SNF

Madonna Manor Nursing Home

CCN: 225475 · NORTH ATTLEBORO, MA 02760 · Bristol County

Overview

Address
85 NORTH WASHINGTON STREET, NORTH ATTLEBORO, MA 02760
Phone
5086992740
Certified beds
129
Avg daily residents
75 (58% of beds filled)
Ownership
Non-profit (church-affiliated)
Provider type
Medicare and Medicaid
Medicare/Medicaid since
1990-07-01
Setting
Urban
4 /5
★★★★★
CMS Overall Rating

CMS 5-Star Ratings

CMS rates every Medicare/Medicaid-certified nursing home on four domains. The Overall rating is driven primarily by Health Inspection results, then adjusted up or down by Staffing and Quality Measures.

Overall Rating
Composite of Health Inspection, Staffing, and Quality Measures.
★★★★★ 4/5
Health Inspection
Based on the three most recent standard surveys, with more weight on recent results.
★★★★★ 3/5
Staffing
Weighted combination of RN and total nurse staffing hours per resident per day, case-mix adjusted.
★★★★★ 5/5
Quality Measures
15 resident-level quality measures split between long-stay and short-stay (post-acute) residents.
★★★★★ 4/5
Quality Measures breakdown
Long-Stay Quality Measures ★★★★★ 4/5
Short-Stay Quality Measures ★★★★★ 5/5

Staffing & Workforce

Direct-care staffing is the strongest operational driver of quality in nursing homes. Values are hours per resident per day, derived from payroll-based journal (PBJ) submissions. "Case-mix" adjusts for resident acuity; "Adjusted" is the CMS rating-input value.

Role Reported Case-mix expected Adjusted Federal floor
Total nurse
All nursing staff combined: RN + LPN + Aide
 3.72 3.29 4.37 ≥ 3.48
Registered Nurse (RN)
Licensed RN hours. Strongest driver of clinical outcomes.
 0.89 0.57 1.04 ≥ 0.55
Licensed Practical Nurse (LPN)
LPN/LVN hours. Often handles medication administration.
 0.88 0.73 1.03 —
Nurse aide
CNA hours. Bulk of direct resident care — bathing, feeding, mobility.
 1.95 1.98 2.29 —
Licensed (RN + LPN)
Combined licensed nurse coverage.
 1.76 — — —
Physical therapist
Rehabilitation therapist hours — important for post-acute / rehab admissions.
 0.01 — — —

Federal minimums (phasing in under the CMS 2024 minimum staffing rule) shown for reference. RN: 0.55 hrs/resident/day. Total nurse: 3.48 hrs/resident/day.

Weekend staffing

Total nurse (weekend)
3.43
hrs / resident / day
RN (weekend)
0.69
hrs / resident / day
Total nurse (adjusted, weekend)
4.03
hrs / resident / day

Weekend under-staffing is a common quality-of-care concern — adverse events are more frequent when licensed coverage drops.

Staff turnover

Total nursing staff turnover
14.5%
annual
RN turnover
6.3%
annual
Administrators departed
0
last 12 months

Resident acuity

Nursing Case-Mix Index
1.16
higher acuity than avg
Case-Mix Index Ratio
0.84
facility / state ratio

Health Inspections

CMS weights three inspection cycles to compute the Health Inspection rating: the most recent (50%), the second most recent (33%), and the oldest (17%). Each standard-survey deficiency is assigned a score based on scope and severity; complaint-survey findings and revisit scores are added to produce the cycle total.

Cycle Date Total defs. Standard Complaint Deficiency score Revisits Total score
Cycle 1 (most recent) 2025-09-11 6 6 0 24 1 24
Cycle 2/3 (prior) 2024-08-21 13 9 4 132 1 132
Total weighted health score
51.0
lower is better

Deficiencies (29)

Individual survey findings. Scope/severity uses the CMS A–L matrix: letters further down the alphabet indicate greater harm and wider scope, up through J–L (immediate jeopardy).

24 D/E/F Actual harm — potential for minor
5 G/H/I Actual harm
Tag Description Scope/Severity Survey date Corrected
0761 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. D 2025-09-11 2025-10-17
0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. D 2025-09-11 2025-10-17
0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. D 2025-09-11 2025-10-17
0840 Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. D 2025-09-11 2025-10-17
0880 Provide and implement an infection prevention and control program. D 2025-09-11 2025-10-17
0887 Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. D 2025-09-11 2025-10-17
0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. D 2024-12-02 2024-12-16
0550 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. D 2024-08-21 2024-09-10
0565 Honor the resident's right to organize and participate in resident/family groups in the facility. E 2024-08-21 2024-09-10
0580 Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. G 2024-08-21 2024-09-10
0585 Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. E 2024-08-21 2024-09-10
0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. E 2024-08-21 2024-09-10
0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. D 2024-08-21 2024-09-10
0692 Provide enough food/fluids to maintain a resident's health. G 2024-08-21 2024-09-10
0695 Provide safe and appropriate respiratory care for a resident when needed. D 2024-08-21 2024-09-10
0880 Provide and implement an infection prevention and control program. D 2024-08-21 2024-09-10
0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. E 2023-12-28 2024-01-19
0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. G 2023-09-06 2023-09-27
0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. G 2023-09-06 2023-09-27
0583 Keep residents' personal and medical records private and confidential. D 2023-07-19 2023-08-16
0584 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. E 2023-07-19 2023-08-16
0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. D 2023-07-19 2023-08-16
0685 Assist a resident in gaining access to vision and hearing services. D 2023-07-19 2023-08-16
0688 Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. D 2023-07-19 2023-08-16
0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. G 2023-07-19 2023-08-16
0756 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. D 2023-07-19 2023-08-16
0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. D 2023-07-19 2023-08-16
0849 Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. D 2023-07-19 2023-08-16
0880 Provide and implement an infection prevention and control program. E 2023-07-19 2023-08-28

Penalties (2)

Fines issued
2
last 3 years
Total fines
$119,373
Date Type Fine amount
2024-08-21 Fine $43,011
2023-07-19 Fine $76,362

Source: CMS Nursing Home Penalties.

Financial Health (FY 2023)

Payer mix (share of resident days)

Medicare 6.6% Medicaid 61.6% Other 31.8%

Operating performance

Operating Margin
-11.4%
Total Margin
-8.8%
Occupancy Rate
79.2%
Cost per Resident Day
$26

Revenue & costs

Net Patient Revenue
$9.3M
Total Costs
$724K
Net Income
-$839K

Balance sheet

Total Assets
$2.4M
Total Liabilities
$2.8M
Fund Balance
-$442K
Current Ratio
0.65

Source: CMS SNF Cost Report (FY 2023). Cost report data lags by ~2 years.

Ownership & Corporate Structure

Chain: DIOCESAN HEALTH FACILITIES

Chain ID
184
Facilities in chain
5
Legal business name
MADONNA MANOR, INC.
Chain-average star ratings (for peer context)
Overall
3.6
Health
3.2
Staffing
4.6
QM
2.8

Owner / manager individuals (5)

Name Role Association
MITCHELL, LAURA OPERATIONAL/MANAGERIAL CONTROL since 02/01/2020
ROQUE, JOANNE OPERATIONAL/MANAGERIAL CONTROL since 07/01/2019
WHEATON, KURT OPERATIONAL/MANAGERIAL CONTROL since 10/18/2021
DA CUNHA, EDGAR CORPORATE OFFICER since 09/24/2014
MAYER, HARRY CONTRACTED MANAGING EMPLOYEE since 01/01/2024

Source: CMS Nursing Home Ownership. Percent ownership is rarely disclosed — CMS only requires it for specific roles.

Facility Features

CCRC
No
Hospital-based
No
Resident / family council
Resident
Sprinkler systems
Partial
Abuse citation flag
No
Methodology & sources

Full methodology →

All Data

Every labeled field shipped for this facility by CMS. No national median or percentile context is available for SNFs in the current release.

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Show 113 rows
Source Metric Value Raw key
Cost Report Cost per Resident Day ($) $26 metrics.cost_per_resident_day
Cost Report Current Ratio 0.65 metrics.current_ratio
Cost Report fiscal_year 2,023 fiscal_year
Cost Report Medicaid Day Share (%) 61.6% metrics.medicaid_day_share
Cost Report Medicare Day Share (%) 6.6% metrics.medicare_day_share
Cost Report Net Income ($) $-839,138 metrics.net_income
Cost Report Net Patient Revenue ($) $9,341,042 metrics.net_patient_revenue
Cost Report Occupancy Rate (%) 79.2% metrics.occupancy_rate
Cost Report Operating Margin (%) -11.4% metrics.operating_margin
Cost Report Total Assets ($) $2,398,013 metrics.total_assets
Cost Report Total Costs ($) $723,970 metrics.total_costs
Cost Report Total Fund Balances ($) $-442,118 metrics.fund_balance
Cost Report Total Liabilities ($) $2,840,131 metrics.total_liabilities
Cost Report Total Margin (%) -8.8% metrics.total_margin
Provider Information Abuse Icon N Abuse Icon
Provider Information Adjusted LPN Staffing Hours per Resident per Day 1.03046 Adjusted LPN Staffing Hours per Resident per Day
Provider Information Adjusted Nurse Aide Staffing Hours per Resident per Day 2.29451 Adjusted Nurse Aide Staffing Hours per Resident per Day
Provider Information Adjusted RN Staffing Hours per Resident per Day 1.04247 Adjusted RN Staffing Hours per Resident per Day
Provider Information Adjusted Total Nurse Staffing Hours per Resident per Day 4.36744 Adjusted Total Nurse Staffing Hours per Resident per Day
Provider Information Adjusted Weekend Total Nurse Staffing Hours per Resident per Day 4.02930 Adjusted Weekend Total Nurse Staffing Hours per Resident per Day
Provider Information Administrator turnover footnote — Administrator turnover footnote
Provider Information Automatic Sprinkler Systems in All Required Areas Partial Automatic Sprinkler Systems in All Required Areas
Provider Information Average Number of Residents per Day 75.3 Average Number of Residents per Day
Provider Information Average Number of Residents per Day Footnote — Average Number of Residents per Day Footnote
Provider Information Case-Mix LPN Staffing Hours per Resident per Day 0.72924 Case-Mix LPN Staffing Hours per Resident per Day
Provider Information Case-Mix Nurse Aide Staffing Hours per Resident per Day 1.98191 Case-Mix Nurse Aide Staffing Hours per Resident per Day
Provider Information Case-Mix RN Staffing Hours per Resident per Day 0.57480 Case-Mix RN Staffing Hours per Resident per Day
Provider Information Case-Mix Total Nurse Staffing Hours per Resident per Day 3.28595 Case-Mix Total Nurse Staffing Hours per Resident per Day
Provider Information Case-Mix Weekend Total Nurse Staffing Hours per Resident per Day 2.89622 Case-Mix Weekend Total Nurse Staffing Hours per Resident per Day
Provider Information Chain Average Health Inspection Rating 3.2 Chain Average Health Inspection Rating
Provider Information Chain Average Overall 5-star Rating 3.6 Chain Average Overall 5-star Rating
Provider Information Chain Average QM Rating 2.8 Chain Average QM Rating
Provider Information Chain Average Staffing Rating 4.6 Chain Average Staffing Rating
Provider Information Chain ID 184 Chain ID
Provider Information Chain Name DIOCESAN HEALTH FACILITIES Chain Name
Provider Information City/Town NORTH ATTLEBORO City/Town
Provider Information CMS Certification Number (CCN) 225475 CMS Certification Number (CCN)
Provider Information Continuing Care Retirement Community N Continuing Care Retirement Community
Provider Information County/Parish Bristol County/Parish
Provider Information Date First Approved to Provide Medicare and Medicaid Services 1990-07-01 Date First Approved to Provide Medicare and Medicaid Services
Provider Information Geocoding Footnote — Geocoding Footnote
Provider Information Health Inspection Rating 3 Health Inspection Rating
Provider Information Health Inspection Rating Footnote — Health Inspection Rating Footnote
Provider Information Latitude 41.9844 Latitude
Provider Information Legal Business Name MADONNA MANOR, INC. Legal Business Name
Provider Information Location 85 NORTH WASHINGTON STREET,NORTH ATTLEBORO,MA,02760 Location
Provider Information Long-Stay QM Rating 4 Long-Stay QM Rating
Provider Information Long-Stay QM Rating Footnote — Long-Stay QM Rating Footnote
Provider Information Longitude -71.332 Longitude
Provider Information Most Recent Health Inspection More Than 2 Years Ago N Most Recent Health Inspection More Than 2 Years Ago
Provider Information Number of administrators who have left the nursing home 0 Number of administrators who have left the nursing home
Provider Information Number of Certified Beds 129 Number of Certified Beds
Provider Information Number of Citations from Infection Control Inspections — Number of Citations from Infection Control Inspections
Provider Information Number of Facilities in Chain 5 Number of Facilities in Chain
Provider Information Number of Fines 2 Number of Fines
Provider Information Number of Payment Denials 0 Number of Payment Denials
Provider Information Nursing Case-Mix Index 1.16407 Nursing Case-Mix Index
Provider Information Nursing Case-Mix Index Ratio 0.84497 Nursing Case-Mix Index Ratio
Provider Information Overall Rating 4 Overall Rating
Provider Information Overall Rating Footnote — Overall Rating Footnote
Provider Information Ownership Type Non profit - Church related Ownership Type
Provider Information Physical Therapist Staffing Footnote — Physical Therapist Staffing Footnote
Provider Information Processing Date 2026-03-01 Processing Date
Provider Information Provider Address 85 NORTH WASHINGTON STREET Provider Address
Provider Information Provider Changed Ownership in Last 12 Months N Provider Changed Ownership in Last 12 Months
Provider Information Provider Name Madonna Manor Nursing Home Provider Name
Provider Information Provider Resides in Hospital N Provider Resides in Hospital
Provider Information Provider SSA County Code 020 Provider SSA County Code
Provider Information Provider Type Medicare and Medicaid Provider Type
Provider Information QM Rating 4 QM Rating
Provider Information QM Rating Footnote — QM Rating Footnote
Provider Information Rating Cycle 1 Health Deficiency Score 24 Rating Cycle 1 Health Deficiency Score
Provider Information Rating Cycle 1 Health Revisit Score 0 Rating Cycle 1 Health Revisit Score
Provider Information Rating Cycle 1 Number of Complaint Health Deficiencies 0 Rating Cycle 1 Number of Complaint Health Deficiencies
Provider Information Rating Cycle 1 Number of Health Revisits 1 Rating Cycle 1 Number of Health Revisits
Provider Information Rating Cycle 1 Number of Standard Health Deficiencies 6 Rating Cycle 1 Number of Standard Health Deficiencies
Provider Information Rating Cycle 1 Standard Survey Health Date 2025-09-11 Rating Cycle 1 Standard Survey Health Date
Provider Information Rating Cycle 1 Total Health Score 24 Rating Cycle 1 Total Health Score
Provider Information Rating Cycle 1 Total Number of Health Deficiencies 6 Rating Cycle 1 Total Number of Health Deficiencies
Provider Information Rating Cycle 2 Number of Standard Health Deficiencies 9 Rating Cycle 2 Number of Standard Health Deficiencies
Provider Information Rating Cycle 2 Standard Health Survey Date 2024-08-21 Rating Cycle 2 Standard Health Survey Date
Provider Information Rating Cycle 2/3 Health Deficiency Score 132 Rating Cycle 2/3 Health Deficiency Score
Provider Information Rating Cycle 2/3 Health Revisit Score 0 Rating Cycle 2/3 Health Revisit Score
Provider Information Rating Cycle 2/3 Number of Complaint Health Deficiencies 4 Rating Cycle 2/3 Number of Complaint Health Deficiencies
Provider Information Rating Cycle 2/3 Number of Health Revisits 1 Rating Cycle 2/3 Number of Health Revisits
Provider Information Rating Cycle 2/3 Total Health Score 132 Rating Cycle 2/3 Total Health Score
Provider Information Rating Cycle 2/3 Total Number of Health Deficiencies 13 Rating Cycle 2/3 Total Number of Health Deficiencies
Provider Information Registered Nurse hours per resident per day on the weekend 0.69164 Registered Nurse hours per resident per day on the weekend
Provider Information Registered Nurse turnover 6.3 Registered Nurse turnover
Provider Information Registered Nurse turnover footnote — Registered Nurse turnover footnote
Provider Information Reported Licensed Staffing Hours per Resident per Day 1.76423 Reported Licensed Staffing Hours per Resident per Day
Provider Information Reported LPN Staffing Hours per Resident per Day 0.87701 Reported LPN Staffing Hours per Resident per Day
Provider Information Reported Nurse Aide Staffing Hours per Resident per Day 1.95281 Reported Nurse Aide Staffing Hours per Resident per Day
Provider Information Reported Physical Therapist Staffing Hours per Resident Per Day 0.01194 Reported Physical Therapist Staffing Hours per Resident Per Day
Provider Information Reported RN Staffing Hours per Resident per Day 0.88722 Reported RN Staffing Hours per Resident per Day
Provider Information Reported Staffing Footnote — Reported Staffing Footnote
Provider Information Reported Total Nurse Staffing Hours per Resident per Day 3.71703 Reported Total Nurse Staffing Hours per Resident per Day
Provider Information Short-Stay QM Rating 5 Short-Stay QM Rating
Provider Information Short-Stay QM Rating Footnote — Short-Stay QM Rating Footnote
Provider Information Special Focus Status — Special Focus Status
Provider Information Staffing Rating 5 Staffing Rating
Provider Information Staffing Rating Footnote — Staffing Rating Footnote
Provider Information State MA State
Provider Information Telephone Number 5086992740 Telephone Number
Provider Information Total Amount of Fines in Dollars 119373.00 Total Amount of Fines in Dollars
Provider Information Total number of nurse staff hours per resident per day on the weekend 3.42925 Total number of nurse staff hours per resident per day on the weekend
Provider Information Total Number of Penalties 2 Total Number of Penalties
Provider Information Total nursing staff turnover 14.5 Total nursing staff turnover
Provider Information Total nursing staff turnover footnote — Total nursing staff turnover footnote
Provider Information Total Weighted Health Survey Score 51.000 Total Weighted Health Survey Score
Provider Information Urban Y Urban
Provider Information With a Resident and Family Council Resident With a Resident and Family Council
Provider Information ZIP Code 02760 ZIP Code