Cycle 1
Health 2025-04-23 · Fire 2025-04-23
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Lenox, MA
Mount Carmel Care Center
3-star overall rating with 3-star inspections with $46,410 in total fines with 6 recent health deficiencies
320 Pittsfield Road, Lenox, MA
(413) 637-2660
Overall
3 / 5
CMS overall stars
Health inspections
3 / 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
69
Certified beds
Average residents
59
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Carmelite Sisters For The Aged And Infirmed
Operator or chain grouping
Approved since
1993-06-03
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
3 facilities
Chain averages 4 overall / 4 health / 4 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
0.63
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.39
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.21
Nurse aide staffing · state 2.26 · national 2.35
Total nurse hours
4.22
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
2.02
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.93
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.52
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.62
CMS adjusted RN staffing hours
Adjusted total hours
4.16
CMS adjusted total nurse staffing hours
Case-mix index
1.39
Higher values indicate more complex resident acuity
RN turnover
56%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
71%
Annual nurse turnover · state 40% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,609
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
26.22
Composite VBP score used to determine payment impact.
Payment multiplier
0.9841
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.69
Baseline 19.21% · Performance 18.79% · Measure score 5.69 · Achievement 5.69 · Improvement 1.41
Healthcare-associated infections
0.75
Baseline 7.69% · Performance 7.61% · Measure score 0.75 · Achievement 0.75 · Improvement 0
Total nurse turnover
0
Baseline 48.48% · Performance 61.64% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
4.04
Baseline 3.69 hours · Performance 4.23 hours · Measure score 4.04 · Achievement 4.04 · Improvement 2.07
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.98% |
10.72%
2.3 pts worse
|
No Different than the National Rate · Eligible stays 196 · Observed rate 13.27% · Lower 95% interval 9.71% |
| Discharge to community | 51.58% |
50.57%
1 pts better
|
No Different than the National Rate · Eligible stays 166 · Observed rate 50% · Lower 95% interval 45.43% |
| Medicare spending per beneficiary | 1.05 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 122 · Denominator 122 |
| Falls with major injury | 4.1% |
0.77%
3.3 pts worse
|
Numerator 5 · Denominator 122 |
| Discharge self-care score | 67.86% |
53.69%
14.2 pts better
|
Numerator 57 · Denominator 84 |
| Discharge mobility score | 65.48% |
50.94%
14.5 pts better
|
Numerator 55 · Denominator 84 |
| Pressure ulcers or injuries, new or worsened | 5.74% |
2.29%
3.5 pts worse
|
Numerator 7 · Denominator 122 · Adjusted rate 4.6% |
| Healthcare-associated infections requiring hospitalization | 7.61% |
7.12%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 127 · Observed rate 6.3% · Lower 95% interval 4.42% |
| Staff COVID-19 vaccination coverage | 47.76% |
8.2%
39.6 pts better
|
Numerator 32 · Denominator 67 |
| Staff flu vaccination coverage | 74.74% |
42%
32.7 pts better
|
Numerator 71 · Denominator 95 |
| Discharge function score | 67.86% |
56.45%
11.4 pts better
|
Numerator 57 · Denominator 84 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 29 · Denominator 29 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 52 · Denominator 52 |
| Resident COVID-19 vaccinations up to date | 71.19% |
25.2%
46 pts better
|
Numerator 42 · Denominator 59 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
1.9
0.2 pts better
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.4 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.8 |
1.5
0.3 pts worse
|
1.8
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.6 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.1% |
92.2%
5.9 pts better
|
93.4%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.1% · Q2 96.5% · Q3 98.0% · Q4 100.0% · 4Q avg 98.1% |
| 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 | 5.3% |
3.5%
1.8 pts worse
|
3.3%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 8.8% · Q3 5.9% · Q4 0.0% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 9.2% |
12.0%
2.8 pts better
|
11.4%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 14.3% · Q3 15.4% · Q4 2.6% · 4Q avg 9.2% |
| Percentage of long-stay residents who lose too much weight | 7.1% |
5.2%
1.9 pts worse
|
5.4%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.3% · Q2 7.8% · Q3 2.3% · Q4 0.0% · 4Q avg 7.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.7% |
19.2%
5.5 pts better
|
19.6%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.2% · Q2 12.7% · Q3 14.9% · Q4 14.3% · 4Q avg 13.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 24.3% |
22.5%
1.8 pts worse
|
16.7%
7.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 25.5% · Q3 22.2% · Q4 24.3% · 4Q avg 24.3% · 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 | 12.3% |
17.7%
5.4 pts better
|
16.3%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 12.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.1% |
17.6%
2.5 pts worse
|
14.9%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.2% · Q2 16.0% · Q3 17.1% · Q4 17.1% · 4Q avg 20.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
1.0%
0.6 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.5% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.5% |
2.0%
0.5 pts worse
|
1.7%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 1.9% · Q3 4.1% · Q4 0.0% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.0% |
21.7%
0.3 pts worse
|
19.8%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.1% · Q2 23.5% · Q3 23.3% · Q4 12.6% · 4Q avg 22.0% |
| Percentage of long-stay residents with pressure ulcers | 5.8% |
4.6%
1.2 pts worse
|
5.1%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 6.9% · Q3 4.9% · Q4 5.9% · 4Q avg 5.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 81.0% |
77.1%
3.9 pts better
|
81.7%
0.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 87.3% · Q2 79.3% · Q3 77.1% · Q4 81.3% · 4Q avg 81.0% |
| 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 10.8% · Expected 10.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.3%
0.7 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.2% |
77.7%
15.5 pts better
|
79.7%
13.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 30.1% |
25.8%
4.3 pts worse
|
23.9%
6.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 30.1% · Observed 26.1% · Expected 20.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-10 · Fire 2024-04-10
13 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2023-01-23 · Fire 2023-01-23
3 health deficiencies
Top issue: Infection Control (2 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-04-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-23
F · Potential for more than minimal harm
2023-01-23
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-02-14
F · Potential for more than minimal harm
2023-01-23
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-02-14
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-04-23
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2025-04-28
D · Potential for more than minimal harm
2025-04-23
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 2025-05-30
D · Potential for more than minimal harm
2025-04-23
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 2025-05-30
D · Potential for more than minimal harm
2025-04-23
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-05-30
D · Potential for more than minimal harm
2025-04-23
F712 · Nursing and Physician Services Deficiencies
Health
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected 2025-05-07
D · Potential for more than minimal harm
2025-04-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-30
G · Actual harm
2024-04-10
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-05-17
F · Potential for more than minimal harm
2024-04-10
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-05-17
F · Potential for more than minimal harm
2024-04-10
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2024-05-17
D · Potential for more than minimal harm
2024-04-10
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 2024-05-14
D · Potential for more than minimal harm
2024-04-10
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 2024-05-14
D · Potential for more than minimal harm
2024-04-10
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-04-10
D · Potential for more than minimal harm
2024-04-10
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-05-17
D · Potential for more than minimal harm
2024-04-10
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 2024-05-14
D · Potential for more than minimal harm
2024-04-10
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-05-14
D · Potential for more than minimal harm
2024-04-10
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-05-17
D · Potential for more than minimal harm
2024-04-10
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-05-17
D · Potential for more than minimal harm
2024-04-10
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 2024-05-17
D · Potential for more than minimal harm
2024-04-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-17
E · Potential for more than minimal harm
2023-01-23
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-02-17
D · Potential for more than minimal harm
2023-01-23
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 2023-02-16
D · Potential for more than minimal harm
2023-01-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-02-14
Penalties and ownership
What sits behind the stars
$46,410
2024-04-10
Fine
Fine · fine $46,410
Fine
Ownership
Carmelite Sisters For The Aged And Infirm, Inc.
5% Or Greater Indirect Ownership Interest · Organization
The Carmelite System Inc
5% Or Greater Direct Ownership Interest · Organization
Haley, Margaret
Corporate Director · Individual
Heery, Mary
Corporate Director · Individual
Kasper, Rose Marie
Corporate Director · Individual
Kasper, Rose Marie
Corporate Officer · Individual
Kearns, John
Corporate Director · Individual
Kirby, Craig
Contracted Managing Employee · Individual
Ouimette, Jodi
W-2 Managing Employee · Individual
Randall, Diane
Corporate Director · Individual
Randall, Diane
Corporate Officer · Individual
Rawdon, Patricia
Corporate Director · Individual
The Carmelite System Inc
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Kimball Farms Nursing Care Center
Lenox, MA
4-star overall rating with 4-star inspections with 3 recent health deficiencies
#2
Berkshire Place
Pittsfield, MA
4-star overall rating with 4-star inspections with $8,648 in total fines with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Springside Rehabilitation And Skilled Care Center
Pittsfield, MA
3-star overall rating with 4-star inspections with $9,770 in total fines with 2 recent health deficiencies
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