North Attleboro, MA

Madonna Manor Nursing Home

4-star overall rating with 3-star inspections with $119,373 in total fines with 6 recent health deficiencies

85 North Washington Street, North Attleboro, MA

(508) 699-2740

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

3 / 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

129

Certified beds

Average residents

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

Diocesan Health Facilities

Operator or chain grouping

Approved since

1990-07-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

5 facilities

Chain averages 4 overall / 3 health / 5 staffing / 3 quality stars

Changed ownership

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

0.89

Registered nurse staffing · state 0.65 · national 0.68

LPN hours / resident day

0.88

Licensed practical nurse staffing · state 0.96 · national 0.87

Aide hours / resident day

1.95

Nurse aide staffing · state 2.26 · national 2.35

Total nurse hours

3.72

All reported nurse hours · state 3.86 · national 3.89

Licensed hours

1.76

RN + LPN hours · state 1.60 · national 1.54

Weekend hours

3.43

Weekend nurse staffing · state 3.45 · national 3.43

Weekend RN hours

0.69

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

1.04

CMS adjusted RN staffing hours

Adjusted total hours

4.37

CMS adjusted total nurse staffing hours

Case-mix index

1.16

Higher values indicate more complex resident acuity

RN turnover

Annual RN turnover · state 45% · national 45%

Total nurse turnover

15%

Annual nurse turnover · state 40% · national 46%

SNF VBP

Value-based purchasing

Program rank

2,450

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

49.71

Composite VBP score used to determine payment impact.

Payment multiplier

1.0037

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Baseline 19.31% · Performance 22.21% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

5.22

Baseline 6.65% · Performance 6.27% · Measure score 5.22 · Achievement 5.22 · Improvement 1.76

Total nurse turnover

Baseline 29.87% · Performance 21.74% · Measure score 10 · Achievement 10 · Improvement 9

Adjusted total nurse staffing

4.66

Baseline 4.58 hours · Performance 4.40 hours · Measure score 4.66 · Achievement 4.66 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	12.56%	10.72% 1.8 pts worse	No Different than the National Rate · Eligible stays 88 · Observed rate 18.18% · Lower 95% interval 9.01%
Discharge to community	43.58%	50.57% 7 pts worse	No Different than the National Rate · Eligible stays 52 · Observed rate 34.62% · Lower 95% interval 31.89%
Medicare spending per beneficiary	0.95	1.02 0.1 pts better
Drug regimen review with follow-up	98.48%	95.27% 3.2 pts better	Numerator 65 · Denominator 66
Falls with major injury	1.52%	0.77% 0.8 pts worse	Numerator 1 · Denominator 66
Discharge self-care score	41.82%	53.69% 11.9 pts worse	Numerator 23 · Denominator 55
Discharge mobility score	58.18%	50.94% 7.2 pts better	Numerator 32 · Denominator 55
Pressure ulcers or injuries, new or worsened	1.52%	2.29% 0.8 pts better	Numerator 1 · Denominator 66 · Adjusted rate 1.21%
Healthcare-associated infections requiring hospitalization	6.27%	7.12% 0.9 pts better	No Different than the National Rate · Eligible stays 48 · Observed rate 4.17% · Lower 95% interval 3.78%
Staff COVID-19 vaccination coverage	25.86%	8.2% 17.7 pts better	Numerator 30 · Denominator 116
Staff flu vaccination coverage	57.25%	42% 15.2 pts better	Numerator 75 · Denominator 131
Discharge function score	52.73%	56.45% 3.7 pts worse	Numerator 29 · Denominator 55
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly.
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	62.16%	25.2% 37 pts better	Numerator 23 · Denominator 37

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.9	1.9 About the same	1.9 About the same	Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.3 · Expected 1.4 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.4	1.5 0.1 pts better	1.8 0.4 pts better	Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.1 · Expected 1.3 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	74.9%	92.2% 17.3 pts worse	93.4% 18.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 75.7% · Q2 75.4% · Q3 75.0% · Q4 73.6% · 4Q avg 74.9%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	97.2%	94.8% 2.4 pts better	95.5% 1.7 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 97.2%
Percentage of long-stay residents experiencing one or more falls with major injury	6.1%	3.5% 2.6 pts worse	3.3% 2.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 5.8% · Q3 7.4% · Q4 5.6% · 4Q avg 6.1% · 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	5.4%	5.2% 0.2 pts worse	5.4% About the same	Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 6.5% · Q3 3.0% · Q4 4.3% · 4Q avg 5.4%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	11.1%	19.2% 8.1 pts better	19.6% 8.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 10.6% · Q2 12.1% · Q3 10.4% · Q4 11.3% · 4Q avg 11.1%
Percentage of long-stay residents who received an antipsychotic medication	20.8%	22.5% 1.7 pts better	16.7% 4.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 19.2% · Q2 19.1% · Q3 22.0% · Q4 22.2% · 4Q avg 20.8% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.4%	0.1% 0.3 pts worse	0.1% 0.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4%
Percentage of long-stay residents whose ability to walk independently worsened	11.6%	17.7% 6.1 pts better	16.3% 4.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 29.2% · Q2 10.0% · Q3 3.4% · Q4 6.2% · 4Q avg 11.6% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	8.2%	17.6% 9.4 pts better	14.9% 6.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 13.1% · Q2 11.3% · Q3 1.6% · Q4 7.2% · 4Q avg 8.2% · 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 1.2% · 4Q avg 0.3% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	2.2%	2.0% 0.2 pts worse	1.7% 0.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 4.6% · Q3 1.5% · Q4 0.0% · 4Q avg 2.2% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	10.3%	21.7% 11.4 pts better	19.8% 9.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 12.6% · Q2 11.3% · Q3 7.6% · Q4 9.9% · 4Q avg 10.3%
Percentage of long-stay residents with pressure ulcers	4.1%	4.6% 0.5 pts better	5.1% 1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 5.3% · Q3 4.1% · Q4 4.0% · 4Q avg 4.1% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	60.8%	77.1% 16.3 pts worse	81.7% 20.9 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 68.0% · Q2 57.1% · Q3 62.9% · Q4 56.0% · 4Q avg 60.8%
Percentage of short-stay residents who had an outpatient emergency department visit	9.6%	11.8% 2.2 pts better	12.0% 2.4 pts better	Short Stay · 20240701-20250630 · Adjusted 9.6% · Observed 8.8% · Expected 10.2% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.0%	1.3% 1.3 pts better	1.6% 1.6 pts better	Short Stay · 2024Q4-2025Q3 · Q3 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	60.0%	77.7% 17.7 pts worse	79.7% 19.7 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 60.0%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	13.6%	25.8% 12.2 pts better	23.9% 10.3 pts better	Short Stay · 20240701-20250630 · Adjusted 13.6% · Observed 10.5% · Expected 18.5% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-09-11 · Fire 2025-09-11

6 health deficiencies

Top issue: Infection Control (2 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 2 Health 2024-08-21 · Fire 2024-08-21

10 health deficiencies

Top issue: Resident Rights (4 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 3 Health 2023-07-19 · Fire 2023-07-19

13 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-09-11

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 2025-10-17

D · Potential for more than minimal harm 2025-09-11

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2025-10-17

D · Potential for more than minimal harm 2025-09-11

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 2025-10-17

D · Potential for more than minimal harm 2025-09-11

F840 · Administration Deficiencies

Health

Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.

Corrected 2025-10-17

D · Potential for more than minimal harm 2025-09-11

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-10-17

D · Potential for more than minimal harm 2025-09-11

F887 · Infection Control Deficiencies

Health

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

Corrected 2025-10-17

D · Potential for more than minimal harm 2024-12-02

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2024-12-16

G · Actual harm 2024-08-21

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2024-09-10

G · Actual harm 2024-08-21

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2024-09-10

E · Potential for more than minimal harm 2024-08-21

F565 · Resident Rights Deficiencies

Health

Honor the resident's right to organize and participate in resident/family groups in the facility.

Corrected 2024-09-10

E · Potential for more than minimal harm 2024-08-21

F585 · Resident Rights Deficiencies

Health

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Corrected 2024-09-10

E · Potential for more than minimal harm 2024-08-21

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 2024-09-10

D · Potential for more than minimal harm 2024-08-21

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 2024-09-10

D · Potential for more than minimal harm 2024-08-21

F690 · Quality of Life and Care Deficiencies

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 2024-09-10

D · Potential for more than minimal harm 2024-08-21

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2024-09-10

D · Potential for more than minimal harm 2024-08-21

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-09-10

E · Potential for more than minimal harm 2023-12-28

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2024-01-19

G · Actual harm 2023-09-06

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 2023-09-27

G · Actual harm 2023-09-06

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 2023-09-27

G · Actual harm 2023-07-19

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 2023-08-16

E · Potential for more than minimal harm 2023-07-19

F584 · Resident Rights Deficiencies

Health

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected 2023-08-16

E · Potential for more than minimal harm 2023-07-19