Cycle 1
Health 2025-05-06 · Fire 2025-05-06
30 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
7 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Waterford, CT
Greentree Manor Nursing And Rehabilitation Center
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $127,702 in total fines with 30 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
4 Greentree Drive, Waterford, CT
(860) 442-0647
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
90
Certified beds
Average residents
78
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Ryders Health Management
Operator or chain grouping
Approved since
1970-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
8 facilities
Chain averages 2 overall / 2 health / 4 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
0.46
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.98
Licensed practical nurse staffing · state 0.84 · national 0.87
Aide hours / resident day
2.19
Nurse aide staffing · state 2.28 · national 2.35
Total nurse hours
3.63
All reported nurse hours · state 3.83 · national 3.89
Licensed hours
1.44
RN + LPN hours · state 1.54 · national 1.54
Weekend hours
3.37
Weekend nurse staffing · state 3.41 · national 3.43
Weekend RN hours
0.33
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.53
CMS adjusted RN staffing hours
Adjusted total hours
4.14
CMS adjusted total nurse staffing hours
Case-mix index
1.20
Higher values indicate more complex resident acuity
RN turnover
82%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
57%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,553
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
3.76
Composite VBP score used to determine payment impact.
Payment multiplier
0.9805
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 18.20% · Performance 21.67% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 4.96% · Performance 8.30% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0
Baseline 40.58% · Performance 65.56% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
1.51
Baseline 3.55 hours · Performance 3.51 hours · Measure score 1.51 · Achievement 1.51 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.99% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 119 · Observed rate 10.08% · Lower 95% interval 6.5% |
| Discharge to community | 56.41% |
50.57%
5.8 pts better
|
No Different than the National Rate · Eligible stays 107 · Observed rate 49.53% · Lower 95% interval 48.27% |
| Medicare spending per beneficiary | 0.68 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 46 · Denominator 46 |
| Falls with major injury | 2.17% |
0.77%
1.4 pts worse
|
Numerator 1 · Denominator 46 |
| Discharge self-care score | 33.33% |
53.69%
20.4 pts worse
|
Numerator 10 · Denominator 30 |
| Discharge mobility score | 40% |
50.94%
10.9 pts worse
|
Numerator 12 · Denominator 30 |
| Pressure ulcers or injuries, new or worsened | 2.17% |
2.29%
0.1 pts better
|
Numerator 1 · Denominator 46 · Adjusted rate 2.4% |
| Healthcare-associated infections requiring hospitalization | 8.3% |
7.12%
1.2 pts worse
|
No Different than the National Rate · Eligible stays 58 · Observed rate 12.07% · Lower 95% interval 5.4% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 107 |
| Staff flu vaccination coverage | 42.97% |
42%
1 pts better
|
Numerator 55 · Denominator 128 |
| Discharge function score | 36.67% |
56.45%
19.8 pts worse
|
Numerator 11 · Denominator 30 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 20 · Denominator 20 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 12.5% |
25.2%
12.7 pts worse
|
Numerator 3 · Denominator 24 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.6 |
2.1
1.5 pts worse
|
1.9
1.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.6 · Observed 3.6 · Expected 1.9 · 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 1.8 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 57.8% |
87.5%
29.7 pts worse
|
93.4%
35.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 67.1% · Q2 59.5% · Q3 51.9% · Q4 52.1% · 4Q avg 57.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 82.0% |
93.5%
11.5 pts worse
|
95.5%
13.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 82.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.9% |
3.4%
1.5 pts worse
|
3.3%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 3.8% · Q3 6.5% · Q4 5.5% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.4% |
17.1%
15.7 pts better
|
11.4%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 0.0% · Q3 0.0% · Q4 1.4% · 4Q avg 1.4% |
| Percentage of long-stay residents who lose too much weight | 6.7% |
6.4%
0.3 pts worse
|
5.4%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 8.6% · Q3 10.3% · Q4 1.7% · 4Q avg 6.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.0% |
17.3%
0.7 pts worse
|
19.6%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.1% · Q2 16.7% · Q3 16.4% · Q4 22.1% · 4Q avg 18.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.1% |
19.4%
2.3 pts better
|
16.7%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.2% · Q2 14.0% · Q3 20.0% · Q4 21.3% · 4Q avg 17.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
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 | 36.2% |
18.1%
18.1 pts worse
|
16.3%
19.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 45.3% · Q2 44.7% · Q3 30.7% · Q4 21.4% · 4Q avg 36.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 30.9% |
18.4%
12.5 pts worse
|
14.9%
16 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 44.9% · Q2 28.4% · Q3 22.5% · Q4 27.4% · 4Q avg 30.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.1% |
0.9%
0.2 pts worse
|
1.0%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.1% · Q3 1.1% · Q4 1.1% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.7% |
1.7%
4 pts worse
|
1.7%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 5.3% · Q3 8.0% · Q4 4.3% · 4Q avg 5.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.2% |
24.8%
0.4 pts worse
|
19.8%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.9% · Q2 28.0% · Q3 22.6% · Q4 17.3% · 4Q avg 25.2% |
| Percentage of long-stay residents with pressure ulcers | 4.7% |
4.4%
0.3 pts worse
|
5.1%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 5.0% · Q3 4.2% · Q4 4.5% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 23.6% |
70.5%
46.9 pts worse
|
81.7%
58.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 28.6% · Q2 21.6% · Q3 19.4% · Q4 24.2% · 4Q avg 23.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 23.1% |
11.1%
12 pts worse
|
12.0%
11.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 23.1% · Observed 25.0% · Expected 12.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.1% |
1.5%
2.6 pts worse
|
1.6%
2.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 9.1% · Q3 0.0% · Q4 0.0% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 22.6% |
69.7%
47.1 pts worse
|
79.7%
57.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 22.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 33.5% |
25.0%
8.5 pts worse
|
23.9%
9.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 33.5% · Observed 38.9% · Expected 27.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-05-25 · Fire 2023-05-25
37 health deficiencies
Top issue: Quality of Life and Care (10 deficiencies)
17 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Cycle 3
Health 2021-02-10 · Fire 2021-02-10
24 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
11 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-05-06
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-06-09
D · Potential for more than minimal harm
2025-05-06
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-06-09
D · Potential for more than minimal harm
2025-05-06
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-06-09
D · Potential for more than minimal harm
2025-05-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-06-09
D · Potential for more than minimal harm
2025-05-06
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2025-06-09
D · Potential for more than minimal harm
2025-05-06
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2025-06-09
D · Potential for more than minimal harm
2025-05-06
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-06-09
E · Potential for more than minimal harm
2023-05-25
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-08-01
E · Potential for more than minimal harm
2023-05-25
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2023-08-01
E · Potential for more than minimal harm
2023-05-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-08-01
E · Potential for more than minimal harm
2023-05-25
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-08-01
D · Potential for more than minimal harm
2023-05-25
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2023-08-01
D · Potential for more than minimal harm
2023-05-25
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-08-01
D · Potential for more than minimal harm
2023-05-25
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-08-01
D · Potential for more than minimal harm
2023-05-25
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2023-08-01
D · Potential for more than minimal harm
2023-05-25
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2023-08-01
D · Potential for more than minimal harm
2023-05-25
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-08-01
D · Potential for more than minimal harm
2023-05-25
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-08-01
D · Potential for more than minimal harm
2023-05-25
K344 · Smoke Deficiencies
Fire Safety
Have an alternate power supply for its alarm system.
Corrected 2023-08-01
D · Potential for more than minimal harm
2023-05-25
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-08-01
D · Potential for more than minimal harm
2023-05-25
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-08-01
D · Potential for more than minimal harm
2023-05-25
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-08-01
D · Potential for more than minimal harm
2023-05-25
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-08-01
D · Potential for more than minimal harm
2023-05-25
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-08-01
F · Potential for more than minimal harm
2021-02-10
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2021-04-09
F · Potential for more than minimal harm
2021-02-10
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2021-04-09
F · Potential for more than minimal harm
2021-02-10
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2021-04-09
F · Potential for more than minimal harm
2021-02-10
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2021-04-09
F · Potential for more than minimal harm
2021-02-10
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-04-09
F · Potential for more than minimal harm
2021-02-10
K926 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Corrected 2021-04-09
F · Potential for more than minimal harm
2021-02-10
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2021-04-09
E · Potential for more than minimal harm
2021-02-10
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-04-09
E · Potential for more than minimal harm
2021-02-10
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2021-04-09
D · Potential for more than minimal harm
2021-02-10
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2021-04-09
D · Potential for more than minimal harm
2021-02-10
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2021-04-09
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-22
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 2026-02-02
E · Potential for more than minimal harm
2025-12-02
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2026-01-13
E · Potential for more than minimal harm
2025-12-02
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 2026-01-13
D · Potential for more than minimal harm
2025-07-08
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 2025-08-19
D · Potential for more than minimal harm
2025-07-08
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 2025-08-19
D · Potential for more than minimal harm
2025-07-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-08-19
D · Potential for more than minimal harm
2025-05-15
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 2025-06-26
G · Actual harm
2025-05-06
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-07-17
G · Actual harm
2025-05-06
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 2025-07-17
E · Potential for more than minimal harm
2025-05-06
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-07-17
E · Potential for more than minimal harm
2025-05-06
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 2025-07-17
E · Potential for more than minimal harm
2025-05-06
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 2025-07-17
E · Potential for more than minimal harm
2025-05-06
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-07-17
E · Potential for more than minimal harm
2025-05-06
F800 · Nutrition and Dietary Deficiencies
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2025-07-17
E · Potential for more than minimal harm
2025-05-06
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 2025-07-17
E · Potential for more than minimal harm
2025-05-06
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2025-07-17
D · Potential for more than minimal harm
2025-05-06
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-07-17
D · Potential for more than minimal harm
2025-05-06
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 2025-07-17
D · Potential for more than minimal harm
2025-05-06
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 2025-07-17
D · Potential for more than minimal harm
2025-05-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-07-17
D · Potential for more than minimal harm
2025-05-06
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-07-17
D · Potential for more than minimal harm
2025-05-06
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-07-17
D · Potential for more than minimal harm
2025-05-06
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-07-17
D · Potential for more than minimal harm
2025-05-06
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 2025-07-17
D · Potential for more than minimal harm
2025-05-06
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 2025-07-17
D · Potential for more than minimal harm
2025-05-06
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 2025-07-17
D · Potential for more than minimal harm
2025-05-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-17
D · Potential for more than minimal harm
2025-05-06
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-07-17
D · Potential for more than minimal harm
2025-05-06
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 2025-07-17
E · Potential for more than minimal harm
2025-03-24
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 2025-05-05
D · Potential for more than minimal harm
2024-10-31
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 2024-12-12
D · Potential for more than minimal harm
2024-10-31
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-12-12
D · Potential for more than minimal harm
2024-10-31
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2024-12-12
D · Potential for more than minimal harm
2024-10-17
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 2024-11-27
D · Potential for more than minimal harm
2024-10-17
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 2024-11-27
D · Potential for more than minimal harm
2024-10-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-11-18
D · Potential for more than minimal harm
2024-08-28
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 2024-10-09
D · Potential for more than minimal harm
2024-08-01
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 2024-10-11
D · Potential for more than minimal harm
2024-08-01
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2024-10-11
D · Potential for more than minimal harm
2024-01-19
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 2024-03-01
D · Potential for more than minimal harm
2024-01-19
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 2024-03-01
D · Potential for more than minimal harm
2024-01-19
F626 · Resident Rights Deficiencies
Health
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Corrected 2024-03-01
D · Potential for more than minimal harm
2024-01-19
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-03-01
D · Potential for more than minimal harm
2023-07-18
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-08-29
D · Potential for more than minimal harm
2023-07-18
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 2023-08-29
D · Potential for more than minimal harm
2023-07-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-08-29
D · Potential for more than minimal harm
2023-06-23
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 2023-08-04
D · Potential for more than minimal harm
2023-06-23
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-08-04
D · Potential for more than minimal harm
2023-06-23
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 2023-08-04
D · Potential for more than minimal harm
2023-06-23
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-08-04
D · Potential for more than minimal harm
2023-06-23
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 2023-08-04
G · Actual harm
2023-05-25
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 2023-06-30
E · Potential for more than minimal harm
2023-05-25
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 2023-07-06
E · Potential for more than minimal harm
2023-05-25
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-07-06
E · Potential for more than minimal harm
2023-05-25
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 2023-07-06
E · Potential for more than minimal harm
2023-05-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-06
D · Potential for more than minimal harm
2023-05-25
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 2023-07-06
D · Potential for more than minimal harm
2023-05-25
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 2023-07-06
D · Potential for more than minimal harm
2023-05-25
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 2023-07-06
D · Potential for more than minimal harm
2023-05-25
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 2023-07-06
D · Potential for more than minimal harm
2023-05-25
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-07-06
D · Potential for more than minimal harm
2023-05-25
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 2023-07-06
D · Potential for more than minimal harm
2023-05-25
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-07-06
D · Potential for more than minimal harm
2023-05-25
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-07-06
D · Potential for more than minimal harm
2023-05-25
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-07-06
D · Potential for more than minimal harm
2023-05-25
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 2023-07-06
D · Potential for more than minimal harm
2023-05-25
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-07-06
D · Potential for more than minimal harm
2023-05-25
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-07-06
D · Potential for more than minimal harm
2023-05-25
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-07-06
D · Potential for more than minimal harm
2023-05-25
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 2023-07-06
D · Potential for more than minimal harm
2023-05-25
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 2023-07-06
D · Potential for more than minimal harm
2023-05-25
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-07-06
D · Potential for more than minimal harm
2023-05-25
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-07-06
D · Potential for more than minimal harm
2023-05-25
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 2023-07-06
D · Potential for more than minimal harm
2023-05-25
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 2023-07-06
D · Potential for more than minimal harm
2023-05-25
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2023-07-06
D · Potential for more than minimal harm
2023-05-25
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2023-07-06
D · Potential for more than minimal harm
2023-05-25
F836 · Administration Deficiencies
Health
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
Corrected 2023-07-06
D · Potential for more than minimal harm
2023-05-25
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-07-06
K · Immediate jeopardy
2023-03-22
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 2023-03-22
E · Potential for more than minimal harm
2021-02-10
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-03-06
E · Potential for more than minimal harm
2021-02-10
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 2021-03-06
D · Potential for more than minimal harm
2021-02-10
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2021-03-06
D · Potential for more than minimal harm
2021-02-10
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 2021-03-06
D · Potential for more than minimal harm
2021-02-10
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 2021-03-06
D · Potential for more than minimal harm
2021-02-10
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2021-03-06
D · Potential for more than minimal harm
2021-02-10
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2021-03-06
D · Potential for more than minimal harm
2021-02-10
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 2021-03-06
D · Potential for more than minimal harm
2021-02-10
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 2021-03-06
D · Potential for more than minimal harm
2021-02-10
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 2021-03-06
D · Potential for more than minimal harm
2021-02-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-03-06
Penalties and ownership
What sits behind the stars
$108,349
2023-05-25
Fine
Fine · fine $108,349
Fine
$19,353
2023-03-22
Fine
Fine · fine $19,353
Fine
Ownership
Sbriglio, Martin
5% Or Greater Direct Ownership Interest · Individual
Kopchik, Kenneth
5% Or Greater Direct Ownership Interest · Individual
Sbriglio, Robert
5% Or Greater Direct Ownership Interest · Individual
Kopchik, Kenneth
Operational/Managerial Control · Individual
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#3
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2-star overall rating with 2-star inspections with abuse icon flag with 13 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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