Worcester, MA

Notre Dame Long Term Care Center

4-star overall rating with 4-star inspections with 3 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle

559 Plantation Street, Worcester, MA

(508) 852-3011

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

123

Certified beds

Average residents

114

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1993-06-12

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

0.37

Registered nurse staffing · state 0.65 · national 0.68

LPN hours / resident day

1.03

Licensed practical nurse staffing · state 0.96 · national 0.87

Aide hours / resident day

2.46

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

1.40

RN + LPN hours · state 1.60 · national 1.54

Weekend hours

3.46

Weekend nurse staffing · state 3.45 · national 3.43

Weekend RN hours

0.29

Weekend registered nurse coverage · state 0.46 · national 0.47

Physical therapist

0.05

Reported PT staffing · state 0.08 · national 0.07

Adjusted RN hours

0.40

CMS adjusted RN staffing hours

Adjusted total hours

4.23

CMS adjusted total nurse staffing hours

Case-mix index

1.25

Higher values indicate more complex resident acuity

RN turnover

50%

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

1,124

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

59.62

Composite VBP score used to determine payment impact.

Payment multiplier

1.0148

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

10

Baseline 21.15% · Performance 16.91% · Measure score 10 · Achievement 10 · Improvement 9

Healthcare-associated infections

3.68

Baseline 6.38% · Performance 6.73% · Measure score 3.68 · Achievement 3.68 · Improvement 0

Total nurse turnover

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Adjusted total nurse staffing

4.21

Baseline 4.04 hours · Performance 4.27 hours · Measure score 4.21 · Achievement 4.21 · Improvement 0.86

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.01%	10.72% 0.3 pts worse	No Different than the National Rate · Eligible stays 164 · Observed rate 10.37% · Lower 95% interval 7.98%
Discharge to community	52.78%	50.57% 2.2 pts better	No Different than the National Rate · Eligible stays 165 · Observed rate 47.27% · Lower 95% interval 44.35%
Medicare spending per beneficiary	0.9	1.02 0.1 pts better
Drug regimen review with follow-up	99.18%	95.27% 3.9 pts better	Numerator 121 · Denominator 122
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 122
Discharge self-care score	44.34%	53.69% 9.3 pts worse	Numerator 47 · Denominator 106
Discharge mobility score	61.32%	50.94% 10.4 pts better	Numerator 65 · Denominator 106
Pressure ulcers or injuries, new or worsened	2.46%	2.29% 0.2 pts worse	Numerator 3 · Denominator 122 · Adjusted rate 2.19%
Healthcare-associated infections requiring hospitalization	6.73%	7.12% 0.4 pts better	No Different than the National Rate · Eligible stays 95 · Observed rate 5.26% · Lower 95% interval 4.08%
Staff COVID-19 vaccination coverage	1.6%	8.2% 6.6 pts worse	Numerator 4 · Denominator 250
Staff flu vaccination coverage	69.46%	42% 27.5 pts better	Numerator 166 · Denominator 239
Discharge function score	52.83%	56.45% 3.6 pts worse	Numerator 56 · Denominator 106
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly.
Transfer of health information to patient	100%	96.28% 3.7 pts better	Numerator 77 · Denominator 77
Resident COVID-19 vaccinations up to date	31.08%	25.2% 5.9 pts better	Numerator 23 · Denominator 74

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.5	1.9 0.4 pts better	1.9 0.4 pts better	Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.1 · Expected 1.3 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	0.5	1.5 1 pts better	1.8 1.3 pts better	Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.4 · Expected 1.4 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	99.5%	92.2% 7.3 pts better	93.4% 6.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 98.1% · 4Q avg 99.5%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	98.1%	94.8% 3.3 pts better	95.5% 2.6 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 98.1%
Percentage of long-stay residents experiencing one or more falls with major injury	5.0%	3.5% 1.5 pts worse	3.3% 1.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 7.1% · Q3 5.3% · Q4 3.8% · 4Q avg 5.0% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	3.3%	12.0% 8.7 pts better	11.4% 8.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 3.4% · Q3 4.5% · Q4 1.0% · 4Q avg 3.3%
Percentage of long-stay residents who lose too much weight	3.6%	5.2% 1.6 pts better	5.4% 1.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 4.6% · Q3 7.1% · Q4 1.1% · 4Q avg 3.6%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	8.5%	19.2% 10.7 pts better	19.6% 11.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 9.7% · Q2 9.0% · Q3 8.0% · Q4 7.4% · 4Q avg 8.5%
Percentage of long-stay residents who received an antipsychotic medication	15.8%	22.5% 6.7 pts better	16.7% 0.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 20.5% · Q2 16.9% · Q3 15.2% · Q4 10.8% · 4Q avg 15.8% · 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	25.0%	17.7% 7.3 pts worse	16.3% 8.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 26.4% · Q2 32.5% · Q3 28.0% · Q4 13.2% · 4Q avg 25.0% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	22.8%	17.6% 5.2 pts worse	14.9% 7.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 26.7% · Q2 21.0% · Q3 15.6% · Q4 27.5% · 4Q avg 22.8% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	3.5%	1.0% 2.5 pts worse	1.0% 2.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 5.1% · Q3 2.8% · Q4 0.7% · 4Q avg 3.5% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	2.3%	2.0% 0.3 pts worse	1.7% 0.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 2.1% · Q3 5.4% · Q4 1.0% · 4Q avg 2.3% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	16.5%	21.7% 5.2 pts better	19.8% 3.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 13.3% · Q2 21.1% · Q3 12.1% · Q4 19.1% · 4Q avg 16.5%
Percentage of long-stay residents with pressure ulcers	6.7%	4.6% 2.1 pts worse	5.1% 1.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 7.4% · Q3 6.4% · Q4 7.0% · 4Q avg 6.7% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	76.9%	77.1% 0.2 pts worse	81.7% 4.8 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 84.7% · Q2 79.6% · Q3 76.8% · Q4 68.1% · 4Q avg 76.9%
Percentage of short-stay residents who had an outpatient emergency department visit	5.1%	11.8% 6.7 pts better	12.0% 6.9 pts better	Short Stay · 20240701-20250630 · Adjusted 5.1% · Observed 4.8% · Expected 10.5% · 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	82.0%	77.7% 4.3 pts better	79.7% 2.3 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 82.0%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	24.8%	25.8% 1 pts better	23.9% 0.9 pts worse	Short Stay · 20240701-20250630 · Adjusted 24.8% · Observed 23.2% · Expected 22.3% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-02-12 · Fire 2025-02-12

3 health deficiencies

Top issue: Infection Control (1 deficiency)

6 fire-safety deficiencies

Top issue: Miscellaneous (3 deficiencies)

Cycle 2 Health 2023-12-15 · Fire 2023-12-15

8 health deficiencies

Top issue: Infection Control (2 deficiencies)

3 fire-safety deficiencies

Top issue: Emergency Preparedness (1 deficiency)

Cycle 3 Health 2022-05-31 · Fire 2022-05-31

5 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

F · Potential for more than minimal harm 2025-02-12

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2025-04-01

F · Potential for more than minimal harm 2025-02-12

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2025-04-01

F · Potential for more than minimal harm 2025-02-12

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2025-04-01

D · Potential for more than minimal harm 2025-02-12

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2025-04-01

D · Potential for more than minimal harm 2025-02-12

K711 · Miscellaneous Deficiencies

Fire Safety

Provide a written emergency evacuation plan.

Corrected 2025-04-01

D · Potential for more than minimal harm 2025-02-12

K754 · Miscellaneous Deficiencies

Fire Safety

Provide properly sized and located linen or trash receptacles.

Corrected 2025-04-01

F · Potential for more than minimal harm 2023-12-15

E41 · Emergency Preparedness Deficiencies

Fire Safety

Implement emergency and standby power systems.

Corrected 2024-02-02

F · Potential for more than minimal harm 2023-12-15

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2024-02-02

F · Potential for more than minimal harm 2023-12-15

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-02-02

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-02-12

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 2025-03-28

D · Potential for more than minimal harm 2025-02-12

F810 · Nutrition and Dietary Deficiencies

Health

Provide special eating equipment and utensils for residents who need them and appropriate assistance.

Corrected 2025-03-28

D · Potential for more than minimal harm 2025-02-12

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-03-28

D · Potential for more than minimal harm 2024-11-20

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 2024-12-31

E · Potential for more than minimal harm 2023-12-15

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 2024-01-28

E · Potential for more than minimal harm 2023-12-15

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-01-28

D · Potential for more than minimal harm 2023-12-15

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 2024-01-28

D · Potential for more than minimal harm 2023-12-15

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 2023-12-15

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2024-01-28

D · Potential for more than minimal harm 2023-12-15

F805 · Nutrition and Dietary Deficiencies

Health

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Corrected 2024-01-28

D · Potential for more than minimal harm 2023-12-15

F883 · Infection Control Deficiencies

Health

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Corrected 2024-01-28

D · Potential for more than minimal harm 2022-05-31

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 2022-07-18

D · Potential for more than minimal harm 2022-05-31

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2022-07-18

D · Potential for more than minimal harm 2022-05-31

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 2022-07-18

D · Potential for more than minimal harm 2022-05-31

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2022-07-18

D · Potential for more than minimal harm 2022-05-31

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 2022-07-18

Penalties and ownership