Cycle 1
Health 2024-12-12 · Fire 2024-12-12
14 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Methuen, MA
Nevins Nursing & Rehabilitation Center
1-star overall rating with 2-star inspections with $17,966 in total fines with 14 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
Ten Ingalls Court, Methuen, MA
(978) 682-7611
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
153
Certified beds
Average residents
139
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1990-07-01
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
0.47
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.06
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.33
Nurse aide staffing · state 2.26 · national 2.35
Total nurse hours
3.86
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.52
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.40
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.46
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.47
CMS adjusted RN staffing hours
Adjusted total hours
3.89
CMS adjusted total nurse staffing hours
Case-mix index
1.36
Higher values indicate more complex resident acuity
RN turnover
12%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
27%
Annual nurse turnover · state 40% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,723
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
42.96
Composite VBP score used to determine payment impact.
Payment multiplier
0.9959
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.43
Baseline 21.42% · Performance 18.45% · Measure score 6.43 · Achievement 6.43 · Improvement 6.26
Healthcare-associated infections
0.53
Baseline 6.03% · Performance 7.68% · Measure score 0.53 · Achievement 0.53 · Improvement 0
Total nurse turnover
7.65
Baseline 30.22% · Performance 32.43% · Measure score 7.65 · Achievement 7.65 · Improvement 0
Adjusted total nurse staffing
2.58
Baseline 4.46 hours · Performance 3.81 hours · Measure score 2.58 · Achievement 2.58 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.26% |
10.72%
0.5 pts better
|
No Different than the National Rate · Eligible stays 283 · Observed rate 8.83% · Lower 95% interval 7.85% |
| Discharge to community | 54% |
50.57%
3.4 pts better
|
No Different than the National Rate · Eligible stays 247 · Observed rate 49.8% · Lower 95% interval 48.64% |
| Medicare spending per beneficiary | 0.73 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 99.47% |
95.27%
4.2 pts better
|
Numerator 187 · Denominator 188 |
| Falls with major injury | 0.53% |
0.77%
0.2 pts better
|
Numerator 1 · Denominator 187 |
| Discharge self-care score | 29.14% |
53.69%
24.5 pts worse
|
Numerator 44 · Denominator 151 |
| Discharge mobility score | 35.1% |
50.94%
15.8 pts worse
|
Numerator 53 · Denominator 151 |
| Pressure ulcers or injuries, new or worsened | 2.15% |
2.29%
0.1 pts better
|
Numerator 4 · Denominator 186 · Adjusted rate 1.71% |
| Healthcare-associated infections requiring hospitalization | 7.68% |
7.12%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 162 · Observed rate 6.79% · Lower 95% interval 4.91% |
| Staff COVID-19 vaccination coverage | 12.55% |
8.2%
4.4 pts better
|
Numerator 33 · Denominator 263 |
| Staff flu vaccination coverage | 47.78% |
42%
5.8 pts better
|
Numerator 129 · Denominator 270 |
| Discharge function score | 33.11% |
56.45%
23.3 pts worse
|
Numerator 50 · Denominator 151 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 33 · Denominator 33 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 98 · Denominator 98 |
| Resident COVID-19 vaccinations up to date | 19.39% |
25.2%
5.8 pts worse
|
Numerator 19 · Denominator 98 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
1.9
0.1 pts worse
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.6 · Expected 1.6 · 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 1.9 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.7% |
92.2%
5.5 pts better
|
93.4%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.3% · Q2 97.5% · Q3 99.1% · Q4 99.2% · 4Q avg 97.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.0% |
94.8%
2.2 pts better
|
95.5%
1.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.7% |
3.5%
1.2 pts worse
|
3.3%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 4.1% · Q3 3.4% · Q4 4.2% · 4Q avg 4.7% · 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 | 5.1% |
5.2%
0.1 pts better
|
5.4%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.6% · Q2 4.0% · Q3 6.4% · Q4 2.1% · 4Q avg 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.0% |
19.2%
0.2 pts better
|
19.6%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.5% · Q2 21.5% · Q3 17.0% · Q4 16.7% · 4Q avg 19.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.0% |
22.5%
2.5 pts better
|
16.7%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.5% · Q2 21.5% · Q3 20.8% · Q4 17.3% · 4Q avg 20.0% · 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 | 25.3% |
17.7%
7.6 pts worse
|
16.3%
9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.0% · Q2 32.0% · Q3 16.0% · Q4 15.9% · 4Q avg 25.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.6% |
17.6%
5 pts worse
|
14.9%
7.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.1% · Q2 21.4% · Q3 16.0% · Q4 25.8% · 4Q avg 22.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.4% |
1.0%
0.4 pts worse
|
1.0%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 0.8% · Q3 1.5% · Q4 0.8% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.3% |
2.0%
2.3 pts worse
|
1.7%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 5.2% · Q3 4.5% · Q4 3.5% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 32.6% |
21.7%
10.9 pts worse
|
19.8%
12.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.0% · Q2 34.7% · Q3 28.6% · Q4 40.4% · 4Q avg 32.6% |
| Percentage of long-stay residents with pressure ulcers | 2.7% |
4.6%
1.9 pts better
|
5.1%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 4.5% · Q3 1.5% · Q4 2.3% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.7% |
77.1%
20.6 pts better
|
81.7%
16 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.6% · Q2 98.2% · Q3 98.6% · Q4 96.3% · 4Q avg 97.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.6% |
11.8%
3.8 pts worse
|
12.0%
3.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.6% · Observed 15.6% · Expected 11.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.9% |
1.3%
0.6 pts worse
|
1.6%
0.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 1.0% · Q3 1.9% · Q4 2.8% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.0% |
77.7%
13.3 pts better
|
79.7%
11.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.0% |
25.8%
2.8 pts better
|
23.9%
0.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.0% · Observed 20.8% · Expected 21.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-14 · Fire 2023-12-14
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-10-14 · Fire 2022-10-14
16 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-12-12
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2025-02-06
F · Potential for more than minimal harm
2024-12-12
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-02-06
F · Potential for more than minimal harm
2024-12-12
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-02-06
F · Potential for more than minimal harm
2024-12-12
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-02-06
E · Potential for more than minimal harm
2024-12-12
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2025-02-06
E · Potential for more than minimal harm
2024-12-12
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2025-02-06
E · Potential for more than minimal harm
2024-12-12
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-02-06
E · Potential for more than minimal harm
2024-12-12
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-02-06
E · Potential for more than minimal harm
2024-12-12
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-02-06
D · Potential for more than minimal harm
2024-12-12
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-02-06
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-12-12
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 2025-01-26
E · Potential for more than minimal harm
2024-12-12
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 2025-01-26
E · Potential for more than minimal harm
2024-12-12
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 2025-01-26
D · Potential for more than minimal harm
2024-12-12
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 2025-01-26
D · Potential for more than minimal harm
2024-12-12
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 2025-01-26
D · Potential for more than minimal harm
2024-12-12
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 2025-01-26
D · Potential for more than minimal harm
2024-12-12
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-01-26
D · Potential for more than minimal harm
2024-12-12
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 2025-01-26
D · Potential for more than minimal harm
2024-12-12
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-01-26
D · Potential for more than minimal harm
2024-12-12
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 2025-01-26
D · Potential for more than minimal harm
2024-12-12
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-01-26
D · Potential for more than minimal harm
2024-12-12
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2025-01-26
D · Potential for more than minimal harm
2024-12-12
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 2025-01-26
D · Potential for more than minimal harm
2024-12-12
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 2025-01-26
G · Actual harm
2024-06-18
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 2024-07-31
G · Actual harm
2024-06-18
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 2024-07-31
D · Potential for more than minimal harm
2023-12-14
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 2024-01-28
D · Potential for more than minimal harm
2023-12-14
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-01-28
D · Potential for more than minimal harm
2023-12-14
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 2024-01-28
D · Potential for more than minimal harm
2023-12-14
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 2024-01-28
D · Potential for more than minimal harm
2023-12-14
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-01-28
D · Potential for more than minimal harm
2023-12-14
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-01-28
G · Actual harm
2023-04-18
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 2023-04-17
G · Actual harm
2022-10-14
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-10-28
E · Potential for more than minimal harm
2022-10-14
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 2022-11-18
D · Potential for more than minimal harm
2022-10-14
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 2022-11-18
D · Potential for more than minimal harm
2022-10-14
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2022-11-18
D · Potential for more than minimal harm
2022-10-14
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 2022-11-18
D · Potential for more than minimal harm
2022-10-14
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2022-11-18
D · Potential for more than minimal harm
2022-10-14
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-11-18
D · Potential for more than minimal harm
2022-10-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-11-18
D · Potential for more than minimal harm
2022-10-14
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 2022-11-18
D · Potential for more than minimal harm
2022-10-14
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-11-18
D · Potential for more than minimal harm
2022-10-14
F712 · Nursing and Physician Services Deficiencies
Health
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected 2022-11-18
D · Potential for more than minimal harm
2022-10-14
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 2022-11-18
D · Potential for more than minimal harm
2022-10-14
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 2022-11-18
D · Potential for more than minimal harm
2022-10-14
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 2022-11-18
D · Potential for more than minimal harm
2022-10-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-11-18
Penalties and ownership
What sits behind the stars
$9,318
2024-06-18
Fine
Fine · fine $9,318
Fine
$8,648
2023-04-18
Fine
Fine · fine $8,648
Fine
Ownership
Demers, Patricia
Corporate Director · Individual
Shannon, Joyce
Corporate Officer · Individual
Walsh, Sharon
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Cedar View Rehabilitation And Healthcare Center
Methuen, MA
5-star overall rating with 5-star inspections with 5 fire-safety deficiencies in the latest cycle
#2
M I Nursing & Restorative Center
Lawrence, MA
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
#3
Royal Wood Mill Center
Lawrence, MA
1-star overall rating with 2-star inspections with 12 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
Jump out