Cycle 1
Health 2025-04-17 · Fire 2025-04-17
23 health deficiencies
Top issue: Resident Rights (6 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Smyrna, DE
Evergreen Post Acute
3-star overall rating with 2-star inspections with $94,156 in total fines with 23 recent health deficiencies
3034 South Dupont Blvd, Smyrna, DE
(302) 653-5085
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
151
Certified beds
Average residents
133
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Prestige Healthcare Administrative Services
Operator or chain grouping
Approved since
1980-10-06
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
15 facilities
Chain averages 3 overall / 3 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
0.50
Registered nurse staffing · state 1.03 · national 0.68
LPN hours / resident day
0.95
Licensed practical nurse staffing · state 1.01 · national 0.87
Aide hours / resident day
2.45
Nurse aide staffing · state 2.47 · national 2.35
Total nurse hours
3.89
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.44
RN + LPN hours · state 2.04 · national 1.54
Weekend hours
3.60
Weekend nurse staffing · state 4.04 · national 3.43
Weekend RN hours
0.33
Weekend registered nurse coverage · state 0.72 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.15 · national 0.07
Adjusted RN hours
0.51
CMS adjusted RN staffing hours
Adjusted total hours
4.03
CMS adjusted total nurse staffing hours
Case-mix index
1.32
Higher values indicate more complex resident acuity
RN turnover
68%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
50%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,525
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
35.9
Composite VBP score used to determine payment impact.
Payment multiplier
0.9894
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.36
Baseline 18.95% · Performance 20.34% · Measure score 2.36 · Achievement 2.36 · Improvement 0
Healthcare-associated infections
4.02
Baseline 6.27% · Performance 6.63% · Measure score 4.02 · Achievement 4.02 · Improvement 0
Total nurse turnover
5.51
Baseline 39.34% · Performance 41.18% · Measure score 5.51 · Achievement 5.51 · Improvement 0
Adjusted total nurse staffing
2.48
Baseline 3.89 hours · Performance 3.78 hours · Measure score 2.48 · Achievement 2.48 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.75% |
10.72%
1 pts better
|
No Different than the National Rate · Eligible stays 207 · Observed rate 9.18% · Lower 95% interval 7.36% |
| Discharge to community | 54.15% |
50.57%
3.6 pts better
|
No Different than the National Rate · Eligible stays 166 · Observed rate 43.37% · Lower 95% interval 46.34% |
| Medicare spending per beneficiary | 0.99 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 93.89% |
95.27%
1.4 pts worse
|
Numerator 123 · Denominator 131 |
| Falls with major injury | 0.76% |
0.77%
About the same
|
Numerator 1 · Denominator 131 |
| Discharge self-care score | 55.56% |
53.69%
1.9 pts better
|
Numerator 40 · Denominator 72 |
| Discharge mobility score | 56.94% |
50.94%
6 pts better
|
Numerator 41 · Denominator 72 |
| Pressure ulcers or injuries, new or worsened | 0.76% |
2.29%
1.5 pts better
|
Numerator 1 · Denominator 131 · Adjusted rate 0.66% |
| Healthcare-associated infections requiring hospitalization | 6.63% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 125 · Observed rate 7.2% · Lower 95% interval 4.41% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 236 |
| Staff flu vaccination coverage | 56.49% |
42%
14.5 pts better
|
Numerator 87 · Denominator 154 |
| Discharge function score | 61.11% |
56.45%
4.7 pts better
|
Numerator 44 · Denominator 72 |
| Transfer of health information to provider | 94.74% |
95.95%
1.2 pts worse
|
Numerator 72 · Denominator 76 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 17.24% |
25.2%
8 pts worse
|
Numerator 10 · Denominator 58 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
1.8
0.2 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.4 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.4
0.2 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.1 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.8% |
95.7%
2.1 pts better
|
93.4%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.5% · Q2 94.8% · Q3 100.0% · Q4 100.0% · 4Q avg 97.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.6% |
97.4%
0.2 pts better
|
95.5%
2.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.9% |
3.2%
0.3 pts better
|
3.3%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 3.5% · Q3 3.4% · Q4 1.9% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 7.3% |
6.5%
0.8 pts worse
|
11.4%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 2.7% · Q3 7.6% · Q4 15.8% · 4Q avg 7.3% |
| Percentage of long-stay residents who lose too much weight | 2.0% |
5.6%
3.6 pts better
|
5.4%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 2.1% · Q3 0.9% · Q4 0.0% · 4Q avg 2.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.0% |
21.1%
6.1 pts better
|
19.6%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 11.4% · Q3 13.9% · Q4 18.1% · 4Q avg 15.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 21.9% |
12.0%
9.9 pts worse
|
16.7%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.7% · Q2 23.6% · Q3 20.7% · Q4 21.4% · 4Q avg 21.9% · 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 | 11.9% |
17.5%
5.6 pts better
|
16.3%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.6% · Q2 11.1% · Q3 13.6% · Q4 9.1% · 4Q avg 11.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.0% |
14.7%
1.7 pts better
|
14.9%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.2% · Q2 13.5% · Q3 9.7% · Q4 12.5% · 4Q avg 13.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
0.7%
0.3 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.8% · Q3 0.7% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.9% |
2.0%
1.1 pts better
|
1.7%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 0.0% · Q3 0.9% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.7% |
21.6%
2.1 pts worse
|
19.8%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.6% · Q2 15.5% · Q3 23.2% · Q4 18.9% · 4Q avg 23.7% |
| Percentage of long-stay residents with pressure ulcers | 5.7% |
4.4%
1.3 pts worse
|
5.1%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 7.7% · Q3 4.1% · Q4 2.5% · 4Q avg 5.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.2% |
83.5%
9.7 pts better
|
81.7%
11.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 92.4% · Q2 92.1% · Q3 95.8% · Q4 92.9% · 4Q avg 93.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.2% |
11.2%
6 pts better
|
12.0%
6.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.2% · Observed 5.4% · Expected 11.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
0.9%
0.9 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 | 97.2% |
83.1%
14.1 pts better
|
79.7%
17.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.6% |
21.5%
3.9 pts better
|
23.9%
6.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.6% · Observed 20.4% · Expected 27.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-30 · Fire 2024-05-30
29 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2023-04-11 · Fire 2023-04-11
12 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-05-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-07-24
E · Potential for more than minimal harm
2024-05-30
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-07-24
Inspection history
Recent health citations
G · Actual harm
2025-04-17
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-09-18
E · Potential for more than minimal harm
2025-04-17
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 2025-06-03
E · Potential for more than minimal harm
2025-04-17
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-06-03
E · Potential for more than minimal harm
2025-04-17
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 2025-06-03
E · Potential for more than minimal harm
2025-04-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-03
D · Potential for more than minimal harm
2025-04-17
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 2025-06-03
D · Potential for more than minimal harm
2025-04-17
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 2025-06-03
D · Potential for more than minimal harm
2025-04-17
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-06-03
D · Potential for more than minimal harm
2025-04-17
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-06-03
D · Potential for more than minimal harm
2025-04-17
F603 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Corrected 2025-06-03
D · Potential for more than minimal harm
2025-04-17
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 2025-06-03
D · Potential for more than minimal harm
2025-04-17
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2025-06-03
D · Potential for more than minimal harm
2025-04-17
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-06-03
D · Potential for more than minimal harm
2025-04-17
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 2025-06-03
D · Potential for more than minimal harm
2025-04-17
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2025-06-03
D · Potential for more than minimal harm
2025-04-17
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 2025-06-03
D · Potential for more than minimal harm
2025-04-17
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 2025-06-03
D · Potential for more than minimal harm
2025-04-17
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-06-03
D · Potential for more than minimal harm
2025-04-17
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 2025-06-03
D · Potential for more than minimal harm
2025-04-17
F808 · Nutrition and Dietary Deficiencies
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2025-06-03
D · Potential for more than minimal harm
2025-04-17
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2025-06-03
D · Potential for more than minimal harm
2025-04-17
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-06-03
B · Minimal harm
2025-04-17
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 2025-06-03
D · Potential for more than minimal harm
2025-01-14
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 2025-01-22
D · Potential for more than minimal harm
2025-01-14
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-01-22
G · Actual harm
2024-05-30
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-07-24
G · Actual harm
2024-05-30
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 2024-07-24
G · Actual harm
2024-05-30
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 2024-07-24
G · Actual harm
2024-05-30
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-07-24
F · Potential for more than minimal harm
2024-05-30
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 2024-07-24
E · Potential for more than minimal harm
2024-05-30
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-07-24
E · Potential for more than minimal harm
2024-05-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-24
D · Potential for more than minimal harm
2024-05-30
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 2024-07-24
D · Potential for more than minimal harm
2024-05-30
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-07-24
D · Potential for more than minimal harm
2024-05-30
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 2024-07-24
D · Potential for more than minimal harm
2024-05-30
F585 · Resident Rights Deficiencies
Health
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.
Corrected 2024-07-24
D · Potential for more than minimal harm
2024-05-30
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 2024-07-24
D · Potential for more than minimal harm
2024-05-30
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-07-24
D · Potential for more than minimal harm
2024-05-30
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-07-24
D · Potential for more than minimal harm
2024-05-30
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 2024-07-24
D · Potential for more than minimal harm
2024-05-30
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-07-24
D · Potential for more than minimal harm
2024-05-30
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 2024-07-24
D · Potential for more than minimal harm
2024-05-30
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-07-24
D · Potential for more than minimal harm
2024-05-30
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 2024-07-24
D · Potential for more than minimal harm
2024-05-30
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-24
D · Potential for more than minimal harm
2024-05-30
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-07-24
D · Potential for more than minimal harm
2024-05-30
F711 · Nursing and Physician Services Deficiencies
Health
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Corrected 2024-07-24
D · Potential for more than minimal harm
2024-05-30
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 2024-07-24
D · Potential for more than minimal harm
2024-05-30
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-07-24
D · Potential for more than minimal harm
2024-05-30
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 2024-07-24
D · Potential for more than minimal harm
2024-05-30
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2024-07-24
D · Potential for more than minimal harm
2024-05-30
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 2024-07-24
E · Potential for more than minimal harm
2023-04-11
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 2023-05-19
D · Potential for more than minimal harm
2023-04-11
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 2023-05-19
D · Potential for more than minimal harm
2023-04-11
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 2023-05-19
D · Potential for more than minimal harm
2023-04-11
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 2023-05-19
D · Potential for more than minimal harm
2023-04-11
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-05-19
D · Potential for more than minimal harm
2023-04-11
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-05-19
D · Potential for more than minimal harm
2023-04-11
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2023-05-19
D · Potential for more than minimal harm
2023-04-11
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-05-19
D · Potential for more than minimal harm
2023-04-11
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-05-19
D · Potential for more than minimal harm
2023-04-11
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2023-05-19
D · Potential for more than minimal harm
2023-04-11
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 2023-05-19
D · Potential for more than minimal harm
2023-04-11
F887 · Infection Control Deficiencies
Health
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.
Corrected 2023-05-19
Penalties and ownership
What sits behind the stars
$17,345
2025-04-17
Fine
Fine · fine $17,345
Fine
$76,811
2024-05-30
Fine
Fine · fine $76,811
Fine
Ownership
Evpa Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Copper De Trust
5% Or Greater Indirect Ownership Interest · Organization
Ellenbogen, Moss
5% Or Greater Indirect Ownership Interest · Individual
Gold De Trust
5% Or Greater Indirect Ownership Interest · Organization
Rastogi, Ritu
Operational/Managerial Control · Individual
Rochester, Jessica
Operational/Managerial Control · Individual
Silver De Trust
5% Or Greater Indirect Ownership Interest · Organization
Star De I Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Star De I Trust
5% Or Greater Indirect Ownership Interest · Organization
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5-star overall rating with 3-star inspections with $82,885 in total fines with 1 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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Westminster Village Health
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4-star overall rating with 3-star inspections with $38,518 in total fines with 11 recent health deficiencies
#3
Complete Care At Silver Lake LLC
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3-star overall rating with 2-star inspections with $47,541 in total fines with 15 recent health deficiencies
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