Cycle 1
Health 2024-06-06 · Fire 2024-06-06
8 health deficiencies
Top issue: Infection Control (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
New Haven, CT
Leeway, Inc
5-star overall rating with 4-star inspections with 8 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
40 Albert Street, New Haven, CT
(203) 865-0068
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
30
Certified beds
Average residents
28
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1995-11-03
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
1.44
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.60
Licensed practical nurse staffing · state 0.84 · national 0.87
Aide hours / resident day
2.26
Nurse aide staffing · state 2.28 · national 2.35
Total nurse hours
4.30
All reported nurse hours · state 3.83 · national 3.89
Licensed hours
2.04
RN + LPN hours · state 1.54 · national 1.54
Weekend hours
3.44
Weekend nurse staffing · state 3.41 · national 3.43
Weekend RN hours
0.86
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
2.04
CMS adjusted RN staffing hours
Adjusted total hours
6.10
CMS adjusted total nurse staffing hours
Case-mix index
0.96
Higher values indicate more complex resident acuity
RN turnover
14%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
29%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
379
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
71.19
Composite VBP score used to determine payment impact.
Payment multiplier
1.0230
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
6.68
Baseline 37.50% · Performance 36.36% · Measure score 6.68 · Achievement 6.68 · Improvement 0.40
Adjusted total nurse staffing
7.56
Baseline 4.13 hours · Performance 5.23 hours · Measure score 7.56 · Achievement 7.56 · Improvement 6.14
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 21 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 5 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.06 |
1.02
About the same
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 12 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 18 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 19.67% |
8.2%
11.5 pts better
|
Numerator 12 · Denominator 61 |
| Staff flu vaccination coverage | 25% |
42%
17 pts worse
|
Numerator 16 · Denominator 64 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
87.5%
12.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.4% |
93.5%
2.9 pts better
|
95.5%
0.9 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.0% |
3.4%
0.4 pts better
|
3.3%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.2% · Q3 4.2% · Q4 3.8% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.2% |
17.1%
15.9 pts better
|
11.4%
10.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.2% |
| Percentage of long-stay residents who lose too much weight | 2.1% |
6.4%
4.3 pts better
|
5.4%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 0.0% · Q3 4.3% · Q4 0.0% · 4Q avg 2.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.4% |
17.3%
5.1 pts worse
|
19.6%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.2% · Q2 20.8% · Q3 20.8% · Q4 29.2% · 4Q avg 22.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 37.5% |
19.4%
18.1 pts worse
|
16.7%
20.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 37.5% · 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 | 11.8% |
18.1%
6.3 pts better
|
16.3%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 11.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.8% |
18.4%
9.6 pts better
|
14.9%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 4.8% · Q3 4.5% · Q4 8.3% · 4Q avg 8.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.4% |
0.9%
0.5 pts worse
|
1.0%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 2.6% · Q3 0.0% · Q4 0.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.0% |
1.7%
0.7 pts better
|
1.7%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 4.3% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 7.1% |
24.8%
17.7 pts better
|
19.8%
12.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 17.4% · Q3 8.3% · Q4 3.6% · 4Q avg 7.1% |
| Percentage of long-stay residents with pressure ulcers | 1.1% |
4.4%
3.3 pts better
|
5.1%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
70.5%
29.5 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q2 100.0% · Q3 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 87.5% |
69.7%
17.8 pts better
|
79.7%
7.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 87.5% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-03-17 · Fire 2022-03-17
7 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2019-08-15 · Fire 2019-08-15
6 health deficiencies
Top issue: Resident Rights (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-06-06
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-07-17
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-09-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-24
E · Potential for more than minimal harm
2024-06-06
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 2024-07-18
E · Potential for more than minimal harm
2024-06-06
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 2024-07-18
D · Potential for more than minimal harm
2024-06-06
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 2024-07-18
D · Potential for more than minimal harm
2024-06-06
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 2024-07-18
D · Potential for more than minimal harm
2024-06-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-18
D · Potential for more than minimal harm
2024-06-06
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-07-18
D · Potential for more than minimal harm
2024-06-06
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 2024-07-18
C · Minimal harm
2024-06-06
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2024-07-18
E · Potential for more than minimal harm
2022-03-17
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 2022-04-21
D · Potential for more than minimal harm
2022-03-17
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2022-04-21
D · Potential for more than minimal harm
2022-03-17
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 2022-04-21
D · Potential for more than minimal harm
2022-03-17
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 2022-04-21
D · Potential for more than minimal harm
2022-03-17
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2022-04-21
B · Minimal harm
2022-03-17
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-04-21
D · Potential for more than minimal harm
2019-08-15
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 2019-09-25
D · Potential for more than minimal harm
2019-08-15
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 2019-09-25
D · Potential for more than minimal harm
2019-08-15
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 2019-09-25
D · Potential for more than minimal harm
2019-08-15
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 2019-09-25
B · Minimal harm
2019-08-15
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 2019-09-25
B · Minimal harm
2019-08-15
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2019-09-25
Penalties and ownership
What sits behind the stars
Ownership
Comer, Patricia
Corporate Director · Individual
Dyson, William
Corporate Director · Individual
Katz, Jay
Operational/Managerial Control · Individual
Katz, Jay
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Mary Wade Home, The Incorporated
New Haven, CT
1-star overall rating with 1-star inspections with abuse icon flag with $20,144 in total fines with 20 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
New Haven Center For Nursing & Rehabilitation LLC
New Haven, CT
1-star overall rating with 1-star inspections with abuse icon flag with $82,140 in total fines with 30 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Whitney Center
Hamden, CT
4-star overall rating with 3-star inspections with 10 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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