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Pines At Bristol For Nursing & Rehabilitation, The

61 Bellevue Avenue, Bristol, CT 06010 · For profit - Corporation · 132 certified beds · (860) 589-1682 Medicare & Medicaid certified

Call the home — (860) 589-1682 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0602) — cited Mar 2026Resident-funds citation (F0565)
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0602), cited Mar 2026
  • it has a citation for mishandling residents’ money or property (F0565)
  • a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its payroll-based staffing rating is low (2/5)
  • about 26% of its spending goes to commonly-owned related companies

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.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's quality-measure rating runs 2 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 — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
46 Goodwin St · (860) 589-5593 · Call to confirm hours
Pharmacy
194 Main St · (860) 845-5492 · Call to confirm hours
Grocery
100 N Main St
Park
40 Queen St · (860) 584-6160 · Typically dawn to dusk

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 5 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 held steady at 4 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 rating4★
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 increased4.1%18.0%15.4%better
Long-stay residents who lose too much weight6.3%6.5%5.4%worse
Long-stay residents with a catheter left in their bladder0.3%0.7%0.9%better
Long-stay residents with a urinary tract infection0.0%1.5%2.0%better
Long-stay residents with depressive symptoms76.5%22.3%6.5%worse than state — see note marked double-dagger 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 injury3.5%3.5%3.3%typical
Long-stay residents whose ability to walk worsened3.9%16.4%16.1%better
Long-stay residents on antianxiety or hypnotic medication18.6%17.6%18.9%typical
Long-stay residents given the seasonal flu vaccine95.5%93.5%95.3%typical
Long-stay residents with pressure ulcers3.1%4.0%4.7%better
Long-stay residents with worsening bladder/bowel control27.2%24.7%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table10.6%17.8%17.1%better
Short-stay residents who newly got an antipsychotic medication0.4%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine83.3%69.7%79.4%typical
Short-stay residents rehospitalized after admission34.0%24.3%22.6%worse
Short-stay residents with an outpatient ER visit10.4%10.7%12.0%better
Long-stay hospitalizations per 1,000 resident days1.962.061.67worse
Long-stay outpatient ER visits per 1,000 resident days1.131.461.80better

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.

65.4% 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 163 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

65.4%U.S. median 51.5%
Got home and stayed home
11.1%U.S. median 10.7%
Went back to hospital
51.4%U.S. median 56.6%
Met the expected recovery
0.29U.S. median 0.31
Therapy hours / resident / day
0.11hours / resident / day
Physical therapy
0.14hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 51.4% 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 35 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 0.29 therapist hours per resident per day in 2026Q1 — more than 45% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 36% 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 SNF65.4%CMS range 57.5–71.551.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.1%CMS range 7.9–14.510.7%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 discharge51.4%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 discharge45.7%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 discharge37.1%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 identified67.8%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 setting93.7%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 stay0.0%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 worsened0.0%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 hospitalization6.6%CMS range 4.0–10.47.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.951.02Oct 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

0.43
RN hours/ resident / day
0.99
LPN hours/ resident / day
2.23
Aide hours/ resident / day
3.65
Total nurse hours/ resident / day
0.21
RN hoursweekends
39.8%
Total nursing turnover
41.2%
RN turnover

How full it usually is: this home is certified for 132 beds and averages 122.3 residents a day — about 93% occupied, or roughly 10 beds typically open. It runs fairly full. 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 3.65 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.43 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.23 is below 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 3.29 hrs/resident/day on weekends vs 3.80 on weekdays — 13% thinner on weekends. RN hours go from 0.52 to 0.21 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 40% is about the same as 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

12
deficiencies at the latest standard inspection (2025-03-26)
8
at the previous standard inspection (2023-02-02)

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.

28 citations, most serious first. The 10 most serious are shown; the remaining 18 are one tap away and print in full.

  • Potential for harm · D2026-03-13 · tag F0602 — failed to protect residents from theft of their belongings — isolated
    Protect each resident from the wrongful use of the resident's belongings or money.
    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 three of five residents (Residents #5, #6 and #7) reviewed for misappropriation, the facility failed to prevent the misappropriation of the residents' controlled narcotic medications. The findings include: Resident #5 was admitted with diagnoses that included lumbar intervertebral disc painful compression and stenosis (narrowing of the spinal canal) and heart failure. A nursing admission/readmission evaluation dated 1/4/2026 at 4:06 PM identified Resident #5 was alert and oriented to person, place, time and situation and needed moderate assistance for walking. An APRN note dated 1/4/2026 at 8:45 AM identified Resident #5 was hospitalized for intractable back pain and several falls at home. Resident #5 was diagnosed with a compression fracture of the lower back (lumbar or L5) and treated with a back brace and pain management. A physician order dated 1/4/2026 directed to administer Hydromorphone HCl (a…

    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 · Dcited before2026-02-20 · 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 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 provide adequate supervision to a resident with dementia who required staff assistance, resulting in a fall with injury. The findings include:Resident #1 had diagnoses that included dementia, fall with fractured femur, stroke, anxiety, history of falls, and atrial fibrillation. A physician's order dated 4/7/20 directed to administer Apixaban (thin blood and prevents blood clots) 2.5 milligram (mg) twice a day and assistance of one with toileting and ambulation using a rolling walker. The Resident Care Plan (RCP) dated 6/3/20 identified Resident #1 was at high risk for falls due to stroke, limited mobility, incontinence, psychotropic medication use, seizure disorder, vision impairment, and dementia. Resident #1 had prior falls on 3/25/20, 3/30/20, and 6/26/20. Interventions included floor mats on both sides of the bed, assist resident…

    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 · E2025-03-26 · tag F0580 — failed to tell family and doctor about changes — pattern
    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 observation, review of the clinical record, facility documentation, facility policy, and interviews for 5 residents (Resident #59, 63, 72, 121, and 346), reviewed as part of the sufficient competent nurse staffing review, the facility failed to ensure that the physician and resident representatives were immediately notified when medication omissions/errors were identified. The findings include: 1. Resident #59 was admitted to the facility in September 2023 with diagnoses that included psychiatric disorder with delusions, dementia, and chronic obstructive pulmonary disease The care plan dated 8/23/24 identified Resident #59 required psychotropic medications. Interventions included to administer medications as ordered. The quarterly MDS dated [DATE] identified Resident #59 had severely impaired cognition, was frequently incontinent of bowel and bladder and required substantial assistance with dressing, bathing and toileting. Review of the September 2024 MAR identified on 9/22/24, LPN #3 signed off morning…

    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 · Ecited before2025-03-26 · tag F0684 — failed to provide proper treatment and quality of care — pattern
    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 7 residents (Resident #59, 63, 68, 72, 85, 121 and 346), the facility failed to provide care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. For 1 of 2 residents (Resident #59) reviewed for edema, the facility failed to follow the physician's order for compression stockings. For 2 of 2 residents (Resident #68 and 85) reviewed for edema, the facility failed to ensure the staff monitored the intake and output for a resident on a fluid restriction. For 5 residents (Residents #59, 63, 72, 121 and 346) the facility failed to ensure medications were administered per the physician's orders, and failed to ensure that following an identified medication administration error, a change of condition nursing assessment was completed. The findings include. 1. Resident #59 was admitted to the facility in July 2022 with diagnoses that included…

    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 · E2025-03-26 · tag F0726 — failed to have competent, trained nursing staff — pattern
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, review of the clinical record review, facility documentation, facility policy, and interviews, the facility failed to ensure all facility nursing staff were educated on the identifying mechanism for enhanced barrier precautions (EBP). The findings include: Observations on 3/23/25 at 11:37 AM of the 1st floor Passport unit identified multiple bright pink circular stickers placed on several exterior name plates for residents on the unit. No other information identifying what the pink stickers were for was observed. Interview with LPN #3 on 3/23/25 at 11:50 AM identified she was unsure what the pink circular stickers were for and identified that she thought they had been placed by the Infection Control Nurse, and had something to do with infections, but did not know anything else about the stickers. Interview with NA #4 on 3/23/25 at 11:51 AM identified she had seen the pink circular stickers on multiple resident entryways but had no idea what the stickers meant. Interview with NA #5 on 3/25/25 at 10:30 AM identified that the pink circular stickers were placed 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-26 · tag F0565 — failed to support the resident council — isolated
    Honor the resident's right to organize and participate in resident/family groups in the facility.
    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, the facility failed to ensure resident council funds, that were raised during fund raising events, had complete and accurate record keeping, and were in an interest-bearing account. The findings include: Review of the resident council meeting minutes identified the following. Minutes dated 9/11/23 identified starting 9/18/23 to 9/27/23 there would be a [NAME] to raise money for resident council. Minutes dated 11/13/23 identified the craft fair on 11/10/23 and 11/11/23 raised $1200. Minutes dated 2/5/24 identified someone donated an Afghan to be raffled off for Mother's Day. Minutes dated 3/11/24 identified residents had a tag sale on 4/26/24 and 4/27/24. The Director of Recreation informed the residents she would be using the proceeds from the raffles and tag sale to purchase cloths for the prom and other recreation items needed for the residents. Minutes dated 4/1/24 identified Director of Recreation informed residents the Easter [NAME]…

    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 · D2025-03-26 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    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 observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #344) reviewed for dignity, the facility failed to ensure that the resident's medical information and care needs remained private. The findings include: Resident #344 was admitted to the facility on [DATE] with diagnoses that included sepsis, muscle weakness, and legal blindness. The care plan dated 3/21/25 identified Resident #344 had impaired visual function. Interventions included to tell the resident where items were being placed and to provide total feed assist with all meals. Observation on 3/23/25 at 11:00 AM identified a sign located on the exterior room door of Resident #344 and Resident #345 with the following: Resident is Legally Blind. Total Feed with meals. Keep items within reach. The sign also identified Resident #344's bed number. The 5 day MDS dated [DATE] identified Resident # 44 had intact cognition, was frequently incontinent of bowel and bladder and 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 Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-26 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    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 interviews for 1 of 3 residents (Resident #59) reviewed for pre-admission screening and resident review (PASARR), the facility failed to refer the resident, who had a new mental health diagnosis, to the State-designated authority. The findings include: Resident #59 was admitted to the facility in July 2022 with diagnoses that included anxiety disorder and osteoporosis with a pathological fracture. Notice of PASARR Level 1 Screen outcome dated 7/13/22 identified Resident #59 had no mental health diagnosis known or suspected and no diagnosis of dementia. No Level 2 is required because no serious behavioral health conditions or intellectual/developmental disabilities exist. If changes occur or new information refutes these findings, a new screen must be submitted. The quarterly MDS dated [DATE] identified Resident #59 had severely impaired cognition and had an active diagnosis of anxiety, depression, and dementia. The psychiatric APRN note dated…

    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 · D2025-03-26 · 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 observation, review of the clinical record, facility policy, and interviews for 1 of 8 residents (Resident #112) reviewed for accidents, the facility failed to administer medications according to professional standards. The findings include: Resident #112 was admitted to the facility in October 2024 with diagnoses that included paroxysmal atrial fibrillation, dysphagia, and hypertension. The care plan dated 3/13/25 identified Resident #112 had a deficit in self-care function: activity intolerance. Interventions included set up/clean up assistance for eating/feeding and personal hygiene/oral care. The quarterly MDS dated [DATE] identified Resident #112 had intact cognition, required set-up or cleaning assistance with eating, had complaints of difficulty or pain with swallowing, and was on a mechanically altered diet while a resident. A physician's order dated 3/21/25 directed to administer the following medications. Apixaban 2.5mg, 1 tablet by mouth, twice daily for blood thinner related to paroxysmal…

    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 · Dcited before2025-03-26 · 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 review of the clinical record, facility documentation, facility policy, and interviews for 1 of 7 residents (Resident #59) reviewed for accidents, the facility failed to ensure every 15 minute checks were completed after an unwitnessed fall, per physician's order and per facility policy. The findings include: Resident #59 was admitted to the facility in July 2022 with diagnoses that included dementia, high blood pressure, history of falls, and heart failure. The quarterly MDS dated [DATE] identified Resident #59 had severely impaired cognition and required maximum assistance with dressing, toileting, and personal hygiene. The care plan dated 10/7/24 identified Resident #59 was at risk for falls Interventions included to remind Resident #59 to call for assistance, neurological checks and fall assessments per facility protocol. A reportable event form dated 11/15/24 at 7:30 AM identified Resident #59 reported falling in the dining room causing a bruise and abrasion to the left flank area. Interventions…

    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
Show the remaining 18 citations
  • Potential for harm · D2025-03-26 · tag F0694 — isolated
    Provide for the safe, appropriate administration of IV fluids for a resident when needed.
    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 assessment, and interviews, the facility failed to ensure a licensed nurse had the competencies and education to administer IV therapy. The findings include: Resident #390 was admitted to the facility on [DATE] with diagnosis that included sepsis, bacteremia, and acute and subacute endocarditis. The admission nurse's note dated 3/22/25 at 5:51 PM identified that Resident #390 was admitted from an acute care facility with a diagnosis of sepsis and acute renal failure. Blood culture showed Group B (beta) strep (Streptococcus) bacteremia and probable endocarditis. A PICC (peripherally inserted central catheter) was placed, and IV (intravenous) antibiotics were ordered for 6 weeks. Physician's orders dated 3/22/25 directed to administer Ceftriaxone Sodium Solution Reconstituted (IV antibiotic) 1gram, use 2 grams intravenously, once daily for sepsis until 4/29/25, before breakfast, and to monitor IV PICC site for redness, swelling, drainage, and…

    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 before2025-03-26 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    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 resident (Resident #4) reviewed for a specialized treatment, the facility failed to ensure that staff consistently monitored and recorded fluid intake and output for a resident on fluid restriction. The findings included: Resident #4 was admitted to the facility in September 2024, with diagnoses that included chronic kidney disease stage 3, and diabetes. The December 2024 physician's order directed a 1500 ml fluid restrictions per day (breakfast 420 ml, lunch 240 ml, dinner 240 ml, nursing 480 ml between days and evenings, and 120 ml on nights). Review of the fluid intake monitoring record dated December 2024 identified staff failed to document the resident's intake 17 out of 93 occasions. Review of the fluid intake monitoring record dated January 2025 identified staff failed to document the resident's intake 34 out of 93 occasions. The care plan dated 2/12/25 identified the resident requires hemodialysis…

    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 · D2025-03-26 · tag F0730 — isolated
    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 observation, review of facility documentation, facility policy, and interviews, the facility failed to ensure that nurse aides had annual performance evaluations completed for 2024, The findings include: During a review of performance evaluations for facility nursing staff on 3/25/25, facility documentation failed to identify a 2024 performance evaluation completed for NA #6. A request was made on 3/25/25 at 10:00 AM to the HR Director to provide the 2024 performance evaluation for NA #6. Review of the provided performance evaluation for NA #6 on 3/25/25 at 10:52 AM identified NA #6 had not signed the evaluation, and the signature from the DNS on the evaluation was dated 10/30/25, 7 months in the future. Interview with the HR Director on 3/25/25 at 10:52 AM identified she observed the DNS sign the evaluation today, just prior to the DNS handing the evaluation to the HR Director. Interview with the DNS on 3/25/25 at 11:00 AM identified she was aware that there were facility nursing staff who did not have annual evaluations completed for 2024, but this was due to the staff…

    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
  • Potential for harm · D2025-03-26 · tag F0880 — failed to prevent and control infections — isolated
    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 observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #340) reviewed for transmission-based precautions, the facility failed to ensure nursing staff adhered to appropriate infection control techniques for a resident on contact precautions. The findings include: Resident #340 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, history of falling, and dysphagia. The admission MDS dated [DATE] identified Resident #340 had moderately impaired cognition, was always continent of bowel, occasionally incontinent of bladder and required partial assistance from facility staff with dressing, bathing, and toileting. The care plan dated 3/22/25 identified Resident #340 had gastroenteritis. Interventions included standard plus enteric contact precautions. A physician's order dated 3/22/25 directed to collect stool sample for Clostridium Difficile (C. Diff) one time for diarrhea. Observation on…

    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 · Dcited before2024-10-22 · 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

    Based on clinical record review, facility documentation review, facility policy review, and interviews for one resident of two residents (Resident #1) reviewed for pressure wounds, the facility failed to ensure care was provide timely. The findings include: Record review identified Person #1 was Resident #1's emergency contact. Resident #1 was admitted with diagnoses that included status post stroke with decreased movement on the right side. A nursing admission evaluation dated 9/26/2024 identified Resident #1 was alert and oriented, was a very high risk for pressure ulcer development and had blanchable redness on the sacrum, coccyx and groin area, and was dependent for transfers and did not walk. Physician note dated 9/26/2024 identified Resident #1 was aphasic (difficulty speaking) and followed commands. The Resident Care Plan dated (RCP) dated 9/27/2024 identified Resident #1 was dependent for toileting, ADLs, and had a potential for skin breakdown. Interventions directed to turn and reposition every two (2) to three (3) as tolerated by the resident and skin checks with care.…

    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
  • Potential for harm · Dcited before2023-08-07 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    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, facility policies and interviews for one sampled resident (Residents #1) who required staff assistance with dressing and was reviewed for an allegation of mistreatment, the facility failed to treat a resident in a dignified and respectful manner when providing care. The findings include: Resident #1's diagnoses included dementia with psychotic disturbance. The Resident Care Plan dated 7/10/23 identified Resident #1 had an activities of daily living self-care performance deficit related to weakness. Interventions directed limited two (2) person assistance with dressing. The admission Minimum Data Set assessment dated [DATE] identified Resident #1's hearing was adequate, Resident #1 did not use hearing aid, rarely or never made self-understood, rarely or never understood others, had some short- and long-term memory deficits, required extensive two (2) person assistance with dressing, and utilized a wheelchair for mobility. The Facility Reported Incident form…

    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 · Ecited before2023-02-02 · tag F0698 — failed to provide proper dialysis care — pattern
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    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 observation, staff interview, review of the clinical record review and facility policy for 1 of 1 sampled residents (Resident #2) reviewed for receiving a hemolytic treatment, the facility failed to monitor intake totals for a resident who was exceeding a physician ordered fluid restriction. Resident #2's diagnoses included end stage renal disease, heart failure, diabetes and Alzheimer's disease. Physician orders dated 9/1/22 (through 2/2/23) directed a fluid restriction of 800 milliliters (ml) per day and hemodialysis 3 times per week at a dialysis center. The Quarterly Minimum Data Sheet (MDS) assessment dated [DATE] identified Resident #2 was severely cognitively impaired and required one person assistance for bed mobility, transfers, dressing, toilet use and personal hygiene. The MDS further identified Resident #2 was independent with eating after being set up and received dialysis. A Resident Care Plan dated 12/15/22 identified Resident #2 was at risk for a nutritional problem secondary to end…

    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 · E2023-02-02 · tag F0791 — failed to provide routine dental services — pattern
    Provide or obtain dental services for each 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 observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident # 89) reviewed for dental services, the facility failed to ensure an oral surgeon referral was arranged in a timely manner. The findings include: Resident #89 was admitted to the facility with diagnoses that included oropharyngeal phase dysphasia, dysphasia oral phase, and gastro-esophageal reflux disease. A Dentist progress note dated 10/17/21 at 7:09 PM identified x-rays were taken and identified Resident #89 was missing the following teeth #1, 4, 5, 7, 9, 10, 13, 14, 16, 19, 22, and 29 - 32. Additionally, coronal portions of teeth #3, 6, 8, 18, 20, 21, 26, and #28. Extensive decay on tooth #24. Removal is recommended. Referral to an oral surgeon may be necessary depending on which teeth become active. The quarterly MDS dated [DATE] identified Resident #89 had intact cognition, was on a mechanically altered diet and was a set up for meals. The Dental Consultation Request…

    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 · E2023-02-02 · tag F0812 — failed to store, cook, and serve food safely — pattern
    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 and staff interview, the facility failed to ensure a trash receptacle was covered and not in the proximity of clean utensils. On 1/31/23 at 11:55 AM, during a walk-through inspection of the Dietary Department with the Food Service Director (FSD) identified a large gray plastic trash receptacle was observed being stored and partially exposed from under the clean side of a 3 bay sink counter. The trash receptacle had a liner, was uncovered, and approximately 2/3 full of garbage. Above the trash receptacle were several clean serving utensils drying on the 3 bay sink counter. Interview at that time with the FSD indicated the utensils on the counter were clean and identified the trash container should have been covered and in its proper location which was on the soiled side of the 3 bay sink (not on the clean side of the sink). Additionally, she identified it was the responsibility of all kitchen staff to maintain sanitary conditions and that the Dietary Aides were primarily responsible to clean the kitchen equipment. Additionally, the FSD…

    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 · Dcited before2023-02-02 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    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 observation, review of the clinical record, facility documentation, facility policy and interviews for 3 of 6 residents (Resident #48, 52 and 89) reviewed for dining, the facility failed to provide a dignified dining experience. The findings include: 1. Resident #48's diagnosis included Alzheimer's disease, dysphagia and feeding difficulties. A Resident Care Plan dated 1/6/23 identified Resident #48 was at risk for an activities of daily living (ADL) self-care deficit secondary to dementia and decreased mobility. Interventions included to provide assistance of one for completion of meals with verbal cues and Resident #48 was non-ambulatory. The Quarterly Minimum Data Sheet (MDS) assessment dated [DATE] identified Resident #48 was severely cognitively impaired and required extensive assistance with two staff for bed mobility, transfers and toilet use. The MDS further identified Resident #48 required extensive assistance with two staff for dressing, personal hygiene and required limited assistance of one…

    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 · D2023-02-02 · tag F0553 — failed to let residents help plan their care — isolated
    Allow resident to participate in the development and implementation of his or her person-centered plan of care.
    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 #97) reviewed for resident rights, the facility failed to ensure the resident and/or resident's representative were invited to participate in the interdisciplinary care plan meetings. The findings include: Resident #89 was admitted to the facility on [DATE] with diagnoses that included diabetes, diabetic neuropathy, and heart failure. The comprehensive care plan record of team meetings indicated that meetings were held on 12/14/21, 5/17/22 (5 months later), 9/15/22 (4 months later), and 1/26/23 (4 months later). Resident #97 nor the resident representative signed the forms as having attended the meetings. The quarterly MDS dated [DATE] identified Resident #97 had moderately impaired cognition and required extensive assistance for bed mobility, dressing, toileting, and personal hygiene. The care plan dated 1/26/23 identified the resident was independent for meeting emotional,…

    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 before2023-02-02 · 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 observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #89) reviewed for positioning, the facility failed to ensure the resident was positioned for meals to meet the resident's needs. The findings include: Resident #89 was admitted to the facility with diagnoses that included chronic obstructive pulmonary disease, oropharyngeal phase dysphasia, dysphasia oral phase, and gastro-esophageal reflux disease. A speech therapy evaluation and treatment plan dated 8/20/20 identified Resident #89 initially had a mild delay in mastication was slow but functional and occasionally a delay throat clearing. Resident #89 was educated to use compulsory strategies of safe swallowing with small bites, slow rate, alternating solids with liquids. Discharge recommendations included Resident #89 was to use and follow strategies and maneuvers during oral intake with general swallowing techniques and precautions upright position during meals and upright…

    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 before2023-02-02 · 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 observation, review of the clinical record, facility documentation, facility policy and interview for 2 of 3 residents (Resident #41 and 82) reviewed for falls, the facility failed to provide the necessary supervision and assistive devices to prevent accidents. The findings include: 1. Resident #41 was admitted to the facility on [DATE] with diagnoses that included heart failure, lymphedema and chronic ischemic heart disease. A Fall Evaluation dated 1/13/23 identified Resident #41 had a history of falls in the last month prior to admission and was at risk for falls. The care plan dated 1/14/23 identified the resident had a self-care performance deficit. Interventions included to provide assistance of 1 with transfers and toileting with use of rolling walker. Further, the resident was at risk for falls related to bilateral lower extremity edema and generalized weakness. Interventions included to ensure appropriate footwear (non-skid socks, non-slip soles on shoes/sneakers) when ambulating or mobilizing…

    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 · E2020-02-27 · tag F0883 — failed to offer flu and pneumonia vaccines — pattern
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    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 record review, review of facility policy and staff interview for 4 of 5 sampled residents (Resident #51, Resident #52, Resident #74 and Resident #80) reviewed for immunizations, the facility failed to ensure accurate immunization tracking and offer the appropriate pneumonia vaccines as appropriate. The findings include: On 2/27/20 at 10:11 AM, interview and review of pneumococcal immunizations with the Infection Control Nurse (ICN) identified the following: a. Resident #51 was admitted to the facility on [DATE]. On 2/25/20, a review of the electronic immunization status identified Resident #51 received a Pneumococcal 23 (PPSV23) on 6/19/19. On 2/27/20, documentation of Resident #51 receiving the PPSV 23 had been changed to Resident #51 receiving the Prevnar 13 on 6/19/19 (and not the PPSV 23). Interview with the ICN at that time identified that subsequent to surveyor inquiry regarding the Infection Control Program and prior to surveyor reviewing immunizations with the ICN, the facility identified 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 · D2020-02-27 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each 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 record review, staff interview and observation for 1 of 1 sampled resident (Resident #221) reviewed for environment, the facility failed to ensure Resident #221's call light was within reach. The findings include: Resident #221 was admitted to the facility 2/20/20 with diagnoses that included end stage renal disease, glaucoma, and gait abnormality. An admission Nursing assessment dated [DATE] identified Resident #221 was alert, oriented to person, place, time and situation. The Nursing Assessment further identified Resident #221 was verbally appropriate and had impaired ability to see in adequate light. A Resident Care Plan dated 2/20/20 identified an activities of daily living deficit with interventions that included to provide limited assistance for bathing, bed mobility, dressing, personal hygiene, and to utilize 2 1/4 side rails up for assistance and bed mobility. On 2/25/20 at 10:12 AM, a resident interview was attempted, but Resident #221 verbalized several times (in a very soft spoken voice)…

    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 · D2020-02-27 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    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 observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #49) reviewed for dining, the facility failed to ensure timely assistance with the meal. The findings include: Resident #49 was admitted to the facility on [DATE] with diagnosis that included dementia, dysphagia, mood disorder and anxiety. Physician's order dated 10/11/19 (and currently in effect) identified aspiration precautions and supervision with all meals, small bites/sips, and remain upright to 90 degrees 30 minutes post meal. The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #49 was moderately cognitively impaired, required extensive assistance of one for bed mobility, dressing, toilet use, and personal hygiene. Additionally, the MDS identified Resident #49 required limited assistance of one for eating, was receiving a mechanically altered diet, and had not had any significant weight loss. The Resident Care Plan dated 1/1/20 identified Resident #49 had…

    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 before2020-02-27 · 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 observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #49) reviewed for dining, the facility failed to ensure adequate supervision was provided during a meal for a resident with dysphagia. The findings include: Resident #49 was admitted to the facility on [DATE] with diagnosis that included dementia, dysphagia, mood disorder and anxiety. Physician's order dated 10/11/19 (and currently in effect) identified aspiration precautions and supervision with all meals, small bites/sips, and to remain upright to 90 degrees 30 minutes post meal. The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #49 was moderately cognitively impaired, required extensive assistance of one for bed mobility, dressing, toilet use, and personal hygiene. Additionally, the MDS identified Resident #49 required limited assistance of one for eating, was receiving a mechanically altered diet, and had not had any significant weight loss. The Resident…

    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 · B2023-02-02 · tag F0645 — pattern
    PASARR screening for Mental disorders or Intellectual Disabilities
    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 interview and record review for 1 of 5 residents (Resident #36) reviewed for Pre-admission Screening and Record Review (PASRR), the facility failed to notify the assessment agency responsible for a PASRR Level 2 determination when the 7 day approval of stay had expired. The findings include: Resident #36 diagnoses included schizophrenia, high blood pressure and chronic obstructive pulmonary disease. A PASRR Level 1 screen dated [DATE] identified Resident #36 was approved for a 7 day stay in a long term care facility terminating on [DATE]. Additionally, the PASRR Level 1 identified from admission, the facility was responsible to notify the responsible assessing agency by submitting screenings to initiate a Level 2 PASRR. A Resident Care Plan (RCP) dated [DATE] identified Resident #36 was dependent on staff for meeting his/her emotional needs and required cognitive stimulation through social activities. Additionally, the RCP identified Resident #36 was taking medications for schizophrenia and depression…

    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

No federal fines in the current CMS record.

Part of a chain

This home belongs to NATIONAL HEALTH CARE ASSOCIATES — 42 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 4 of 53.2+0.8 vs chain
Health inspection 3 of 52.8+0.2 vs chain
Staffing 2 of 53.0-1.0 vs chain
Quality measures 5 of 54.1+0.9 vs chain
The other 41 homes this chain runs (chain average 3.2★, per CMS)
1 of 5Brentwood Center For Health & Rehabilitation, LLCYarmouth, ME 1 of 5The Pines At Utica Center For Nursing And RehabUtica, NY 2 of 5Beacon Brook Center For Health & RehabilitationNaugatuck, CT 2 of 5Bloomfield Center For Nursing & RehabilitationBloomfield, CT 2 of 5Eastside Center For Health & Rehabilitation, LLCBangor, ME 2 of 5Kennebunk Center For Health & Rehabilitation, LLCKennebunk, ME 2 of 5Ludlowe Center For Health & RehabilitationFairfield, CT 2 of 5Mansfield Center For Nursing And RehabilitationStorrs Mansfield, CT 2 of 5Montowese Center For Health & RehabilitationNorth Haven, CT 2 of 5Riverside Health & Rehabilitation CenterEast Hartford, CT 2 of 5Shady Knoll Center For Health & RehabilitationSeymour, CT 2 of 5Summit At Plantsville Center For Health & RehabiliPlantsville, CT 2 of 5The Pines At Catskill Center For Nursing & RehabCatskill, NY 2 of 5The Pines At Glens Falls Ctr For Nursing & RehabGlens Falls, NY 3 of 5Augusta Center For Health & Rehabilitation, LLCAugusta, ME 3 of 5Cambridge Health And Rehabilitation CenterFairfield, CT 3 of 5Evergreen Center For Health & RehabilitationStafford Springs, CT 3 of 5Glastonbury Center For Health & RehabilitationGlastonbury, CT 3 of 5Hebrew Center For Health And RehabilitationWest Hartford, CT 3 of 5Laurel Ridge Center For Health & RehabilitationRidgefield, CT 3 of 5Maefair Center For Health & RehabilitationTrumbull, CT 3 of 5Marlborough Health & Rehabilitation CenterMarlborough, CT 3 of 5Reservoir Center For Health & Rehabilitation, TheMarlborough, MA 3 of 5Water's Edge Center For Health & RehabilitationMiddletown, CT 3 of 5Winship Green Center for Health & Rehab, LLCBath, ME 4 of 5Bethel Health Care CenterBethel, CT 4 of 5Brewer Center For Health & Rehabilitation, LLCBrewer, ME 4 of 5Dover Center For Health & RehabilitationDover, NH 4 of 5Huntington Hills Center for Health and RehabilitatMelville, NY 4 of 5Sharon Center For Health & RehabilitationSharon, CT 4 of 5Stone Bridge Center For Health & RehabilitationNewtown, CT 4 of 5The Pines At Poughkeepsie Ctr For Nursing & RehabPoughkeepsie, NY 4 of 5The Pines at Rutland Center for Nursing & RehabiliRutland, VT 4 of 5Village Crest Center For Health & RehabilitationNew Milford, CT 5 of 5Belair Care Center IncBellmore, NY 5 of 5Maple View Health & Rehabilitation CenterRocky Hill, CT 5 of 5Milford Health And Rehabilitation CenterMilford, CT 5 of 5Norway Center For Health & Rehabilitation, LLCNorway, ME 5 of 5Pine Heights at Brattleboro Center for Nursing & RBrattleboro, VT 5 of 5Regency House Nursing And Rehabilitation CenterWallingford, CT

Showing 40 of 41; lowest-rated first.

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
BNB HEALTH CARE FUNDS LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST7%since 01/01/2013
COHEN, DAVIDIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST7%since 09/01/2007
FUCHS, MORRISIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST8%since 09/01/2007
GOLDENBERG, CHAIMIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST5%since 09/01/2007
LIPMAN, MICHAELIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST5%since 09/01/2007
MANELA, MAGDAIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST5%since 09/01/2007
ROBERTS, TZIVYIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST7%since 01/01/2014
BINNS, YASMINIndividualW-2 MANAGING EMPLOYEEsince 05/09/2022
OSTREICHER, MARVINIndividualOPERATIONAL/MANAGERIAL CONTROLsince 03/26/2007
BOKOW, BARRYIndividualGENERAL PARTNERSHIP INTERESTsince 09/01/2007

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.

$17.5M
Net patient revenuemost recent cost report
-2.5%
Operating marginrevenue minus expenses
$4.7M
Related-party expense26% of expenses
Who pays — share of resident-days
Medicaid 76%Medicare 7%Other / private 17%

About 76% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $4.7M paid to related parties — landlords or management companies under common ownership — equal to about 26% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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

$395per resident / day
operating cost
$11,993per month
≈ monthly operating cost
$385per 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

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Connecticut Medicaid page.

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 075221. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-03-26, 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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