Cycle 1
Health 2024-12-06 · Fire 2024-12-06
4 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Williamstown, MA
Williamstown Commons Nursing & Rehab
4-star overall rating with 4-star inspections with 4 recent health deficiencies
25 Adams Road, Williamstown, MA
(413) 458-2111
Overall
4 / 5
CMS overall stars
Health inspections
4 / 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
180
Certified beds
Average residents
124
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Integritus Healthcare
Operator or chain grouping
Approved since
1989-02-17
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
0.39
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.10
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.09
Nurse aide staffing · state 2.26 · national 2.35
Total nurse hours
3.58
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
3.15
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.11
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.36
CMS adjusted RN staffing hours
Adjusted total hours
3.33
CMS adjusted total nurse staffing hours
Case-mix index
1.47
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
41%
Annual nurse turnover · state 40% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,557
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
29.44
Composite VBP score used to determine payment impact.
Payment multiplier
0.9855
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.56
Baseline 21.91% · Performance 18.95% · Measure score 5.56 · Achievement 5.35 · Improvement 5.56
Healthcare-associated infections
2.39
Baseline 8.29% · Performance 7.34% · Measure score 2.39 · Achievement 1.66 · Improvement 2.39
Total nurse turnover
2.09
Baseline 42.73% · Performance 55.14% · Measure score 2.09 · Achievement 2.09 · Improvement 0
Adjusted total nurse staffing
1.73
Baseline 3.51 hours · Performance 3.57 hours · Measure score 1.73 · Achievement 1.73 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.68% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 282 · Observed rate 10.64% · Lower 95% interval 7.65% |
| Discharge to community | 53.82% |
50.57%
3.2 pts better
|
No Different than the National Rate · Eligible stays 253 · Observed rate 47.04% · Lower 95% interval 46.09% |
| Medicare spending per beneficiary | 1.09 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 99.39% |
95.27%
4.1 pts better
|
Numerator 164 · Denominator 165 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 165 |
| Discharge self-care score | 35.25% |
53.69%
18.4 pts worse
|
Numerator 43 · Denominator 122 |
| Discharge mobility score | 54.1% |
50.94%
3.2 pts better
|
Numerator 66 · Denominator 122 |
| Pressure ulcers or injuries, new or worsened | 3.03% |
2.29%
0.7 pts worse
|
Numerator 5 · Denominator 165 · Adjusted rate 3.99% |
| Healthcare-associated infections requiring hospitalization | 7.34% |
7.12%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 172 · Observed rate 7.56% · Lower 95% interval 4.59% |
| Staff COVID-19 vaccination coverage | 17.81% |
8.2%
9.6 pts better
|
Numerator 26 · Denominator 146 |
| Staff flu vaccination coverage | 67.77% |
42%
25.8 pts better
|
Numerator 82 · Denominator 121 |
| Discharge function score | 53.28% |
56.45%
3.2 pts worse
|
Numerator 65 · Denominator 122 |
| Transfer of health information to provider | 97.62% |
95.95%
1.7 pts better
|
Numerator 41 · Denominator 42 |
| Transfer of health information to patient | 98.55% |
96.28%
2.3 pts better
|
Numerator 68 · Denominator 69 |
| Resident COVID-19 vaccinations up to date | 53.16% |
25.2%
28 pts better
|
Numerator 42 · Denominator 79 |
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 1.6 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.3 |
1.5
0.8 pts worse
|
1.8
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.1 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.5% |
92.2%
7.3 pts better
|
93.4%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 99.0% · Q3 100.0% · Q4 99.0% · 4Q avg 99.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.6% |
94.8%
0.8 pts better
|
95.5%
0.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.5% |
3.5%
2 pts worse
|
3.3%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 5.8% · Q3 2.9% · Q4 7.8% · 4Q avg 5.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 30.0% |
12.0%
18 pts worse
|
11.4%
18.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.4% · Q2 30.3% · Q3 28.6% · Q4 35.1% · 4Q avg 30.0% |
| Percentage of long-stay residents who lose too much weight | 4.7% |
5.2%
0.5 pts better
|
5.4%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 4.9% · Q3 5.6% · Q4 5.7% · 4Q avg 4.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.4% |
19.2%
1.2 pts worse
|
19.6%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.6% · Q2 20.5% · Q3 19.8% · Q4 17.9% · 4Q avg 20.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.4% |
22.5%
4.1 pts better
|
16.7%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.8% · Q2 15.5% · Q3 19.4% · Q4 20.5% · 4Q avg 18.4% · 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 | 15.3% |
17.7%
2.4 pts better
|
16.3%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 29.1% · Q2 9.1% · Q3 7.2% · Q4 13.5% · 4Q avg 15.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.3% |
17.6%
0.3 pts better
|
14.9%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.8% · Q2 17.9% · Q3 4.8% · Q4 14.8% · 4Q avg 17.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
1.0%
0.3 pts better
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.9% · Q3 0.0% · Q4 0.9% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.8% |
2.0%
1.8 pts worse
|
1.7%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 2.0% · Q3 6.0% · Q4 4.3% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 31.5% |
21.7%
9.8 pts worse
|
19.8%
11.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.2% · Q2 32.1% · Q3 24.9% · Q4 33.4% · 4Q avg 31.5% |
| Percentage of long-stay residents with pressure ulcers | 3.6% |
4.6%
1 pts better
|
5.1%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 5.0% · Q3 2.3% · Q4 3.6% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.6% |
77.1%
16.5 pts better
|
81.7%
11.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 94.3% · Q2 92.1% · Q3 92.9% · Q4 95.2% · 4Q avg 93.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 18.0% |
11.8%
6.2 pts worse
|
12.0%
6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 18.0% · Observed 18.4% · Expected 11.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.3% |
1.3%
1 pts worse
|
1.6%
0.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.9% · Q3 4.7% · Q4 1.2% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.2% |
77.7%
15.5 pts better
|
79.7%
13.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.1% |
25.8%
1.7 pts better
|
23.9%
0.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.1% · Observed 22.8% · Expected 22.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-24 · Fire 2023-10-24
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2022-10-18 · Fire 2022-10-18
15 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2023-10-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-01-05
D · Potential for more than minimal harm
2023-10-24
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-01-05
D · Potential for more than minimal harm
2023-10-24
K226 · Egress Deficiencies
Fire Safety
Have horizontal exits used in accordance with safety requirements.
Corrected 2024-01-05
D · Potential for more than minimal harm
2023-10-24
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-01-05
D · Potential for more than minimal harm
2023-10-24
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-01-05
D · Potential for more than minimal harm
2023-10-24
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-01-05
D · Potential for more than minimal harm
2022-10-18
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2022-11-17
D · Potential for more than minimal harm
2022-10-18
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-11-17
D · Potential for more than minimal harm
2022-10-18
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-11-17
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-12-06
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 2025-01-14
D · Potential for more than minimal harm
2024-12-06
F646 · Resident Assessment and Care Planning Deficiencies
Health
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
Corrected 2025-01-14
D · Potential for more than minimal harm
2024-12-06
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-01-14
D · Potential for more than minimal harm
2024-12-06
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 2025-01-14
F · Potential for more than minimal harm
2023-10-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-30
E · Potential for more than minimal harm
2023-10-24
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 2023-11-30
D · Potential for more than minimal harm
2023-10-24
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 2023-11-30
D · Potential for more than minimal harm
2023-10-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-30
D · Potential for more than minimal harm
2023-10-24
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-11-30
D · Potential for more than minimal harm
2023-09-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-14
D · Potential for more than minimal harm
2023-09-22
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-10-14
D · Potential for more than minimal harm
2023-08-09
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-09-09
G · Actual harm
2022-10-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-11-18
G · Actual harm
2022-10-18
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-12-02
D · Potential for more than minimal harm
2022-10-18
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 2022-11-18
D · Potential for more than minimal harm
2022-10-18
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 2022-11-18
D · Potential for more than minimal harm
2022-10-18
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-11-18
D · Potential for more than minimal harm
2022-10-18
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 2022-11-18
D · Potential for more than minimal harm
2022-10-18
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2022-11-18
D · Potential for more than minimal harm
2022-10-18
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 2022-11-18
D · Potential for more than minimal harm
2022-10-18
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2022-11-18
D · Potential for more than minimal harm
2022-10-18
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2022-11-18
D · Potential for more than minimal harm
2022-10-18
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2022-11-18
D · Potential for more than minimal harm
2022-10-18
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 2022-11-18
Penalties and ownership
What sits behind the stars
Ownership
Integritus Healthcare Inc
5% Or Greater Indirect Ownership Interest · Organization
Willowood Extended Care Services Inc
5% Or Greater Direct Ownership Interest · Organization
Gingras, Marcie Jo
Corporate Officer · Individual
Integritus Healthcare Management Services Inc
Operational/Managerial Control · Organization
Jones, William
Corporate Officer · Individual
Ouimette, Jodi
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
North Adams Commons Nursing & Rehabilitation Cente
North Adams, MA
5-star overall rating with 5-star inspections
#2
Bennington Health & Rehab
Bennington, VT
2-star overall rating with 2-star inspections with $167,424 in total fines with 10 recent health deficiencies
#3
Crescent Manor Care Ctrs
Bennington, VT
3-star overall rating with 3-star inspections with $47,258 in total fines with 10 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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