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Caleb Hitchcock Health Center

10 Loeffler Rd, Bloomfield, CT 06002 · Non profit - Corporation · 60 certified beds · (860) 726-2000 Medicare only — no Medicaid

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Flagged for abuse1 actual-harm citation2 actual-harm citations CMS recorded as corrected before the inspection ended (past non-compliance)$47,216 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a high payroll-based staffing rating (5/5)
  • lower-than-typical staff turnover (24% vs 45% nationally) — better care continuity
Worth asking about
  • CMS has flagged it for abuse
  • it has abuse, neglect, or exploitation citations (F0600, F0603) — most recent Nov 2025
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 1 actual-harm citation
  • inspectors recorded 2 serious findings as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (21) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $47,216 in federal fines (most recent 2025-11-25)
  • its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
  • its independent health-inspection rating is low (1/5)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 1 of 5
StaffingFrom payroll records (PBJ) 5 of 5
Quality measuresSelf-reported by the facility 4 of 5

Worth a closer look. This home's staffing and quality-measure ratings run 4 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
Urgent care / clinic
Pause CT0.9 mi
3 Barnard Ln · (860) 322-8008 · Call to confirm hours
Pharmacy
Rite Aid1.1 mi
835 Park Ave · (860) 242-5551 · Call to confirm hours
Grocery
1 Regency Dr Ste 202
Park
Filley Park, 33 Tunxis Ave · (860) 243-9721 · Typically dawn to dusk
Place of worship
54 Maple Ave · (860) 242-8996

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 4 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 5 to 2 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased10.4%18.0%15.4%better
Long-stay residents who lose too much weight1.3%6.5%5.4%better
Long-stay residents with a catheter left in their bladder0.5%0.7%0.9%better
Long-stay residents with a urinary tract infection4.8%1.5%2.0%worse
Long-stay residents with depressive symptoms0.0%22.3%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury8.9%3.5%3.3%worse
Long-stay residents whose ability to walk worsened6.6%16.4%16.1%better
Long-stay residents on antianxiety or hypnotic medication9.6%17.6%18.9%better
Long-stay residents given the seasonal flu vaccine97.5%93.5%95.3%typical
Long-stay residents with pressure ulcers1.4%4.0%4.7%better
Long-stay residents with worsening bladder/bowel control24.4%24.7%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table17.6%17.8%17.1%typical
Short-stay residents who newly got an antipsychotic medication1.4%1.5%1.4%typical
Short-stay residents given the seasonal flu vaccine90.7%69.7%79.4%better
Short-stay residents rehospitalized after admission30.0%24.3%22.6%worse
Short-stay residents with an outpatient ER visit14.6%10.7%12.0%worse
Long-stay hospitalizations per 1,000 resident days0.482.061.67better
Long-stay outpatient ER visits per 1,000 resident days0.601.461.80better

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

63.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 180 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

63.8%U.S. median 51.5%
Got home and stayed home
10.4%U.S. median 10.7%
Went back to hospital
60.9%U.S. median 56.6%
Met the expected recovery
0.66U.S. median 0.31
Therapy hours / resident / day
0.28hours / resident / day
Physical therapy
0.32hours / resident / day
Occupational therapy
0.06hours / resident / day
Speech therapy

Met the expected recovery: 60.9% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 64 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.66 therapist hours per resident per day in 2026Q1 — more than 90% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 22% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF63.8%CMS range 55.5–70.251.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.4%CMS range 7.7–13.510.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge60.9%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge40.6%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge60.9%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified93.6%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay1.1%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened1.1%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.8%CMS range 3.8–11.67.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.831.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

1.56
RN hours/ resident / day
0.66
LPN hours/ resident / day
3.68
Aide hours/ resident / day
5.91
Total nurse hours/ resident / day
1.20
RN hoursweekends
24.3%
Total nursing turnover
21.1%
RN turnover

How full it usually is: this home is certified for 60 beds and averages 50.3 residents a day — about 84% occupied, or roughly 10 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 5.91 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.56 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.68 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 5.64 hrs/resident/day on weekends vs 6.01 on weekdays — 6% thinner on weekends. RN hours go from 1.71 to 1.20 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 24% is below the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

8
deficiencies at the latest standard inspection (2025-11-25)
7
at the previous standard inspection (2024-01-24)

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

21 citations, most serious first. The 13 most serious are shown; the remaining 8 are one tap away and print in full.

  • Actual harm · Gcited before2025-11-25 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 2 residents (Resident #6) reviewed for hospitalization, the facility failed to ensure Resident #6 who exhibited self-injurious behaviors (biting, gnawing and sucking), had a comprehensive care plan developed and interventions implemented to minimize the risk of injury. The facility's failure to develop a comprehensive care plan with individualized interventions to address self-injurious behaviors resulting in the development of an open area, progressing to osteomyelitis (a bone infection) and gangrene which required a partial right third finger amputation. These failures resulted in the finding of immediate jeopardy. Additionally, for 1 of 3 residents (Resident #1) reviewed for accidents, the facility failed to ensure the resident care plan was comprehensive for Resident #1's history of fractures and seizures. The findings include: 1.Resident #6 was admitted to the facility from the hospital on [DATE] with…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Past Non-Compliance
  • Actual harm · G2025-11-25 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 2 residents (Resident #6) reviewed for hospitalization, the facility failed to protect the skin of a resident with known behaviors of picking and gnawing at his/her fingers, failed to monitor the fingers after gnawing caused skin deterioration of the finger, failed to document an assessment when the fingers were noted with breakdown which resulted in Resident #6 developing osteomyelitis (a bone infection),and gangrene requiring a partial right third finger amputation. These failures resulted in the finding of Immediate Jeopardy. Resident #6 was admitted to the facility from the hospital on [DATE] with diagnosis that included a urinary tract infection, hypertension and chronic obstructive pulmonary disease (there was no admitting diagnosis of peripheral vascular disease (PVD), diabetes or neuropathy). A progress note written by MD #3 prior to Resident #6's admission to the facility, obtained by the facility…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Past Non-Compliance
  • Actual harm · G2025-11-17 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for abuse, the facility failed to ensure care was provided gently when staff repositioned Resident #1 and staff pulled on Resident #1's wrist to turn him/her in the bed. The findings include:Resident #1's diagnoses included dementia. The significant change Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of one out of fifteen, indicative of severe cognitive impairment, was incontinent of bowel and bladder, was dependent on staff for personal hygiene, and required maximal assistance with bed mobility. The Resident Care Plan (RCP) dated 9/17/2025 identified incontinence, alteration in mobility, becomes easily agitated with occasional aggressive outbursts. Interventions directed two (2) staff for personal care, wrap a bath towel around quarter side rails to prevent injury when resistive or…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-11-25 · tag F0882 — widespread
    Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility documentation, facility policy and interviews regarding the employment of an Infection Preventionist, the facility failed to designate an individual with the required training and certification to oversee the Infection Control Program. The findings include: Interview with the Director of Nursing Services (DNS) on 11/19/25 at 2:00 PM identified that she was designated as the Infection Preventionist (IP) in October 2025 until a new IP was hired to the position.Interview with Registered Nurse (RN) #8 on 11/24/25 at 10:30 AM identified she was a full time RN-Designee at the Assisted Living Services Agency (another entity of the Long Term Care Facility) and was not actively a facility employee. RN #8 identified she had assisted the previous IP in the past around 2 times a week with training on support in her IP position but since the DNS took over coverage for the IP position, she only helped to answer questions periodically when the DNS called her. RN #8 identified that she did not review infection prevention documents and reports at the facility, and that…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-11-25 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documentation, facility policy, and interviews regarding the facility Infection Control program, the facility failed to document Covid-19 staff effected on a line list, failed to document and complete Covid-19 testing per facility policy, and failed to provide facility-initiated education to non-nursing personnel related to Covid-19, The findings include: Review of a Department of Public Health (DPH) Facility Licensing and Investigations Section (FLIS) Resolution Report dated [DATE] identified the facility had a COVID -19 outbreak which was declared as resolved on [DATE] and involved 2 residents (Resident #6 and Resident #66) and 2 staff members.a. Review of the facility COVID-19 outbreak documentation for [DATE]-[DATE] failed to identify a line list for staff members. The nurse aide (NA) and Life Enrichment Director who tested positive for COVID-19 during the outbreak were not documented on a staff line list which would have documented their age, gender, primary floor assignment,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-11-25 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 3 residents (Resident #1) reviewed for accidents, the facility failed to follow professional standards of practice for the monitoring of neurological assessments following an unwitnessed fall. Additionally, for 1 of 2 residents (Resident #6) reviewed for hospitalization, the facility failed to follow professional standards of practice regarding completing a skin assessment when Resident #6 was observed to sustain bloody areas to the fingers of the right hand caused by the behaviors of sucking, biting and picking and failed to ensure routine skin assessments were completed by a Registered Nurse (RN) and not a Licensed Practical Nurse (LPN). The findings include: 1.Resident #1 had diagnoses that included epilepsy (seizure disorder), vascular dementia, and fracture of right sided skull and facial bones with routine healing. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-11-25 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, observations, interviews and facility policy for 1 of 3 sampled residents (Resident #12) reviewed for pressure ulcers, the facility failed to ensure the alternating pressure mattress was set correctly. The findings include: Resident #12 was admitted to the facility in January 2024 with diagnoses that included dementia, osteoporosis, and mobility impairment. The quarterly Minimum Data Set, dated [DATE] identified Resident #12 was severely cognitively impaired, was dependent on staff for all of activities of daily living, required assistance of 2 for transfers with a mechanical lift, and was at risk for developing pressure ulcers/injuries. Additionally, the MDS identified Resident #12 did not have a pressure ulcer.The physician's orders (undated) directed to apply Triad paste (a zinc-based sterile wound dressing in paste form) to the coccyx two times a day, skin prep to bilateral heels twice a day, mechanical lift for transfers and weekly skin checks. The physician's orders…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-11-25 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the clinical record, facility documentation, facility policy and interviews for 1 of 3 sampled residents (Resident #4) reviewed for positioning and mobility, the facility failed to obtain a physician's order, develop a plan of care and provide staff education for a resident's lower extremity brace. The findings include: Resident #4 was admitted to the facility in January 2024 with diagnoses that included difficulty in walking, unsteadiness on feet and unspecified abnormalities of gait and mobility. The quarterly Minimum Data Set (MDS) assessment dated [DATE], identified Resident #4 had no cognitive impairment and was independent with toileting, bed mobility and transfers. The MDS further indicated Resident #4 required partial/moderate assistance with lower body dressing and had a diagnosis of weakness and difficulty in walking. The Resident Care Plan (RCP) dated 8/27/25 identified Resident #4 required assistance with activities of daily living and had an AFO (Ankle-Foot-Orthosis)…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-11-25 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, facility documentation and facility policy for 1 of 1 supply closets observed, the facility failed to ensure the nursing supply closet on the secured Memory Care unit was locked/secured. Review of the Resident Listing Report dated 11/18/25 indicated there were 12 residents living on the facility's secured Memory Care unit.An observation on the secured Memory Care unit on 11/18/25 at 10:30 AM identified the nursing supply closet was unlocked and contained 20 bottles of peri wash (8.1 ounces (oz) each), 24 bottles of non-alcohol mouthwash (4 oz each bottle), 22 bottles of body cream (5 oz in each bottle), 12 tubes of barrier cream, 25 bottles of body lotion (8 oz in each bottle). 40 fingernail clippers, 8 disposable razors, 2 containers of Sani cloth bleach wipes with 75 wipes in each, 5 containers of Sani cloth PDI- germicidal wipes with 160 wipes in each, 5 cans of shaving cream (11oz in each can), and 17 bottles of Purell hand sanitizers (12 oz. in each bottle).A second observation on 11/18/25 at 3:00 PM identified that the nursing supply closet…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-11-17 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for abuse, the facility failed to ensure staff reported an allegation of abuse timely. The findings include:Resident #1's diagnoses included dementia. The significant change Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of one out of fifteen, indicative of severe cognitive impairment, was incontinent of bowel and bladder, was dependent on staff for personal hygiene, and required maximal assistance with bed mobility. The Resident Care Plan (RCP) dated 9/17/2025 identified incontinence, alteration in mobility, becomes easily agitated with occasional aggressive outbursts. Interventions directed two (2) staff for personal care, wrap bath towel around quarter side rails to prevent injury when resistive or combative with care, use a calm approach and an unhurried manner when dealing with…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-01-24 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation of the Dietary Department, staff interview, and facility policy, the facility failed to ensure cleanliness of the kitchen, a food items were labeled when opened, contained an expiration date, failed to failed to perform hand hygiene, and adequately store a chemical solution away from food. The findings include: Tour of the Dietary department on 1/18/24 at 10:32 AM and 1/23/24 at 12:16 PM with the Director of Dietary identified the following: 1a. A 1 gallon container that was 1/4 full of fresh, peeled garlic was observed to be located inside the reach in cooler and was noted to be opened but not labeled with the date of opening, contained a green substance inside the container and lacked an expiration date. b. A five gallon plastic container containing loose flour (almost full) was not dated to identify when the flour was placed into the container and failed to identify the expiration date. c. A five gallon plastic container containing loose sugar (approximately 3/4 full) was not dated to identify when the sugar was placed into the container and failed to…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-01-24 · tag F0603 — failed to not confine residents against their will — pattern
    Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, review of facility policy and interview for 2 of 5 resident living units, the facility failed to ensure that all residents, except those assessed to require a secured unit, were allowed to freely move off the unit or about the facility resulting in the finding of a pattern of involuntary seclusion. The findings included: Observation during tour on 1/18/24 noted that the exit doors to the resident care units, Elm, and Fir, were always locked and exiting required a security code. Although it was noted that some alert and oriented residents had been provided with the code to open the doors, other residents were unable to independently exit the unit. Interview with the Administrator and Director of Nursing on 1/24/24 at 11:40 AM identified the facility lacked policies and procedures for assessing which residents required living on a secure unit and that there was no facility documentation, in any resident's clinical record, for those residents residing on the locked units, indicating criteria for secured/locked area placement. The Administrator indicated the doors…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-01-24 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, review of facility documentation, facility policy, and interviews, the facility failed to ensure laundry was handled in a clean manner. The findings include: During a tour of the soiled laundry area on 1/22/24 at 12:00 PM, two barrels, used to contain dirty linen, were in direct contact with a clean rack of personal clothing items that were under a mesh cover. In the clean laundry folding areas, two of the three ceiling intake valves were coated with a gray substance. Additionally, in the clean laundry area, one running fan, coated with a gray substance on the blades and the grill, was blowing directly on the table where clean linen was folded. Interview, observation, review of facility documentation, and review of facility policy on 1/22/24 at 12:08 PM with Laundry Operator #1, indicated that the facility policy was to keep clean and dirty laundry items separated (dirty laundry barrels from the clean personal clothing rack) and clean items should not be stored in the soiled linen area. Laundry Operator #1 identified that the gray substance on the ceiling…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
Show the remaining 8 citations
  • Potential for harm · Dcited before2024-01-24 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility policy, and interviews for 2 of 5 residents (Resident #6 and #19) reviewed for unnecessary medications, the facility failed to initiate a care plan for an anticoagulant (blood thinning) medication. The findings include: 1. Resident #6 had diagnoses that included heart failure, atrial fibrillation, and falls. The Quarterly MDS (minimum data set) assessment dated [DATE] identified Resident #6 was without cognitive impairment and required partial/moderate assistance with transfers and supervision/touch assistance with ambulation. Additionally, the MDS had anticoagulation coded for consideration for care planning. The physician's order dated 8/1/23 directed facility staff to administer Eliquis (an anticoagulation medication) 2.5 milligrams (mg) twice daily. Review of the Resident Care Plan failed to identify a care plan related to the use of an anticoagulant medication. Review of the NA care card (care plan) failed to identify that NA staff were to monitor for…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-24 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility policy and interviews for the only sampled resident (Resident #10) reviewed for hearing loss, the facility failed to review and revise the care plan when a hearing aid was unavailable. The findings include: Resident #10's diagnosis included dementia, age related cognitive decline, and anxiety. The MDS assessment dated [DATE] identified Resident #10 had moderate hearing loss, was severely cognitively impaired, and required assistance with eating, personal hygiene, and transfers. The Resident Care Plan dated 1/10/24 identified Resident #10 had hearing loss and required bilateral hearing aids. Interventions included assisting with proper care and maintenance of hearing aids, audiology consults as ordered, and use simple and direct communication. A nurses note dated 12/2/23 at 6:52 PM identified that Resident #10 was transferred to the hospital with his/her right hearing aid. A re-admission nursing observation document dated 12/7/23 identified bilateral hearing aids.…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-24 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility policy, and interviews for 2 of 2 residents (Resident #17 and Resident #36) reviewed for nutrition, for Resident #17 the facility failed to assess the resident's nutritional needs following a significant weight loss and for Resident #36, failed to follow a dietician's recommendation for nutritional supplements The findings include: 1. Resident #17's diagnoses included dementia with behavioral disturbances, chronic kidney disease, and iron deficiency anemia. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #17 as severely cognitively impaired and required set up assistance for eating, mechanical lift for transfers, and supervision for bed mobility. A Quarterly Registered Dietician Review dated 10/5/23 identified that Resident #17's intake was variable but frequently 50% or less of meals were consumed. A recommendation for Medpass 2.0 (a nutritional supplement) 120 milliliters (ml) three times daily was given and was accepted by the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-10-27 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 4 residents (Resident #63) reviewed for accidents, the facility failed to ensure timely notification of Resident #63's physician and responsible person when a change in skin integrity was identified. The findings include: Resident #63 was admitted to the facility on [DATE] with diagnoses that included dementia, encephalopathy, atrial fibrillation and history of a cerebral vascular accident. A physician's order dated 5/1/19 directed to administer Eliquis (a medication to treat and prevent blood clots) 2.5 mg twice a day. The quarterly MDS assessment dated [DATE] identified Resident #63 had moderately impaired cognition, required extensive two-person physical assistance with mobility and transfers and utilized a wheelchair. The Resident Care Plan (RCP) dated 2/21/20 identified Resident #63 required assistance with activities of daily living and was unsteady with transfers. Interventions included to encourage…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-10-27 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility documentation and interviews for 1 of 4 sampled residents (Resident #263) reviewed for accidents, the facility failed to ensure a mechanical transfer was provided according to the plan of care. The findings include: Resident #263's diagnoses included Diabetes Mellitus, osteoporosis, osteoarthritis, muscle weakness and cervical spondylosis. A Resident Care Plan (RCP) dated 4/4/19 identified a problem with a self-care deficit, generalized weakness, difficulty with transfers and needing assistance. Interventions included to provide assistance of 2 for transfers, toilet use, bathing, grooming, and dressing. Additional interventions included to encourage maximum level of performance and adequate time for self-performance, asses for decline in function, and rehabilitation screens as needed. A physician's order dated 5/6/19 directed to transfer Resident #263 with assistance of 2 using a Sara lift, including toilet use and showering and to discontinue stand pivot…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2024-01-24 · tag F0577 — widespread
    Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, facility documentation, and interviews for 11 of 11 residents (Resident #'s 1, 7, 16, 22, 27, 29, 42, 44, 46, 401, and 402) interviewed during the Resident Council meeting, the facility failed to ensure survey results were accessible to residents. The findings include: An observation on 1/23/24 at 9:35 AM identified the state survey inspection results were located in the lobby at the entrance to the facility. Access to the lobby from the nursing units was noted to be key coded (locked) for exit. An interview with the Resident Council members, Resident #'s 1, 7, 16, 22, 27, 29, 42, 44, 46, 401, and 402 on 1/22/24 at 3:25 PM indicated they were unaware of the state survey results location. Interview with Receptionist #1 on 1/23/24 at 10:01 AM indicated that family members and staff were the only individuals that have the code to gain access from the nursing units to the front lobby. Receptionist #1 denied residents had the exit code. Interview with the ADNS on 1/23/24 at 10:44 AM indicated that staff and the receptionist were the only individuals who have the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2021-10-27 · tag F0730 — widespread
    Observe each nurse aide's job performance and give regular training.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews, review of employee files, and facility policy for 3 of 3 Nurse Aides (NAs) reviewed (NA #4, NA #5, and NA #6), the facility failed to complete an annual performance appraisal for NA #4, NA #6 and failed to complete a 90 day evaluation for NA #5 per facility policy. The findings include: 1. NA #4 was hired on 3/10/10, had an annual evaluation last completed on 7/2/19 but failed to reflect subsequent annual performance appraisals had been completed. 2. NA #5 was hired on 12/4/20, was due for a 90 day evaluation on 3/4/20 which had not been completed as of 10/27/21. 3. NA #6 was hired on 9/1/04 with a last annual performance evaluation completed on 5/1/19 but failed to reflect subsequent annual performance appraisals had been completed. Facility policy regarding Performance Review stated the performance reviews are completed annually on the date designated by the facility each year and are to be conducted after the first 90 days of employment and annually on the date designated. Interview with the Human Resource Specialist identified that all evaluations/appraisals…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2021-10-27 · tag F0640 — pattern
    Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation and staff interview for 5 residents (Residents #1, Resident #2, Resident #3, Resident #4 and Resident #5) reviewed for resident assessment, the facility failed to ensure the Discharge assessment-return not anticipated MDS' were transmitted to the CMS System according to established timeframes. The findings include: 1. Resident #1 was admitted to the facility on [DATE] and discharged on 5/6/21. The Discharge assessment-return not anticipated MDS was completed on 5/7/21. Interview with the MDS Coordinator, RN #1 on 10/25/21 at 2:45 PM identified the MDS was put in a batch to be transmitted on 5/18/21 however, was not transmitted per the validation report. 2. Resident #2 was admitted to the facility on [DATE] and discharged on 5/10/21. The Discharge assessment-return not anticipated MDS was completed on 5/12/21. Interview with the RN #1 on 10/25/21 at 2:45 PM identified the MDS was put in a batch to be transmitted on 5/18/21 however, was not transmitted…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$47,216 in federal fines across 2 penalties.

  • $15,106 — penalty dated 2025-11-25
  • $32,110 — penalty dated 2025-11-17

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Who owns this facility

Owner / managerTypeRoleSince
ANDERSON, ELIZABETHIndividualW-2 MANAGING EMPLOYEEsince 12/01/2009
MORTENSEN, CAROLIndividualW-2 MANAGING EMPLOYEEsince 12/01/2009
O'BRIEN, MICHAELIndividualW-2 MANAGING EMPLOYEE; CORPORATE DIRECTORsince 12/01/2009
BETTS, JAMESIndividualCORPORATE DIRECTORsince 05/09/2013
BYRNES, JOHNIndividualCORPORATE DIRECTORsince 12/01/2009
COCHERAN, WILLIAMIndividualCORPORATE DIRECTORsince 12/01/2009
HINCKS, MARCIAIndividualCORPORATE DIRECTORsince 05/09/2013
KING, SONDRAIndividualCORPORATE DIRECTORsince 12/01/2009
KOLTENUK, DEBORAHIndividualCORPORATE DIRECTORsince 12/01/2009
SHULANSKY, JOHNIndividualCORPORATE DIRECTORsince 05/09/2014
SPIVEY, MARIEIndividualCORPORATE DIRECTORsince 05/09/2014
TRACY, DANIELIndividualCORPORATE DIRECTORsince 05/09/2013
LEAKE, ROBERTIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 01/03/2023
DUNCASTER, INCORPORATEDOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 12/01/2009

CMS files one row per role, so the 16 rows in the source record cover these 14 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$23.2M
Net patient revenuemost recent cost report
-39.9%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 0%Medicare 14%Other / private 86%

A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$1,666per resident / day
operating cost
$50,638per month
≈ monthly operating cost
$1,191per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in CT

Paying with Medicaid

CMS lists this home as Medicare-certified only — it is not Medicaid-certified, so it generally cannot accept Medicaid as payment for a long-term stay. That makes it one of roughly 545 homes nationally where a Medicaid-funded placement is not an option. If you expect to rely on Medicaid, ask the home directly before you tour, and see the Connecticut Medicaid page for homes that do.

Typical monthly cost in Connecticut
$15,208/mo
Nursing home (semi-private)
$16,729/mo
Nursing home (private)
$9,118/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 075301. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-11-25, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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