(a) For any application of licensure for the acquisition of a nursing home, any potential nursing home licensee or owner shall submit in writing, a change in ownership application with respect to the facility for which the change in ownership is sought. The application shall be submitted in the form and manner prescribed by the Commissioner of Public Health. The commissioner shall include on the first page of the application the following statement: “NOTICE: The State of Connecticut values the quality of care provided to all nursing home residents. Please know that any nursing home licensee, owner or officer, including, but not limited to, a director, trustee, limited partner, managing partner, general partner or any person having at least a ten per cent ownership interest in the nursing home or the entity that owns the nursing home, and any administrator, assistant administrator, medical director, director of nursing or assistant director of nursing may be subject to civil and criminal liability, as well as administrative sanctions under applicable federal and state law, for the abuse or neglect of a resident of the nursing home perpetrated by an employee of the nursing home.”.

(b) Such statement shall not be construed as expanding or otherwise affecting the liability of any person or entity referenced in the statement. The application shall also include questions as to whether such potential nursing home licensee or owner has had (1) three or more civil penalties imposed through final order of the commissioner in accordance with the provisions of sections 19a-524 to 19a-528, inclusive, or civil penalties imposed pursuant to the statutes or regulations of another state, during the two-year period preceding the application, (2) in any state, sanctions, other than civil penalties of less than twenty thousand dollars, imposed through final adjudication under the Medicare or Medicaid program pursuant to Title XVIII or XIX of the federal Social Security Act, 42 USC 301, as from time to time amended, or (3) in any state, such potential licensee’s or owner’s Medicare or Medicaid provider agreement terminated or not renewed. If a potential nursing home licensee or owner’s application contains information concerning civil penalties, sanctions, terminations or nonrenewals, as described in this section, the commissioner shall not approve the application to acquire another nursing home in this state for a period of five years from the date of final order on such civil penalties, final adjudication of such sanctions, or termination or nonrenewal, except for good cause shown.