Cycle 1
Health 2025-03-12 · Fire 2025-03-12
5 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Boston, MA
Spaulding Nursing And Therapy Center - Brighton
5-star overall rating with 4-star inspections with 5 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
100 N Beacon Street, Boston, MA
(617) 325-5400
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
123
Certified beds
Average residents
91
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1967-01-01
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
3.46
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
0.40
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
4.38
Nurse aide staffing · state 2.26 · national 2.35
Total nurse hours
8.24
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
3.86
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
7.02
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
2.45
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.51
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
3.56
CMS adjusted RN staffing hours
Adjusted total hours
8.49
CMS adjusted total nurse staffing hours
Case-mix index
1.33
Higher values indicate more complex resident acuity
RN turnover
57%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 40% · national 46%
SNF VBP
Value-based purchasing
Program rank
87
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
87.13
Composite VBP score used to determine payment impact.
Payment multiplier
1.0270
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
8.79
Baseline 16.55% · Performance 17.36% · Measure score 8.79 · Achievement 8.79 · Improvement 0
Healthcare-associated infections
10
Baseline 3.88% · Performance 4.51% · Measure score 10 · Achievement 10 · Improvement 0
Total nurse turnover
6.07
Baseline 27.34% · Performance 38.89% · Measure score 6.07 · Achievement 6.07 · Improvement 0
Adjusted total nurse staffing
10
Baseline 8.02 hours · Performance 8.78 hours · Measure score 10 · Achievement 10 · Improvement 9
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.66% |
10.72%
2.1 pts better
|
Better than the National Rate · Eligible stays 1137 · Observed rate 6.95% · Lower 95% interval 7.13% |
| Discharge to community | 74.49% |
50.57%
23.9 pts better
|
Better than the National Rate · Eligible stays 1158 · Observed rate 75.22% · Lower 95% interval 72.31% |
| Medicare spending per beneficiary | 0.7 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 98.86% |
95.27%
3.6 pts better
|
Numerator 783 · Denominator 792 |
| Falls with major injury | 0.13% |
0.77%
0.6 pts better
|
Numerator 1 · Denominator 792 |
| Discharge self-care score | 52.47% |
53.69%
1.2 pts worse
|
Numerator 351 · Denominator 669 |
| Discharge mobility score | 50.07% |
50.94%
0.9 pts worse
|
Numerator 335 · Denominator 669 |
| Pressure ulcers or injuries, new or worsened | 1.89% |
2.29%
0.4 pts better
|
Numerator 15 · Denominator 792 · Adjusted rate 2.97% |
| Healthcare-associated infections requiring hospitalization | 4.51% |
7.12%
2.6 pts better
|
Better than the National Rate · Eligible stays 673 · Observed rate 3.27% · Lower 95% interval 3.41% |
| Staff COVID-19 vaccination coverage | 15.66% |
8.2%
7.5 pts better
|
Numerator 57 · Denominator 364 |
| Staff flu vaccination coverage | 96.88% |
42%
54.9 pts better
|
Numerator 372 · Denominator 384 |
| Discharge function score | 62.33% |
56.45%
5.9 pts better
|
Numerator 417 · Denominator 669 |
| Transfer of health information to provider | 96.96% |
95.95%
1 pts better
|
Numerator 702 · Denominator 724 |
| Transfer of health information to patient | 97.73% |
96.28%
1.5 pts better
|
Numerator 43 · Denominator 44 |
| Resident COVID-19 vaccinations up to date | 48.31% |
25.2%
23.1 pts better
|
Numerator 200 · Denominator 414 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 44.4% |
92.2%
47.8 pts worse
|
93.4%
49 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 48.0% · Q2 36.0% · Q3 37.0% · Q4 59.1% · 4Q avg 44.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 93.3% |
94.8%
1.5 pts worse
|
95.5%
2.2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 93.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.0% |
3.5%
2.5 pts better
|
3.3%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% · 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% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 2.1% |
5.2%
3.1 pts better
|
5.4%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.2% · Q3 3.8% · Q4 0.0% · 4Q avg 2.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.7% |
19.2%
5.5 pts better
|
19.6%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 16.7% · Q3 11.5% · Q4 5.0% · 4Q avg 13.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.6% |
22.5%
3.9 pts better
|
16.7%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 18.6% · 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 | 31.0% |
17.7%
13.3 pts worse
|
16.3%
14.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 31.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 24.0% |
17.6%
6.4 pts worse
|
14.9%
9.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 20.0% · Q3 36.4% · 4Q avg 24.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
1.0%
0.4 pts better
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.2% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.1% |
2.0%
1.1 pts worse
|
1.7%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 0.0% · Q3 0.0% · Q4 9.1% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.4% |
21.7%
2.3 pts better
|
19.8%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.3% · Q2 28.6% · Q3 8.6% · 4Q avg 19.4% |
| Percentage of long-stay residents with pressure ulcers | 15.7% |
4.6%
11.1 pts worse
|
5.1%
10.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 12.6% · Q3 22.2% · Q4 12.8% · 4Q avg 15.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 37.8% |
77.1%
39.3 pts worse
|
81.7%
43.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 44.5% · Q2 34.4% · Q3 31.9% · Q4 40.5% · 4Q avg 37.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.9% |
11.8%
0.9 pts better
|
12.0%
1.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.9% · Observed 10.2% · Expected 10.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.3%
0.5 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 0.6% · Q3 0.6% · Q4 1.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 88.9% |
77.7%
11.2 pts better
|
79.7%
9.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 88.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.0% |
25.8%
1.8 pts better
|
23.9%
0.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.0% · Observed 20.6% · Expected 20.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-03 · Fire 2024-04-03
1 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-02-15 · Fire 2023-02-15
0 health deficiencies
No concentrated health issue counts in this cycle.
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
2025-03-12
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 2025-04-23
F · Potential for more than minimal harm
2025-03-12
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2025-04-23
F · Potential for more than minimal harm
2025-03-12
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-04-23
F · Potential for more than minimal harm
2025-03-12
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-05-08
F · Potential for more than minimal harm
2025-03-12
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2025-04-23
E · Potential for more than minimal harm
2025-03-12
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-04-23
E · Potential for more than minimal harm
2025-03-12
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-04-23
E · Potential for more than minimal harm
2025-03-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-23
E · Potential for more than minimal harm
2025-03-12
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-04-23
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-03-12
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-04-22
D · Potential for more than minimal harm
2025-03-12
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-04-22
D · Potential for more than minimal harm
2025-03-12
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-04-22
D · Potential for more than minimal harm
2025-03-12
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 2025-04-22
D · Potential for more than minimal harm
2025-03-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-22
D · Potential for more than minimal harm
2024-03-19
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-03-18
Penalties and ownership
What sits behind the stars
Ownership
Mass General Brigham Incorporated
5% Or Greater Indirect Ownership Interest · Organization
Spaulding Rehabilitation, Inc.
5% Or Greater Direct Ownership Interest · Organization
Baggio Tormey, Monica
Operational/Managerial Control · Individual
Baggio Tormey, Monica
Corporate Officer · Individual
Brennan, Melissa
Corporate Officer · Individual
Desantis, Samantha
Operational/Managerial Control · Individual
Desantis, Samantha
Corporate Director · Individual
Fischer, David
Corporate Director · Individual
Gee, Michael
Corporate Director · Individual
Jackson, Ruel
Operational/Managerial Control · Individual
Jackson, Ruel
Corporate Officer · Individual
Jones, Daniel
Corporate Director · Individual
Jones, Robin
Corporate Director · Individual
Joy, Michael
Operational/Managerial Control · Individual
Kaniaru, Martha
Operational/Managerial Control · Individual
Kennedy, Joseph
Corporate Director · Individual
Luken, Donna
Corporate Officer · Individual
Mass General Brigham Incorporated
Operational/Managerial Control · Organization
Mccreary, Makeeba
Corporate Director · Individual
Mcdermott, Vincent
Operational/Managerial Control · Individual
Mcdermott, Vincent
Corporate Officer · Individual
Piedrahita, Vicente
Corporate Director · Individual
Pollard, Tevia
Corporate Director · Individual
Pullen, Matthew
Corporate Director · Individual
Raja, Ali
Corporate Director · Individual
Ryan, Joseph
Corporate Director · Individual
Sallop, Linda
Corporate Director · Individual
Schneider, Jeffrey
Corporate Director · Individual
Schwartz, Jonathon
Operational/Managerial Control · Individual
Schwartz, Jonathon
Corporate Director · Individual
Silbersweig, David
Corporate Director · Individual
Spaulding Rehabilitation, Inc.
Operational/Managerial Control · Organization
Speers, Paula
Corporate Officer · Individual
Waldman, Louis
Operational/Managerial Control · Individual
Wheeler, Mark
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Brighton Post Acute Care
Brighton, MA
4-star overall rating with 3-star inspections with $200,070 in total fines with 9 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Watertown Rehabilitation And Nursing Center
Watertown, MA
2-star overall rating with 2-star inspections with $69,440 in total fines with 19 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
Presentation Rehab And Skilled Care Center
Boston, MA
2-star overall rating with 2-star inspections with $56,940 in total fines with 15 recent health deficiencies
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