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
Chain footprint
15 facilities
Chain averages 3 overall / 3 health / 3 staffing / 2 quality stars
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
0.94
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
0.82
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.48
Nurse aide staffing · state 2.26 · national 2.35
Total nurse hours
4.23
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.75
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.81
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.75
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.82
CMS adjusted RN staffing hours
Adjusted total hours
3.70
CMS adjusted total nurse staffing hours
Case-mix index
1.57
Higher values indicate more complex resident acuity
RN turnover
24%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
47%
Annual nurse turnover · state 40% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,932
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
34.55
Composite VBP score used to determine payment impact.
Payment multiplier
0.9885
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.04% · Performance 24.94% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
8.19
Baseline 4.63% · Performance 5.39% · Measure score 8.19 · Achievement 8.19 · Improvement 0
Total nurse turnover
2.80
Baseline 49.14% · Performance 52.25% · Measure score 2.80 · Achievement 2.80 · Improvement 0
Adjusted total nurse staffing
2.84
Baseline 3.60 hours · Performance 3.88 hours · Measure score 2.84 · Achievement 2.84 · Improvement 0.79
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.65% |
10.72%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 359 · Observed rate 13.65% · Lower 95% interval 9.49% |
| Discharge to community | 55.05% |
50.57%
4.5 pts better
|
No Different than the National Rate · Eligible stays 319 · Observed rate 45.77% · Lower 95% interval 49.16% |
| Medicare spending per beneficiary | 0.79 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 98.96% |
95.27%
3.7 pts better
|
Numerator 285 · Denominator 288 |
| Falls with major injury | 0.35% |
0.77%
0.4 pts better
|
Numerator 1 · Denominator 288 |
| Discharge self-care score | 35.84% |
53.69%
17.8 pts worse
|
Numerator 81 · Denominator 226 |
| Discharge mobility score | 36.28% |
50.94%
14.7 pts worse
|
Numerator 82 · Denominator 226 |
| Pressure ulcers or injuries, new or worsened | 0.69% |
2.29%
1.6 pts better
|
Numerator 2 · Denominator 288 · Adjusted rate 0.83% |
| Healthcare-associated infections requiring hospitalization | 5.39% |
7.12%
1.7 pts better
|
No Different than the National Rate · Eligible stays 237 · Observed rate 4.64% · Lower 95% interval 3.52% |
| Staff COVID-19 vaccination coverage | 6.06% |
8.2%
2.1 pts worse
|
Numerator 6 · Denominator 99 |
| Staff flu vaccination coverage | 61.48% |
42%
19.5 pts better
|
Numerator 83 · Denominator 135 |
| Discharge function score | 41.59% |
56.45%
14.9 pts worse
|
Numerator 94 · Denominator 226 |
| Transfer of health information to provider | 98.46% |
95.95%
2.5 pts better
|
Numerator 192 · Denominator 195 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 40.43% |
25.2%
15.2 pts better
|
Numerator 57 · Denominator 141 |
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 · Adjusted 2.8 · Observed 2.3 · Expected 1.6 · Used in QM five-star |
| 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 · Adjusted 0.8 · Observed 0.7 · Expected 1.5 · Used in QM five-star |
| 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 · Q1 99.0% · Q2 99.0% · Q3 100.0% · Q4 99.0% · 4Q avg 99.3% |
| 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 | 2.6% |
3.5%
0.9 pts better
|
3.3%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 1.0% · Q3 1.9% · Q4 5.7% · 4Q avg 2.6% · Used in QM five-star |
| 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 · Q1 44.6% · Q2 44.6% · Q3 52.1% · Q4 43.0% · 4Q avg 46.0% |
| 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 · Q1 1.1% · Q2 3.4% · Q3 3.6% · Q4 9.2% · 4Q avg 4.3% |
| 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 · Q1 15.2% · Q2 17.2% · Q3 18.7% · Q4 17.0% · 4Q avg 17.0% |
| 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 · Q1 20.0% · Q2 26.8% · Q3 27.1% · Q4 28.0% · 4Q avg 25.4% · 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 | 19.1% |
17.7%
1.4 pts worse
|
16.3%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.7% · Q2 16.4% · Q3 16.1% · Q4 20.5% · 4Q avg 19.1% · Used in QM five-star |
| 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 · Q1 38.4% · Q2 5.7% · Q3 23.5% · Q4 16.9% · 4Q avg 21.0% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.7% · Q4 0.7% · 4Q avg 0.3% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 1.0% · Q3 0.0% · Q4 1.0% · 4Q avg 0.5% · Used in QM five-star |
| 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 · Q1 33.8% · Q2 32.3% · Q3 26.2% · Q4 23.4% · 4Q avg 29.1% |
| 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 · Q1 2.5% · Q2 3.4% · Q3 2.6% · Q4 5.2% · 4Q avg 3.4% · Used in QM five-star |
| 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 · Q1 100.0% · Q2 99.5% · Q3 99.5% · Q4 97.4% · 4Q avg 99.2% |
| 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 · Adjusted 13.2% · Observed 13.4% · Expected 11.3% · Used in QM five-star |
| 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 · Q1 0.9% · Q2 0.8% · Q3 1.6% · Q4 0.9% · 4Q avg 1.1% · Used in QM five-star |
| 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 · 4Q avg 98.5% |
| 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 · Adjusted 28.4% · Observed 27.1% · Expected 22.8% · Used in QM five-star |
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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