Cycle 1
Health 2024-11-07 · Fire 2024-11-07
6 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Winchester, MA
Winchester Rehabilitation And Nursing Center
4-star overall rating with 3-star inspections with $7,901 in total fines with 6 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
223 Swanton Street, #1968, Winchester, MA
(781) 530-0656
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
121
Certified beds
Average residents
101
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Stellar Health Group
Operator or chain grouping
Approved since
1989-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
7 facilities
Chain averages 3 overall / 3 health / 3 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
1.14
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
0.73
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.32
Nurse aide staffing · state 2.26 · national 2.35
Total nurse hours
4.19
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.87
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.68
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.88
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.15
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
1.10
CMS adjusted RN staffing hours
Adjusted total hours
4.06
CMS adjusted total nurse staffing hours
Case-mix index
1.41
Higher values indicate more complex resident acuity
RN turnover
15%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
25%
Annual nurse turnover · state 40% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,982
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
37.87
Composite VBP score used to determine payment impact.
Payment multiplier
0.9910
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.28% · Performance 22.40% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
2.95
Baseline 5.81% · Performance 6.95% · Measure score 2.95 · Achievement 2.95 · Improvement 0
Total nurse turnover
9.40
Baseline 40.57% · Performance 25.25% · Measure score 9.40 · Achievement 9.40 · Improvement 9
Adjusted total nurse staffing
2.80
Baseline 3.77 hours · Performance 3.87 hours · Measure score 2.80 · Achievement 2.80 · Improvement 0.02
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.94% |
10.72%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 429 · Observed rate 9.56% · Lower 95% interval 8.65% |
| Discharge to community | 60.07% |
50.57%
9.5 pts better
|
Better than the National Rate · Eligible stays 396 · Observed rate 57.07% · Lower 95% interval 56.29% |
| Medicare spending per beneficiary | 0.88 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 99.64% |
95.27%
4.4 pts better
|
Numerator 279 · Denominator 280 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 280 |
| Discharge self-care score | 41.86% |
53.69%
11.8 pts worse
|
Numerator 90 · Denominator 215 |
| Discharge mobility score | 57.67% |
50.94%
6.7 pts better
|
Numerator 124 · Denominator 215 |
| Pressure ulcers or injuries, new or worsened | 0.36% |
2.29%
1.9 pts better
|
Numerator 1 · Denominator 280 · Adjusted rate 0.33% |
| Healthcare-associated infections requiring hospitalization | 6.95% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 263 · Observed rate 5.7% · Lower 95% interval 4.59% |
| Staff COVID-19 vaccination coverage | 12.21% |
8.2%
4 pts better
|
Numerator 21 · Denominator 172 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 49.3% |
56.45%
7.2 pts worse
|
Numerator 106 · Denominator 215 |
| Transfer of health information to provider | 99.12% |
95.95%
3.2 pts better
|
Numerator 226 · Denominator 228 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 23.81% |
25.2%
1.4 pts worse
|
Numerator 35 · Denominator 147 |
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 | 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 | 100.0% |
92.2%
7.8 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.8% |
94.8%
3 pts better
|
95.5%
2.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.7% |
3.5%
0.8 pts better
|
3.3%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 1.2% · Q3 2.9% · Q4 4.3% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 15.2% |
12.0%
3.2 pts worse
|
11.4%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 17.1% · Q3 17.2% · Q4 19.4% · 4Q avg 15.2% |
| Percentage of long-stay residents who lose too much weight | 3.1% |
5.2%
2.1 pts better
|
5.4%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 6.0% · Q3 3.2% · Q4 3.3% · 4Q avg 3.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.3% |
19.2%
3.9 pts better
|
19.6%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.4% · Q2 19.1% · Q3 20.6% · Q4 9.8% · 4Q avg 15.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 24.5% |
22.5%
2 pts worse
|
16.7%
7.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.1% · Q2 27.7% · Q3 23.1% · Q4 27.1% · 4Q avg 24.5% · 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 | 22.4% |
17.7%
4.7 pts worse
|
16.3%
6.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.8% · Q2 27.2% · Q3 20.8% · Q4 13.0% · 4Q avg 22.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.4% |
17.6%
2.8 pts worse
|
14.9%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.7% · Q2 23.4% · Q3 22.4% · Q4 12.3% · 4Q avg 20.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
1.0%
0.1 pts better
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 1.2% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.3% |
2.0%
1.7 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.3% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.9% |
21.7%
3.8 pts better
|
19.8%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.0% · Q2 25.9% · Q3 12.2% · Q4 15.5% · 4Q avg 17.9% |
| Percentage of long-stay residents with pressure ulcers | 2.1% |
4.6%
2.5 pts better
|
5.1%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 1.1% · Q3 2.5% · Q4 1.2% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
77.1%
22.9 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.9% |
11.8%
2.9 pts better
|
12.0%
3.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.9% · Observed 6.9% · Expected 8.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.3%
0.6 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 0.7% · Q3 1.5% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.5% |
77.7%
21.8 pts better
|
79.7%
19.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.5% |
25.8%
3.3 pts better
|
23.9%
1.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.5% · Observed 19.0% · Expected 20.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-22 · Fire 2023-11-22
8 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
5 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2022-10-21 · Fire 2022-10-21
11 health deficiencies
Top issue: Pharmacy Service (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
2024-11-07
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-12-20
F · Potential for more than minimal harm
2024-11-07
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-12-20
F · Potential for more than minimal harm
2024-11-07
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-01-10
F · Potential for more than minimal harm
2024-11-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-20
F · Potential for more than minimal harm
2024-11-07
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-12-20
F · Potential for more than minimal harm
2024-11-07
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-12-20
F · Potential for more than minimal harm
2023-11-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-01-12
D · Potential for more than minimal harm
2023-11-22
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-12-14
D · Potential for more than minimal harm
2023-11-22
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-12-11
D · Potential for more than minimal harm
2023-11-22
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-01-12
D · Potential for more than minimal harm
2023-11-22
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-12-14
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-11-07
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 2024-11-26
D · Potential for more than minimal harm
2024-11-07
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 2024-11-26
D · Potential for more than minimal harm
2024-11-07
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 2024-11-26
D · Potential for more than minimal harm
2024-11-07
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-11-26
D · Potential for more than minimal harm
2024-11-07
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 2024-11-26
D · Potential for more than minimal harm
2024-11-07
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 2024-11-26
D · Potential for more than minimal harm
2024-10-02
F573 · Resident Rights Deficiencies
Health
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Corrected 2024-10-17
D · Potential for more than minimal harm
2024-10-02
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 2024-10-17
E · Potential for more than minimal harm
2023-11-22
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 2023-12-18
D · Potential for more than minimal harm
2023-11-22
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2023-12-18
D · Potential for more than minimal harm
2023-11-22
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 2023-12-18
D · Potential for more than minimal harm
2023-11-22
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-12-18
D · Potential for more than minimal harm
2023-11-22
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 2023-12-18
D · Potential for more than minimal harm
2023-11-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-18
D · Potential for more than minimal harm
2023-11-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-08
G · Actual harm
2023-06-13
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 2023-06-15
G · Actual harm
2023-06-13
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 2023-06-15
D · Potential for more than minimal harm
2022-10-21
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2022-11-04
D · Potential for more than minimal harm
2022-10-21
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 2022-11-04
D · Potential for more than minimal harm
2022-10-21
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 2022-11-04
D · Potential for more than minimal harm
2022-10-21
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 2022-11-04
D · Potential for more than minimal harm
2022-10-21
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 2022-11-04
D · Potential for more than minimal harm
2022-10-21
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2022-11-04
D · Potential for more than minimal harm
2022-10-21
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2022-11-04
D · Potential for more than minimal harm
2022-10-21
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 2022-11-04
Penalties and ownership
What sits behind the stars
$7,901
2023-06-13
Fine
Fine · fine $7,901
Fine
Ownership
Winchester Operations LLC
5% Or Greater Direct Ownership Interest · Organization
Boston Master Tenant LLC
5% Or Greater Indirect Ownership Interest · Organization
Erlichman, Ariel
5% Or Greater Indirect Ownership Interest · Individual
Erlichman, Ariel
Corporate Director · Individual
Erlichman, Ariel
Corporate Officer · Individual
Pelrine, Anne
W-2 Managing Employee · Individual
Pugliese, Nicholas
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Aberjona Rehabilitation And Nursing Center
Winchester, MA
5-star overall rating with 5-star inspections with $3,250 in total fines
#2
Park Avenue Health Center
Arlington, MA
1-star overall rating with 1-star inspections with $113,612 in total fines with 17 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Woburn Rehabilitation And Nursing Center
Woburn, MA
1-star overall rating with 2-star inspections with $8,512 in total fines with 15 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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