Cycle 1
Health 2025-02-25 · Fire 2025-02-25
11 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
11 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Framingham, MA
St Patrick's Manor
2-star overall rating with 2-star inspections with $33,157 in total fines with 11 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
863 Central Street, Framingham, MA
(508) 879-8000
Overall
2 / 5
CMS overall stars
Health inspections
2 / 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
333
Certified beds
Average residents
276
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Carmelite Sisters For The Aged & Infirm
Operator or chain grouping
Approved since
1990-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
8 facilities
Chain averages 3 overall / 2 health / 3 staffing / 4 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
0.55
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
2.16
Nurse aide staffing · state 2.26 · national 2.35
Total nurse hours
3.65
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.49
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.31
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.36
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
0.57
CMS adjusted RN staffing hours
Adjusted total hours
3.76
CMS adjusted total nurse staffing hours
Case-mix index
1.33
Higher values indicate more complex resident acuity
RN turnover
12%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
31%
Annual nurse turnover · state 40% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,289
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
33.39
Composite VBP score used to determine payment impact.
Payment multiplier
0.9877
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.61% · Performance 21.78% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
2.22
Baseline 4.82% · Performance 7.17% · Measure score 2.22 · Achievement 2.22 · Improvement 0
Total nurse turnover
8.61
Baseline 36.17% · Performance 28.50% · Measure score 8.61 · Achievement 8.61 · Improvement 6.28
Adjusted total nurse staffing
2.53
Baseline 3.82 hours · Performance 3.80 hours · Measure score 2.53 · Achievement 2.53 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.74% |
10.72%
1 pts better
|
No Different than the National Rate · Eligible stays 442 · Observed rate 8.82% · Lower 95% interval 7.82% |
| Discharge to community | 49.74% |
50.57%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 402 · Observed rate 44.78% · Lower 95% interval 44.59% |
| Medicare spending per beneficiary | 0.82 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 99.57% |
95.27%
4.3 pts better
|
Numerator 234 · Denominator 235 |
| Falls with major injury | 0.85% |
0.77%
0.1 pts worse
|
Numerator 2 · Denominator 235 |
| Discharge self-care score | 56.7% |
53.69%
3 pts better
|
Numerator 110 · Denominator 194 |
| Discharge mobility score | 57.22% |
50.94%
6.3 pts better
|
Numerator 111 · Denominator 194 |
| Pressure ulcers or injuries, new or worsened | 3.4% |
2.29%
1.1 pts worse
|
Numerator 8 · Denominator 235 · Adjusted rate 3.42% |
| Healthcare-associated infections requiring hospitalization | 7.17% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 241 · Observed rate 6.64% · Lower 95% interval 4.91% |
| Staff COVID-19 vaccination coverage | 14.33% |
8.2%
6.1 pts better
|
Numerator 45 · Denominator 314 |
| Staff flu vaccination coverage | 32.82% |
42%
9.2 pts worse
|
Numerator 107 · Denominator 326 |
| Discharge function score | 57.22% |
56.45%
0.8 pts better
|
Numerator 111 · Denominator 194 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 152 · Denominator 152 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 47.46% |
25.2%
22.3 pts better
|
Numerator 56 · Denominator 118 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
1.9
0.3 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.2 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
1.5
0.5 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.8 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.9% |
92.2%
7.7 pts better
|
93.4%
6.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 99.6% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.9% |
| 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 | 3.3% |
3.5%
0.2 pts better
|
3.3%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 3.3% · Q3 2.5% · Q4 3.2% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.4% |
12.0%
10.6 pts better
|
11.4%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 1.3% · Q3 1.3% · Q4 1.7% · 4Q avg 1.4% |
| Percentage of long-stay residents who lose too much weight | 4.0% |
5.2%
1.2 pts better
|
5.4%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 7.7% · Q3 5.0% · Q4 1.3% · 4Q avg 4.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.1% |
19.2%
8.1 pts better
|
19.6%
8.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.9% · Q2 11.3% · Q3 12.2% · Q4 10.0% · 4Q avg 11.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 21.5% |
22.5%
1 pts better
|
16.7%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.9% · Q2 23.9% · Q3 21.4% · Q4 16.0% · 4Q avg 21.5% · 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 | 19.8% |
17.7%
2.1 pts worse
|
16.3%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.4% · Q2 23.8% · Q3 9.1% · Q4 17.2% · 4Q avg 19.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.1% |
17.6%
2.5 pts worse
|
14.9%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.0% · Q2 25.6% · Q3 13.8% · Q4 17.6% · 4Q avg 20.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.0%
1 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.2% |
2.0%
0.8 pts better
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.4% · Q2 1.7% · Q3 0.9% · Q4 1.7% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.9% |
21.7%
9.2 pts worse
|
19.8%
11.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.1% · Q2 29.0% · Q3 31.0% · Q4 29.7% · 4Q avg 30.9% |
| Percentage of long-stay residents with pressure ulcers | 2.4% |
4.6%
2.2 pts better
|
5.1%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 2.6% · Q3 2.6% · Q4 2.4% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.5% |
77.1%
20.4 pts better
|
81.7%
15.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.7% · Q2 99.4% · Q3 97.4% · Q4 97.3% · 4Q avg 97.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.7% |
11.8%
0.1 pts better
|
12.0%
0.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.7% · Observed 10.7% · Expected 10.2% · 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 | 95.5% |
77.7%
17.8 pts better
|
79.7%
15.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.7% |
25.8%
3.1 pts better
|
23.9%
1.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.7% · Observed 20.3% · Expected 21.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-05 · Fire 2023-12-05
7 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-05-02 · Fire 2022-05-02
11 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-25
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2025-04-04
F · Potential for more than minimal harm
2025-02-25
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2025-04-04
F · Potential for more than minimal harm
2025-02-25
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2025-04-04
F · Potential for more than minimal harm
2025-02-25
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-04-04
F · Potential for more than minimal harm
2025-02-25
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-04-04
F · Potential for more than minimal harm
2025-02-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-04
F · Potential for more than minimal harm
2025-02-25
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-04-04
F · Potential for more than minimal harm
2025-02-25
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-04-04
F · Potential for more than minimal harm
2025-02-25
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-04-04
F · Potential for more than minimal harm
2025-02-25
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-04-04
F · Potential for more than minimal harm
2025-02-25
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-04-04
F · Potential for more than minimal harm
2022-05-02
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-05-16
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-02-25
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-04-04
D · Potential for more than minimal harm
2025-02-25
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 2025-04-04
D · Potential for more than minimal harm
2025-02-25
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2025-04-04
D · Potential for more than minimal harm
2025-02-25
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-04-04
D · Potential for more than minimal harm
2025-02-25
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2025-04-04
D · Potential for more than minimal harm
2025-02-25
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2025-04-04
D · Potential for more than minimal harm
2025-02-25
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-04-04
D · Potential for more than minimal harm
2025-02-25
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 2025-04-04
B · Minimal harm
2025-02-25
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2025-04-04
B · Minimal harm
2025-02-25
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2025-04-04
B · Minimal harm
2025-02-25
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-04-04
G · Actual harm
2024-07-24
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 2024-07-18
G · Actual harm
2024-07-24
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-07-18
G · Actual harm
2024-04-30
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-05-24
D · Potential for more than minimal harm
2024-04-30
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-05-24
D · Potential for more than minimal harm
2023-12-05
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 2024-01-11
D · Potential for more than minimal harm
2023-12-05
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 2024-01-11
D · Potential for more than minimal harm
2023-12-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-11
J · Immediate jeopardy
2023-08-25
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2023-08-28
D · Potential for more than minimal harm
2023-07-25
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2023-08-18
D · Potential for more than minimal harm
2023-07-25
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-08-18
D · Potential for more than minimal harm
2023-07-25
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-08-18
D · Potential for more than minimal harm
2023-07-25
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-08-18
D · Potential for more than minimal harm
2022-05-02
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 2022-06-15
D · Potential for more than minimal harm
2022-05-02
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-06-15
D · Potential for more than minimal harm
2022-05-02
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2022-06-15
D · Potential for more than minimal harm
2022-05-02
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-06-15
D · Potential for more than minimal harm
2022-05-02
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 2022-06-15
D · Potential for more than minimal harm
2022-05-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-06-15
Penalties and ownership
What sits behind the stars
$9,318
2024-07-24
Fine
Fine · fine $9,318
Fine
$9,318
2024-04-30
Fine
Fine · fine $9,318
Fine
$14,521
2023-08-25
Fine
Fine · fine $14,521
Fine
Ownership
Hines, David
Operational/Managerial Control · Individual
Hines, David
W-2 Managing Employee · Individual
Kizik, Donna
Operational/Managerial Control · Individual
Kizik, Donna
W-2 Managing Employee · Individual
Mcdonough, Maureen
Operational/Managerial Control · Individual
Mcdonough, Maureen
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Casa De Ramana Rehabilitation Center
Framingham, MA
4-star overall rating with 4-star inspections with $8,512 in total fines with 6 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Carlyle House
Framingham, MA
1-star overall rating with 1-star inspections with $16,153 in total fines with 10 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Oak Knoll Rehabilitation And Healthcare Center
Framingham, MA
1-star overall rating with 1-star inspections with $211,819 in total fines with 12 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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