Cycle 1
Health 2025-03-20 · Fire 2025-03-20
6 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Topsfield, MA
Masconomet Rehabilitation And Healthcare Center
4-star overall rating with 4-star inspections with 6 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
123 High Street, Topsfield, MA
(978) 887-7002
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
123
Certified beds
Average residents
113
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Atlas Healthcare
Operator or chain grouping
Approved since
1999-07-06
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
28 facilities
Chain averages 4 overall / 3 health / 2 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
0.67
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
0.92
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
1.96
Nurse aide staffing · state 2.26 · national 2.35
Total nurse hours
3.56
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.59
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.29
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.59
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.63
CMS adjusted RN staffing hours
Adjusted total hours
3.35
CMS adjusted total nurse staffing hours
Case-mix index
1.45
Higher values indicate more complex resident acuity
RN turnover
39%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
51%
Annual nurse turnover · state 40% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,315
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
50.26
Composite VBP score used to determine payment impact.
Payment multiplier
1.0044
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.94
Baseline 23.26% · Performance 21.11% · Measure score 2.94 · Achievement 0.69 · Improvement 2.94
Healthcare-associated infections
5.52
Baseline 5.13% · Performance 6.18% · Measure score 5.52 · Achievement 5.52 · Improvement 0
Total nurse turnover
7.91
Baseline 31.63% · Performance 31.36% · Measure score 7.91 · Achievement 7.91 · Improvement 0
Adjusted total nurse staffing
3.73
Baseline 3.78 hours · Performance 4.14 hours · Measure score 3.73 · Achievement 3.73 · Improvement 1.29
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.47% |
10.72%
2.8 pts worse
|
No Different than the National Rate · Eligible stays 395 · Observed rate 13.67% · Lower 95% interval 10.4% |
| Discharge to community | 54.19% |
50.57%
3.6 pts better
|
No Different than the National Rate · Eligible stays 370 · Observed rate 49.19% · Lower 95% interval 49.47% |
| Medicare spending per beneficiary | 0.91 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 99.63% |
95.27%
4.4 pts better
|
Numerator 271 · Denominator 272 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 272 |
| Discharge self-care score | 10% |
53.69%
43.7 pts worse
|
Numerator 21 · Denominator 210 |
| Discharge mobility score | 5.24% |
50.94%
45.7 pts worse
|
Numerator 11 · Denominator 210 |
| Pressure ulcers or injuries, new or worsened | 4.41% |
2.29%
2.1 pts worse
|
Numerator 12 · Denominator 272 · Adjusted rate 3.41% |
| Healthcare-associated infections requiring hospitalization | 6.18% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 258 · Observed rate 5.04% · Lower 95% interval 4.22% |
| Staff COVID-19 vaccination coverage | 24.11% |
8.2%
15.9 pts better
|
Numerator 34 · Denominator 141 |
| Staff flu vaccination coverage | 85.36% |
42%
43.4 pts better
|
Numerator 204 · Denominator 239 |
| Discharge function score | 5.24% |
56.45%
51.2 pts worse
|
Numerator 11 · Denominator 210 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 60 · Denominator 60 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 165 · Denominator 165 |
| Resident COVID-19 vaccinations up to date | 26.03% |
25.2%
0.8 pts better
|
Numerator 38 · Denominator 146 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
1.9
0.3 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.4 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
1.5
0.2 pts better
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.3 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.9% |
92.2%
6.7 pts better
|
93.4%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 95.2% · 4Q avg 98.9% |
| 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 | 3.6% |
3.5%
0.1 pts worse
|
3.3%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 2.0% · Q3 5.5% · Q4 3.6% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 9.8% |
12.0%
2.2 pts better
|
11.4%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 16.1% · Q4 25.3% · 4Q avg 9.8% |
| 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 2.8% · Q2 2.6% · Q3 4.3% · Q4 4.5% · 4Q avg 3.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.3% |
19.2%
1.1 pts worse
|
19.6%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 22.8% · Q3 22.5% · Q4 15.7% · 4Q avg 20.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 23.9% |
22.5%
1.4 pts worse
|
16.7%
7.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.6% · Q2 28.6% · Q3 25.5% · Q4 20.0% · 4Q avg 23.9% · 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 | 29.2% |
17.7%
11.5 pts worse
|
16.3%
12.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.9% · Q2 14.8% · Q3 34.2% · 4Q avg 29.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.6% |
17.6%
3 pts better
|
14.9%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.7% · Q2 18.7% · Q3 6.3% · Q4 12.3% · 4Q avg 14.6% · 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 1.5% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.6% |
2.0%
1.4 pts better
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.0% · Q3 1.1% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.4% |
21.7%
8.7 pts worse
|
19.8%
10.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.9% · Q2 34.4% · Q3 29.6% · Q4 31.3% · 4Q avg 30.4% |
| Percentage of long-stay residents with pressure ulcers | 4.7% |
4.6%
0.1 pts worse
|
5.1%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 4.9% · Q3 4.4% · Q4 4.0% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.7% |
77.1%
14.6 pts better
|
81.7%
10 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.9% · Q2 97.3% · Q3 92.0% · Q4 79.7% · 4Q avg 91.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.5% |
11.8%
5.3 pts better
|
12.0%
5.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.5% · Observed 5.9% · Expected 10.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.3%
0.5 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 0.8% · Q3 0.8% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 92.3% |
77.7%
14.6 pts better
|
79.7%
12.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 31.8% |
25.8%
6 pts worse
|
23.9%
7.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 31.8% · Observed 27.0% · Expected 20.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-11 · Fire 2024-04-11
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-04-07 · Fire 2023-04-07
4 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-20
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-04-24
F · Potential for more than minimal harm
2025-03-20
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-04-24
F · Potential for more than minimal harm
2025-03-20
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-04-24
E · Potential for more than minimal harm
2025-03-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-24
E · Potential for more than minimal harm
2025-03-20
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2025-04-24
F · Potential for more than minimal harm
2023-04-07
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-05-12
F · Potential for more than minimal harm
2023-04-07
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-05-12
D · Potential for more than minimal harm
2023-04-07
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-05-12
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-03-20
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2025-04-28
D · Potential for more than minimal harm
2025-03-20
F568 · Resident Rights Deficiencies
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2025-04-28
D · Potential for more than minimal harm
2025-03-20
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 2025-04-28
D · Potential for more than minimal harm
2025-03-20
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-04-28
D · Potential for more than minimal harm
2025-03-20
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-04-28
D · Potential for more than minimal harm
2025-03-20
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 2025-04-28
D · Potential for more than minimal harm
2024-04-11
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-05-16
D · Potential for more than minimal harm
2023-04-07
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 2023-05-08
D · Potential for more than minimal harm
2023-04-07
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-05-08
D · Potential for more than minimal harm
2023-04-07
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-05-08
D · Potential for more than minimal harm
2023-04-07
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2023-05-08
Penalties and ownership
What sits behind the stars
Ownership
Whittier Mop Operations Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Bak, Pinchos
Corporate Officer · Individual
Bearse, Brook
Operational/Managerial Control · Individual
Elms, Diane
Operational/Managerial Control · Individual
Glen Oak 11, LLC
Limited Partnership Interest · Organization
Jmh Family LLC
5% Or Greater Indirect Ownership Interest · Organization
Jmh Family LLC
Limited Partnership Interest · Organization
Jmh Family Trust
5% Or Greater Indirect Ownership Interest · Organization
Jmh Family Trust
Limited Partnership Interest · Organization
Malt Family Trust
Limited Partnership Interest · Organization
Miller, Nachum
5% Or Greater Indirect Ownership Interest · Individual
Miller, Nachum
Limited Partnership Interest · Individual
Miller, Nachum
Operational/Managerial Control · Individual
Mls Family LLC
5% Or Greater Indirect Ownership Interest · Organization
Mls Family LLC
Limited Partnership Interest · Organization
Mls Family Trust
5% Or Greater Indirect Ownership Interest · Organization
Mls Family Trust
Limited Partnership Interest · Organization
Sgs 2010 Family Trust
Limited Partnership Interest · Organization
Sgs Family LLC
5% Or Greater Indirect Ownership Interest · Organization
Sgs Family LLC
Limited Partnership Interest · Organization
Sgs Family Trust
5% Or Greater Indirect Ownership Interest · Organization
Sgs Family Trust
Limited Partnership Interest · Organization
Sonnenschein, Moshe
Operational/Managerial Control · Individual
Tyh 2017 Trust
Limited Partnership Interest · Organization
Udom, Chieke
Operational/Managerial Control · Individual
Whittier 6 Operations Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Whittier 6 Operations Holdings LLC
Limited Partnership Interest · Organization
Whittier Opco Manager LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Hunt Nursing & Rehab Center
Danvers, MA
3-star overall rating with 3-star inspections with $10,517 in total fines with 5 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
#2
Hathorne Hill Rehabilitation And Healthcare Center
Danvers, MA
4-star overall rating with 4-star inspections with $242,785 in total fines with 3 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#3
Twin Oaks Center
Danvers, MA
1-star overall rating with 1-star inspections with $141,733 in total fines with 19 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
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