Cycle 1
Health 2025-08-27 · Fire 2025-08-27
4 health deficiencies
Top issue: Resident Rights (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Holyoke, MA
Mary's Meadow At Providence Place
5-star overall rating with 4-star inspections with 4 recent health deficiencies
12 Gamelin Street, Holyoke, MA
(413) 493-2749
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
40
Certified beds
Average residents
37
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1998-01-22
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
0.76
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.28
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
3.44
Nurse aide staffing · state 2.26 · national 2.35
Total nurse hours
5.48
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
2.04
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
5.03
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.55
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.83
CMS adjusted RN staffing hours
Adjusted total hours
6.01
CMS adjusted total nurse staffing hours
Case-mix index
1.25
Higher values indicate more complex resident acuity
RN turnover
38%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
37%
Annual nurse turnover · state 40% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,239
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
58.49
Composite VBP score used to determine payment impact.
Payment multiplier
1.0137
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.92
Baseline 14.99% · Performance 18.22% · Measure score 6.92 · Achievement 6.92 · Improvement 0
Healthcare-associated infections
2.48
Baseline 6.16% · Performance 7.09% · Measure score 2.48 · Achievement 2.48 · Improvement 0
Total nurse turnover
5.2
Baseline 43.33% · Performance 42.42% · Measure score 5.2 · Achievement 5.2 · Improvement 0
Adjusted total nurse staffing
8.79
Baseline 6.69 hours · Performance 5.58 hours · Measure score 8.79 · Achievement 8.79 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.7% |
10.72%
2 pts worse
|
No Different than the National Rate · Eligible stays 339 · Observed rate 11.5% · Lower 95% interval 9.55% |
| Discharge to community | 65.86% |
50.57%
15.3 pts better
|
Better than the National Rate · Eligible stays 324 · Observed rate 68.52% · Lower 95% interval 60.53% |
| Medicare spending per beneficiary | 0.75 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 99.48% |
95.27%
4.2 pts better
|
Numerator 190 · Denominator 191 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 191 |
| Discharge self-care score | 79.78% |
53.69%
26.1 pts better
|
Numerator 146 · Denominator 183 |
| Discharge mobility score | 79.78% |
50.94%
28.8 pts better
|
Numerator 146 · Denominator 183 |
| Pressure ulcers or injuries, new or worsened | 2.09% |
2.29%
0.2 pts better
|
Numerator 4 · Denominator 191 · Adjusted rate 2.83% |
| Healthcare-associated infections requiring hospitalization | 7.09% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 179 · Observed rate 5.03% · Lower 95% interval 4.07% |
| Staff COVID-19 vaccination coverage | 7.79% |
8.2%
0.4 pts worse
|
Numerator 6 · Denominator 77 |
| Staff flu vaccination coverage | 93.1% |
42%
51.1 pts better
|
Numerator 108 · Denominator 116 |
| Discharge function score | 83.06% |
56.45%
26.6 pts better
|
Numerator 152 · Denominator 183 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 163 · Denominator 163 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 42.57% |
25.2%
17.4 pts better
|
Numerator 43 · Denominator 101 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.2 |
1.9
1.7 pts better
|
1.9
1.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.2 · Observed 0.2 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
1.5
0.8 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.6 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
92.2%
7.8 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 | 6.6% |
3.5%
3.1 pts worse
|
3.3%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 9.5% · Q3 4.3% · Q4 4.0% · 4Q avg 6.6% · 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% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 3.4% |
5.2%
1.8 pts better
|
5.4%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 0.0% · Q3 4.3% · Q4 0.0% · 4Q avg 3.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.8% |
19.2%
0.6 pts worse
|
19.6%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.2% · Q2 19.0% · Q3 21.7% · Q4 20.0% · 4Q avg 19.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 0.0% |
22.5%
22.5 pts better
|
16.7%
16.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 0.0% · 4Q avg 0.0% · 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 | 24.1% |
17.7%
6.4 pts worse
|
16.3%
7.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 24.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.1% |
17.6%
4.5 pts worse
|
14.9%
7.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.6% · Q2 10.0% · Q3 13.6% · Q4 34.8% · 4Q avg 22.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.0%
1 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.1% |
2.0%
0.9 pts better
|
1.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 4.3% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 39.1% |
21.7%
17.4 pts worse
|
19.8%
19.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 47.5% · Q3 32.8% · 4Q avg 39.1% |
| Percentage of long-stay residents with pressure ulcers | 1.7% |
4.6%
2.9 pts better
|
5.1%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 6.7% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
77.1%
22.9 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.6% |
11.8%
0.2 pts better
|
12.0%
0.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.6% · Observed 9.7% · Expected 9.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.2% |
1.3%
1.1 pts better
|
1.6%
1.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.1% |
77.7%
18.4 pts better
|
79.7%
16.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 14.6% |
25.8%
11.2 pts better
|
23.9%
9.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 14.6% · Observed 12.1% · Expected 19.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-10 · Fire 2024-07-10
0 health deficiencies
No concentrated health issue counts in this cycle.
2 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Cycle 3
Health 2023-07-10 · Fire 2023-07-10
6 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-07-10
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-07-30
E · Potential for more than minimal harm
2024-07-10
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-07-30
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-08-27
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 2025-09-19
D · Potential for more than minimal harm
2025-08-27
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 2025-09-19
D · Potential for more than minimal harm
2025-08-27
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 2025-09-19
B · Minimal harm
2025-08-27
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2025-09-19
E · Potential for more than minimal harm
2023-07-10
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2023-08-11
D · Potential for more than minimal harm
2023-07-10
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-08-11
D · Potential for more than minimal harm
2023-07-10
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 2023-08-11
D · Potential for more than minimal harm
2023-07-10
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-08-11
D · Potential for more than minimal harm
2023-07-10
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-08-11
D · Potential for more than minimal harm
2023-07-10
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 2023-08-11
Penalties and ownership
What sits behind the stars
Ownership
Sisters Of Providence Ministry Corporation
5% Or Greater Direct Ownership Interest · Organization
Arguin, Patrick
W-2 Managing Employee · Individual
Dana, Eric
Contracted Managing Employee · Individual
Fulton, Agnes
Corporate Director · Individual
Fulton, Agnes
Corporate Officer · Individual
Geary, Mary
Corporate Director · Individual
Geary, Mary
Corporate Officer · Individual
Keough, Jill
Corporate Director · Individual
Noonan, Geraldine
Corporate Director · Individual
Popko, Kathleen
Corporate Director · Individual
Popko, Kathleen
Corporate Officer · Individual
Sjoberg, John
Corporate Director · Individual
Tremble, Michael
Corporate Director · Individual
Trinity Senior Services Management Inc
Operational/Managerial Control · Organization
Wesolowski, John
Corporate Officer · Individual
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#3
Mission Care At Holyoke
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2-star overall rating with 2-star inspections with abuse icon flag with $16,985 in total fines with 17 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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