Cycle 1
Health 2025-07-30 · Fire 2025-07-30
3 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
9 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Marblehead, MA
Devereux Skilled Nursing & Rehabilitation Center
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
39 Lafayette Street, Marblehead, MA
(781) 631-6120
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
64
Certified beds
Average residents
52
Average occupied residents
Ownership
For-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
0.42
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
0.88
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.33
Nurse aide staffing · state 2.26 · national 2.35
Total nurse hours
3.63
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.30
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.25
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.36
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.44
CMS adjusted RN staffing hours
Adjusted total hours
3.80
CMS adjusted total nurse staffing hours
Case-mix index
1.31
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
1,899
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
53.15
Composite VBP score used to determine payment impact.
Payment multiplier
1.0078
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.48
Baseline 19.96% · Performance 19.82% · Measure score 3.48 · Achievement 3.48 · Improvement 0
Healthcare-associated infections
4.64
Baseline 7.11% · Performance 6.45% · Measure score 4.64 · Achievement 4.64 · Improvement 2.62
Total nurse turnover
10
Baseline 68.18% · Performance 23.08% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
3.14
Baseline 4.07 hours · Performance 3.97 hours · Measure score 3.14 · Achievement 3.14 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.43% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 57 · Observed rate 8.77% · Lower 95% interval 6.83% |
| Discharge to community | 42.73% |
50.57%
7.8 pts worse
|
No Different than the National Rate · Eligible stays 42 · Observed rate 33.33% · Lower 95% interval 31.84% |
| Medicare spending per beneficiary | 0.99 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 91.23% |
95.27%
4 pts worse
|
Numerator 52 · Denominator 57 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 57 |
| Discharge self-care score | 34.38% |
53.69%
19.3 pts worse
|
Numerator 11 · Denominator 32 |
| Discharge mobility score | 40.63% |
50.94%
10.3 pts worse
|
Numerator 13 · Denominator 32 |
| Pressure ulcers or injuries, new or worsened | 1.75% |
2.29%
0.5 pts better
|
Numerator 1 · Denominator 57 · Adjusted rate 1.65% |
| Healthcare-associated infections requiring hospitalization | 6.45% |
7.12%
0.7 pts better
|
No Different than the National Rate · Eligible stays 35 · Observed rate 2.86% · Lower 95% interval 2.89% |
| Staff COVID-19 vaccination coverage | 38.36% |
8.2%
30.2 pts better
|
Numerator 28 · Denominator 73 |
| Staff flu vaccination coverage | 48.19% |
42%
6.2 pts better
|
Numerator 40 · Denominator 83 |
| Discharge function score | 46.88% |
56.45%
9.6 pts worse
|
Numerator 15 · Denominator 32 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 16% |
25.2%
9.2 pts worse
|
Numerator 4 · Denominator 25 |
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 1.5 · Expected 1.7 · 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 1.6 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 69.0% |
92.2%
23.2 pts worse
|
93.4%
24.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 59.5% · Q2 64.0% · Q3 69.6% · Q4 81.6% · 4Q avg 69.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.8%
5.2 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.6% |
3.5%
1.9 pts better
|
3.3%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 2.0% · Q3 2.2% · Q4 0.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.6% |
12.0%
11.4 pts better
|
11.4%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% |
| Percentage of long-stay residents who lose too much weight | 5.3% |
5.2%
0.1 pts worse
|
5.4%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 10.6% · Q3 2.3% · Q4 2.3% · 4Q avg 5.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.3% |
19.2%
3.1 pts worse
|
19.6%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.7% · Q2 19.1% · Q3 25.0% · Q4 21.7% · 4Q avg 22.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 26.4% |
22.5%
3.9 pts worse
|
16.7%
9.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.9% · Q2 21.6% · Q3 25.7% · Q4 35.0% · 4Q avg 26.4% · 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 | 15.0% |
17.7%
2.7 pts better
|
16.3%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 18.9% · Q4 14.5% · 4Q avg 15.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.1% |
17.6%
2.5 pts better
|
14.9%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 20.0% · Q3 7.1% · Q4 16.3% · 4Q avg 15.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
1.0%
0.2 pts better
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 3.1% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.8% |
2.0%
1.8 pts worse
|
1.7%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 4.0% · Q3 6.5% · Q4 2.2% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 15.5% |
21.7%
6.2 pts better
|
19.8%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.8% · Q2 10.4% · Q3 28.3% · Q4 10.7% · 4Q avg 15.5% |
| 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 2.4% · Q2 7.8% · Q3 6.2% · Q4 4.8% · 4Q avg 5.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 78.0% |
77.1%
0.9 pts better
|
81.7%
3.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 63.4% · Q2 83.3% · Q3 88.0% · 4Q avg 78.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.6% |
11.8%
1.2 pts better
|
12.0%
1.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.6% · Observed 11.1% · Expected 11.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.7% |
1.3%
0.4 pts worse
|
1.6%
0.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.8% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 88.0% |
77.7%
10.3 pts better
|
79.7%
8.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 88.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.9% |
25.8%
5.9 pts better
|
23.9%
4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.9% · Observed 19.4% · Expected 23.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-21 · Fire 2024-08-21
7 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-08-23 · Fire 2023-08-23
9 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
1 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-07-30
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2025-09-08
F · Potential for more than minimal harm
2025-07-30
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-09-08
F · Potential for more than minimal harm
2025-07-30
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-09-08
F · Potential for more than minimal harm
2025-07-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-09-08
F · Potential for more than minimal harm
2025-07-30
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-09-08
F · Potential for more than minimal harm
2025-07-30
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-09-08
E · Potential for more than minimal harm
2025-07-30
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2025-09-08
E · Potential for more than minimal harm
2025-07-30
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2025-09-08
D · Potential for more than minimal harm
2025-07-30
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-09-08
F · Potential for more than minimal harm
2024-08-21
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-11-01
F · Potential for more than minimal harm
2024-08-21
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-10-14
F · Potential for more than minimal harm
2024-08-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-10-14
D · Potential for more than minimal harm
2024-08-21
K361 · Smoke Deficiencies
Fire Safety
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
Corrected 2024-10-15
D · Potential for more than minimal harm
2024-08-21
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-10-14
F · Potential for more than minimal harm
2023-08-23
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2023-09-14
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-07-30
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-08-25
D · Potential for more than minimal harm
2025-07-30
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2025-08-25
D · Potential for more than minimal harm
2025-07-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-25
E · Potential for more than minimal harm
2024-08-21
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 2024-09-20
D · Potential for more than minimal harm
2024-08-21
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 2024-09-20
D · Potential for more than minimal harm
2024-08-21
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-09-20
D · Potential for more than minimal harm
2024-08-21
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-09-20
D · Potential for more than minimal harm
2024-08-21
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 2024-09-20
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 2024-09-20
D · Potential for more than minimal harm
2024-08-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-20
E · Potential for more than minimal harm
2023-08-23
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 2023-09-19
E · Potential for more than minimal harm
2023-08-23
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-09-19
D · Potential for more than minimal harm
2023-08-23
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 2023-09-19
D · Potential for more than minimal harm
2023-08-23
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 2023-09-19
D · Potential for more than minimal harm
2023-08-23
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 2023-09-19
D · Potential for more than minimal harm
2023-08-23
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-09-19
D · Potential for more than minimal harm
2023-08-23
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 2023-09-19
C · Minimal harm
2023-08-23
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-09-19
D · Potential for more than minimal harm
2023-05-03
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-06-02
Penalties and ownership
What sits behind the stars
Ownership
Blake, Mark
5% Or Greater Direct Ownership Interest · Individual
Khan, Amir
5% Or Greater Direct Ownership Interest · Individual
Qureshi, Tariq
5% Or Greater Direct Ownership Interest · Individual
Blake, Mark
Operational/Managerial Control · Individual
Blake, Mark
Corporate Director · Individual
Elmi, Saied
Operational/Managerial Control · Individual
Khan, Amir
Operational/Managerial Control · Individual
Khan, Amir
Corporate Director · Individual
Qureshi, Tariq
Operational/Managerial Control · Individual
Qureshi, Tariq
Corporate Director · Individual
Shaw, Jennifer
Operational/Managerial Control · Individual
Spriggs, Berthelina
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Lafayette Rehabilitation & Skilled Nursing
Marblehead, MA
5-star overall rating with 5-star inspections with 7 fire-safety deficiencies in the latest cycle
#2
Salem Rehab Center
Salem, MA
2-star overall rating with 3-star inspections with $252,785 in total fines with 4 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#3
Abbott Skilled Nursing & Rehabilitation Center
Lynn, MA
3-star overall rating with 4-star inspections with 5 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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