2 health deficiencies
Top issue: Infection Control (1 deficiency)
7 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Worcester, MA
5-star overall rating with 4-star inspections with $10,517 in total fines with 2 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
629 Salisbury Street, Worcester, MA
(508) 798-8653
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
141
Certified beds
Average residents
133
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1968-11-19
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
RN hours / resident day
0.51
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.46
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.77
Nurse aide staffing · state 2.26 · national 2.35
Total nurse hours
4.73
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.97
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
4.16
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.28
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.51
CMS adjusted RN staffing hours
Adjusted total hours
4.70
CMS adjusted total nurse staffing hours
Case-mix index
1.38
Higher values indicate more complex resident acuity
RN turnover
41%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
43%
Annual nurse turnover · state 40% · national 46%
SNF VBP
Program rank
658
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
65.77
Composite VBP score used to determine payment impact.
Payment multiplier
1.0199
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
6.83
Baseline 21.80% · Performance 18.30% · Measure score 6.83 · Achievement 6.75 · Improvement 6.83
Healthcare-associated infections
8.35
Baseline 4.34% · Performance 5.34% · Measure score 8.35 · Achievement 8.35 · Improvement 0
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
4.55
Baseline 4.12 hours · Performance 4.37 hours · Measure score 4.55 · Achievement 4.55 · Improvement 1.05
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.53% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 399 · Observed rate 9.52% · Lower 95% interval 8.19% |
| Discharge to community | 66.49% |
50.57%
15.9 pts better
|
Better than the National Rate · Eligible stays 404 · Observed rate 65.84% · Lower 95% interval 61.53% |
| Medicare spending per beneficiary | 0.76 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 99.67% |
95.27%
4.4 pts better
|
Numerator 300 · Denominator 301 |
| Falls with major injury | 1% |
0.77%
0.2 pts worse
|
Numerator 3 · Denominator 301 |
| Discharge self-care score | 31.98% |
53.69%
21.7 pts worse
|
Numerator 79 · Denominator 247 |
| Discharge mobility score | 44.53% |
50.94%
6.4 pts worse
|
Numerator 110 · Denominator 247 |
| Pressure ulcers or injuries, new or worsened | 2.33% |
2.29%
About the same
|
Numerator 7 · Denominator 301 · Adjusted rate 2.47% |
| Healthcare-associated infections requiring hospitalization | 5.34% |
7.12%
1.8 pts better
|
No Different than the National Rate · Eligible stays 244 · Observed rate 3.28% · Lower 95% interval 3.32% |
| Staff COVID-19 vaccination coverage | 92.02% |
8.2%
83.8 pts better
|
Numerator 242 · Denominator 263 |
| Staff flu vaccination coverage | 95.54% |
42%
53.5 pts better
|
Numerator 407 · Denominator 426 |
| Discharge function score | 41.3% |
56.45%
15.2 pts worse
|
Numerator 102 · Denominator 247 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 249 · Denominator 249 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 55.26% |
25.2%
30.1 pts better
|
Numerator 84 · Denominator 152 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.8 |
1.9
1.1 pts better
|
1.9
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.6 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.2 |
1.5
1.3 pts better
|
1.8
1.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.2 · Observed 0.2 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.5% |
92.2%
7.3 pts better
|
93.4%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.1% |
94.8%
4.3 pts better
|
95.5%
3.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.0% |
3.5%
0.5 pts better
|
3.3%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 3.0% · Q3 3.0% · Q4 1.0% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.2% |
12.0%
9.8 pts better
|
11.4%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.1% · Q3 2.5% · Q4 1.3% · 4Q avg 2.2% |
| Percentage of long-stay residents who lose too much weight | 3.7% |
5.2%
1.5 pts better
|
5.4%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 5.3% · Q3 2.7% · Q4 1.4% · 4Q avg 3.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.0% |
19.2%
12.2 pts better
|
19.6%
12.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 3.8% · Q3 9.2% · Q4 10.8% · 4Q avg 7.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.2% |
22.5%
7.3 pts better
|
16.7%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.2% · Q2 13.8% · Q3 13.1% · Q4 16.7% · 4Q avg 15.2% · 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 | 23.0% |
17.7%
5.3 pts worse
|
16.3%
6.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.9% · Q2 33.4% · Q3 9.7% · Q4 20.4% · 4Q avg 23.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.3% |
17.6%
7.3 pts better
|
14.9%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.2% · Q2 14.3% · Q3 5.9% · Q4 7.7% · 4Q avg 10.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.0%
1 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.3% |
2.0%
2.3 pts worse
|
1.7%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 6.1% · Q3 6.0% · Q4 3.2% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.1% |
21.7%
2.4 pts worse
|
19.8%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.5% · Q2 23.9% · Q3 17.3% · Q4 24.8% · 4Q avg 24.1% |
| Percentage of long-stay residents with pressure ulcers | 3.1% |
4.6%
1.5 pts better
|
5.1%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 3.8% · Q3 3.2% · Q4 1.6% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.5% |
77.1%
19.4 pts better
|
81.7%
14.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 93.9% · Q2 96.3% · Q3 97.6% · Q4 98.0% · 4Q avg 96.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.5% |
11.8%
4.3 pts better
|
12.0%
4.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.5% · Observed 7.1% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.9% |
1.3%
0.4 pts better
|
1.6%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.5% · Q3 0.5% · Q4 1.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.6% |
77.7%
18.9 pts better
|
79.7%
16.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.7% |
25.8%
7.1 pts better
|
23.9%
5.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.7% · Observed 17.6% · Expected 22.4% · Used in QM five-star |
Survey summary
Top issue: Infection Control (1 deficiency)
7 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Top issue: Pharmacy Service (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2024-11-30
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2024-11-30
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-11-30
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-11-30
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2024-11-30
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-11-30
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-11-30
Inspection history
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-11-18
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-18
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-08-18
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-08-18
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-08-18
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-08-18
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 2023-08-18
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2023-08-18
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 2023-09-06
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-08-18
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-06-30
Health
Provide and implement an infection prevention and control program.
Corrected 2021-09-15
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 2021-09-15
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2021-09-15
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2021-09-15
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2021-09-15
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2021-09-15
Health
Provide appropriate foot care.
Corrected 2021-09-15
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2021-09-15
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2021-09-15
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2021-09-15
Penalties and ownership
Fine · fine $10,517
Fine
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Officer · Individual
Corporate Director · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Officer · Individual
Corporate Director · Individual
Nearby options
Worcester, MA
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
Worcester, MA
2-star overall rating with 2-star inspections with $106,301 in total fines with 11 recent health deficiencies with 19 fire-safety deficiencies in the latest cycle
Worcester, MA
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
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