Cycle 1
Health 2024-10-17 · Fire 2024-10-17
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Lawrence, MA
M I Nursing & Restorative Center
4-star overall rating with 4-star inspections with $21,916 in total fines with 3 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
172 Lawrence Street, Lawrence, MA
(978) 620-1401
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
250
Certified beds
Average residents
194
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Covenant Health
Operator or chain grouping
Approved since
1968-03-13
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
11 facilities
Chain averages 3 overall / 3 health / 5 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
0.72
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
0.71
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.29
Nurse aide staffing · state 2.26 · national 2.35
Total nurse hours
3.71
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.43
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.27
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.60
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.84
CMS adjusted RN staffing hours
Adjusted total hours
4.33
CMS adjusted total nurse staffing hours
Case-mix index
1.17
Higher values indicate more complex resident acuity
RN turnover
31%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
31%
Annual nurse turnover · state 40% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,433
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
56.75
Composite VBP score used to determine payment impact.
Payment multiplier
1.0119
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.37
Baseline 18.55% · Performance 19.87% · Measure score 3.37 · Achievement 3.37 · Improvement 0
Healthcare-associated infections
8.38
Baseline 6.02% · Performance 5.33% · Measure score 8.38 · Achievement 8.38 · Improvement 6.23
Total nurse turnover
6.07
Baseline 56.68% · Performance 38.86% · Measure score 6.07 · Achievement 6.07 · Improvement 5.10
Adjusted total nurse staffing
4.88
Baseline 3.87 hours · Performance 4.47 hours · Measure score 4.88 · Achievement 4.88 · Improvement 2.62
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.92% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 218 · Observed rate 8.72% · Lower 95% interval 7.06% |
| Discharge to community | 54.94% |
50.57%
4.4 pts better
|
No Different than the National Rate · Eligible stays 197 · Observed rate 48.73% · Lower 95% interval 47.36% |
| Medicare spending per beneficiary | 0.7 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 143 · Denominator 143 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 143 |
| Discharge self-care score | 25.2% |
53.69%
28.5 pts worse
|
Numerator 31 · Denominator 123 |
| Discharge mobility score | 26.02% |
50.94%
24.9 pts worse
|
Numerator 32 · Denominator 123 |
| Pressure ulcers or injuries, new or worsened | 2.8% |
2.29%
0.5 pts worse
|
Numerator 4 · Denominator 143 · Adjusted rate 2.7% |
| Healthcare-associated infections requiring hospitalization | 5.33% |
7.12%
1.8 pts better
|
No Different than the National Rate · Eligible stays 127 · Observed rate 2.36% · Lower 95% interval 3.14% |
| Staff COVID-19 vaccination coverage | 12.24% |
8.2%
4 pts better
|
Numerator 35 · Denominator 286 |
| Staff flu vaccination coverage | 95.5% |
42%
53.5 pts better
|
Numerator 297 · Denominator 311 |
| Discharge function score | 35.77% |
56.45%
20.7 pts worse
|
Numerator 44 · Denominator 123 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 40 · Denominator 40 |
| Transfer of health information to patient | 94.59% |
96.28%
1.7 pts worse
|
Numerator 35 · Denominator 37 |
| Resident COVID-19 vaccinations up to date | 30.49% |
25.2%
5.3 pts better
|
Numerator 25 · Denominator 82 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
1.9
0.3 pts worse
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 1.7 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.1 |
1.5
0.6 pts worse
|
1.8
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 1.7 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.4% |
92.2%
3.2 pts better
|
93.4%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.3% · Q2 94.8% · Q3 95.3% · Q4 96.1% · 4Q avg 95.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.3% |
94.8%
3.5 pts better
|
95.5%
2.8 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.1% |
3.5%
1.6 pts worse
|
3.3%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 4.6% · Q3 5.9% · Q4 4.4% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
12.0%
12 pts better
|
11.4%
11.4 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 who lose too much weight | 6.5% |
5.2%
1.3 pts worse
|
5.4%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 8.7% · Q3 7.9% · Q4 6.0% · 4Q avg 6.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.3% |
19.2%
0.1 pts worse
|
19.6%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 20.1% · Q3 17.9% · Q4 19.1% · 4Q avg 19.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 22.5% |
22.5%
About the same
|
16.7%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.7% · Q2 20.9% · Q3 21.0% · Q4 22.7% · 4Q avg 22.5% · 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 | 24.9% |
17.7%
7.2 pts worse
|
16.3%
8.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.7% · Q2 29.2% · Q3 24.0% · Q4 12.4% · 4Q avg 24.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.3% |
17.6%
3.7 pts worse
|
14.9%
6.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.4% · Q2 19.7% · Q3 18.8% · Q4 11.3% · 4Q avg 21.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
1.0%
0.1 pts better
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 0.5% · Q3 0.0% · Q4 1.2% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.2% |
2.0%
0.8 pts better
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 0.6% · Q3 1.2% · Q4 1.7% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.6% |
21.7%
0.9 pts worse
|
19.8%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.9% · Q2 28.3% · Q3 18.1% · Q4 14.6% · 4Q avg 22.6% |
| Percentage of long-stay residents with pressure ulcers | 5.5% |
4.6%
0.9 pts worse
|
5.1%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 5.1% · Q3 5.2% · Q4 6.4% · 4Q avg 5.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 87.3% |
77.1%
10.2 pts better
|
81.7%
5.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 87.9% · Q2 82.6% · Q3 86.8% · Q4 92.9% · 4Q avg 87.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.1% |
11.8%
4.3 pts worse
|
12.0%
4.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.1% · Observed 15.2% · Expected 10.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.3% |
1.3%
2 pts worse
|
1.6%
1.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 3.4% · Q3 0.0% · Q4 0.0% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 83.6% |
77.7%
5.9 pts better
|
79.7%
3.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 83.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.9% |
25.8%
3.1 pts worse
|
23.9%
5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.9% · Observed 22.7% · Expected 18.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-03 · Fire 2023-10-03
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-09-09 · Fire 2022-09-09
11 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-10-17
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2024-11-21
E · Potential for more than minimal harm
2024-10-17
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2024-11-21
E · Potential for more than minimal harm
2024-10-17
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-11-21
E · Potential for more than minimal harm
2024-10-17
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-11-18
E · Potential for more than minimal harm
2024-10-17
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-11-21
E · Potential for more than minimal harm
2024-10-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-21
E · Potential for more than minimal harm
2024-10-17
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-11-21
E · Potential for more than minimal harm
2024-10-17
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-11-05
D · Potential for more than minimal harm
2024-10-17
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-11-05
D · Potential for more than minimal harm
2024-10-17
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-11-18
D · Potential for more than minimal harm
2024-10-17
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-11-13
D · Potential for more than minimal harm
2024-10-17
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-11-21
D · Potential for more than minimal harm
2023-10-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-10-27
D · Potential for more than minimal harm
2023-10-03
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-10-27
D · Potential for more than minimal harm
2023-10-03
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-10-27
D · Potential for more than minimal harm
2023-10-03
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-10-27
D · Potential for more than minimal harm
2022-09-09
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-10-07
D · Potential for more than minimal harm
2022-09-09
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-10-12
Inspection history
Recent health citations
G · Actual harm
2025-10-02
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 2025-10-08
D · Potential for more than minimal harm
2024-10-17
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 2024-11-01
D · Potential for more than minimal harm
2024-10-17
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-11-01
E · Potential for more than minimal harm
2023-10-03
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 2023-10-20
D · Potential for more than minimal harm
2023-10-03
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-10-20
D · Potential for more than minimal harm
2023-10-03
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 2023-10-20
D · Potential for more than minimal harm
2023-10-03
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-10-20
D · Potential for more than minimal harm
2023-10-03
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-10-20
D · Potential for more than minimal harm
2023-10-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-20
G · Actual harm
2023-09-27
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-10-20
E · Potential for more than minimal harm
2022-09-09
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 2022-09-28
D · Potential for more than minimal harm
2022-09-09
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-09-28
D · Potential for more than minimal harm
2022-09-09
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-09-28
D · Potential for more than minimal harm
2022-09-09
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2022-09-28
D · Potential for more than minimal harm
2022-09-09
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2022-09-28
D · Potential for more than minimal harm
2022-09-09
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2022-09-28
D · Potential for more than minimal harm
2022-09-09
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-09-28
D · Potential for more than minimal harm
2022-09-09
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2022-09-28
D · Potential for more than minimal harm
2022-09-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-09-28
D · Potential for more than minimal harm
2022-09-09
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2022-09-28
Penalties and ownership
What sits behind the stars
$14,015
2025-10-02
Fine
Fine · fine $14,015
Fine
$7,901
2023-09-27
Fine
Fine · fine $7,901
Fine
Ownership
Covenant Health
5% Or Greater Direct Ownership Interest · Organization
Castillo, Nicole
W-2 Managing Employee · Individual
Downing, Delbert
Corporate Officer · Individual
Nearby options
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