Total nurse staffing hours per resident per day, case-mix adjusted
Registered nurses: 0.60 hours per resident per day
Nursing staff turnover: 75% a year
Derived by CMS from the Payroll-Based Journal and refreshed quarterly.
Inspection history
Inspected April 7, 2025
22 citations · from a complaint investigation · Health
B
F0623No actual harm with potential for minimal harm · Pattern
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Deficient, Provider has date of correction · corrected April 28, 2025
B
F0625No actual harm with potential for minimal harm · Pattern
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Deficient, Provider has date of correction · corrected April 28, 2025
D
F0550No actual harm with potential for more than minimal harm · Isolated
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Deficient, Provider has date of correction · corrected April 28, 2025
D
F0557No actual harm with potential for more than minimal harm · Isolated
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Deficient, Provider has date of correction · corrected April 28, 2025
D
F0558No actual harm with potential for more than minimal harm · Isolated
Reasonably accommodate the needs and preferences of each resident.
Deficient, Provider has date of correction · corrected April 28, 2025
D
F0561No actual harm with potential for more than minimal harm · Isolated
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Deficient, Provider has date of correction · corrected April 28, 2025
D
F0578No actual harm with potential for more than minimal harm · Isolated
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.
Deficient, Provider has date of correction · corrected April 28, 2025
D
F0580No actual harm with potential for more than minimal harm · Isolated
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Deficient, Provider has date of correction · corrected April 28, 2025
D
F0582No actual harm with potential for more than minimal harm · Isolated
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Deficient, Provider has date of correction · corrected April 28, 2025
D
F0584No actual harm with potential for more than minimal harm · Isolated
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.
Deficient, Provider has date of correction · corrected April 28, 2025
D
F0657No actual harm with potential for more than minimal harm · Isolated
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Deficient, Provider has date of correction · corrected April 28, 2025
D
F0690No actual harm with potential for more than minimal harm · Isolated
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Deficient, Provider has date of correction · corrected April 28, 2025
D
F0695No actual harm with potential for more than minimal harm · Isolated
Provide safe and appropriate respiratory care for a resident when needed.
Deficient, Provider has date of correction · corrected April 28, 2025
D
F0756No actual harm with potential for more than minimal harm · Isolated
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Deficient, Provider has date of correction · corrected April 28, 2025
D
F0842No actual harm with potential for more than minimal harm · Isolated
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Deficient, Provider has date of correction · corrected April 28, 2025
E
F0677No actual harm with potential for more than minimal harm · Pattern
Provide care and assistance to perform activities of daily living for any resident who is unable.
Deficient, Provider has date of correction · corrected April 28, 2025
E
F0806No actual harm with potential for more than minimal harm · Pattern
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Deficient, Provider has date of correction · corrected April 28, 2025
E
F0883No actual harm with potential for more than minimal harm · Pattern
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Deficient, Provider has date of correction · corrected April 28, 2025
F
F0812No actual harm with potential for more than minimal harm · Widespread
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Deficient, Provider has date of correction · corrected April 28, 2025
F
F0838No actual harm with potential for more than minimal harm · Widespread
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.
Deficient, Provider has date of correction · corrected April 28, 2025
F
F0880No actual harm with potential for more than minimal harm · Widespread
Provide and implement an infection prevention and control program.
Deficient, Provider has date of correction · corrected April 28, 2025
G
F0684Actual harm · Isolated
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Deficient, Provider has date of correction · corrected April 28, 2025
Inspected January 16, 2025
1 citation · from a complaint investigation · Health
E
F0689No actual harm with potential for more than minimal harm · Pattern
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has date of correction · corrected January 17, 2025
Inspected December 5, 2024
1 citation · from a complaint investigation · Health
D
F0697No actual harm with potential for more than minimal harm · Isolated
Provide safe, appropriate pain management for a resident who requires such services.
Deficient, Provider has date of correction · corrected December 6, 2024
Inspected October 16, 2024
2 citations · from a complaint investigation · Health
E
F0550No actual harm with potential for more than minimal harm · Pattern
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Deficient, Provider has date of correction · corrected November 5, 2024
G
F0689Actual harm · Isolated
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has date of correction · corrected November 5, 2024
Inspected July 30, 2024
4 citations · from a complaint investigation · Health
D
F0580No actual harm with potential for more than minimal harm · Isolated
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Deficient, Provider has date of correction · corrected August 23, 2024
D
F0600No actual harm with potential for more than minimal harm · Isolated
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Deficient, Provider has date of correction · corrected August 23, 2024
D
F0609No actual harm with potential for more than minimal harm · Isolated
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Deficient, Provider has date of correction · corrected August 23, 2024
D
F0842No actual harm with potential for more than minimal harm · Isolated
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Deficient, Provider has date of correction · corrected August 23, 2024
Inspected April 23, 2024
5 citations · from a complaint investigation · Health
D
F0609No actual harm with potential for more than minimal harm · Isolated
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Deficient, Provider has date of correction · corrected May 14, 2024
E
F0803No actual harm with potential for more than minimal harm · Pattern
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Deficient, Provider has date of correction · corrected May 14, 2024
F
F0812No actual harm with potential for more than minimal harm · Widespread
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Deficient, Provider has date of correction · corrected May 14, 2024
F
F0814No actual harm with potential for more than minimal harm · Widespread
Dispose of garbage and refuse properly.
Deficient, Provider has date of correction · corrected May 14, 2024
F
F0880No actual harm with potential for more than minimal harm · Widespread
Provide and implement an infection prevention and control program.
Deficient, Provider has date of correction · corrected May 14, 2024
Inspected March 5, 2024
12 citations · from a complaint investigation · Health
D
F0557No actual harm with potential for more than minimal harm · Isolated
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Deficient, Provider has date of correction · corrected May 14, 2024
D
F0657No actual harm with potential for more than minimal harm · Isolated
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Deficient, Provider has date of correction · corrected May 14, 2024
D
F0689No actual harm with potential for more than minimal harm · Isolated
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has date of correction · corrected May 14, 2024
D
F0849No actual harm with potential for more than minimal harm · Isolated
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.
Deficient, Provider has date of correction · corrected May 14, 2024
D
F0880No actual harm with potential for more than minimal harm · Isolated
Provide and implement an infection prevention and control program.
Deficient, Provider has date of correction · corrected May 14, 2024
E
F0584No actual harm with potential for more than minimal harm · Pattern
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.
Deficient, Provider has date of correction · corrected May 14, 2024
F
F0607No actual harm with potential for more than minimal harm · Widespread
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Deficient, Provider has date of correction · corrected May 14, 2024
F
F0679No actual harm with potential for more than minimal harm · Widespread
Provide activities to meet all resident's needs.
Deficient, Provider has date of correction · corrected May 14, 2024
F
F0680No actual harm with potential for more than minimal harm · Widespread
Ensure the activities program is directed by a qualified professional.
Deficient, Provider has date of correction · corrected May 14, 2024
F
F0804No actual harm with potential for more than minimal harm · Widespread
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Deficient, Provider has date of correction · corrected May 14, 2024
F
F0850No actual harm with potential for more than minimal harm · Widespread
Hire a qualified full-time social worker in a facility with more than 120 beds.
Deficient, Provider has date of correction · corrected May 14, 2024
F
F0921No actual harm with potential for more than minimal harm · Widespread
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Deficient, Provider has date of correction · corrected May 14, 2024
Inspected November 23, 2023
5 citations · Health
D
F0578No actual harm with potential for more than minimal harm · Isolated
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.
Deficient, Provider has date of correction · corrected January 12, 2024
D
F0622No actual harm with potential for more than minimal harm · Isolated
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.
Deficient, Provider has date of correction · corrected January 12, 2024
D
F0636No actual harm with potential for more than minimal harm · Isolated
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Deficient, Provider has date of correction · corrected January 12, 2024
D
F0695No actual harm with potential for more than minimal harm · Isolated
Provide safe and appropriate respiratory care for a resident when needed.
Deficient, Provider has date of correction · corrected January 12, 2024
D
F0758No actual harm with potential for more than minimal harm · Isolated
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Deficient, Provider has date of correction · corrected January 12, 2024
Inspected October 12, 2023
1 citation · from a complaint investigation · Health
F
F0921No actual harm with potential for more than minimal harm · Widespread
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Deficient, Provider has date of correction · corrected October 26, 2023
Inspected September 22, 2023
3 citations · from a complaint investigation · Health
D
F0690No actual harm with potential for more than minimal harm · Isolated
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Deficient, Provider has date of correction · corrected October 26, 2023
D
F0695No actual harm with potential for more than minimal harm · Isolated
Provide safe and appropriate respiratory care for a resident when needed.
Deficient, Provider has date of correction · corrected October 26, 2023
G
F0689Actual harm · Isolated
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has date of correction · corrected October 26, 2023
Inspected July 27, 2023
1 citation · from a complaint investigation · Health
E
F0558No actual harm with potential for more than minimal harm · Pattern
Reasonably accommodate the needs and preferences of each resident.
Deficient, Provider has date of correction · corrected July 29, 2023
Inspected July 6, 2023
6 citations · from a complaint investigation · Health
D
F0550No actual harm with potential for more than minimal harm · Isolated
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Deficient, Provider has date of correction · corrected July 29, 2023
D
F0585No actual harm with potential for more than minimal harm · Isolated
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Deficient, Provider has date of correction · corrected July 29, 2023
D
F0687No actual harm with potential for more than minimal harm · Isolated
Provide appropriate foot care.
Deficient, Provider has date of correction · corrected July 29, 2023
D
F0791No actual harm with potential for more than minimal harm · Isolated
Provide or obtain dental services for each resident.
Deficient, Provider has date of correction · corrected July 29, 2023
F
F0812No actual harm with potential for more than minimal harm · Widespread
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Deficient, Provider has date of correction · corrected July 29, 2023
G
F0686Actual harm · Isolated
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Deficient, Provider has date of correction · corrected July 29, 2023
Inspected June 15, 2023
1 citation · from a complaint investigation · Health
D
F0689No actual harm with potential for more than minimal harm · Isolated
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has date of correction · corrected July 29, 2023
Inspected February 27, 2020
10 citations · Health
C
F0623No actual harm with potential for minimal harm · Widespread
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Deficient, Provider has plan of correction · corrected March 27, 2020
C
F0625No actual harm with potential for minimal harm · Widespread
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Deficient, Provider has plan of correction · corrected March 27, 2020
D
F0557No actual harm with potential for more than minimal harm · Isolated
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Deficient, Provider has date of correction · corrected March 27, 2020
D
F0582No actual harm with potential for more than minimal harm · Isolated
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Deficient, Provider has date of correction · corrected March 27, 2020
D
F0641No actual harm with potential for more than minimal harm · Isolated
Ensure each resident receives an accurate assessment.
Deficient, Provider has date of correction · corrected March 27, 2020
D
F0677No actual harm with potential for more than minimal harm · Isolated
Provide care and assistance to perform activities of daily living for any resident who is unable.
Deficient, Provider has date of correction · corrected March 27, 2020
D
F0684No actual harm with potential for more than minimal harm · Isolated
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Deficient, Provider has date of correction · corrected March 27, 2020
D
F0686No actual harm with potential for more than minimal harm · Isolated
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Deficient, Provider has date of correction · corrected March 27, 2020
F
F0725No actual harm with potential for more than minimal harm · Widespread
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Deficient, Provider has date of correction · corrected March 27, 2020
F
F0804No actual harm with potential for more than minimal harm · Widespread
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Deficient, Provider has date of correction · corrected March 27, 2020
Penalties
Date
Type
Amount
April 7, 2025
Fine
$104,650
September 22, 2023
Fine
$44,970
September 22, 2023
Payment Denial · 12 days
Ownership transfers
Effective
Seller
Buyer
09/01/2021
Brainard Leasing LLC
Embassy Lyndhurst, LLC
From the CMS Skilled Nursing Facility Change of Ownership dataset. A sale does not by itself say anything about care quality.