Cycle 1
Health 2025-02-06 · Fire 2025-02-06
10 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
2 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Falmouth, MA
Jml Care Center Inc
2-star overall rating with 3-star inspections with 10 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
184 Ter Heun Drive, Falmouth, MA
(508) 457-4621
Overall
2 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
132
Certified beds
Average residents
92
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1989-12-27
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
1.03
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
0.80
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
4.16
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.84
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.89
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.71
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.17
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
1.03
CMS adjusted RN staffing hours
Adjusted total hours
4.16
CMS adjusted total nurse staffing hours
Case-mix index
1.37
Higher values indicate more complex resident acuity
RN turnover
32%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
42%
Annual nurse turnover · state 40% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,582
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
39.38
Composite VBP score used to determine payment impact.
Payment multiplier
0.9924
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 22.12% · Performance 24.10% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
5.58
Baseline 6.16% · Performance 6.17% · Measure score 5.58 · Achievement 5.58 · Improvement 0
Total nurse turnover
6.11
Baseline 31.65% · Performance 38.71% · Measure score 6.11 · Achievement 6.11 · Improvement 0
Adjusted total nurse staffing
4.06
Baseline 4.13 hours · Performance 4.23 hours · Measure score 4.06 · Achievement 4.06 · Improvement 0.11
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.63% |
10.72%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 625 · Observed rate 10.24% · Lower 95% interval 9.53% |
| Discharge to community | 62.99% |
50.57%
12.4 pts better
|
Better than the National Rate · Eligible stays 622 · Observed rate 62.7% · Lower 95% interval 58.53% |
| Medicare spending per beneficiary | 0.7 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 91.65% |
95.27%
3.6 pts worse
|
Numerator 417 · Denominator 455 |
| Falls with major injury | 0.88% |
0.77%
0.1 pts worse
|
Numerator 4 · Denominator 455 |
| Discharge self-care score | 48.57% |
53.69%
5.1 pts worse
|
Numerator 170 · Denominator 350 |
| Discharge mobility score | 59.14% |
50.94%
8.2 pts better
|
Numerator 207 · Denominator 350 |
| Pressure ulcers or injuries, new or worsened | 3.08% |
2.29%
0.8 pts worse
|
Numerator 14 · Denominator 455 · Adjusted rate 3.75% |
| Healthcare-associated infections requiring hospitalization | 6.17% |
7.12%
1 pts better
|
No Different than the National Rate · Eligible stays 417 · Observed rate 4.56% · Lower 95% interval 4.05% |
| Staff COVID-19 vaccination coverage | 11.83% |
8.2%
3.6 pts better
|
Numerator 20 · Denominator 169 |
| Staff flu vaccination coverage | 81.3% |
42%
39.3 pts better
|
Numerator 213 · Denominator 262 |
| Discharge function score | 49.43% |
56.45%
7 pts worse
|
Numerator 173 · Denominator 350 |
| Transfer of health information to provider | 99.73% |
95.95%
3.8 pts better
|
Numerator 369 · Denominator 370 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 42.11% |
25.2%
16.9 pts better
|
Numerator 96 · Denominator 228 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.1 |
1.9
1.2 pts worse
|
1.9
1.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.1 · Observed 2.8 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.7 |
1.5
1.2 pts worse
|
1.8
0.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 2.5 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 80.1% |
92.2%
12.1 pts worse
|
93.4%
13.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 95.6% · Q2 83.3% · Q3 69.9% · Q4 72.5% · 4Q avg 80.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 91.1% |
94.8%
3.7 pts worse
|
95.5%
4.4 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 91.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.0% |
3.5%
1.5 pts worse
|
3.3%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 6.9% · Q3 6.8% · Q4 4.3% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.4% |
12.0%
11.6 pts better
|
11.4%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% |
| Percentage of long-stay residents who lose too much weight | 7.9% |
5.2%
2.7 pts worse
|
5.4%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 6.6% · Q3 10.2% · Q4 11.7% · 4Q avg 7.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.2% |
19.2%
10 pts better
|
19.6%
10.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.6% · Q2 5.8% · Q3 14.7% · Q4 8.8% · 4Q avg 9.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.4% |
22.5%
3.1 pts better
|
16.7%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.1% · Q2 22.8% · Q3 20.0% · Q4 19.3% · 4Q avg 19.4% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 17.6% |
17.7%
0.1 pts better
|
16.3%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.1% · Q2 10.8% · Q3 15.4% · Q4 33.5% · 4Q avg 17.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.3% |
17.6%
5.7 pts worse
|
14.9%
8.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.2% · Q2 12.5% · Q3 30.5% · Q4 31.6% · 4Q avg 23.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.5% |
1.0%
0.5 pts worse
|
1.0%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 2.3% · Q3 1.5% · Q4 0.7% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 6.8% |
2.0%
4.8 pts worse
|
1.7%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 2.9% · Q3 7.2% · Q4 12.5% · 4Q avg 6.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 35.6% |
21.7%
13.9 pts worse
|
19.8%
15.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.9% · Q2 29.5% · Q3 49.1% · Q4 33.6% · 4Q avg 35.6% |
| Percentage of long-stay residents with pressure ulcers | 12.3% |
4.6%
7.7 pts worse
|
5.1%
7.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.5% · Q2 16.1% · Q3 12.9% · Q4 5.3% · 4Q avg 12.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 67.2% |
77.1%
9.9 pts worse
|
81.7%
14.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 91.5% · Q2 79.4% · Q3 56.9% · Q4 42.7% · 4Q avg 67.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.6% |
11.8%
4.8 pts worse
|
12.0%
4.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.6% · Observed 14.6% · Expected 9.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.9% |
1.3%
0.6 pts worse
|
1.6%
0.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 1.9% · Q3 1.3% · Q4 1.9% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 71.8% |
77.7%
5.9 pts worse
|
79.7%
7.9 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 71.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.8% |
25.8%
3 pts worse
|
23.9%
4.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.8% · Observed 24.5% · Expected 20.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-14 · Fire 2023-12-14
7 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
6 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Cycle 3
Health 2021-09-20 · Fire 2021-09-20
6 health deficiencies
Top issue: Infection Control (2 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-02-06
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-03-26
D · Potential for more than minimal harm
2025-02-06
K111 · Construction Deficiencies
Fire Safety
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
Corrected 2025-03-26
E · Potential for more than minimal harm
2023-12-14
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-01-03
E · Potential for more than minimal harm
2023-12-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-01-31
E · Potential for more than minimal harm
2023-12-14
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-01-31
E · Potential for more than minimal harm
2023-12-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-01-03
D · Potential for more than minimal harm
2023-12-14
K111 · Construction Deficiencies
Fire Safety
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
Corrected 2024-01-31
D · Potential for more than minimal harm
2023-12-14
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-12-22
E · Potential for more than minimal harm
2021-09-20
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2021-10-18
E · Potential for more than minimal harm
2021-09-20
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 2021-10-08
E · Potential for more than minimal harm
2021-09-20
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2021-11-26
E · Potential for more than minimal harm
2021-09-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-10-29
E · Potential for more than minimal harm
2021-09-20
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2021-10-15
D · Potential for more than minimal harm
2021-09-20
K111 · Construction Deficiencies
Fire Safety
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
Corrected 2021-11-26
D · Potential for more than minimal harm
2021-09-20
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2021-09-22
D · Potential for more than minimal harm
2021-09-20
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2021-10-19
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-02-06
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 2025-03-12
E · Potential for more than minimal harm
2025-02-06
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 2025-03-12
E · Potential for more than minimal harm
2025-02-06
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2025-03-12
D · Potential for more than minimal harm
2025-02-06
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 2025-03-12
D · Potential for more than minimal harm
2025-02-06
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 2025-03-12
D · Potential for more than minimal harm
2025-02-06
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 2025-03-12
D · Potential for more than minimal harm
2025-02-06
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-03-12
D · Potential for more than minimal harm
2025-02-06
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-03-12
B · Minimal harm
2025-02-06
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-03-12
B · Minimal harm
2025-02-06
F712 · Nursing and Physician Services Deficiencies
Health
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected 2025-03-12
F · Potential for more than minimal harm
2023-12-14
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 2024-01-19
E · Potential for more than minimal harm
2023-12-14
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 2024-01-19
E · Potential for more than minimal harm
2023-12-14
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 2024-01-19
D · Potential for more than minimal harm
2023-12-14
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 2024-01-19
D · Potential for more than minimal harm
2023-12-14
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-01-19
D · Potential for more than minimal harm
2023-12-14
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-01-19
D · Potential for more than minimal harm
2023-12-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-19
D · Potential for more than minimal harm
2023-11-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-01
F · Potential for more than minimal harm
2021-09-20
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2021-11-03
D · Potential for more than minimal harm
2021-09-20
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 2021-11-03
D · Potential for more than minimal harm
2021-09-20
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2021-11-03
D · Potential for more than minimal harm
2021-09-20
F849 · Administration Deficiencies
Health
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.
Corrected 2021-11-03
D · Potential for more than minimal harm
2021-09-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-11-03
Penalties and ownership
What sits behind the stars
Ownership
Lauf, Michael
Corporate Officer · Individual
Mcdonough Anastos, Mary
W-2 Managing Employee · Individual
Pino, Colleen
Corporate Director · Individual
Spofford, Robin
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Royal Nursing Center, LLC
Falmouth, MA
3-star overall rating with 3-star inspections with $8,278 in total fines with 7 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Royal Megansett Nursing & Rehabilitation
N Falmouth, MA
4-star overall rating with 4-star inspections with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Royal Of Cotuit
Mashpee, MA
2-star overall rating with 2-star inspections with $7,901 in total fines with 12 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
Jump out