Cycle 1
Health 2025-08-14 · Fire 2025-08-14
3 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Beverly, MA
Ledgewood Rehabilitation And Nursing Center
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
87 Herrick Street, Beverly, MA
(978) 921-1392
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
Facility snapshot
Beds
123
Certified beds
Average residents
109
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Banecare Management
Operator or chain grouping
Approved since
1988-03-28
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
8 facilities
Chain averages 4 overall / 4 health / 3 staffing / 4 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
0.56
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.25
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.09
Nurse aide staffing · state 2.26 · national 2.35
Total nurse hours
3.90
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.81
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.45
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
0.15
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.61
CMS adjusted RN staffing hours
Adjusted total hours
4.19
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
21%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
26%
Annual nurse turnover · state 40% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,872
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
42.33
Composite VBP score used to determine payment impact.
Payment multiplier
0.9953
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 17.92% · Performance 21.83% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
10
Baseline 5.35% · Performance 4.97% · Measure score 10 · Achievement 10 · Improvement 9
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
2.70
Baseline 3.89 hours · Performance 3.85 hours · Measure score 2.70 · Achievement 2.70 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.46% |
10.72%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 550 · Observed rate 11.45% · Lower 95% interval 9.68% |
| Discharge to community | 67.7% |
50.57%
17.1 pts better
|
Better than the National Rate · Eligible stays 507 · Observed rate 63.91% · Lower 95% interval 62.91% |
| Medicare spending per beneficiary | 0.82 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 99.49% |
95.27%
4.2 pts better
|
Numerator 389 · Denominator 391 |
| Falls with major injury | 0.77% |
0.77%
About the same
|
Numerator 3 · Denominator 391 |
| Discharge self-care score | 63.98% |
53.69%
10.3 pts better
|
Numerator 206 · Denominator 322 |
| Discharge mobility score | 57.45% |
50.94%
6.5 pts better
|
Numerator 185 · Denominator 322 |
| Pressure ulcers or injuries, new or worsened | 4.6% |
2.29%
2.3 pts worse
|
Numerator 18 · Denominator 391 · Adjusted rate 5.98% |
| Healthcare-associated infections requiring hospitalization | 4.97% |
7.12%
2.2 pts better
|
Better than the National Rate · Eligible stays 336 · Observed rate 2.98% · Lower 95% interval 2.94% |
| Staff COVID-19 vaccination coverage | 35.39% |
8.2%
27.2 pts better
|
Numerator 63 · Denominator 178 |
| Staff flu vaccination coverage | 69.2% |
42%
27.2 pts better
|
Numerator 191 · Denominator 276 |
| Discharge function score | 65.53% |
56.45%
9.1 pts better
|
Numerator 211 · Denominator 322 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 323 · Denominator 323 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 48.6% |
25.2%
23.4 pts better
|
Numerator 104 · Denominator 214 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
1.9
0.7 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.1 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
1.5
0.4 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.1 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.9% |
92.2%
1.7 pts better
|
93.4%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.5% · Q2 95.3% · Q3 92.4% · Q4 90.7% · 4Q avg 93.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.9% |
94.8%
4.1 pts better
|
95.5%
3.4 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.7% |
3.5%
0.2 pts worse
|
3.3%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 3.5% · Q3 3.8% · Q4 6.7% · 4Q avg 3.7% · 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 1.2% · Q3 1.4% · Q4 1.4% · 4Q avg 1.0% |
| Percentage of long-stay residents who lose too much weight | 3.5% |
5.2%
1.7 pts better
|
5.4%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 6.0% · Q3 3.2% · Q4 3.2% · 4Q avg 3.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.3% |
19.2%
5.9 pts better
|
19.6%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 11.1% · Q3 12.1% · Q4 17.5% · 4Q avg 13.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.0% |
22.5%
11.5 pts better
|
16.7%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.7% · Q2 12.8% · Q3 9.6% · Q4 11.1% · 4Q avg 11.0% · 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 | 18.2% |
17.7%
0.5 pts worse
|
16.3%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 27.5% · Q3 11.7% · Q4 13.9% · 4Q avg 18.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.9% |
17.6%
0.7 pts better
|
14.9%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 24.6% · Q3 18.8% · Q4 6.6% · 4Q avg 16.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
1.0%
0.7 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.1% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.3% |
2.0%
0.7 pts better
|
1.7%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.2% · Q3 1.3% · Q4 1.4% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.8% |
21.7%
2.1 pts worse
|
19.8%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.0% · Q2 23.0% · Q3 31.3% · Q4 14.2% · 4Q avg 23.8% |
| Percentage of long-stay residents with pressure ulcers | 6.4% |
4.6%
1.8 pts worse
|
5.1%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 7.2% · Q3 7.6% · Q4 7.8% · 4Q avg 6.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 75.7% |
77.1%
1.4 pts worse
|
81.7%
6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 74.6% · Q2 83.3% · Q3 75.4% · Q4 70.1% · 4Q avg 75.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.0% |
11.8%
3.8 pts better
|
12.0%
4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.0% · Observed 7.1% · Expected 9.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.3%
0.7 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.5% · Q2 0.5% · Q3 0.0% · Q4 1.4% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 78.8% |
77.7%
1.1 pts better
|
79.7%
0.9 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 78.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.8% |
25.8%
1 pts better
|
23.9%
0.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.8% · Observed 19.3% · Expected 18.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-01 · Fire 2024-08-01
4 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-06-15 · Fire 2023-06-15
7 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-08-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-10-01
F · Potential for more than minimal harm
2024-08-01
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-09-30
F · Potential for more than minimal harm
2024-08-01
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-09-30
E · Potential for more than minimal harm
2024-08-01
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-09-30
E · Potential for more than minimal harm
2024-08-01
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-09-30
E · Potential for more than minimal harm
2023-06-15
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-07-25
E · Potential for more than minimal harm
2023-06-15
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-07-25
E · Potential for more than minimal harm
2023-06-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-07-25
D · Potential for more than minimal harm
2023-06-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-07-25
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-08-05
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 2025-08-03
D · Potential for more than minimal harm
2025-08-05
F659 · Resident Assessment and Care Planning Deficiencies
Health
Provide care by qualified persons according to each resident's written plan of care.
Corrected 2025-08-03
D · Potential for more than minimal harm
2025-06-11
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 2025-07-18
E · Potential for more than minimal harm
2024-08-01
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 2024-09-06
D · Potential for more than minimal harm
2024-08-01
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 2024-09-06
D · Potential for more than minimal harm
2024-08-01
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-09-06
D · Potential for more than minimal harm
2024-08-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-06
D · Potential for more than minimal harm
2023-06-15
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 2023-07-08
D · Potential for more than minimal harm
2023-06-15
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-06-15
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 2023-07-28
D · Potential for more than minimal harm
2023-06-15
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-06-15
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-06-15
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 2023-07-28
D · Potential for more than minimal harm
2023-06-15
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 2023-07-28
Penalties and ownership
What sits behind the stars
Ownership
Morris, Kevin
5% Or Greater Direct Ownership Interest · Individual
Mahoney, Paul
W-2 Managing Employee · Individual
Morris, Kevin
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Blueberry Hill Rehabilitation And Healthcare Ctr
Beverly, MA
1-star overall rating with 1-star inspections with $231,459 in total fines with 7 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Care One At Essex Park
Beverly, MA
5-star overall rating with 4-star inspections with $35,968 in total fines with 7 fire-safety deficiencies in the latest cycle
#3
Brentwood Rehabilitation And Healthcare Ctr (The)
Danvers, MA
3-star overall rating with 3-star inspections with 12 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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