11 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
19 fire-safety deficiencies
Top issue: Emergency Preparedness (7 deficiencies)
Worcester, MA
2-star overall rating with 2-star inspections with $106,301 in total fines with 11 recent health deficiencies with 19 fire-safety deficiencies in the latest cycle
104 Randolph Road, Worcester, MA
(508) 853-6687
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Beds
100
Certified beds
Average residents
92
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
RN hours / resident day
0.63
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
0.94
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.04
Nurse aide staffing · state 2.26 · national 2.35
Total nurse hours
3.61
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.57
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.26
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.47
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.00
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.67
CMS adjusted RN staffing hours
Adjusted total hours
3.82
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
30%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
30%
Annual nurse turnover · state 40% · national 46%
SNF VBP
Program rank
2,943
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
46.79
Composite VBP score used to determine payment impact.
Payment multiplier
1.0002
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
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
3.81
Baseline 38.33% · Performance 48.10% · Measure score 3.81 · Achievement 3.81 · Improvement 0
Adjusted total nurse staffing
5.55
Baseline 3.98 hours · Performance 4.66 hours · Measure score 5.55 · Achievement 5.55 · Improvement 3.24
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 20 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 9 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 18 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 5 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 15.6% |
8.2%
7.4 pts better
|
Numerator 17 · Denominator 109 |
| Staff flu vaccination coverage | 68.94% |
42%
26.9 pts better
|
Numerator 91 · Denominator 132 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
1.9
0.5 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.0 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.4 |
1.5
0.9 pts worse
|
1.8
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 2.2 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 90.9% |
92.2%
1.3 pts worse
|
93.4%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 84.4% · Q2 85.4% · Q3 95.0% · Q4 98.9% · 4Q avg 90.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 93.5% |
94.8%
1.3 pts worse
|
95.5%
2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 93.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.9% |
3.5%
2.4 pts worse
|
3.3%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 6.1% · Q3 6.2% · Q4 5.6% · 4Q avg 5.9% · 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 | 5.3% |
5.2%
0.1 pts worse
|
5.4%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 4.2% · Q3 8.5% · Q4 7.2% · 4Q avg 5.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.6% |
19.2%
0.6 pts better
|
19.6%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.3% · Q2 21.6% · Q3 16.2% · Q4 16.7% · 4Q avg 18.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 34.8% |
22.5%
12.3 pts worse
|
16.7%
18.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.7% · Q2 30.8% · Q3 36.5% · Q4 35.1% · 4Q avg 34.8% · 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 | 21.9% |
17.7%
4.2 pts worse
|
16.3%
5.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.1% · Q2 21.7% · Q3 28.7% · Q4 17.5% · 4Q avg 21.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.3% |
17.6%
2.7 pts worse
|
14.9%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.1% · Q2 21.2% · Q3 29.7% · Q4 16.2% · 4Q avg 20.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.1% |
1.0%
0.1 pts worse
|
1.0%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 0.0% · Q3 1.2% · Q4 2.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.3% |
2.0%
1.3 pts worse
|
1.7%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 2.4% · Q3 5.2% · Q4 3.4% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.7% |
21.7%
2 pts worse
|
19.8%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.1% · Q2 21.9% · Q3 31.2% · Q4 24.5% · 4Q avg 23.7% |
| 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 4.1% · Q2 4.4% · Q3 4.4% · Q4 5.8% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 59.6% |
77.1%
17.5 pts worse
|
81.7%
22.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q2 25.9% · Q3 75.0% · Q4 96.6% · 4Q avg 59.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.4% |
11.8%
0.4 pts better
|
12.0%
0.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.4% · Observed 13.6% · Expected 13.3% · 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 assessed and appropriately given the seasonal influenza vaccine | 62.1% |
77.7%
15.6 pts worse
|
79.7%
17.6 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 62.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.3% |
25.8%
0.5 pts worse
|
23.9%
2.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.3% · Observed 27.3% · Expected 24.7% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (3 deficiencies)
19 fire-safety deficiencies
Top issue: Emergency Preparedness (7 deficiencies)
Top issue: Quality of Life and Care (5 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2025-01-30
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2025-01-30
Fire Safety
Establish emergency prep training and testing.
Corrected 2025-01-30
Fire Safety
Establish staff and initial training requirements.
Corrected 2025-01-30
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-01-30
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-01-30
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2025-01-30
Fire Safety
Provide hallway or ground-level exits in all residents' rooms.
Corrected 2025-01-30
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-01-30
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-01-30
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-01-30
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2025-01-30
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-01-30
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-01-30
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-01-30
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-01-30
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-01-30
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-01-30
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-01-30
Inspection history
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-01-23
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2025-01-23
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-01-23
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-01-23
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-01-23
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2025-01-23
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-01-23
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-23
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 2025-01-23
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-01-23
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2025-01-23
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-01-19
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-01-19
Health
Respond appropriately to all alleged violations.
Corrected 2024-01-19
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-17
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-11-17
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-11-17
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-11-17
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-12-23
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-17
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 2023-11-17
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-11-17
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-11-17
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-11-17
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-12-23
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-04-15
Health
Give the resident's representative the ability to exercise the resident's rights.
Corrected 2022-04-15
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2022-04-15
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2022-04-15
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2022-04-15
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-04-15
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 2022-04-15
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-04-15
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 2022-04-15
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2022-04-15
Health
Post nurse staffing information every day.
Corrected 2022-04-15
Penalties and ownership
Fine · fine $106,301
Fine
Payment Denial · denial start 2024-01-06 · 13 days
13 day denial
5% Or Greater Direct Ownership Interest · Organization
General Partnership Interest · Organization
Corporate Officer · Individual
W-2 Managing Employee · Individual
Nearby options
Worcester, MA
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
Worcester, MA
2-star overall rating with 3-star inspections with 10 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
Worcester, MA
5-star overall rating with 4-star inspections with 5 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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