Cycle 1
Health 2025-06-11 · Fire 2025-06-11
0 health deficiencies
No concentrated health issue counts in this cycle.
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Melrose, MA
Elmhurst Healthcare (The)
5-star overall rating with 5-star inspections with 7 fire-safety deficiencies in the latest cycle
743 Main Street, Melrose, MA
(781) 662-7500
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
45
Certified beds
Average residents
26
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Next Step Healthcare
Operator or chain grouping
Approved since
1994-12-30
CMS approved date
Coverage
Medicare
Participation flags
Chain footprint
14 facilities
Chain averages 2 overall / 2 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
1.06
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.44
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.19
Nurse aide staffing · state 2.26 · national 2.35
Total nurse hours
4.69
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
2.50
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
4.46
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.97
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.29
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
1.02
CMS adjusted RN staffing hours
Adjusted total hours
4.52
CMS adjusted total nurse staffing hours
Case-mix index
1.42
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
50%
Annual nurse turnover · state 40% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,705
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
43.03
Composite VBP score used to determine payment impact.
Payment multiplier
0.9960
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.85
Baseline 22.88% · Performance 22.09% · Measure score 0.85 · Achievement 0 · Improvement 0.85
Healthcare-associated infections
7.40
Baseline 5.57% · Performance 5.62% · Measure score 7.40 · Achievement 7.40 · Improvement 0
Total nurse turnover
4.51
Baseline 54.05% · Performance 45.24% · Measure score 4.51 · Achievement 4.51 · Improvement 2.52
Adjusted total nurse staffing
4.45
Baseline 4.14 hours · Performance 4.34 hours · Measure score 4.45 · Achievement 4.45 · Improvement 0.72
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.37% |
10.72%
2.6 pts worse
|
Worse than the National Rate · Eligible stays 349 · Observed rate 14.61% · Lower 95% interval 10.85% |
| Discharge to community | 64.24% |
50.57%
13.7 pts better
|
Better than the National Rate · Eligible stays 353 · Observed rate 58.36% · Lower 95% interval 58.97% |
| Medicare spending per beneficiary | 1.05 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 94.49% |
95.27%
0.8 pts worse
|
Numerator 257 · Denominator 272 |
| Falls with major injury | 0.37% |
0.77%
0.4 pts better
|
Numerator 1 · Denominator 272 |
| Discharge self-care score | 52.69% |
53.69%
1 pts worse
|
Numerator 88 · Denominator 167 |
| Discharge mobility score | 52.69% |
50.94%
1.8 pts better
|
Numerator 88 · Denominator 167 |
| Pressure ulcers or injuries, new or worsened | 1.47% |
2.29%
0.8 pts better
|
Numerator 4 · Denominator 272 · Adjusted rate 1.74% |
| Healthcare-associated infections requiring hospitalization | 5.62% |
7.12%
1.5 pts better
|
No Different than the National Rate · Eligible stays 225 · Observed rate 4% · Lower 95% interval 3.39% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 48 |
| Staff flu vaccination coverage | 60.71% |
42%
18.7 pts better
|
Numerator 34 · Denominator 56 |
| Discharge function score | 59.88% |
56.45%
3.4 pts better
|
Numerator 100 · Denominator 167 |
| Transfer of health information to provider | 99.05% |
95.95%
3.1 pts better
|
Numerator 104 · Denominator 105 |
| Transfer of health information to patient | 98.18% |
96.28%
1.9 pts better
|
Numerator 162 · Denominator 165 |
| Resident COVID-19 vaccinations up to date | 30.86% |
25.2%
5.7 pts better
|
Numerator 50 · Denominator 162 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 76.8% |
77.1%
0.3 pts worse
|
81.7%
4.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 76.2% · Q2 63.5% · Q3 77.4% · Q4 95.7% · 4Q avg 76.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.3% |
11.8%
3.5 pts better
|
12.0%
3.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.3% · Observed 8.8% · Expected 11.8% · 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 2.1% · Q2 1.3% · Q3 0.8% · Q4 1.8% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 71.4% |
77.7%
6.3 pts worse
|
79.7%
8.3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 71.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 35.3% |
25.8%
9.5 pts worse
|
23.9%
11.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 35.3% · Observed 35.6% · Expected 24.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-10 · Fire 2024-07-10
4 health deficiencies
Top issue: Infection Control (1 deficiency)
3 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Cycle 3
Health 2023-05-10 · Fire 2023-05-10
18 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-06-11
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 2025-07-10
F · Potential for more than minimal harm
2025-06-11
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-07-10
F · Potential for more than minimal harm
2025-06-11
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-07-10
F · Potential for more than minimal harm
2025-06-11
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-07-10
F · Potential for more than minimal harm
2025-06-11
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-07-10
E · Potential for more than minimal harm
2025-06-11
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2025-07-10
E · Potential for more than minimal harm
2025-06-11
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-07-10
F · Potential for more than minimal harm
2024-07-10
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2024-08-02
F · Potential for more than minimal harm
2024-07-10
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-08-02
F · Potential for more than minimal harm
2024-07-10
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-08-02
D · Potential for more than minimal harm
2023-05-10
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-05-19
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-07-10
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2024-07-26
D · Potential for more than minimal harm
2024-07-10
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 2024-07-26
D · Potential for more than minimal harm
2024-07-10
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 2024-07-26
D · Potential for more than minimal harm
2024-07-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-26
D · Potential for more than minimal harm
2023-05-10
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 2023-05-30
D · Potential for more than minimal harm
2023-05-10
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2023-05-30
D · Potential for more than minimal harm
2023-05-10
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-05-30
D · Potential for more than minimal harm
2023-05-10
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 2023-05-30
D · Potential for more than minimal harm
2023-05-10
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 2023-05-30
D · Potential for more than minimal harm
2023-05-10
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-05-30
D · Potential for more than minimal harm
2023-05-10
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 2023-05-30
D · Potential for more than minimal harm
2023-05-10
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-05-30
D · Potential for more than minimal harm
2023-05-10
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-05-30
D · Potential for more than minimal harm
2023-05-10
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-05-30
D · Potential for more than minimal harm
2023-05-10
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-05-30
D · Potential for more than minimal harm
2023-05-10
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 2023-05-30
D · Potential for more than minimal harm
2023-05-10
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 2023-05-30
D · Potential for more than minimal harm
2023-05-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-05-30
D · Potential for more than minimal harm
2023-05-10
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-05-30
B · Minimal harm
2023-05-10
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-05-30
D · Potential for more than minimal harm
2023-03-02
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 2023-01-03
D · Potential for more than minimal harm
2023-03-02
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-01-03
Penalties and ownership
What sits behind the stars
Ownership
Next Step Healthcare LLC
5% Or Greater Direct Ownership Interest · Organization
Dell'anno, Damian
5% Or Greater Indirect Ownership Interest · Individual
Stephan, William
5% Or Greater Indirect Ownership Interest · Individual
Dell'anno, Damian
Corporate Officer · Individual
Likhi, Rishi
Operational/Managerial Control · Individual
Next Step Healthcare LLC
Operational/Managerial Control · Organization
Stephan, William
Corporate Officer · Individual
Weiss, Alexis
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Melrose Healthcare
Melrose, MA
1-star overall rating with 1-star inspections with $49,324 in total fines with 27 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Greenwood Nursing & Rehabilitation Center
Wakefield, MA
5-star overall rating with 4-star inspections with 8 recent health deficiencies
#3
Life Care Center Of Stoneham
Stoneham, MA
3-star overall rating with 2-star inspections with abuse icon flag with $39,559 in total fines with 6 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
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