Cycle 1
Health 2025-11-13 · Fire 2025-11-13
51 health deficiencies
Top issue: Quality of Life and Care (11 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Novato, CA
Novato Healthcare Center
1-star overall rating with 1-star inspections with abuse icon flag with $90,206 in total fines with 51 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
1565 Hill Road, Novato, CA
(415) 897-6161
Overall
1 / 5
CMS overall stars
Health inspections
1 / 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
181
Certified beds
Average residents
169
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2007-10-31
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
0.49
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
0.82
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.98
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
4.29
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.31
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
3.94
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.38
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.55
CMS adjusted RN staffing hours
Adjusted total hours
4.73
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
62%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,148
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
41.13
Composite VBP score used to determine payment impact.
Payment multiplier
0.9940
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.4
Baseline 15.72% · Performance 18.93% · Measure score 5.4 · Achievement 5.4 · Improvement 0
Healthcare-associated infections
0
Baseline 6.41% · Performance 8.03% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
8.59
Baseline 24.75% · Performance 28.57% · Measure score 8.59 · Achievement 8.59 · Improvement 0
Adjusted total nurse staffing
2.46
Baseline 4.28 hours · Performance 3.78 hours · Measure score 2.46 · Achievement 2.46 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.15% |
10.72%
1.6 pts better
|
No Different than the National Rate · Eligible stays 145 · Observed rate 6.21% · Lower 95% interval 6.84% |
| Discharge to community | 45.16% |
50.57%
5.4 pts worse
|
No Different than the National Rate · Eligible stays 137 · Observed rate 37.23% · Lower 95% interval 34.7% |
| Medicare spending per beneficiary | 1.42 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 95.59% |
95.27%
0.3 pts better
|
Numerator 130 · Denominator 136 |
| Falls with major injury | 1.47% |
0.77%
0.7 pts worse
|
Numerator 2 · Denominator 136 |
| Discharge self-care score | 27.84% |
53.69%
25.8 pts worse
|
Numerator 27 · Denominator 97 |
| Discharge mobility score | 20.62% |
50.94%
30.3 pts worse
|
Numerator 20 · Denominator 97 |
| Pressure ulcers or injuries, new or worsened | 6.62% |
2.29%
4.3 pts worse
|
Numerator 9 · Denominator 136 · Adjusted rate 5.92% |
| Healthcare-associated infections requiring hospitalization | 8.03% |
7.12%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 136 · Observed rate 9.56% · Lower 95% interval 5.23% |
| Staff COVID-19 vaccination coverage | 99.44% |
8.2%
91.2 pts better
|
Numerator 177 · Denominator 178 |
| Staff flu vaccination coverage | 95.26% |
42%
53.3 pts better
|
Numerator 362 · Denominator 380 |
| Discharge function score | 38.14% |
56.45%
18.3 pts worse
|
Numerator 37 · Denominator 97 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 31 · Denominator 31 |
| Transfer of health information to patient | 94.12% |
96.28%
2.2 pts worse
|
Numerator 32 · Denominator 34 |
| Resident COVID-19 vaccinations up to date | 41.51% |
25.2%
16.3 pts better
|
Numerator 22 · Denominator 53 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
2.3
0.5 pts better
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.6 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
1.6
About the same
|
1.8
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.7 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
98.5%
1.3 pts better
|
93.4%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 99.4% · 4Q avg 99.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.2% |
98.2%
1 pts worse
|
95.5%
1.7 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.8% |
1.6%
0.8 pts better
|
3.3%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.6% · Q2 0.6% · Q3 0.6% · Q4 1.2% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 39.5% |
6.8%
32.7 pts worse
|
11.4%
28.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.4% · Q2 43.1% · Q3 40.3% · Q4 38.4% · 4Q avg 39.5% |
| Percentage of long-stay residents who lose too much weight | 4.9% |
4.1%
0.8 pts worse
|
5.4%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 6.1% · Q3 5.3% · Q4 2.7% · 4Q avg 4.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.2% |
13.7%
5.5 pts worse
|
19.6%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.3% · Q2 19.3% · Q3 18.2% · Q4 19.0% · 4Q avg 19.2% |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.4%
0.4 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 | 27.3% |
11.0%
16.3 pts worse
|
16.3%
11 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 43.7% · Q2 22.4% · Q3 18.0% · Q4 19.4% · 4Q avg 27.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.4% |
10.7%
9.7 pts worse
|
14.9%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.9% · Q2 16.5% · Q3 19.3% · Q4 17.6% · 4Q avg 20.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
1.0%
0.8 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.5% · Q2 0.0% · Q3 0.0% · Q4 0.3% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.6% |
1.2%
0.6 pts better
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 0.0% · Q3 1.2% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.7% |
10.9%
11.8 pts worse
|
19.8%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.8% · Q2 23.2% · Q3 21.1% · Q4 21.5% · 4Q avg 22.7% |
| Percentage of long-stay residents with pressure ulcers | 7.8% |
4.7%
3.1 pts worse
|
5.1%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 10.5% · Q3 7.7% · Q4 5.3% · 4Q avg 7.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.4% |
94.0%
1.4 pts better
|
81.7%
13.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.8% · Q2 100.0% · Q3 95.8% · Q4 89.7% · 4Q avg 95.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.1% |
11.2%
4.9 pts worse
|
12.0%
4.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.1% · Observed 17.6% · Expected 12.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.8% |
1.5%
2.3 pts worse
|
1.6%
2.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.0% · Q3 3.4% · Q4 0.0% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.5% |
93.2%
2.3 pts better
|
79.7%
15.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.0% |
23.2%
3.2 pts better
|
23.9%
3.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.0% · Observed 19.4% · Expected 23.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-11 · Fire 2024-01-11
15 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
20 fire-safety deficiencies
Top issue: Emergency Preparedness (10 deficiencies)
Cycle 3
Health 2021-04-23 · Fire 2021-04-23
27 health deficiencies
Top issue: Quality of Life and Care (11 deficiencies)
8 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-11-13
K342 · Smoke Deficiencies
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2025-11-27
E · Potential for more than minimal harm
2025-11-13
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-11-27
D · Potential for more than minimal harm
2025-11-13
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2025-11-27
D · Potential for more than minimal harm
2025-11-13
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 2025-11-27
D · Potential for more than minimal harm
2025-11-13
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-11-27
D · Potential for more than minimal harm
2025-11-13
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-11-27
D · Potential for more than minimal harm
2025-11-13
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-11-27
D · Potential for more than minimal harm
2025-11-13
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-11-27
D · Potential for more than minimal harm
2025-11-13
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2025-11-27
D · Potential for more than minimal harm
2025-11-13
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-11-27
F · Potential for more than minimal harm
2024-01-11
E22 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2024-02-15
F · Potential for more than minimal harm
2024-01-11
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-02-15
F · Potential for more than minimal harm
2024-01-11
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-02-15
F · Potential for more than minimal harm
2024-01-11
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-02-15
E · Potential for more than minimal harm
2024-01-11
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2024-02-15
E · Potential for more than minimal harm
2024-01-11
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 2024-02-15
E · Potential for more than minimal harm
2024-01-11
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-02-15
D · Potential for more than minimal harm
2024-01-11
E23 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2024-02-15
D · Potential for more than minimal harm
2024-01-11
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2024-02-15
D · Potential for more than minimal harm
2024-01-11
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2024-02-15
D · Potential for more than minimal harm
2024-01-11
E33 · Emergency Preparedness Deficiencies
Fire Safety
Establish methods for sharing information.
Corrected 2024-02-15
D · Potential for more than minimal harm
2024-01-11
E34 · Emergency Preparedness Deficiencies
Fire Safety
Provide a means of sharing information on occupancy/needs.
Corrected 2024-02-15
D · Potential for more than minimal harm
2024-01-11
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2024-02-15
D · Potential for more than minimal harm
2024-01-11
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-02-15
D · Potential for more than minimal harm
2024-01-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-02-15
D · Potential for more than minimal harm
2024-01-11
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-02-15
D · Potential for more than minimal harm
2024-01-11
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-02-15
D · Potential for more than minimal harm
2024-01-11
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-02-15
D · Potential for more than minimal harm
2024-01-11
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2024-02-15
D · Potential for more than minimal harm
2024-01-11
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-02-15
E · Potential for more than minimal harm
2021-04-23
K343 · Smoke Deficiencies
Fire Safety
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Corrected 2021-06-15
E · Potential for more than minimal harm
2021-04-23
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2021-06-15
D · Potential for more than minimal harm
2021-04-23
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2021-06-15
D · Potential for more than minimal harm
2021-04-23
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2021-06-15
D · Potential for more than minimal harm
2021-04-23
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2021-06-15
D · Potential for more than minimal harm
2021-04-23
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2021-06-15
D · Potential for more than minimal harm
2021-04-23
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2021-06-15
D · Potential for more than minimal harm
2021-04-23
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-06-15
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-31
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 2026-01-05
D · Potential for more than minimal harm
2025-12-31
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2026-01-05
D · Potential for more than minimal harm
2025-12-03
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-12-17
D · Potential for more than minimal harm
2025-11-20
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 2025-12-17
D · Potential for more than minimal harm
2025-11-20
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 2025-12-17
F · Potential for more than minimal harm
2025-11-13
F802 · Nutrition and Dietary Deficiencies
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2025-11-29
F · Potential for more than minimal harm
2025-11-13
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-11-29
F · Potential for more than minimal harm
2025-11-13
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 2025-11-29
E · Potential for more than minimal harm
2025-11-13
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 2025-11-29
E · Potential for more than minimal harm
2025-11-13
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 2025-11-29
E · Potential for more than minimal harm
2025-11-13
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-11-29
E · Potential for more than minimal harm
2025-11-13
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-11-29
E · Potential for more than minimal harm
2025-11-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-11-29
D · Potential for more than minimal harm
2025-11-13
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-11-29
D · Potential for more than minimal harm
2025-11-13
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-11-30
D · Potential for more than minimal harm
2025-11-13
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2025-11-29
D · Potential for more than minimal harm
2025-11-13
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-11-29
D · Potential for more than minimal harm
2025-11-13
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-11-29
D · Potential for more than minimal harm
2025-11-13
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-11-29
D · Potential for more than minimal harm
2025-11-13
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 2025-11-29
D · Potential for more than minimal harm
2025-11-13
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-11-29
D · Potential for more than minimal harm
2025-11-13
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-11-29
D · Potential for more than minimal harm
2025-11-13
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2025-11-29
D · Potential for more than minimal harm
2025-11-13
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2025-11-29
G · Actual harm
2025-09-08
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-10-07
D · Potential for more than minimal harm
2025-09-08
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 2025-10-07
D · Potential for more than minimal harm
2025-09-08
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2025-10-07
D · Potential for more than minimal harm
2025-08-28
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 2025-09-16
D · Potential for more than minimal harm
2025-08-28
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-09-16
D · Potential for more than minimal harm
2025-08-20
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 2025-08-28
D · Potential for more than minimal harm
2025-08-08
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-09-16
D · Potential for more than minimal harm
2025-08-08
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 2025-09-16
F · Potential for more than minimal harm
2025-07-18
F895 · Administration Deficiencies
Health
Have a Compliance and Ethics Program.
Corrected 2025-08-01
E · Potential for more than minimal harm
2025-07-09
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-07-31
E · Potential for more than minimal harm
2025-07-09
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-07-31
E · Potential for more than minimal harm
2025-07-09
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2025-07-31
D · Potential for more than minimal harm
2025-07-03
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 2025-07-22
F · Potential for more than minimal harm
2025-05-19
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-06-20
F · Potential for more than minimal harm
2025-05-19
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-07-10
F · Potential for more than minimal harm
2025-05-19
F940 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Corrected 2025-07-10
D · Potential for more than minimal harm
2025-05-19
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 2025-06-20
E · Potential for more than minimal harm
2025-05-14
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-06-20
E · Potential for more than minimal harm
2025-05-14
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 2025-06-20
E · Potential for more than minimal harm
2025-05-14
F926 · Environmental Deficiencies
Health
Have policies on smoking.
Corrected 2025-06-20
D · Potential for more than minimal harm
2025-05-14
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 2025-06-20
D · Potential for more than minimal harm
2025-05-14
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-06-20
D · Potential for more than minimal harm
2025-05-01
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 2025-05-28
D · Potential for more than minimal harm
2025-05-01
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-05-28
G · Actual harm
2025-04-25
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-05-18
D · Potential for more than minimal harm
2025-04-23
F825 · Quality of Life and Care Deficiencies
Health
Provide or get specialized rehabilitative services as required for a resident.
Corrected 2025-05-08
D · Potential for more than minimal harm
2025-03-05
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2025-04-03
F · Potential for more than minimal harm
2025-02-24
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-03-14
F · Potential for more than minimal harm
2025-02-24
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 2025-03-14
D · Potential for more than minimal harm
2025-01-09
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 2025-02-11
D · Potential for more than minimal harm
2025-01-09
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 2025-02-11
D · Potential for more than minimal harm
2025-01-09
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-02-11
D · Potential for more than minimal harm
2024-09-05
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2024-09-30
E · Potential for more than minimal harm
2024-09-04
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-09-27
D · Potential for more than minimal harm
2024-07-17
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 2024-08-13
F · Potential for more than minimal harm
2024-01-11
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 2024-02-21
D · Potential for more than minimal harm
2024-01-11
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 2024-02-21
D · Potential for more than minimal harm
2024-01-11
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-02-21
D · Potential for more than minimal harm
2024-01-11
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 2024-02-21
D · Potential for more than minimal harm
2024-01-11
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2024-02-21
D · Potential for more than minimal harm
2024-01-11
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-02-21
D · Potential for more than minimal harm
2024-01-11
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 2024-02-21
D · Potential for more than minimal harm
2023-10-25
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2023-11-03
E · Potential for more than minimal harm
2023-10-09
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-10-25
G · Actual harm
2023-09-05
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 2023-10-23
E · Potential for more than minimal harm
2023-07-11
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-08-02
E · Potential for more than minimal harm
2023-07-11
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 2023-08-02
D · Potential for more than minimal harm
2023-05-23
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-06-19
D · Potential for more than minimal harm
2023-05-23
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-06-19
E · Potential for more than minimal harm
2021-04-23
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 2021-05-28
E · Potential for more than minimal harm
2021-04-23
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 2021-05-28
E · Potential for more than minimal harm
2021-04-23
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 2021-05-28
E · Potential for more than minimal harm
2021-04-23
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2021-05-28
E · Potential for more than minimal harm
2021-04-23
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2021-05-28
E · Potential for more than minimal harm
2021-04-23
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2021-05-28
E · Potential for more than minimal harm
2021-04-23
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-05-28
E · Potential for more than minimal harm
2021-04-23
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2021-05-28
E · Potential for more than minimal harm
2021-04-23
F741 · Quality of Life and Care Deficiencies
Health
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
Corrected 2021-05-28
E · Potential for more than minimal harm
2021-04-23
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2021-05-28
E · Potential for more than minimal harm
2021-04-23
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 2021-05-28
E · Potential for more than minimal harm
2021-04-23
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2021-05-28
E · Potential for more than minimal harm
2021-04-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-05-28
D · Potential for more than minimal harm
2021-04-23
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 2021-05-28
D · Potential for more than minimal harm
2021-04-23
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2021-05-28
D · Potential for more than minimal harm
2021-04-23
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2021-05-28
D · Potential for more than minimal harm
2021-04-23
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 2021-05-28
D · Potential for more than minimal harm
2021-04-23
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2021-05-28
D · Potential for more than minimal harm
2021-04-23
F825 · Quality of Life and Care Deficiencies
Health
Provide or get specialized rehabilitative services as required for a resident.
Corrected 2021-05-28
D · Potential for more than minimal harm
2021-04-23
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2021-05-28
Penalties and ownership
What sits behind the stars
$17,342
2025-08-08
Fine
Fine · fine $17,342
Fine
$72,864
2025-04-23
Fine
Fine · fine $72,864
Fine
$0
2025-04-23
Payment Denial
Payment Denial · denial start 2025-05-23 · 70 days
70 day denial
Ownership
Asru LLC
5% Or Greater Direct Ownership Interest · Organization
Brius LLC
5% Or Greater Direct Ownership Interest · Organization
Corporate Interface Services LLC
Operational/Managerial Control · Organization
Kaur, Gurbinder
Operational/Managerial Control · Individual
Rechnitz, Shlomo
Operational/Managerial Control · Individual
Rockport Administrative Services, LLC
Operational/Managerial Control · Organization
Sockell, Mark
Operational/Managerial Control · Individual
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#3
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