · Fire 2025-07-25
0 health deficiencies
No concentrated health issue counts in this cycle.
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Lowell, MA
D'youville Care For Advanced Therapy
5-star overall rating with 5-star inspections with 7 fire-safety deficiencies in the latest cycle
1071 Varnum Avenue, Lowell, MA
(978) 569-1071
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
33
Certified beds
Average residents
28
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Carmelite Sisters For The Aged And Infirmed
Operator or chain grouping
Approved since
2012-03-29
CMS approved date
Coverage
Medicare
Participation flags
Chain footprint
3 facilities
Chain averages 4 overall / 4 health / 4 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
No
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
2.02
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.47
Nurse aide staffing · state 2.26 · national 2.35
Total nurse hours
5.30
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
2.83
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
4.95
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.61
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.19
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.66
CMS adjusted RN staffing hours
Adjusted total hours
4.31
CMS adjusted total nurse staffing hours
Case-mix index
1.68
Higher values indicate more complex resident acuity
RN turnover
62%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
52%
Annual nurse turnover · state 40% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,041
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
41.56
Composite VBP score used to determine payment impact.
Payment multiplier
0.9945
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.89
Baseline 22.91% · Performance 21.50% · Measure score 1.89 · Achievement 0 · Improvement 1.89
Healthcare-associated infections
6.69
Baseline 4.72% · Performance 5.84% · Measure score 6.69 · Achievement 6.69 · Improvement 0
Total nurse turnover
1.53
Performance 57.41% · Measure score 1.53 · Achievement 1.53 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
6.51
Performance 4.93 hours · Measure score 6.51 · Achievement 6.51 · This facility did not have sufficient data to calculate a baseline period measure result.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.28% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 513 · Observed rate 8.97% · Lower 95% interval 7.94% |
| Discharge to community | 66.63% |
50.57%
16.1 pts better
|
Better than the National Rate · Eligible stays 537 · Observed rate 67.97% · Lower 95% interval 63.1% |
| Medicare spending per beneficiary | 0.69 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 98.89% |
95.27%
3.6 pts better
|
Numerator 357 · Denominator 361 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 361 |
| Discharge self-care score | 61.51% |
53.69%
7.8 pts better
|
Numerator 187 · Denominator 304 |
| Discharge mobility score | 55.92% |
50.94%
5 pts better
|
Numerator 170 · Denominator 304 |
| Pressure ulcers or injuries, new or worsened | 1.39% |
2.29%
0.9 pts better
|
Numerator 5 · Denominator 361 · Adjusted rate 2.04% |
| Healthcare-associated infections requiring hospitalization | 5.84% |
7.12%
1.3 pts better
|
No Different than the National Rate · Eligible stays 260 · Observed rate 3.85% · Lower 95% interval 3.51% |
| Staff COVID-19 vaccination coverage | 8.5% |
8.2%
0.3 pts better
|
Numerator 13 · Denominator 153 |
| Staff flu vaccination coverage | 76.79% |
42%
34.8 pts better
|
Numerator 86 · Denominator 112 |
| Discharge function score | 54.61% |
56.45%
1.8 pts worse
|
Numerator 166 · Denominator 304 |
| Transfer of health information to provider | 97.65% |
95.95%
1.7 pts better
|
Numerator 83 · Denominator 85 |
| Transfer of health information to patient | 99.26% |
96.28%
3 pts better
|
Numerator 269 · Denominator 271 |
| Resident COVID-19 vaccinations up to date | 27.51% |
25.2%
2.3 pts better
|
Numerator 52 · Denominator 189 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.0% |
77.1%
21.9 pts better
|
81.7%
17.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.4% · Q2 99.3% · Q3 99.3% · Q4 98.9% · 4Q avg 99.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.8% |
11.8%
3 pts better
|
12.0%
3.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.8% · Observed 7.6% · Expected 9.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.3%
0.9 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.5% · Q4 1.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.0% |
77.7%
18.3 pts better
|
79.7%
16.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 31.7% |
25.8%
5.9 pts worse
|
23.9%
7.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 31.7% · Observed 27.0% · Expected 20.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-21 · Fire 2024-08-21
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
13 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2023-08-23 · Fire 2023-08-23
3 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-07-25
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2025-09-15
F · Potential for more than minimal harm
2025-07-25
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2025-09-15
F · Potential for more than minimal harm
2025-07-25
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-09-15
F · Potential for more than minimal harm
2025-07-25
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-09-15
F · Potential for more than minimal harm
2025-07-25
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-09-15
F · Potential for more than minimal harm
2025-07-25
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-09-15
E · Potential for more than minimal harm
2025-07-25
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-09-15
E · Potential for more than minimal harm
2024-08-21
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2024-10-11
E · Potential for more than minimal harm
2024-08-21
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-11-14
E · Potential for more than minimal harm
2024-08-21
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2024-10-30
E · Potential for more than minimal harm
2024-08-21
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-10-30
D · Potential for more than minimal harm
2024-08-21
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2024-10-18
D · Potential for more than minimal harm
2024-08-21
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2024-10-18
D · Potential for more than minimal harm
2024-08-21
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-10-18
D · Potential for more than minimal harm
2024-08-21
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-10-18
D · Potential for more than minimal harm
2024-08-21
K344 · Smoke Deficiencies
Fire Safety
Have an alternate power supply for its alarm system.
Corrected 2024-10-30
D · Potential for more than minimal harm
2024-08-21
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-10-18
D · Potential for more than minimal harm
2024-08-21
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-10-18
D · Potential for more than minimal harm
2024-08-21
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-10-18
D · Potential for more than minimal harm
2024-08-21
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-10-18
E · Potential for more than minimal harm
2023-08-23
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-10-16
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-04-09
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 2024-05-23
D · Potential for more than minimal harm
2024-04-09
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 2024-05-23
D · Potential for more than minimal harm
2023-10-16
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2023-11-23
D · Potential for more than minimal harm
2023-08-23
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-09-20
D · Potential for more than minimal harm
2023-08-23
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-09-20
Penalties and ownership
What sits behind the stars
Ownership
Altenweg, Mark
Operational/Managerial Control · Individual
Altenweg, Mark
Corporate Officer · Individual
Altenweg, Mark
W-2 Managing Employee · Individual
Archambault, Jeanne
Operational/Managerial Control · Individual
Bresnick, Louis
Operational/Managerial Control · Individual
Brown, Thomas
Operational/Managerial Control · Individual
Carmelite Sisters For The Aged And Infirm, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Cochran, Mark
Operational/Managerial Control · Individual
D'youville Leadership Solutions, Inc
Operational/Managerial Control · Organization
Frechette, Gerard
Operational/Managerial Control · Individual
Gori, Peter
Operational/Managerial Control · Individual
Heery, Mary
Corporate Director · Individual
Hoey, Amy
Operational/Managerial Control · Individual
Howard, Carol
Operational/Managerial Control · Individual
Knight, Margaret
Operational/Managerial Control · Individual
Larochelle, Steven
Operational/Managerial Control · Individual
Leblanc, Pauline
Operational/Managerial Control · Individual
Malo, Prescille
Operational/Managerial Control · Individual
Prendergast, Naomi
Operational/Managerial Control · Individual
Prendergast, Naomi
Corporate Officer · Individual
Prendergast, Naomi
W-2 Managing Employee · Individual
Ramirez, Judith
Operational/Managerial Control · Individual
Rawdon, Patricia
Corporate Director · Individual
Sutcliffe, Arthur
Operational/Managerial Control · Individual
The Carmelite System Inc
5% Or Greater Indirect Ownership Interest · Organization
Young, Robert
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Northwood Rehabilitation & Healthcare Center
Lowell, MA
1-star overall rating with 1-star inspections with $165,780 in total fines with 22 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
#2
D'Youville Senior Care
Lowell, MA
2-star overall rating with 2-star inspections with $10,517 in total fines with 13 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
Fairhaven Healthcare Center
Lowell, MA
2-star overall rating with 2-star inspections with $15,030 in total fines with 13 recent health deficiencies with 23 fire-safety deficiencies in the latest cycle
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