Cycle 1
Health 2025-01-30 · Fire 2025-01-30
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Peabody, MA
Pilgrim Rehabilitation & Skilled Nursing Center
4-star overall rating with 4-star inspections with 6 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
96 Forest Street, Peabody, MA
(978) 532-0303
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
152
Certified beds
Average residents
121
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Integritus Healthcare
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.94
Registered nurse staffing
LPN hours / resident day
0.82
Licensed practical nurse staffing
Aide hours / resident day
2.48
Nurse aide staffing
Weekend hours
3.81
Weekend nurse staffing
RN turnover
24%
Annual RN turnover
Total nurse turnover
47%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.8 |
1.9
0.9 pts worse
|
1.9
0.9 pts worse
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
1.5
0.7 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.3% |
92.2%
7.1 pts better
|
93.4%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.6% |
3.5%
0.9 pts better
|
3.3%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 46.0% |
12.0%
34 pts worse
|
11.4%
34.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 4.3% |
5.2%
0.9 pts better
|
5.4%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.0% |
19.2%
2.2 pts better
|
19.6%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 25.4% |
22.5%
2.9 pts worse
|
16.7%
8.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 19.1% |
17.7%
1.4 pts worse
|
16.3%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.0% |
17.6%
3.4 pts worse
|
14.9%
6.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
1.0%
0.7 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.5% |
2.0%
1.5 pts better
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.1% |
21.7%
7.4 pts worse
|
19.8%
9.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 3.4% |
4.6%
1.2 pts better
|
5.1%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.2% |
77.1%
22.1 pts better
|
81.7%
17.5 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.2% |
11.8%
1.4 pts worse
|
12.0%
1.2 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.3%
0.2 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.5% |
77.7%
20.8 pts better
|
79.7%
18.8 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.4% |
25.8%
2.6 pts worse
|
23.9%
4.5 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-29 · Fire 2024-02-29
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-01-05 · Fire 2023-01-05
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-30
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 2025-03-26
F · Potential for more than minimal harm
2025-01-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-26
F · Potential for more than minimal harm
2025-01-30
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-03-26
F · Potential for more than minimal harm
2025-01-30
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-03-26
E · Potential for more than minimal harm
2025-01-30
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-03-26
E · Potential for more than minimal harm
2025-01-30
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-03-26
E · Potential for more than minimal harm
2025-01-30
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-03-26
E · Potential for more than minimal harm
2025-01-30
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2025-03-26
E · Potential for more than minimal harm
2025-01-30
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-26
E · Potential for more than minimal harm
2025-01-30
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-03-26
D · Potential for more than minimal harm
2023-01-05
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-02-10
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-01-30
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 2025-02-18
D · Potential for more than minimal harm
2025-01-30
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 2025-02-18
D · Potential for more than minimal harm
2025-01-30
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 2025-02-18
D · Potential for more than minimal harm
2025-01-30
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-02-18
D · Potential for more than minimal harm
2025-01-30
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-02-18
D · Potential for more than minimal harm
2025-01-30
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 2025-02-18
D · Potential for more than minimal harm
2024-02-29
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-03-13
G · Actual harm
2023-01-05
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-01-30
E · Potential for more than minimal harm
2023-01-05
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 2023-01-30
D · Potential for more than minimal harm
2023-01-05
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 2023-01-30
D · Potential for more than minimal harm
2023-01-05
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 2023-01-30
D · Potential for more than minimal harm
2023-01-05
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-01-30
D · Potential for more than minimal harm
2023-01-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-01-30
D · Potential for more than minimal harm
2023-01-05
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2023-01-30
D · Potential for more than minimal harm
2023-01-05
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 2023-01-30
D · Potential for more than minimal harm
2023-01-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-01-30
Penalties and ownership
What sits behind the stars
Ownership
Fairview Extended Care Services Inc
5% Or Greater Direct Ownership Interest · Organization
Integritus Healthcare Inc
5% Or Greater Indirect Ownership Interest · Organization
Collins, Jennifer
W-2 Managing Employee · Individual
Gingras, Marcie Jo
Corporate Officer · Individual
Integritus Healthcare Management Services Inc
Operational/Managerial Control · Organization
Jones, William
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Jeffrey & Susan Brudnick Center For Living
Peabody, MA
5-star overall rating with 4-star inspections with $10,194 in total fines with 4 recent health deficiencies with 4 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
Continuing Care At Brooksby Village
Peabody, MA
3-star overall rating with 2-star inspections with $167,099 in total fines with 11 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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