Cycle 1
Health 2025-04-11 · Fire 2025-04-11
13 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Lowell, MA
D'Youville Senior Care
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
981 Varnum Avenue, Lowell, MA
(978) 458-4083
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
208
Certified beds
Average residents
201
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1990-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.27
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.32
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.16
Nurse aide staffing · state 2.26 · national 2.35
Total nurse hours
3.76
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.59
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.52
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.19
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.27
CMS adjusted RN staffing hours
Adjusted total hours
3.81
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
37%
Annual nurse turnover · state 40% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,614
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
26.20
Composite VBP score used to determine payment impact.
Payment multiplier
0.9841
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 24.18% · Performance 23.97% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
4.33
Baseline 5.63% · Performance 6.54% · Measure score 4.33 · Achievement 4.33 · Improvement 0
Total nurse turnover
2.74
Baseline 48.33% · Performance 52.47% · Measure score 2.74 · Achievement 2.74 · Improvement 0
Adjusted total nurse staffing
3.41
Baseline 3.99 hours · Performance 4.05 hours · Measure score 3.41 · Achievement 3.41 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.15% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 299 · Observed rate 9.36% · Lower 95% interval 7.63% |
| Discharge to community | 53.46% |
50.57%
2.9 pts better
|
No Different than the National Rate · Eligible stays 253 · Observed rate 49.01% · Lower 95% interval 47.52% |
| Medicare spending per beneficiary | 0.64 |
1.02
0.4 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 157 · Denominator 157 |
| Falls with major injury | 0.64% |
0.77%
0.1 pts better
|
Numerator 1 · Denominator 157 |
| Discharge self-care score | 50% |
53.69%
3.7 pts worse
|
Numerator 53 · Denominator 106 |
| Discharge mobility score | 48.11% |
50.94%
2.8 pts worse
|
Numerator 51 · Denominator 106 |
| Pressure ulcers or injuries, new or worsened | 1.27% |
2.29%
1 pts better
|
Numerator 2 · Denominator 157 · Adjusted rate 1.22% |
| Healthcare-associated infections requiring hospitalization | 6.54% |
7.12%
0.6 pts better
|
No Different than the National Rate · Eligible stays 189 · Observed rate 4.76% · Lower 95% interval 4.04% |
| Staff COVID-19 vaccination coverage | 5.72% |
8.2%
2.5 pts worse
|
Numerator 17 · Denominator 297 |
| Staff flu vaccination coverage | 43.58% |
42%
1.6 pts better
|
Numerator 224 · Denominator 514 |
| Discharge function score | 50.94% |
56.45%
5.5 pts worse
|
Numerator 54 · Denominator 106 |
| Transfer of health information to provider | 97.14% |
95.95%
1.2 pts better
|
Numerator 34 · Denominator 35 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 64 · Denominator 64 |
| Resident COVID-19 vaccinations up to date | 22.22% |
25.2%
3 pts worse
|
Numerator 16 · Denominator 72 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
1.9
About the same
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.6 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.8 |
1.5
0.3 pts worse
|
1.8
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.7 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.5% |
92.2%
4.3 pts better
|
93.4%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.8% · Q2 96.8% · Q3 94.8% · Q4 96.8% · 4Q avg 96.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.0% |
94.8%
4.2 pts better
|
95.5%
3.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.1% |
3.5%
1.6 pts worse
|
3.3%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 5.9% · Q3 4.7% · Q4 2.6% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.0% |
12.0%
11 pts better
|
11.4%
10.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.3% · Q3 1.9% · Q4 0.6% · 4Q avg 1.0% |
| Percentage of long-stay residents who lose too much weight | 4.1% |
5.2%
1.1 pts better
|
5.4%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 5.0% · Q3 4.2% · Q4 1.3% · 4Q avg 4.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.4% |
19.2%
3.2 pts worse
|
19.6%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.6% · Q2 21.2% · Q3 24.7% · Q4 23.1% · 4Q avg 22.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 21.6% |
22.5%
0.9 pts better
|
16.7%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.8% · Q2 20.5% · Q3 26.5% · Q4 23.2% · 4Q avg 21.6% · 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 | 24.1% |
17.7%
6.4 pts worse
|
16.3%
7.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.2% · Q2 30.3% · Q3 22.2% · Q4 18.6% · 4Q avg 24.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.4% |
17.6%
3.2 pts better
|
14.9%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.6% · Q2 16.2% · Q3 12.3% · Q4 11.5% · 4Q avg 14.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
1.0%
0.1 pts better
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 0.8% · Q3 0.7% · Q4 0.4% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.2% |
2.0%
0.2 pts worse
|
1.7%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 3.9% · Q3 1.1% · Q4 0.5% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.2% |
21.7%
6.5 pts worse
|
19.8%
8.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.4% · Q2 25.0% · Q3 30.8% · Q4 23.7% · 4Q avg 28.2% |
| Percentage of long-stay residents with pressure ulcers | 7.0% |
4.6%
2.4 pts worse
|
5.1%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 6.9% · Q3 6.9% · Q4 6.5% · 4Q avg 7.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.3% |
77.1%
19.2 pts better
|
81.7%
14.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.1% · Q2 96.1% · Q3 97.8% · Q4 95.5% · 4Q avg 96.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.8% |
11.8%
4 pts worse
|
12.0%
3.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.8% · Observed 14.0% · Expected 9.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.5% |
1.3%
0.2 pts worse
|
1.6%
0.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 3.4% · Q3 1.2% · Q4 0.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.8% |
77.7%
17.1 pts better
|
79.7%
15.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 33.0% |
25.8%
7.2 pts worse
|
23.9%
9.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 33.0% · Observed 28.1% · Expected 20.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-31 · Fire 2024-05-31
10 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 2023-04-13 · Fire 2023-04-13
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-11
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2025-05-07
F · Potential for more than minimal harm
2025-04-11
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 2025-05-07
F · Potential for more than minimal harm
2025-04-11
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2025-05-07
F · Potential for more than minimal harm
2025-04-11
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-05-07
F · Potential for more than minimal harm
2025-04-11
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-05-07
F · Potential for more than minimal harm
2025-04-11
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-05-07
E · Potential for more than minimal harm
2025-04-11
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2025-05-07
D · Potential for more than minimal harm
2025-04-11
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-05-07
E · Potential for more than minimal harm
2023-04-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-06-06
D · Potential for more than minimal harm
2023-04-13
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-06-06
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-13
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 2026-02-27
D · Potential for more than minimal harm
2026-01-13
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2026-02-13
D · Potential for more than minimal harm
2026-01-13
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2026-02-13
D · Potential for more than minimal harm
2025-12-04
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2025-12-31
E · Potential for more than minimal harm
2025-04-11
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 2025-05-07
E · Potential for more than minimal harm
2025-04-11
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 2025-05-07
D · Potential for more than minimal harm
2025-04-11
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-04-11
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 2025-05-07
D · Potential for more than minimal harm
2025-04-11
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 2025-05-07
D · Potential for more than minimal harm
2025-04-11
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-05-07
D · Potential for more than minimal harm
2025-04-11
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 2025-05-07
D · Potential for more than minimal harm
2025-04-11
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 2025-05-07
D · Potential for more than minimal harm
2025-04-11
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 2025-05-07
D · Potential for more than minimal harm
2024-08-21
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
E · Potential for more than minimal harm
2024-05-31
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 2024-06-22
E · Potential for more than minimal harm
2024-05-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-22
D · Potential for more than minimal harm
2024-05-31
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 2024-06-22
D · Potential for more than minimal harm
2024-05-31
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-06-22
D · Potential for more than minimal harm
2024-05-31
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-06-22
D · Potential for more than minimal harm
2024-05-31
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2024-06-22
D · Potential for more than minimal harm
2024-05-31
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2024-06-22
D · Potential for more than minimal harm
2024-05-31
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 2024-06-22
D · Potential for more than minimal harm
2024-05-31
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2024-06-22
G · Actual harm
2023-04-13
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 2023-04-21
E · Potential for more than minimal harm
2023-04-13
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 2023-05-22
E · Potential for more than minimal harm
2023-04-13
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 2023-05-22
D · Potential for more than minimal harm
2023-04-13
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2023-05-22
D · Potential for more than minimal harm
2023-04-13
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 2023-05-22
D · Potential for more than minimal harm
2023-04-13
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-05-22
D · Potential for more than minimal harm
2023-04-13
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 2023-05-22
D · Potential for more than minimal harm
2023-04-13
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 2023-05-22
D · Potential for more than minimal harm
2023-04-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-05-22
Penalties and ownership
What sits behind the stars
$10,517
2023-04-13
Fine
Fine · fine $10,517
Fine
Ownership
Altenweg, Mark
Operational/Managerial Control · Individual
Altenweg, Mark
Corporate Director · 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
Clermont, Joaseph
Operational/Managerial Control · Individual
Cochran, Mark
Operational/Managerial Control · Individual
D'youville Leadership Solutions, Inc
Operational/Managerial Control · Organization
Ferrick, Michael
Operational/Managerial Control · Individual
Ferrick, Michael
W-2 Managing Employee · Individual
Frechette, Gerard
Operational/Managerial Control · Individual
Gori, Peter
Operational/Managerial Control · Individual
Harden, Diane
W-2 Managing Employee · 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
Linnehan, James
Operational/Managerial Control · Individual
Malo, Prescille
Operational/Managerial Control · Individual
Martin, William
Operational/Managerial Control · Individual
Prendergast, Naomi
Operational/Managerial Control · Individual
Prendergast, Naomi
Corporate Director · Individual
Prendergast, Naomi
Corporate Officer · Individual
Prendergast, Naomi
W-2 Managing Employee · Individual
Ramirez, Judith
Operational/Managerial Control · Individual
Sutcliffe, Arthur
Operational/Managerial Control · Individual
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 Care For Advanced Therapy
Lowell, MA
5-star overall rating with 5-star inspections with 7 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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