Cycle 1
Health 2024-11-18 · Fire 2024-11-18
17 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Westborough, MA
Westborough Healthcare
2-star overall rating with 2-star inspections with $28,772 in total fines with 17 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
8 Colonial Drive, Westborough, MA
(508) 366-9131
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
117
Certified beds
Average residents
90
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Next Step Healthcare
Operator or chain grouping
Approved since
1975-10-03
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
14 facilities
Chain averages 2 overall / 2 health / 2 staffing / 3 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
0.60
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
0.93
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.11
Nurse aide staffing · state 2.26 · national 2.35
Total nurse hours
3.64
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.53
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.40
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.51
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
0.51
CMS adjusted RN staffing hours
Adjusted total hours
3.12
CMS adjusted total nurse staffing hours
Case-mix index
1.60
Higher values indicate more complex resident acuity
RN turnover
57%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
42%
Annual nurse turnover · state 40% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,173
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
7.74
Composite VBP score used to determine payment impact.
Payment multiplier
0.9807
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 18.45% · Performance 21.63% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 6.31% · Performance 7.86% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
1.73
Baseline 58.33% · Performance 56.63% · Measure score 1.73 · Achievement 1.73 · Improvement 0.01
Adjusted total nurse staffing
1.37
Baseline 3.03 hours · Performance 3.47 hours · Measure score 1.37 · Achievement 1.37 · Improvement 1.09
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.59% |
10.72%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 92 · Observed rate 16.3% · Lower 95% interval 8.52% |
| Discharge to community | 39.83% |
50.57%
10.7 pts worse
|
No Different than the National Rate · Eligible stays 74 · Observed rate 27.03% · Lower 95% interval 30.12% |
| Medicare spending per beneficiary | 1.11 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 38.64% |
95.27%
56.6 pts worse
|
Numerator 17 · Denominator 44 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 44 |
| Discharge self-care score | 21.88% |
53.69%
31.8 pts worse
|
Numerator 7 · Denominator 32 |
| Discharge mobility score | 34.38% |
50.94%
16.6 pts worse
|
Numerator 11 · Denominator 32 |
| Pressure ulcers or injuries, new or worsened | 2.27% |
2.29%
About the same
|
Numerator 1 · Denominator 44 · Adjusted rate 1.81% |
| Healthcare-associated infections requiring hospitalization | 7.86% |
7.12%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 50 · Observed rate 12% · Lower 95% interval 4.88% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 80 |
| Staff flu vaccination coverage | 63.37% |
42%
21.4 pts better
|
Numerator 64 · Denominator 101 |
| Discharge function score | 31.25% |
56.45%
25.2 pts worse
|
Numerator 10 · Denominator 32 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
1.9
0.1 pts better
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.9 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.9 |
1.5
0.4 pts worse
|
1.8
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.9 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 83.6% |
92.2%
8.6 pts worse
|
93.4%
9.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 72.7% · Q2 80.7% · Q3 92.9% · Q4 88.4% · 4Q avg 83.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.8% |
94.8%
2 pts better
|
95.5%
1.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.1% |
3.5%
1.4 pts better
|
3.3%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 2.4% · Q3 1.2% · Q4 2.3% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 60.2% |
12.0%
48.2 pts worse
|
11.4%
48.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 45.7% · Q2 57.1% · Q3 65.4% · Q4 71.2% · 4Q avg 60.2% |
| Percentage of long-stay residents who lose too much weight | 5.4% |
5.2%
0.2 pts worse
|
5.4%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 6.4% · Q3 8.0% · Q4 6.3% · 4Q avg 5.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.9% |
19.2%
5.7 pts worse
|
19.6%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.1% · Q2 28.4% · Q3 25.6% · Q4 21.7% · 4Q avg 24.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 39.0% |
22.5%
16.5 pts worse
|
16.7%
22.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.3% · Q2 38.3% · Q3 39.3% · Q4 41.1% · 4Q avg 39.0% · 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 | 4.9% |
17.7%
12.8 pts better
|
16.3%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.6% · Q2 5.2% · Q3 7.2% · Q4 0.0% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.8% |
17.6%
5.8 pts better
|
14.9%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.8% · Q2 11.3% · Q3 15.5% · Q4 2.7% · 4Q avg 11.8% · 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 2.4% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.0% |
2.0%
1 pts worse
|
1.7%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.8% · Q3 2.6% · Q4 6.0% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.1% |
21.7%
1.6 pts better
|
19.8%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.0% · Q2 15.5% · Q3 12.7% · Q4 24.7% · 4Q avg 20.1% |
| 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 1.4% · Q2 4.8% · Q3 3.2% · Q4 4.1% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 36.1% |
77.1%
41 pts worse
|
81.7%
45.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 37.0% · Q2 34.0% · Q3 30.4% · Q4 44.0% · 4Q avg 36.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.6% |
11.8%
3.2 pts better
|
12.0%
3.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.6% · Observed 10.4% · Expected 13.5% · 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 0.0% · Q2 0.0% · Q4 5.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 62.0% |
77.7%
15.7 pts worse
|
79.7%
17.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 62.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.8% |
25.8%
4 pts worse
|
23.9%
5.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.8% · Observed 33.3% · Expected 26.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-02 · Fire 2023-08-02
8 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2021-11-22 · Fire 2021-11-22
14 health deficiencies
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 citations
F · Potential for more than minimal harm
2024-11-18
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-12-23
F · Potential for more than minimal harm
2024-11-18
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2024-12-23
F · Potential for more than minimal harm
2024-11-18
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-12-23
F · Potential for more than minimal harm
2024-11-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-23
F · Potential for more than minimal harm
2024-11-18
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-12-23
D · Potential for more than minimal harm
2024-11-18
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-12-23
D · Potential for more than minimal harm
2024-11-18
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-12-23
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-04-10
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 2025-04-07
E · Potential for more than minimal harm
2024-11-18
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2024-12-20
E · Potential for more than minimal harm
2024-11-18
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 2024-12-20
E · Potential for more than minimal harm
2024-11-18
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-12-20
E · Potential for more than minimal harm
2024-11-18
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-12-20
E · Potential for more than minimal harm
2024-11-18
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 2024-12-20
D · Potential for more than minimal harm
2024-11-18
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-11-18
F584 · Resident Rights Deficiencies
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 2024-12-20
D · Potential for more than minimal harm
2024-11-18
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-11-18
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-11-18
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-11-18
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 2024-12-20
D · Potential for more than minimal harm
2024-11-18
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 2024-12-20
D · Potential for more than minimal harm
2024-11-18
F690 · Quality of Life and Care Deficiencies
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 2024-12-20
D · Potential for more than minimal harm
2024-11-18
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-11-18
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-11-18
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-09-25
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2024-10-23
D · Potential for more than minimal harm
2023-10-19
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-10-25
G · Actual harm
2023-08-02
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 2023-08-23
E · Potential for more than minimal harm
2023-08-02
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 2023-09-01
D · Potential for more than minimal harm
2023-08-02
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 2023-08-23
D · Potential for more than minimal harm
2023-08-02
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 2023-08-23
D · Potential for more than minimal harm
2023-08-02
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-09-01
D · Potential for more than minimal harm
2023-08-02
F690 · Quality of Life and Care Deficiencies
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 2023-08-23
D · Potential for more than minimal harm
2023-08-02
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 2023-08-23
G · Actual harm
2023-03-21
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 2023-03-29
D · Potential for more than minimal harm
2023-03-21
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-03-29
E · Potential for more than minimal harm
2021-11-22
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 2022-01-08
E · Potential for more than minimal harm
2021-11-22
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 2022-01-08
D · Potential for more than minimal harm
2021-11-22
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-01-08
D · Potential for more than minimal harm
2021-11-22
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2022-01-08
D · Potential for more than minimal harm
2021-11-22
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 2022-01-08
D · Potential for more than minimal harm
2021-11-22
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2022-01-08
D · Potential for more than minimal harm
2021-11-22
F690 · Quality of Life and Care Deficiencies
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 2022-01-08
D · Potential for more than minimal harm
2021-11-22
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-01-08
D · Potential for more than minimal harm
2021-11-22
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-01-08
D · Potential for more than minimal harm
2021-11-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-01-08
D · Potential for more than minimal harm
2021-11-22
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2022-01-08
Penalties and ownership
What sits behind the stars
$8,648
2023-08-02
Fine
Fine · fine $8,648
Fine
$20,124
2023-03-21
Fine
Fine · fine $20,124
Fine
Ownership
Dell'anno, Damian
Corporate Officer · Individual
Govoni, Richard
Operational/Managerial Control · Individual
Malik, Faisal
Operational/Managerial Control · Individual
Next Step Healthcare LLC
Operational/Managerial Control · Organization
Stephan, William
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Beaumont Rehab & Skilled Nursing Ctr - Westboro
Westborough, MA
4-star overall rating with 4-star inspections with 5 recent health deficiencies
#2
Whittier Westborough Transitional Care Unit
Westborough, MA
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Beaumont Rehab & Skilled Nursing Ctr - Northboro
Northborough, MA
5-star overall rating with 4-star inspections with 3 recent health deficiencies
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