Cycle 1
Health 2024-10-30 · Fire 2024-10-30
20 health deficiencies
Top issue: Resident Assessment and Care Planning (5 deficiencies)
15 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Califon, NJ
Little Brook Nursing And Convalescent Home
1-star overall rating with 1-star inspections with Special Focus status with $495,198 in total fines with 20 recent health deficiencies with 15 fire-safety deficiencies in the latest cycle
78 Sliker Road, Califon, NJ
(908) 832-2220
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
36
Certified beds
Average residents
27
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2001-02-01
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
0.84
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.84
Licensed practical nurse staffing · state 0.94 · national 0.87
Aide hours / resident day
1.85
Nurse aide staffing · state 2.23 · national 2.35
Total nurse hours
3.52
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.67
RN + LPN hours · state 1.62 · national 1.54
Weekend hours
3.31
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.55
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.86
CMS adjusted RN staffing hours
Adjusted total hours
3.61
CMS adjusted total nurse staffing hours
Case-mix index
1.33
Higher values indicate more complex resident acuity
RN turnover
78%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
60%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,232
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
33.57
Composite VBP score used to determine payment impact.
Payment multiplier
0.9878
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
4.23
Baseline 86.96% · Performance 57.58% · Measure score 4.23 · Achievement 1.49 · Improvement 4.23
Adjusted total nurse staffing
2.48
Baseline 2.22 hours · Performance 3.28 hours · Measure score 2.48 · Achievement 0.72 · Improvement 2.48
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 17 · 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 9 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 11 · 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 14 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 34.78% |
8.2%
26.6 pts better
|
Numerator 16 · Denominator 46 |
| Staff flu vaccination coverage | 96% |
42%
54 pts better
|
Numerator 48 · Denominator 50 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| 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 |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.1 |
2.1
1 pts worse
|
1.9
1.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.1 · Observed 2.0 · Expected 1.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
1.1
0.5 pts worse
|
1.8
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.2 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 72.8% |
93.0%
20.2 pts worse
|
93.4%
20.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 71.0% · Q2 77.4% · Q3 65.5% · Q4 78.3% · 4Q avg 72.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 93.9% |
97.2%
3.3 pts worse
|
95.5%
1.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 93.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.9% |
2.4%
1.5 pts better
|
3.3%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.7% |
11.4%
9.7 pts better
|
11.4%
9.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 4.5% · Q4 0.0% · 4Q avg 1.7% |
| Percentage of long-stay residents who lose too much weight | 4.2% |
4.6%
0.4 pts better
|
5.4%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 4.0% · Q3 0.0% · Q4 4.8% · 4Q avg 4.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 3.9% |
19.0%
15.1 pts better
|
19.6%
15.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 7.1% · Q3 0.0% · Q4 0.0% · 4Q avg 3.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 33.3% |
13.5%
19.8 pts worse
|
16.7%
16.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 40.0% · 4Q avg 33.3% · 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 | 33.4% |
9.8%
23.6 pts worse
|
16.3%
17.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 33.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 33.3% |
9.7%
23.6 pts worse
|
14.9%
18.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 40.0% · 4Q avg 33.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
0.7%
0.1 pts better
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.1% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.9% |
0.8%
0.1 pts worse
|
1.7%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 0.0% · Q3 0.0% · 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 | 15.1% |
15.9%
0.8 pts better
|
19.8%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.1% · Q2 12.3% · Q3 18.3% · Q4 13.3% · 4Q avg 15.1% |
| Percentage of long-stay residents with pressure ulcers | 8.8% |
6.0%
2.8 pts worse
|
5.1%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 9.5% · Q3 14.8% · Q4 7.8% · 4Q avg 8.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 36.1% |
78.7%
42.6 pts worse
|
81.7%
45.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q4 42.9% · 4Q avg 36.1% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 13.6% |
1.2%
12.4 pts worse
|
1.6%
12 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 13.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-06-15 · Fire 2023-06-15
17 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
14 fire-safety deficiencies
Top issue: Emergency Preparedness (5 deficiencies)
Cycle 3
Health 2021-05-21 · Fire 2021-05-21
17 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (5 deficiencies)
11 fire-safety deficiencies
Top issue: Egress (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-30
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2024-11-22
F · Potential for more than minimal harm
2024-10-30
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-11-22
F · Potential for more than minimal harm
2024-10-30
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2024-11-22
F · Potential for more than minimal harm
2024-10-30
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-11-27
F · Potential for more than minimal harm
2024-10-30
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 2024-11-22
F · Potential for more than minimal harm
2024-10-30
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-11-22
F · Potential for more than minimal harm
2024-10-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-22
F · Potential for more than minimal harm
2024-10-30
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-11-25
F · Potential for more than minimal harm
2024-10-30
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-11-25
F · Potential for more than minimal harm
2024-10-30
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-11-25
F · Potential for more than minimal harm
2024-10-30
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-11-25
F · Potential for more than minimal harm
2024-10-30
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 2024-11-25
F · Potential for more than minimal harm
2024-10-30
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-11-27
F · Potential for more than minimal harm
2024-10-30
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-11-25
E · Potential for more than minimal harm
2024-10-30
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 2024-11-22
F · Potential for more than minimal harm
2023-06-15
E25 · Emergency Preparedness Deficiencies
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2023-07-26
F · Potential for more than minimal harm
2023-06-15
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2023-07-26
F · Potential for more than minimal harm
2023-06-15
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-07-26
F · Potential for more than minimal harm
2023-06-15
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-07-26
F · Potential for more than minimal harm
2023-06-15
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2023-07-26
F · Potential for more than minimal harm
2023-06-15
K252 · Egress Deficiencies
Fire Safety
Provide at least two remote exits on each floor or fire section of the building.
Corrected 2023-08-21
F · Potential for more than minimal harm
2023-06-15
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-07-25
F · Potential for more than minimal harm
2023-06-15
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2023-08-21
F · Potential for more than minimal harm
2023-06-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-08-17
F · Potential for more than minimal harm
2023-06-15
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-07-25
F · Potential for more than minimal harm
2023-06-15
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-08-16
F · Potential for more than minimal harm
2023-06-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-07-27
E · Potential for more than minimal harm
2023-06-15
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-07-25
E · Potential for more than minimal harm
2023-06-15
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 2023-07-25
E · Potential for more than minimal harm
2021-05-21
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2021-06-09
E · Potential for more than minimal harm
2021-05-21
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2021-05-31
E · Potential for more than minimal harm
2021-05-21
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2021-11-15
E · Potential for more than minimal harm
2021-05-21
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2021-06-07
D · Potential for more than minimal harm
2021-05-21
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2021-06-01
D · Potential for more than minimal harm
2021-05-21
K252 · Egress Deficiencies
Fire Safety
Provide at least two remote exits on each floor or fire section of the building.
Corrected 2021-09-28
D · Potential for more than minimal harm
2021-05-21
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2021-06-12
D · Potential for more than minimal harm
2021-05-21
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2021-05-24
C · Minimal harm
2021-05-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-06-10
C · Minimal harm
2021-05-21
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2021-06-01
C · Minimal harm
2021-05-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-06-06
Inspection history
Recent health citations
J · Immediate jeopardy
2025-07-10
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 2025-08-18
J · Immediate jeopardy
2025-03-18
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-05-14
E · Potential for more than minimal harm
2025-03-18
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-05-14
E · Potential for more than minimal harm
2025-03-18
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 2025-05-14
D · Potential for more than minimal harm
2025-03-18
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 2025-05-14
D · Potential for more than minimal harm
2025-03-18
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2025-05-14
J · Immediate jeopardy
2024-10-30
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 2024-11-20
F · Potential for more than minimal harm
2024-10-30
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2024-11-21
F · Potential for more than minimal harm
2024-10-30
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-11-21
F · Potential for more than minimal harm
2024-10-30
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 2024-11-21
F · Potential for more than minimal harm
2024-10-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-22
D · Potential for more than minimal harm
2024-10-30
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 2024-12-09
D · Potential for more than minimal harm
2024-10-30
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-11-21
D · Potential for more than minimal harm
2024-10-30
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 2024-11-21
D · Potential for more than minimal harm
2024-10-30
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 2024-11-22
D · Potential for more than minimal harm
2024-10-30
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-11-21
D · Potential for more than minimal harm
2024-10-30
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-11-22
D · Potential for more than minimal harm
2024-10-30
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 2024-11-21
D · Potential for more than minimal harm
2024-10-30
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 2024-11-21
D · Potential for more than minimal harm
2024-10-30
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 2025-01-22
D · Potential for more than minimal harm
2024-10-30
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 2024-11-21
D · Potential for more than minimal harm
2024-03-04
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-04-01
E · Potential for more than minimal harm
2023-12-12
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 2024-01-31
E · Potential for more than minimal harm
2023-12-12
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-01-31
E · Potential for more than minimal harm
2023-12-12
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 2024-01-31
L · Immediate jeopardy
2023-06-15
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 2023-07-25
L · Immediate jeopardy
2023-06-15
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2023-07-25
L · Immediate jeopardy
2023-06-15
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 2023-07-03
K · Immediate jeopardy
2023-06-15
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 2023-07-25
K · Immediate jeopardy
2023-06-15
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-07-25
F · Potential for more than minimal harm
2023-06-15
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 2023-07-25
F · Potential for more than minimal harm
2023-06-15
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2023-07-25
F · Potential for more than minimal harm
2023-06-15
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 2023-07-25
E · Potential for more than minimal harm
2023-06-15
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2023-07-25
D · Potential for more than minimal harm
2023-06-15
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 2023-07-25
D · Potential for more than minimal harm
2023-06-15
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-07-25
D · Potential for more than minimal harm
2023-06-15
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 2023-07-25
D · Potential for more than minimal harm
2023-06-15
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-07-25
D · Potential for more than minimal harm
2023-06-15
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-07-25
D · Potential for more than minimal harm
2023-06-15
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-07-25
F · Potential for more than minimal harm
2021-05-21
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 2021-06-10
F · Potential for more than minimal harm
2021-05-21
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2021-06-08
F · Potential for more than minimal harm
2021-05-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-06-22
E · Potential for more than minimal harm
2021-05-21
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 2021-07-04
E · Potential for more than minimal harm
2021-05-21
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2021-06-12
D · Potential for more than minimal harm
2021-05-21
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2021-05-24
D · Potential for more than minimal harm
2021-05-21
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 2021-06-07
D · Potential for more than minimal harm
2021-05-21
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2021-06-08
D · Potential for more than minimal harm
2021-05-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-06-09
D · Potential for more than minimal harm
2021-05-21
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 2021-06-08
D · Potential for more than minimal harm
2021-05-21
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 2021-06-06
B · Minimal harm
2021-05-21
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 2021-05-23
B · Minimal harm
2021-05-21
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2021-05-24
B · Minimal harm
2021-05-21
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2021-05-26
Penalties and ownership
What sits behind the stars
$61,552
2025-07-10
Fine
Fine · fine $61,552
Fine
$382,570
2025-03-18
Fine
Fine · fine $382,570
Fine
$37,522
2024-10-30
Fine
Fine · fine $37,522
Fine
$13,554
2023-06-15
Fine
Fine · fine $13,554
Fine
Ownership
Lazare Group, Inc
5% Or Greater Indirect Ownership Interest · Organization
Fernandez, Rosa
5% Or Greater Direct Ownership Interest · Individual
Bethane Properties, Inc
5% Or Greater Mortgage Interest · Organization
Bradford, Cynthia
Operational/Managerial Control · Individual
Bradford, Cynthia
Corporate Director · Individual
Caissie, Elizabeth
Operational/Managerial Control · Individual
Caissie, Elizabeth
Corporate Officer · Individual
Fernandez, Rosemarie
Corporate Officer · Individual
Hampilos, John
5% Or Greater Direct Ownership Interest · Individual
Hampilos, John
Operational/Managerial Control · Individual
Hampilos, John
Corporate Officer · Individual
Lazare Group, Inc
Operational/Managerial Control · Organization
Segaram, Sandira
Operational/Managerial Control · Individual
Segaram, Sandira
Corporate Director · Individual
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