Cycle 1
Health 2024-09-11 · Fire 2024-09-11
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
North Chatham, MA
Liberty Commons
5-star overall rating with 4-star inspections with 5 recent health deficiencies
390 Orleans Road, North Chatham, MA
(508) 945-4611
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
132
Certified beds
Average residents
127
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1989-02-02
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
0.88
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
0.85
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.67
Nurse aide staffing · state 2.26 · national 2.35
Total nurse hours
4.40
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.73
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.80
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.56
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.14
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.96
CMS adjusted RN staffing hours
Adjusted total hours
4.82
CMS adjusted total nurse staffing hours
Case-mix index
1.25
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
49%
Annual nurse turnover · state 40% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,236
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
21.03
Composite VBP score used to determine payment impact.
Payment multiplier
0.9825
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.71
Baseline 20.47% · Performance 21.10% · Measure score 0.71 · Achievement 0.71 · Improvement 0
Healthcare-associated infections
3.26
Baseline 5.67% · Performance 6.86% · Measure score 3.26 · Achievement 3.26 · Improvement 0
Total nurse turnover
0
Baseline 29.29% · Performance 77.05% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
4.44
Baseline 4.04 hours · Performance 4.34 hours · Measure score 4.44 · Achievement 4.44 · Improvement 1.26
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.55% |
10.72%
1.2 pts better
|
No Different than the National Rate · Eligible stays 756 · Observed rate 7.14% · Lower 95% interval 7.48% |
| Discharge to community | 65.45% |
50.57%
14.9 pts better
|
Better than the National Rate · Eligible stays 793 · Observed rate 65.57% · Lower 95% interval 61.47% |
| Medicare spending per beneficiary | 0.89 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 98.23% |
95.27%
3 pts better
|
Numerator 500 · Denominator 509 |
| Falls with major injury | 0.98% |
0.77%
0.2 pts worse
|
Numerator 5 · Denominator 509 |
| Discharge self-care score | 62.15% |
53.69%
8.5 pts better
|
Numerator 243 · Denominator 391 |
| Discharge mobility score | 70.84% |
50.94%
19.9 pts better
|
Numerator 277 · Denominator 391 |
| Pressure ulcers or injuries, new or worsened | 1.57% |
2.29%
0.7 pts better
|
Numerator 8 · Denominator 509 · Adjusted rate 2.04% |
| Healthcare-associated infections requiring hospitalization | 6.86% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 526 · Observed rate 5.32% · Lower 95% interval 5.15% |
| Staff COVID-19 vaccination coverage | 41.04% |
8.2%
32.8 pts better
|
Numerator 110 · Denominator 268 |
| Staff flu vaccination coverage | 55.94% |
42%
13.9 pts better
|
Numerator 179 · Denominator 320 |
| Discharge function score | 69.05% |
56.45%
12.6 pts better
|
Numerator 270 · Denominator 391 |
| Transfer of health information to provider | 99.5% |
95.95%
3.5 pts better
|
Numerator 398 · Denominator 400 |
| Transfer of health information to patient | 98% |
96.28%
1.7 pts better
|
Numerator 49 · Denominator 50 |
| Resident COVID-19 vaccinations up to date | 38.04% |
25.2%
12.8 pts better
|
Numerator 97 · Denominator 255 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
1.9
0.6 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.2 · Expected 1.7 · 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 1.0 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 86.4% |
92.2%
5.8 pts worse
|
93.4%
7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 85.7% · Q2 88.1% · Q3 82.1% · Q4 89.7% · 4Q avg 86.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.4% |
94.8%
0.4 pts worse
|
95.5%
1.1 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.4% |
| 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 2.6% · Q2 3.6% · Q3 2.4% · Q4 3.4% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.3% |
12.0%
11.7 pts better
|
11.4%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% |
| Percentage of long-stay residents who lose too much weight | 1.2% |
5.2%
4 pts better
|
5.4%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 1.5% · Q3 0.0% · Q4 1.6% · 4Q avg 1.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.0% |
19.2%
5.2 pts better
|
19.6%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.7% · Q2 14.5% · Q3 14.5% · Q4 14.3% · 4Q avg 14.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.2% |
22.5%
13.3 pts better
|
16.7%
7.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.4% · Q2 6.0% · Q3 7.3% · Q4 8.3% · 4Q avg 9.2% · 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 | 29.6% |
17.7%
11.9 pts worse
|
16.3%
13.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 41.5% · Q2 32.0% · Q3 37.4% · Q4 6.4% · 4Q avg 29.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.6% |
17.6%
6 pts worse
|
14.9%
8.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.1% · Q2 26.9% · Q3 18.2% · Q4 18.8% · 4Q avg 23.6% · 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 0.0% · Q4 1.1% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.7% |
2.0%
2.7 pts worse
|
1.7%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 7.4% · Q3 6.3% · Q4 2.4% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 32.6% |
21.7%
10.9 pts worse
|
19.8%
12.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.8% · Q2 30.3% · Q3 29.5% · Q4 34.0% · 4Q avg 32.6% |
| Percentage of long-stay residents with pressure ulcers | 1.8% |
4.6%
2.8 pts better
|
5.1%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.1% · Q3 1.0% · Q4 3.9% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 82.9% |
77.1%
5.8 pts better
|
81.7%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 81.3% · Q2 77.4% · Q3 84.0% · Q4 89.5% · 4Q avg 82.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.5% |
11.8%
1.7 pts worse
|
12.0%
1.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.5% · Observed 12.2% · Expected 10.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.6% |
1.3%
0.3 pts worse
|
1.6%
About the same
|
Short Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 1.4% · Q3 2.8% · Q4 1.4% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 70.5% |
77.7%
7.2 pts worse
|
79.7%
9.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 70.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.2% |
25.8%
3.6 pts better
|
23.9%
1.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.2% · Observed 18.4% · Expected 19.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-06-28 · Fire 2023-06-28
2 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2020-10-27 · Fire 2020-10-27
4 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-09-11
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 2024-10-09
E · Potential for more than minimal harm
2024-09-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-09
D · Potential for more than minimal harm
2024-09-11
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-10-09
D · Potential for more than minimal harm
2024-09-11
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-10-09
D · Potential for more than minimal harm
2024-09-11
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-10-09
E · Potential for more than minimal harm
2023-06-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-20
D · Potential for more than minimal harm
2023-06-28
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-07-20
G · Actual harm
2020-10-27
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2020-11-20
D · Potential for more than minimal harm
2020-10-27
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2020-11-20
D · Potential for more than minimal harm
2020-10-27
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 2020-11-20
D · Potential for more than minimal harm
2020-10-27
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 2020-11-20
Penalties and ownership
What sits behind the stars
Ownership
Bogdanovich, William
5% Or Greater Direct Ownership Interest · Individual
Bogdanovich, William
Operational/Managerial Control · Individual
Bogdanovich, William
Corporate Director · Individual
Bogdanovich, William
Corporate Officer · Individual
Jones, Christopher
Operational/Managerial Control · Individual
Lahaie, Donna
Operational/Managerial Control · Individual
Lavallee, Jason
Operational/Managerial Control · Individual
Weber, Eric
Operational/Managerial Control · Individual
Nearby options
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#3
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