Cycle 1
Health 2025-03-19 · Fire 2025-03-19
9 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
11 fire-safety deficiencies
Top issue: Emergency Preparedness (6 deficiencies)
Danvers, MA
New England Homes For The Deaf, Inc
4-star overall rating with 3-star inspections with $3,174 in total fines with 9 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
154 Water Street, Danvers, MA
(978) 774-0445
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
81
Certified beds
Average residents
29
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2004-08-01
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
0.81
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.01
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
3.21
Nurse aide staffing · state 2.26 · national 2.35
Total nurse hours
5.03
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.82
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
4.56
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
0.19
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.97
CMS adjusted RN staffing hours
Adjusted total hours
6.02
CMS adjusted total nurse staffing hours
Case-mix index
1.14
Higher values indicate more complex resident acuity
RN turnover
20%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
35%
Annual nurse turnover · state 40% · national 46%
SNF VBP
Value-based purchasing
Program rank
712
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
65.01
Composite VBP score used to determine payment impact.
Payment multiplier
1.0193
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
4.57
Baseline 19.05% · Performance 45.00% · Measure score 4.57 · Achievement 4.57 · Improvement 0
Adjusted total nurse staffing
8.43
Baseline 4.06 hours · Performance 5.48 hours · Measure score 8.43 · Achievement 8.43 · Improvement 7.73
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.11% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 33 · Observed rate 6.06% · Lower 95% interval 5.82% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 18 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.87 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 71.88% |
95.27%
23.4 pts worse
|
Numerator 23 · Denominator 32 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 32 |
| Discharge self-care score | 58.33% |
53.69%
4.6 pts better
|
Numerator 14 · Denominator 24 |
| Discharge mobility score | 29.17% |
50.94%
21.8 pts worse
|
Numerator 7 · Denominator 24 |
| Pressure ulcers or injuries, new or worsened | 6.25% |
2.29%
4 pts worse
|
Numerator 2 · Denominator 32 · Adjusted rate 10.51% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 23 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 27.78% |
8.2%
19.6 pts better
|
Numerator 30 · Denominator 108 |
| Staff flu vaccination coverage | 96.83% |
42%
54.8 pts better
|
Numerator 122 · Denominator 126 |
| Discharge function score | 58.33% |
56.45%
1.9 pts better
|
Numerator 14 · Denominator 24 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.5 |
1.9
1.6 pts worse
|
1.9
1.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.5 · Observed 2.7 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.3 |
1.5
1.8 pts worse
|
1.8
1.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.3 · Observed 2.9 · Expected 1.5 · 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 | 6.2% |
3.5%
2.7 pts worse
|
3.3%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 8.7% · Q3 8.0% · Q4 3.7% · 4Q avg 6.2% · 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 | 3.0% |
5.2%
2.2 pts better
|
5.4%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 4.8% · 4Q avg 3.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.8% |
19.2%
1.6 pts worse
|
19.6%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q4 18.2% · 4Q avg 20.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 23.5% |
22.5%
1 pts worse
|
16.7%
6.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 23.5% · 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 | 29.0% |
17.7%
11.3 pts worse
|
16.3%
12.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 29.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 30.9% |
17.6%
13.3 pts worse
|
14.9%
16 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q4 25.0% · 4Q avg 30.9% · 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 · Q2 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 | 0.0% |
2.0%
2 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.2% |
21.7%
1.5 pts worse
|
19.8%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 27.0% · Q3 19.7% · Q4 26.2% · 4Q avg 23.2% |
| Percentage of long-stay residents with pressure ulcers | 3.6% |
4.6%
1 pts better
|
5.1%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 0.0% · Q4 5.7% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 84.1% |
77.1%
7 pts better
|
81.7%
2.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q3 90.5% · 4Q avg 84.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.7% |
11.8%
0.1 pts better
|
12.0%
0.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.7% · Observed 11.8% · Expected 11.2% · 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 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.9% |
25.8%
5.9 pts better
|
23.9%
4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.9% · Observed 17.6% · Expected 21.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-21 · Fire 2024-03-21
6 health deficiencies
Top issue: Environmental (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-10-27 · Fire 2022-10-27
7 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-19
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2025-04-30
F · Potential for more than minimal harm
2025-03-19
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2025-04-30
F · Potential for more than minimal harm
2025-03-19
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2025-04-30
F · Potential for more than minimal harm
2025-03-19
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-04-16
F · Potential for more than minimal harm
2025-03-19
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-04-30
F · Potential for more than minimal harm
2025-03-19
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2025-04-30
F · Potential for more than minimal harm
2025-03-19
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2025-04-12
F · Potential for more than minimal harm
2025-03-19
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-04-30
F · Potential for more than minimal harm
2025-03-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-09
F · Potential for more than minimal harm
2025-03-19
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2025-04-16
F · Potential for more than minimal harm
2025-03-19
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-04-30
F · Potential for more than minimal harm
2022-10-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-11-30
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-03-19
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 2025-04-10
D · Potential for more than minimal harm
2025-03-19
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 2025-04-10
D · Potential for more than minimal harm
2025-03-19
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-04-10
D · Potential for more than minimal harm
2025-03-19
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 2025-04-10
D · Potential for more than minimal harm
2025-03-19
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 2025-04-10
D · Potential for more than minimal harm
2025-03-19
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-04-10
D · Potential for more than minimal harm
2025-03-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-10
D · Potential for more than minimal harm
2025-03-19
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-04-10
D · Potential for more than minimal harm
2025-03-19
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 2025-04-10
F · Potential for more than minimal harm
2024-03-21
F909 · Environmental Deficiencies
Health
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Corrected 2024-05-01
D · Potential for more than minimal harm
2024-03-21
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 2024-05-01
D · Potential for more than minimal harm
2024-03-21
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-05-01
D · Potential for more than minimal harm
2024-03-21
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 2024-05-01
D · Potential for more than minimal harm
2024-03-21
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-05-01
D · Potential for more than minimal harm
2024-03-21
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-05-01
D · Potential for more than minimal harm
2022-10-27
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 2022-12-11
D · Potential for more than minimal harm
2022-10-27
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2022-12-11
D · Potential for more than minimal harm
2022-10-27
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 2022-12-11
D · Potential for more than minimal harm
2022-10-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-12-11
D · Potential for more than minimal harm
2022-10-27
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 2022-12-11
D · Potential for more than minimal harm
2022-10-27
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 2022-12-11
D · Potential for more than minimal harm
2022-10-27
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2022-12-11
Penalties and ownership
What sits behind the stars
$3,174
2023-10-30
Fine
Fine · fine $3,174
Fine
Ownership
Ikomi, Emmanuel
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Brentwood Rehabilitation And Healthcare Ctr (The)
Danvers, MA
3-star overall rating with 3-star inspections with 12 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Care One At Peabody
Peabody, MA
4-star overall rating with 4-star inspections with 4 recent health deficiencies
#3
Pilgrim Rehabilitation & Skilled Nursing Center
Peabody, MA
4-star overall rating with 4-star inspections with 6 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
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