Cycle 1
Health 2025-03-27 · Fire 2025-03-27
44 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (8 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Waterford, CT
New London Sub-Acute And Nursing
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $70,275 in total fines with 41 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
90 Clark Lane, Waterford, CT
(860) 442-0471
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
98
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1967-01-01
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
0.72
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.83
Licensed practical nurse staffing · state 0.84 · national 0.87
Aide hours / resident day
2.27
Nurse aide staffing · state 2.28 · national 2.35
Total nurse hours
3.82
All reported nurse hours · state 3.83 · national 3.89
Licensed hours
1.55
RN + LPN hours · state 1.54 · national 1.54
Weekend hours
3.21
Weekend nurse staffing · state 3.41 · national 3.43
Weekend RN hours
0.48
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.79
CMS adjusted RN staffing hours
Adjusted total hours
4.17
CMS adjusted total nurse staffing hours
Case-mix index
1.25
Higher values indicate more complex resident acuity
RN turnover
56%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
45%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,332
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
50.18
Composite VBP score used to determine payment impact.
Payment multiplier
1.0043
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.21
Baseline 22.38% · Performance 18.25% · Measure score 7.21 · Achievement 6.86 · Improvement 7.21
Healthcare-associated infections
4.46
Baseline 7.68% · Performance 6.50% · Measure score 4.46 · Achievement 4.46 · Improvement 3.89
Total nurse turnover
5.49
Baseline 54.95% · Performance 41.24% · Measure score 5.49 · Achievement 5.49 · Improvement 4.06
Adjusted total nurse staffing
2.91
Baseline 4.51 hours · Performance 3.91 hours · Measure score 2.91 · Achievement 2.91 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.07% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 91 · Observed rate 8.79% · Lower 95% interval 6.73% |
| Discharge to community | 50.04% |
50.57%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 82 · Observed rate 41.46% · Lower 95% interval 41.66% |
| Medicare spending per beneficiary | 1.02 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 65 · Denominator 65 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 65 |
| Discharge self-care score | 50% |
53.69%
3.7 pts worse
|
Numerator 22 · Denominator 44 |
| Discharge mobility score | 54.55% |
50.94%
3.6 pts better
|
Numerator 24 · Denominator 44 |
| Pressure ulcers or injuries, new or worsened | 1.54% |
2.29%
0.8 pts better
|
Numerator 1 · Denominator 65 · Adjusted rate 1.33% |
| Healthcare-associated infections requiring hospitalization | 6.5% |
7.12%
0.6 pts better
|
No Different than the National Rate · Eligible stays 43 · Observed rate 4.65% · Lower 95% interval 3.98% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 175 |
| Staff flu vaccination coverage | 15.21% |
42%
26.8 pts worse
|
Numerator 33 · Denominator 217 |
| Discharge function score | 52.27% |
56.45%
4.2 pts worse
|
Numerator 23 · Denominator 44 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 34 · Denominator 34 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 40% |
25.2%
14.8 pts better
|
Numerator 12 · Denominator 30 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.9 |
2.1
0.8 pts worse
|
1.9
1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.9 · Observed 3.0 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
1.5
0.1 pts worse
|
1.8
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.5 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 82.5% |
87.5%
5 pts worse
|
93.4%
10.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 94.9% · Q2 96.8% · Q3 74.3% · Q4 63.8% · 4Q avg 82.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.0% |
93.5%
5.5 pts better
|
95.5%
3.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.1% |
3.4%
0.3 pts better
|
3.3%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 3.2% · Q3 5.0% · Q4 2.1% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 13.5% |
17.1%
3.6 pts better
|
11.4%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.8% · Q2 22.1% · Q3 8.6% · Q4 2.2% · 4Q avg 13.5% |
| Percentage of long-stay residents who lose too much weight | 6.0% |
6.4%
0.4 pts better
|
5.4%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 5.7% · Q3 5.3% · Q4 7.9% · 4Q avg 6.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.9% |
17.3%
0.4 pts better
|
19.6%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.6% · Q2 16.5% · Q3 16.2% · Q4 19.6% · 4Q avg 16.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 27.1% |
19.4%
7.7 pts worse
|
16.7%
10.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.4% · Q2 23.5% · Q3 28.0% · Q4 28.4% · 4Q avg 27.1% · 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 | 13.0% |
18.1%
5.1 pts better
|
16.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.0% · Q2 12.5% · Q3 12.4% · Q4 13.1% · 4Q avg 13.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.6% |
18.4%
5.2 pts worse
|
14.9%
8.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.6% · Q2 36.9% · Q3 16.7% · Q4 15.5% · 4Q avg 23.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
0.9%
0.5 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.0% · Q3 0.7% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.8% |
1.7%
0.9 pts better
|
1.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.0% · Q4 1.1% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.7% |
24.8%
0.9 pts worse
|
19.8%
5.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.4% · Q2 21.9% · Q3 30.9% · Q4 15.7% · 4Q avg 25.7% |
| Percentage of long-stay residents with pressure ulcers | 6.4% |
4.4%
2 pts worse
|
5.1%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 7.3% · Q3 7.3% · Q4 3.6% · 4Q avg 6.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 54.8% |
70.5%
15.7 pts worse
|
81.7%
26.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 56.0% · Q2 68.4% · Q3 62.9% · Q4 29.5% · 4Q avg 54.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.9% |
11.1%
6.2 pts better
|
12.0%
7.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.9% · Observed 5.1% · Expected 11.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.0% |
1.5%
1.5 pts worse
|
1.6%
1.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 4.0% · Q3 5.0% · Q4 0.0% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 85.7% |
69.7%
16 pts better
|
79.7%
6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 85.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 12.5% |
25.0%
12.5 pts better
|
23.9%
11.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 12.5% · Observed 12.8% · Expected 24.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-11-03 · Fire 2022-11-03
16 health deficiencies
Top issue: Administration (4 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2019-12-20 · Fire 2019-12-20
9 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
12 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
2025-03-27
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2025-04-04
D · Potential for more than minimal harm
2025-03-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-04
D · Potential for more than minimal harm
2025-03-27
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-04-04
D · Potential for more than minimal harm
2025-03-27
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-04-04
F · Potential for more than minimal harm
2022-11-03
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-01-23
F · Potential for more than minimal harm
2022-11-03
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-01-23
F · Potential for more than minimal harm
2022-11-03
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-01-23
D · Potential for more than minimal harm
2022-11-03
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2023-01-23
D · Potential for more than minimal harm
2022-11-03
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-01-23
D · Potential for more than minimal harm
2022-11-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-01-23
D · Potential for more than minimal harm
2022-11-03
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2023-01-23
D · Potential for more than minimal harm
2022-11-03
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-01-23
D · Potential for more than minimal harm
2022-11-03
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2023-01-23
E · Potential for more than minimal harm
2019-12-20
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2020-02-05
D · Potential for more than minimal harm
2019-12-20
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2020-02-05
D · Potential for more than minimal harm
2019-12-20
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2020-02-05
D · Potential for more than minimal harm
2019-12-20
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 2020-02-05
D · Potential for more than minimal harm
2019-12-20
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2020-02-05
D · Potential for more than minimal harm
2019-12-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-02-05
D · Potential for more than minimal harm
2019-12-20
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2020-02-05
D · Potential for more than minimal harm
2019-12-20
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2020-02-05
D · Potential for more than minimal harm
2019-12-20
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2020-02-05
D · Potential for more than minimal harm
2019-12-20
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2020-02-05
D · Potential for more than minimal harm
2019-12-20
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2020-02-05
D · Potential for more than minimal harm
2019-12-20
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2020-02-05
Inspection history
Recent health citations
J · Immediate jeopardy
2025-08-21
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-09-03
H · Actual harm
2025-08-21
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 2025-09-03
E · Potential for more than minimal harm
2025-08-21
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 2025-09-03
E · Potential for more than minimal harm
2025-08-21
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2025-09-03
E · Potential for more than minimal harm
2025-08-21
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2025-09-03
D · Potential for more than minimal harm
2025-08-21
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 2025-09-03
D · Potential for more than minimal harm
2025-08-21
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2025-09-03
D · Potential for more than minimal harm
2025-08-21
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 2025-09-03
J · Immediate jeopardy
2025-06-30
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-09-05
E · Potential for more than minimal harm
2025-06-30
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-07-21
D · Potential for more than minimal harm
2025-06-30
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 2025-07-21
D · Potential for more than minimal harm
2025-06-30
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 2025-07-02
D · Potential for more than minimal harm
2025-06-30
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-07-02
D · Potential for more than minimal harm
2025-06-30
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 2025-07-31
K · Immediate jeopardy
2025-03-27
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-05-07
K · Immediate jeopardy
2025-03-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-05-07
J · Immediate jeopardy
2025-03-27
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-05-07
G · Actual harm
2025-03-27
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 2025-05-13
E · Potential for more than minimal harm
2025-03-27
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2025-05-13
E · Potential for more than minimal harm
2025-03-27
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 2025-05-13
E · Potential for more than minimal harm
2025-03-27
F603 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Corrected 2025-05-13
E · Potential for more than minimal harm
2025-03-27
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 2025-05-13
E · Potential for more than minimal harm
2025-03-27
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-05-13
E · Potential for more than minimal harm
2025-03-27
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 2025-05-13
E · Potential for more than minimal harm
2025-03-27
F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2025-05-13
E · Potential for more than minimal harm
2025-03-27
F946 · Administration Deficiencies
Health
Provide training in compliance and ethics.
Corrected 2025-05-13
D · Potential for more than minimal harm
2025-03-27
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-05-13
D · Potential for more than minimal harm
2025-03-27
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 2025-05-13
D · Potential for more than minimal harm
2025-03-27
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-05-13
D · Potential for more than minimal harm
2025-03-27
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2025-05-13
D · Potential for more than minimal harm
2025-03-27
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 2025-05-13
D · Potential for more than minimal harm
2025-03-27
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-05-13
D · Potential for more than minimal harm
2025-03-27
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-05-13
D · Potential for more than minimal harm
2025-03-27
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-05-13
D · Potential for more than minimal harm
2025-03-27
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 2025-05-13
D · Potential for more than minimal harm
2025-03-27
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 2025-05-13
D · Potential for more than minimal harm
2025-03-27
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2025-05-13
D · Potential for more than minimal harm
2025-03-27
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2025-05-13
D · Potential for more than minimal harm
2025-03-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-13
C · Minimal harm
2025-03-27
F949 · Administration Deficiencies
Health
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Corrected 2025-05-13
B · Minimal harm
2025-03-27
F570 · Resident Rights Deficiencies
Health
Assure the security of all personal funds of residents deposited with the facility.
Corrected 2025-05-13
B · Minimal harm
2025-03-27
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 2025-05-13
B · Minimal harm
2025-03-27
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2025-05-13
B · Minimal harm
2025-03-27
F944 · Administration Deficiencies
Health
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Corrected 2025-05-13
D · Potential for more than minimal harm
2025-01-13
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 2025-02-11
D · Potential for more than minimal harm
2023-11-21
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 2024-01-02
D · Potential for more than minimal harm
2023-11-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-01-02
D · Potential for more than minimal harm
2023-08-23
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-09-15
E · Potential for more than minimal harm
2022-11-03
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2023-01-08
E · Potential for more than minimal harm
2022-11-03
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 2023-01-08
E · Potential for more than minimal harm
2022-11-03
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 2023-01-08
E · Potential for more than minimal harm
2022-11-03
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2022-12-14
E · Potential for more than minimal harm
2022-11-03
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2022-12-14
E · Potential for more than minimal harm
2022-11-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-01-08
E · Potential for more than minimal harm
2022-11-03
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-01-08
E · Potential for more than minimal harm
2022-11-03
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2022-12-14
D · Potential for more than minimal harm
2022-11-03
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 2023-01-08
D · Potential for more than minimal harm
2022-11-03
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-01-08
D · Potential for more than minimal harm
2022-11-03
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-12-14
D · Potential for more than minimal harm
2022-11-03
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-01-08
D · Potential for more than minimal harm
2022-11-03
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 2023-01-08
D · Potential for more than minimal harm
2022-11-03
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2023-01-08
D · Potential for more than minimal harm
2022-11-03
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-01-08
E · Potential for more than minimal harm
2019-12-20
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 2020-01-31
D · Potential for more than minimal harm
2019-12-20
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 2020-01-31
D · Potential for more than minimal harm
2019-12-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2020-01-31
D · Potential for more than minimal harm
2019-12-20
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 2020-01-31
D · Potential for more than minimal harm
2019-12-20
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2020-01-31
D · Potential for more than minimal harm
2019-12-20
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2020-01-31
Penalties and ownership
What sits behind the stars
$34,600
2025-06-30
Fine
Fine · fine $34,600
Fine
$26,855
2025-03-27
Fine
Fine · fine $26,855
Fine
$2,470
2023-08-14
Fine
Fine · fine $2,470
Fine
$2,117
2023-08-07
Fine
Fine · fine $2,117
Fine
$4,233
2023-07-17
Fine
Fine · fine $4,233
Fine
Ownership
Mirlis Children Trust
5% Or Greater Direct Ownership Interest · Organization
Miller, John
W-2 Managing Employee · Individual
Mirlis, Eliyahu
Corporate Officer · Individual
Rose, Nathan
Operational/Managerial Control · Individual
Rose, Nathan
Corporate Officer · Individual
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