Cycle 1
Health 2025-08-06 · Fire 2025-08-06
0 health deficiencies
No concentrated health issue counts in this cycle.
7 fire-safety deficiencies
Top issue: Egress (4 deficiencies)
Marblehead, MA
Lafayette Rehabilitation & Skilled Nursing
5-star overall rating with 5-star inspections with 7 fire-safety deficiencies in the latest cycle
25 Lafayette Street, Marblehead, MA
(781) 631-4535
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
65
Certified beds
Average residents
43
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Lme Family Holdings
Operator or chain grouping
Approved since
1990-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
15 facilities
Chain averages 2 overall / 2 health / 3 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
0.66
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.24
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.46
Nurse aide staffing · state 2.26 · national 2.35
Total nurse hours
4.35
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.90
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.95
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.37
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.33
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.76
CMS adjusted RN staffing hours
Adjusted total hours
5.06
CMS adjusted total nurse staffing hours
Case-mix index
1.18
Higher values indicate more complex resident acuity
RN turnover
83%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
53%
Annual nurse turnover · state 40% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,576
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
43.70
Composite VBP score used to determine payment impact.
Payment multiplier
0.9967
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 17.71% · Performance 22.08% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
5.99
Baseline 5.71% · Performance 6.04% · Measure score 5.99 · Achievement 5.99 · Improvement 0
Total nurse turnover
5.42
Baseline 50.00% · Performance 41.51% · Measure score 5.42 · Achievement 5.42 · Improvement 2.88
Adjusted total nurse staffing
6.07
Baseline 3.95 hours · Performance 4.80 hours · Measure score 6.07 · Achievement 6.07 · Improvement 4.16
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.04% |
10.72%
1.7 pts better
|
No Different than the National Rate · Eligible stays 94 · Observed rate 4.26% · Lower 95% interval 5.93% |
| Discharge to community | 46.03% |
50.57%
4.5 pts worse
|
No Different than the National Rate · Eligible stays 84 · Observed rate 39.29% · Lower 95% interval 38.07% |
| Medicare spending per beneficiary | 0.81 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 92.73% |
95.27%
2.5 pts worse
|
Numerator 51 · Denominator 55 |
| Falls with major injury | 1.82% |
0.77%
1.1 pts worse
|
Numerator 1 · Denominator 55 |
| Discharge self-care score | 13.51% |
53.69%
40.2 pts worse
|
Numerator 5 · Denominator 37 |
| Discharge mobility score | 21.62% |
50.94%
29.3 pts worse
|
Numerator 8 · Denominator 37 |
| Pressure ulcers or injuries, new or worsened | 5.45% |
2.29%
3.2 pts worse
|
Numerator 3 · Denominator 55 · Adjusted rate 5.64% |
| Healthcare-associated infections requiring hospitalization | 6.05% |
7.12%
1.1 pts better
|
No Different than the National Rate · Eligible stays 51 · Observed rate 1.96% · Lower 95% interval 3% |
| Staff COVID-19 vaccination coverage | 13.43% |
8.2%
5.2 pts better
|
Numerator 9 · Denominator 67 |
| Staff flu vaccination coverage | 69.61% |
42%
27.6 pts better
|
Numerator 71 · Denominator 102 |
| Discharge function score | 37.84% |
56.45%
18.6 pts worse
|
Numerator 14 · Denominator 37 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 27 · Denominator 27 |
| Resident COVID-19 vaccinations up to date | 61.76% |
25.2%
36.6 pts better
|
Numerator 21 · Denominator 34 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.9 |
1.9
1 pts better
|
1.9
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.7 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
1.5
0.5 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.8 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.3% |
92.2%
7.1 pts better
|
93.4%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.4% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.3% |
| 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 | 2.1% |
3.5%
1.4 pts better
|
3.3%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 0.0% · Q3 0.0% · Q4 2.9% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.5% |
12.0%
7.5 pts better
|
11.4%
6.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 6.1% · Q3 5.9% · Q4 3.4% · 4Q avg 4.5% |
| Percentage of long-stay residents who lose too much weight | 2.6% |
5.2%
2.6 pts better
|
5.4%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 3.8% · Q3 0.0% · Q4 3.2% · 4Q avg 2.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.2% |
19.2%
5 pts worse
|
19.6%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.2% · Q2 18.5% · Q3 31.0% · Q4 22.6% · 4Q avg 24.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 35.2% |
22.5%
12.7 pts worse
|
16.7%
18.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.4% · Q2 36.4% · Q3 34.6% · Q4 33.3% · 4Q avg 35.2% · 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 | 10.7% |
17.7%
7 pts better
|
16.3%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.4% |
17.6%
0.2 pts better
|
14.9%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.9% · Q2 20.0% · Q3 14.8% · Q4 17.2% · 4Q avg 17.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.1% |
1.0%
1.1 pts worse
|
1.0%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 2.4% · Q3 0.0% · Q4 1.8% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.6% |
2.0%
1.6 pts worse
|
1.7%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 0.0% · Q3 0.0% · Q4 8.6% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 32.5% |
21.7%
10.8 pts worse
|
19.8%
12.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.7% · Q2 44.8% · Q3 24.3% · Q4 23.0% · 4Q avg 32.5% |
| Percentage of long-stay residents with pressure ulcers | 8.7% |
4.6%
4.1 pts worse
|
5.1%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 12.2% · Q3 9.6% · Q4 9.7% · 4Q avg 8.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.1% |
77.1%
14 pts better
|
81.7%
9.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.2% · Q2 91.7% · Q3 86.4% · Q4 91.3% · 4Q avg 91.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.3% |
11.8%
2.5 pts better
|
12.0%
2.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.3% · Observed 9.3% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.5% |
1.3%
1.2 pts worse
|
1.6%
0.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q4 3.6% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.9% |
77.7%
18.2 pts better
|
79.7%
16.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.6% |
25.8%
1.2 pts better
|
23.9%
0.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.6% · Observed 24.1% · Expected 23.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-28 · Fire 2024-08-28
4 health deficiencies
Top issue: Resident Rights (2 deficiencies)
5 fire-safety deficiencies
Top issue: Egress (4 deficiencies)
Cycle 3
Health 2023-08-09 · Fire 2023-08-09
5 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
5 fire-safety deficiencies
Top issue: Egress (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-08-06
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2025-09-01
F · Potential for more than minimal harm
2025-08-06
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-09-01
F · Potential for more than minimal harm
2025-08-06
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2025-09-01
F · Potential for more than minimal harm
2025-08-06
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2025-09-01
F · Potential for more than minimal harm
2025-08-06
K254 · Egress Deficiencies
Fire Safety
Provide hallway or ground-level exits in all residents' rooms.
Corrected 2025-09-01
F · Potential for more than minimal harm
2025-08-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-10-03
F · Potential for more than minimal harm
2025-08-06
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-10-03
F · Potential for more than minimal harm
2024-08-28
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-10-03
F · Potential for more than minimal harm
2024-08-28
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-10-03
F · Potential for more than minimal harm
2024-08-28
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2024-10-03
F · Potential for more than minimal harm
2024-08-28
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2024-10-03
F · Potential for more than minimal harm
2024-08-28
K254 · Egress Deficiencies
Fire Safety
Provide hallway or ground-level exits in all residents' rooms.
Corrected 2024-10-03
F · Potential for more than minimal harm
2023-08-09
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2023-09-05
F · Potential for more than minimal harm
2023-08-09
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-09-05
F · Potential for more than minimal harm
2023-08-09
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2023-09-05
F · Potential for more than minimal harm
2023-08-09
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2023-09-05
F · Potential for more than minimal harm
2023-08-09
K254 · Egress Deficiencies
Fire Safety
Provide hallway or ground-level exits in all residents' rooms.
Corrected 2023-09-05
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-08-28
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 2024-09-06
E · Potential for more than minimal harm
2024-08-28
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2024-08-28
D · Potential for more than minimal harm
2024-08-28
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-09-06
D · Potential for more than minimal harm
2024-08-28
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-09-05
D · Potential for more than minimal harm
2023-08-09
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 2023-08-31
D · Potential for more than minimal harm
2023-08-09
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-09-15
D · Potential for more than minimal harm
2023-08-09
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-09-15
D · Potential for more than minimal harm
2023-08-09
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-09-15
B · Minimal harm
2023-08-09
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-08-31
Penalties and ownership
What sits behind the stars
Ownership
Lme Family Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Ml Family Tree Trust
5% Or Greater Indirect Ownership Interest · Organization
Hirsch, Shmuel
5% Or Greater Direct Ownership Interest · Individual
Probst, Sarah
5% Or Greater Direct Ownership Interest · Individual
Probst, Seth
5% Or Greater Direct Ownership Interest · Individual
Hirsch, Nisson
5% Or Greater Direct Ownership Interest · Individual
Barbuzzi, George
Contracted Managing Employee · Individual
Hirsch, Nisson
Operational/Managerial Control · Individual
Hirsch, Shmuel
Operational/Managerial Control · Individual
Lahasky, Ephram
Operational/Managerial Control · Individual
Lme Family Holdings LLC
Operational/Managerial Control · Organization
Probst, Sarah
Operational/Managerial Control · Individual
Probst, Seth
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
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Devereux Skilled Nursing & Rehabilitation Center
Marblehead, MA
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 9 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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