Cycle 1
Health 2025-05-06 · Fire 2025-05-06
19 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
8 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Watertown, MA
Watertown Rehabilitation And Nursing Center
2-star overall rating with 2-star inspections with $69,440 in total fines with 19 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
59 Coolidge Hill Road, Watertown, MA
(617) 924-1130
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
163
Certified beds
Average residents
128
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Ephram Lahasky
Operator or chain grouping
Approved since
1990-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
28 facilities
Chain averages 2 overall / 2 health / 2 staffing / 3 quality stars
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
0.50
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
0.97
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
1.86
Nurse aide staffing · state 2.26 · national 2.35
Total nurse hours
3.32
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.46
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.28
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.54
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.41
CMS adjusted RN staffing hours
Adjusted total hours
2.74
CMS adjusted total nurse staffing hours
Case-mix index
1.66
Higher values indicate more complex resident acuity
RN turnover
45%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
28%
Annual nurse turnover · state 40% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,522
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
35.93
Composite VBP score used to determine payment impact.
Payment multiplier
0.9895
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.66% · Performance 21.68% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
2.73
Baseline 8.59% · Performance 7.43% · Measure score 2.73 · Achievement 1.36 · Improvement 2.73
Total nurse turnover
10
Performance 22.97% · Measure score 10 · Achievement 10 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
1.64
Baseline 3.87 hours · Performance 3.55 hours · Measure score 1.64 · Achievement 1.64 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.4% |
10.72%
1.3 pts better
|
No Different than the National Rate · Eligible stays 76 · Observed rate 6.58% · Lower 95% interval 6.46% |
| Discharge to community | 48.65% |
50.57%
1.9 pts worse
|
No Different than the National Rate · Eligible stays 40 · Observed rate 30% · Lower 95% interval 31.03% |
| Medicare spending per beneficiary | 0.98 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 68 · Denominator 68 |
| Falls with major injury | 1.47% |
0.77%
0.7 pts worse
|
Numerator 1 · Denominator 68 |
| Discharge self-care score | 34.88% |
53.69%
18.8 pts worse
|
Numerator 15 · Denominator 43 |
| Discharge mobility score | 18.6% |
50.94%
32.3 pts worse
|
Numerator 8 · Denominator 43 |
| Pressure ulcers or injuries, new or worsened | 4.41% |
2.29%
2.1 pts worse
|
Numerator 3 · Denominator 68 · Adjusted rate 3.2% |
| Healthcare-associated infections requiring hospitalization | 7.43% |
7.12%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 55 · Observed rate 9.09% · Lower 95% interval 4.29% |
| Staff COVID-19 vaccination coverage | 6.73% |
8.2%
1.5 pts worse
|
Numerator 7 · Denominator 104 |
| Staff flu vaccination coverage | 29.33% |
42%
12.7 pts worse
|
Numerator 44 · Denominator 150 |
| Discharge function score | 27.91% |
56.45%
28.5 pts worse
|
Numerator 12 · Denominator 43 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 23 · Denominator 23 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 46.15% |
25.2%
20.9 pts better
|
Numerator 18 · Denominator 39 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.7 |
1.9
0.8 pts worse
|
1.9
0.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 3.1 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 4.0 |
1.5
2.5 pts worse
|
1.8
2.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 4.0 · Observed 4.4 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
92.2%
7.4 pts better
|
93.4%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.4% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.2% |
94.8%
4.4 pts better
|
95.5%
3.7 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.4% |
3.5%
3.1 pts better
|
3.3%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 0.8% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 87.7% |
12.0%
75.7 pts worse
|
11.4%
76.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 87.5% · Q2 90.9% · Q3 85.6% · Q4 87.0% · 4Q avg 87.7% |
| Percentage of long-stay residents who lose too much weight | 5.9% |
5.2%
0.7 pts worse
|
5.4%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 10.5% · Q3 4.4% · Q4 2.8% · 4Q avg 5.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.9% |
19.2%
5.7 pts worse
|
19.6%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.1% · Q2 23.6% · Q3 25.9% · Q4 25.9% · 4Q avg 24.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 34.0% |
22.5%
11.5 pts worse
|
16.7%
17.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 42.4% · Q2 39.7% · Q3 29.2% · Q4 26.8% · 4Q avg 34.0% · 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 | 11.0% |
17.7%
6.7 pts better
|
16.3%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 28.1% · Q2 9.9% · Q3 2.2% · Q4 2.5% · 4Q avg 11.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.1% |
17.6%
7.5 pts better
|
14.9%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 26.7% · Q2 7.8% · Q3 1.0% · Q4 4.7% · 4Q avg 10.1% · 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 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.7% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
2.0%
2 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 8.6% |
21.7%
13.1 pts better
|
19.8%
11.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 26.8% · Q2 3.9% · Q3 2.5% · Q4 0.9% · 4Q avg 8.6% |
| Percentage of long-stay residents with pressure ulcers | 4.0% |
4.6%
0.6 pts better
|
5.1%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 3.2% · Q3 5.0% · Q4 4.2% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 90.7% |
77.1%
13.6 pts better
|
81.7%
9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 78.5% · Q2 89.1% · Q3 96.6% · Q4 100.0% · 4Q avg 90.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 18.3% |
11.8%
6.5 pts worse
|
12.0%
6.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 18.3% · Observed 22.0% · Expected 13.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.3% |
1.3%
About the same
|
1.6%
0.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 0.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 82.8% |
77.7%
5.1 pts better
|
79.7%
3.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 82.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.8% |
25.8%
2 pts worse
|
23.9%
3.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.8% · Observed 30.5% · Expected 26.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-10 · Fire 2024-05-10
23 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
5 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Cycle 3
Health 2023-03-20 · Fire 2023-03-20
20 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-06
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2025-06-20
F · Potential for more than minimal harm
2025-05-06
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2025-06-20
F · Potential for more than minimal harm
2025-05-06
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-06-20
F · Potential for more than minimal harm
2025-05-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-06-20
F · Potential for more than minimal harm
2025-05-06
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2025-06-20
F · Potential for more than minimal harm
2025-05-06
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-06-20
F · Potential for more than minimal harm
2025-05-06
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-06-20
E · Potential for more than minimal harm
2025-05-06
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-06-20
F · Potential for more than minimal harm
2024-05-10
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-06-25
F · Potential for more than minimal harm
2024-05-10
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-06-04
F · Potential for more than minimal harm
2024-05-10
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-06-25
F · Potential for more than minimal harm
2024-05-10
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-06-25
F · Potential for more than minimal harm
2024-05-10
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-06-25
F · Potential for more than minimal harm
2023-03-20
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-04-14
F · Potential for more than minimal harm
2023-03-20
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2023-04-20
F · Potential for more than minimal harm
2023-03-20
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-04-20
D · Potential for more than minimal harm
2023-03-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-03-29
D · Potential for more than minimal harm
2023-03-20
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-04-20
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-03
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 2025-12-26
D · Potential for more than minimal harm
2025-12-03
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-12-26
D · Potential for more than minimal harm
2025-08-12
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 2025-09-01
E · Potential for more than minimal harm
2025-05-06
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 2025-06-09
E · Potential for more than minimal harm
2025-05-06
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-06-09
E · Potential for more than minimal harm
2025-05-06
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-06-09
E · Potential for more than minimal harm
2025-05-06
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 2025-06-09
D · Potential for more than minimal harm
2025-05-06
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-06-09
D · Potential for more than minimal harm
2025-05-06
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-06-09
D · Potential for more than minimal harm
2025-05-06
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-06-09
D · Potential for more than minimal harm
2025-05-06
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-06-09
D · Potential for more than minimal harm
2025-05-06
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-06-09
D · Potential for more than minimal harm
2025-05-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-06-09
D · Potential for more than minimal harm
2025-05-06
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-06-09
D · Potential for more than minimal harm
2025-05-06
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-06-09
D · Potential for more than minimal harm
2025-05-06
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2025-06-09
D · Potential for more than minimal harm
2025-05-06
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 2025-06-09
D · Potential for more than minimal harm
2025-05-06
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2025-06-09
D · Potential for more than minimal harm
2025-05-06
F926 · Environmental Deficiencies
Health
Have policies on smoking.
Corrected 2025-06-09
D · Potential for more than minimal harm
2024-11-06
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-11-25
G · Actual harm
2024-08-28
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-09-30
E · Potential for more than minimal harm
2024-08-28
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 2024-10-04
D · Potential for more than minimal harm
2024-08-28
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-09-30
D · Potential for more than minimal harm
2024-08-28
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 2024-09-30
D · Potential for more than minimal harm
2024-08-28
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 2024-09-30
D · Potential for more than minimal harm
2024-08-28
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2024-09-30
D · Potential for more than minimal harm
2024-08-28
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-09-30
D · Potential for more than minimal harm
2024-08-28
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 2024-10-04
D · Potential for more than minimal harm
2024-08-28
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-09-30
D · Potential for more than minimal harm
2024-07-02
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 2024-07-18
E · Potential for more than minimal harm
2024-05-10
F568 · Resident Rights Deficiencies
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2024-06-10
E · Potential for more than minimal harm
2024-05-10
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-06-10
E · Potential for more than minimal harm
2024-05-10
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 2024-06-10
D · Potential for more than minimal harm
2024-05-10
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 2024-06-10
D · Potential for more than minimal harm
2024-05-10
F626 · Resident Rights Deficiencies
Health
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Corrected 2024-06-10
D · Potential for more than minimal harm
2024-05-10
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 2024-06-10
D · Potential for more than minimal harm
2024-05-10
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-06-10
D · Potential for more than minimal harm
2024-05-10
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-06-10
D · Potential for more than minimal harm
2024-05-10
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-06-10
D · Potential for more than minimal harm
2024-05-10
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 2024-06-10
D · Potential for more than minimal harm
2024-05-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-10
F · Potential for more than minimal harm
2024-04-30
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2024-06-10
D · Potential for more than minimal harm
2023-10-25
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 2023-11-22
F · Potential for more than minimal harm
2023-03-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-15
E · Potential for more than minimal harm
2023-03-20
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 2023-04-15
E · Potential for more than minimal harm
2023-03-20
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-04-15
E · Potential for more than minimal harm
2023-03-20
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-04-15
E · Potential for more than minimal harm
2023-03-20
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 2023-04-15
E · Potential for more than minimal harm
2023-03-20
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 2023-04-15
D · Potential for more than minimal harm
2023-03-20
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 2023-04-15
D · Potential for more than minimal harm
2023-03-20
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2023-04-15
D · Potential for more than minimal harm
2023-03-20
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 2023-04-15
D · Potential for more than minimal harm
2023-03-20
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 2023-04-15
D · Potential for more than minimal harm
2023-03-20
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-04-15
D · Potential for more than minimal harm
2023-03-20
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-04-15
D · Potential for more than minimal harm
2023-03-20
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2023-04-15
D · Potential for more than minimal harm
2023-03-20
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-04-15
D · Potential for more than minimal harm
2023-03-20
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 2023-04-15
D · Potential for more than minimal harm
2023-03-20
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2023-04-15
D · Potential for more than minimal harm
2023-03-20
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 2023-04-15
D · Potential for more than minimal harm
2023-03-20
F888 · Infection Control Deficiencies
Health
Ensure staff are vaccinated for COVID-19
Corrected 2023-04-15
B · Minimal harm
2023-03-20
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-04-15
Penalties and ownership
What sits behind the stars
$56,440
2024-08-28
Fine
Fine · fine $56,440
Fine
$13,000
2023-03-20
Fine
Fine · fine $13,000
Fine
Ownership
Horowitz, Akiva
5% Or Greater Direct Ownership Interest · Individual
Lahasky, Ephram
5% Or Greater Direct Ownership Interest · Individual
Mbugua, Andrew
Operational/Managerial Control · Individual
Merchant, Asif
Operational/Managerial Control · Individual
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#3
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4-star overall rating with 4-star inspections with 6 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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