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Cherry Brook Health Care Center

102 Dyer Avenue, Canton, CT 06019 · Non profit - Corporation · 100 certified beds · (860) 693-7777 Medicare & Medicaid certified

Call the home — (860) 693-7777 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Dec 2024Resident-funds citation (F0565)1 actual-harm citation$11,175 in federal fines
Insights

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

Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Dec 2024
  • 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 a citation for mishandling residents’ money or property (F0565)
  • it has 1 actual-harm citation
  • 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
  • the CMS record shows $11,175 in federal fines (most recent 2026-01-28)
  • its independent health-inspection rating is low (2/5)
  • its facility-reported quality-measure rating is low (2/5)

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 2 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 2 of 5

Location & what’s nearby

Hospital
Urgent care / clinic
141 Dowd Ave · (860) 693-1881 · Call to confirm hours
Pharmacy
220 Albany Tpke · (860) 693-8329 · Call to confirm hours
Grocery
Aldi1.9 mi
101 Albany Tpke · (855) 955-2534 · Call to confirm hours
Park
10 East Hill Rd · (860) 693-5808 · Typically dawn to dusk
Place of worship

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 2 of 5
Long-stay residentspeople who live here 2 of 5
Short-stay residentsrehab / post-hospital 3 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 increased17.7%18.0%15.4%worse
Long-stay residents who lose too much weight4.5%6.5%5.4%better
Long-stay residents with a catheter left in their bladder2.1%0.7%0.9%worse
Long-stay residents with a urinary tract infection1.9%1.5%2.0%typical
Long-stay residents with depressive symptoms1.5%22.3%6.5%better 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 injury3.4%3.5%3.3%typical
Long-stay residents whose ability to walk worsened12.6%16.4%16.1%better
Long-stay residents on antianxiety or hypnotic medication13.9%17.6%18.9%better
Long-stay residents given the seasonal flu vaccine89.9%93.5%95.3%typical
Long-stay residents with pressure ulcers4.4%4.0%4.7%typical
Long-stay residents with worsening bladder/bowel control27.0%24.7%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table20.3%17.8%17.1%worse
Short-stay residents who newly got an antipsychotic medication1.4%1.5%1.4%typical
Short-stay residents given the seasonal flu vaccine46.3%69.7%79.4%worse
Short-stay residents rehospitalized after admission25.9%24.3%22.6%worse
Short-stay residents with an outpatient ER visit21.3%10.7%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.972.061.67worse
Long-stay outpatient ER visits per 1,000 resident days1.961.461.80typical

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.

59.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 98 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

59.8%U.S. median 51.5%
Got home and stayed home
9.7%U.S. median 10.7%
Went back to hospital
50.6%U.S. median 56.6%
Met the expected recovery
0.44U.S. median 0.31
Therapy hours / resident / day
0.27hours / resident / day
Physical therapy
0.13hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 50.6% 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 87 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 0.44 therapist hours per resident per day in 2026Q1 — more than 74% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 14% 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 SNF59.8%CMS range 50.2–68.351.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.7%CMS range 6.8–13.310.7%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 discharge50.6%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 discharge37.9%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 discharge52.9%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 identified100.0%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 setting97.6%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 discharge94.3%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.9%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 worsened1.8%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 hospitalization7.7%CMS range 4.6–13.37.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.781.02Oct 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

0.45
RN hours/ resident / day
1.02
LPN hours/ resident / day
2.12
Aide hours/ resident / day
3.59
Total nurse hours/ resident / day
0.31
RN hoursweekends
55.4%
Total nursing turnover
50.0%
RN turnover

How full it usually is: this home is certified for 100 beds and averages 96.2 residents a day — about 96% occupied, or roughly 4 beds typically open. It runs essentially full — expect a waiting list. 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 3.59 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.45 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.12 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 3.22 hrs/resident/day on weekends vs 3.75 on weekdays — 14% thinner on weekends. RN hours go from 0.51 to 0.31 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 55% 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

14
deficiencies at the latest standard inspection (2024-12-23)
4
at the previous standard inspection (2022-09-13)

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 11 most serious are shown; the remaining 17 are one tap away and print in full.

  • Actual harm · G2026-01-28 · 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, interviews, and facility documentation/policies for one (1) of three (3) sampled residents (Resident #1) reviewed for accidents, the facility failed to follow physician orders which directed the assistance of two (2) staff for bed mobility which resulted in a dislocation of the left shoulder, and for one (1) of three (3) residents (Resident #4) reviewed for accidents, the facility failed provide adequate supervision by failing to initiate appropriate fall prevention interventions (toileting plan/schedule) and failing to implement an established care plan intervention (gripper socks) for a resident with progressive incontinence patters who was at high risk for falls. The findings included:1.Resident #1's diagnoses included hemiplegia and hemiparesis after cerebral infarct affecting the left, non-dominant side. A Nurse's note dated 12/11/25 at 10:13 PM identified Resident #1 was alert and oriented times four. A Physician's admission Assessment note dated 12/12/25 at 11:30 AM…

    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 before2026-01-28 · 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 clinical record review, interviews, and facility documentation/policies for one (1) of three (3) residents (Resident #4) reviewed for accidents, the facility failed to initiate appropriate fall prevention interventions (toileting plan/schedule) and failed to implement an established care plan intervention (gripper socks) for a resident with progressive incontinence patterns who was at high risk for falls. The findings included:Resident #4 was admitted to the facility in February of 2025 and had diagnoses that included dementia, cerebral infarction, and difficulty in walking.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #4 had severely impaired cognition (Brief Mental Interview for Mental Status (BIMS) score of 3), was dependent with toileting hygiene and bathing, required substantial assistance with ambulation, was occasionally incontinent of urine, and utilized a wheelchair. The Resident Care Plan (RCP) dated 6/12/25 identified Resident #4 was at risk for falls…

    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 · D2026-01-28 · 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 clinical record review, interviews, and review of facility documentation and policies for one (1) of three (3) residents (Resident #4) reviewed for accidents, the facility failed to perform a Bowel and Bladder Assessment upon readmission to the facility, in accordance with facility policy. The findings included:Resident #4 was admitted to the facility in February of 2025 and had diagnoses that included dementia, cerebral infarction, and difficulty in walking.The Bladder and Bowel assessment dated [DATE] identified Resident #4 was continent of bowel and the bladder section indicated non applicable. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #4 had severely impaired cognition (Brief Mental Interview for Mental Status (BIMS) of 3), required substantial assistance with toileting hygiene, personal hygiene, and ambulation, utilized a wheelchair, and was frequently incontinent of bowel and bladder. The Resident Care Plan (RCP) dated 9/24/25 failed to identify Resident #4's…

    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 before2026-01-28 · 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 clinical record review, interviews, and facility documentation/policies for one (1) of three (3) residents (Resident #5) reviewed for falls, the facility failed to provide adequate supervision for a hospice resident suffering from terminal agitation who sustained several falls within a 24-hour period resulting in injury. The findings included:Resident #5 was admitted to the facility in December of 2025 with diagnoses which included chronic obstructive pulmonary disease (COPD), malignant neoplasm of the lung, anxiety disorder, depression and was admitted to hospice care on 12/19/25.The Nursing admission assessment dated [DATE] identified Resident #5 was oriented to person, drowsy, and confused and required maximal assistance with toileting, personal hygiene, and rolling from side to side. The Nursing admission Assessment failed to identify Resident #5 was assessed for ambulation.The Resident Care Plan (RCP) dated 12/20/25 identified Resident #5 was at risk for falls secondary to being newly admitted 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-28 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    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 two (2) of three (3) sampled residents reviewed for medication administration (Residents #2 and #3), the facility failed to ensure medications were administered in accordance with physician orders when Resident #2 received Lacosamide prescribed for Resident #3 instead of the ordered Tramadol. The findings include:Resident #2's diagnoses included Parkinson's Disease, dementia, and anxiety. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 had severe cognitive impairment (Brief Interview for Mental Status (BIMS) score of 5) and was dependent on staff for all care. The Resident Care Plan (RCP) dated 9/11/25 identified Resident #2 had a diagnosis of alcohol and polysubstance abuse. Interventions directed to monitor the resident's psychosocial status, provide support, and arrange psychiatric services as needed. A physician's order for Resident #2 dated 11/13/25 directed to administer…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-18 · 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 record review, facility documentation review, and staff interviews for one of three residents (Resident #1) reviewed for abuse, the facility failed to ensure staff reported an allegation of mistreatment timely. The findings include:Based on record review, facility documentation review, and staff interviews for one of three residents (Resident #1) reviewed for abuse, the facility failed to ensure staff reported an allegation of mistreatment timely. The findings include: Resident #1 had a diagnosis of Traumatic Brain Injury (TBI), dysphagia (difficulty swallowing) aphasia (inability to communicate. The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of 0 indicating severely impaired cognition, no swallowing difficulties, and required setting up for feeding. The Resident Care Plan (RCP) dated 6/24/2025 identified a potential for impaired nutrition due to dysphagia. Interventions directed to allow resident time to consume meals, use…

    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 · D2025-08-18 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    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, facility documentation review, and staff interviews for one of three residents (Resident #1) reviewed for abuse, the facility failed to ensure the medical record was complete and accurate to include support visits made after an allegation of mistreatment. The findings include:Based on record review, facility documentation review, and staff interviews for one of three residents (Resident #1) reviewed for abuse, the facility failed to ensure the medical record was complete and accurate to include support visits made after an allegation of mistreatment. The findings include: Resident #1 had a diagnosis of Traumatic Brain Injury (TBI), dysphagia (difficulty swallowing) aphasia (inability to communicate. The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of 0 indicating severely impaired cognition, no swallowing difficulties, and required setting up for feeding. The Resident Care Plan (RCP) dated 6/24/2025 identified 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-12-23 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    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 store discontinued controlled drugs in a separately locked permanently affixed compartment, and failed to have a system to limit access to controlled drugs. The findings include: Observation on 12/19/24 at 12:20 PM identified the DNS office door was open without any staff present within the office. Interview with the DNS on 12/20/24 at 9:30 AM identified the discontinued controlled drugs were kept in a cabinet drawer in her office until destroyed. Observation on 12/20/24 at 2:15 PM identified the DNS office door was open without any staff present in the office. Interview on 12/20/24 at 2:20 PM with the DNS identified the keys to both locks of the discontinued controlled drugs cabinet drawer were located in her unlocked desk drawer and that she normally kept the keys stored in that drawer. Observation on 12/20/24 at 2:20 PM with the DNS identified the desk drawer containing the keys to the discontinued controlled drugs cabinet drawer was unlocked. Observation on 12/20/24 at…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-12-23 · 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 observations, staff interviews, and review of facility documentation, the facility failed to ensure open food items were dated and labeled. The findings include: Tour of the Dietary Department on 12/17/24 at 10:05 AM with the Kitchen Manager identified the following: a. The walk-in refrigerator was noted to contain an opened 1-pound bag of cheddar cheese (that was ½ full), an opened 1-gallon container of mayonnaise (that was ¼ full), and an opened bag of 7 croissants with no open date or expiration date identified. b. The walk-in freezer was noted to contain an opened 3-pound bag of French fries (that was ¼ full), an opened bag of 2 fish filets, and an opened 3-pound bag of potato tots (that was ¼ full) with no open date or expiration date identified. c. The dry storage room was noted to contain an opened 3-pound bag of elbow noodles (that was ½ full), an opened 3-pound bag of tri-color macaroni noodles (that was ½ full), an opened 5-pound bag of taco seasoning (that was ¾ full), and an opened 1-pound bag of pearled barley (that was ½ full) with no open date or expiration…

    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 · E2024-12-23 · tag F0868 — pattern
    Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on facility documentation review, facility policy review and interviews, the facility failed to perform quarterly Quality Assurance meetings and failed to ensure Quality Assurance meetings consisted of the minimum required members to maintain an effective and comprehensive Quality Assurance and Performance Improvement (QAPI) program. The findings include: 1. Review of the attendance record for the Quality Assurance Review meeting provided by the administrator failed to show that a Quality Assurance meeting was completed for September 2024. Interview with the administrator on 12/18/24 at 1:03 PM identified there was no QAPI meeting held since 6/2024. The administrator was unable to provide QAPI meeting minutes (official records of discussions, decisions, and actions taken during QAPI meetings) for the 6/2024 QAPI meeting and produced, only, a sign in sheet. The administrator identified she began working in the facility in 9/2024 as an interim administrator up until 3 weeks prior to the current date when she accepted the role permanently. She identified the previous…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-12-23 · 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 observations, review of the clinical record, facility documentation, facility policy and interviews for 1 of 1 resident (Resident #1) observed on facility tour, 10 of 32 residents (Resident #5, Resident #12, Resident #20, Resident #32, Resident #36, Resident #51, Resident #53, Resident #67, Resident #70, and Resident #244) reviewed for Enhanced Barrier Precautions (EBP) and 1 of 2 residents (Resident #242) reviewed for Transmission Based Precautions (TBP), the facility facility failed to properly store a urinary containment bag and failed to initiate and maintain EBP per the Center of Disease Control (CDC) guidelines for residents with a history of Multiple Drug Resistant Organisms (MDROs) and failed to utilize personal protective equipment (PPE) while assisting a resident requiring EBP and failed to maintain TBP while assisting a resident with a positive COVID-19 diagnosis and failed to maintain a clean and sanitary environment. The findings include: 1. Resident #1's diagnoses included paraplegia,…

    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 17 citations
  • Potential for harm · D2024-12-23 · 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 observations, clinical record review, review of facility policy, and interviews for 1 resident, (Resident #63) reviewed for dignity, the facility failed to ensure Residents #63 was treated in a dignified manner while services were provided. The findings include. Resident #63's diagnoses include spinal stenosis, anxiety and depression. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #63 was cognitively intact with no impairment, independent with eating, dependent with toileting, and maximal assist for bathing, transfers, and personal hygiene. Review of the Resident Council minutes from 10/2024 identified that residents had concerns regarding distractions, such as ear buds and cell phones, used by nursing staff. Interview with Resident #63 on 12/19/24 at 11:08 AM identified LPN #6 was performing the medication pass during the evening on 12/18/24 and was on her cell phone arguing with someone. LPN #6 had her ear buds in and was swearing at the person she was on the phone 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 Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-12-23 · 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 interview for the only sampled resident (Resident #3) reviewed for trauma informed care, the facility failed to develop a comprehensive care plan for a resident with post-traumatic stress disorder (PTSD). The findings include: Resident #3 was admitted to the facility in November of 2017 and had diagnoses that included cerebral palsy, PTSD, and major depressive disorder. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #3 was moderately cognitively impaired (Brief Interview for Mental Status (BIMS) score of 11), had PTSD as an active diagnosis, required setup or clean-up assistance with eating, substantial/maximal assistance with bed mobility and was dependent for transfers. The Resident Care Plan (RCP) dated 10/29/2024 identified Resident #3 had a history of accusatory behaviors related to a diagnosis of bipolar disorder, and traumatic history, and Resident #3 was uncomfortable with male care givers but was comfortable…

    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 before2024-12-23 · 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, review of facility policy, and interviews for one sampled resident (Resident #20) reviewed for weight loss, the facility failed to follow a dietician recommendation for a resident with known weight loss. The findings include: Resident #20 was admitted to the facility in May of 2022 with diagnoses which included dementia, diabetes, and abnormal weight loss. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #20 was severely cognitively impaired (Brief Interview for Mental Status (BIMS) score of 3), required setup or clean-up assistance with eating, partial/moderate assistance with bed mobility and substantial/maximal assistance with bed/chair transfers. The Resident Care Plan (RCP) dated 11/6/2024 identified Resident #20 had potential for impaired nutrition related to dementia and was at risk for weight loss. Interventions included to allow Resident #20 adequate time to consume meals, assist with meals as needed, and monitor weight as needed.…

    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 · D2024-12-23 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    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 policy and interviews for 1 of 2 residents (Resident #75) reviewed for bladder and bowel incontinence, the facility failed to follow the toileting plan and provide incontinence care as directed in the plan of care. The findings include: Resident #75 was admitted to the facility in November of 2023 with diagnoses which included Diffuse Traumatic Brain Injury, Aphasia, Dysphagia, Gastrostomy Tube status, Seizures, and Quadriplegia. The annual Minimum Data Set assessment dated [DATE] identified Resident #75 was severely cognitively impaired (Brief Interview for Mental Status (BIMS) score of 0) and required total assistance with eating, bathing, dressing, toileting and mobility. Resident #75 was always incontinent of bladder and bowel. The Resident Care Plan (RCP) dated 11/26/24 identified Resident #75 was incontinent of bowel and/or bladder with a history of urinary retention. Interventions included a maintenance toileting plan which instructed 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-23 · 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 observations, review of the clinical record, facility policy and interviews for the only sampled resident (Resident # 75) reviewed for activities, the facility failed to ensure aspiration precautions were maintained during pleasure eating. The findings include: Resident #75 was admitted to the facility in November of 2023 with diagnoses which included Diffuse Traumatic Brain Injury (TBI), Aphasia, Dysphagia, Gastrostomy Tube status, Seizures, and Quadriplegia. A physician's order dated 2/9/24 directed to provide pureed food including a magic cup and honey thick liquids, by teaspoon only, and with strict aspiration precautions for oral pleasure. The annual Minimum Data Set assessment dated [DATE] identified Resident #75 was severely cognitively impaired (Brief Interview for Mental Status (BIMS) score of 0) and required total assistance with eating, bathing, dressing, toileting and mobility. Resident #75 had a feeding tube. The Resident Care Plan dated 11/26/24 identified Resident #75 was at elevated risk…

    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 · D2024-12-23 · tag F0699 — isolated
    Provide care or services that was trauma informed and/or culturally competent.
    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 the only sampled resident (Resident #3) reviewed for trauma informed care, the facility failed to provide trauma-informed care to minimize triggers and/or re-traumatization for a resident with post-traumatic stress disorder (PTSD). The findings include: Resident #3 was admitted to the facility in November of 2017 with diagnoses which included cerebral palsy, PTSD, and bipolar disorder. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #3 was moderately cognitively impaired (Brief Interview for Mental Status (BIMS) score of 11), had PTSD as an active diagnosis, required setup or clean-up assistance with eating, substantial/maximal assistance with bed mobility and was dependent for transfers. The Resident Care Plan (RCP) dated 10/29/2024 identified Resident #3 was uncomfortable with male care givers and preferred to not have male Nurse Aides (NA) but was comfortable receiving medications…

    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 · D2024-12-23 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    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 maintain completed shift change reconciliation records for controlled drugs and failed to periodically reconcile the facility inventory of controlled drugs. The findings include: Review of the Apple Gate South medication cart on 12/18/24 at 9:41AM identified the Count Sheets for Narcotics and Sedatives form (the controlled drug reconciliation form that on-coming and off-going nurses complete to ensure controlled drugs were counted) were missing signatures on the following dates: a. 11/19/24: off-going b. 11/26/24 on-coming and off-going c. 11/27/24 on-coming and off-going d. 12/6/24 on-coming e. 12/7/24 on-coming f. 12/8/24 off-going and on-coming g. 12/11/24 off-going h. 12/16/24 on-coming and off-going i. 12/17/24 off-going j. 12/18/24 on-coming, off-going, on-coming and off-going k. 12/19/24 on-coming, off-going and off-going. Interview with LPN #2 on 12/18/24 at 9:41 AM indicated that upon completion of the Count Sheet for Narcotics and Sedatives, the sheets were placed…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-23 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    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 3 residents reviewed for facility medication administration, the facility failed to maintain a medication error rate of less than 5% (omission of 3 medications out of 35 opportunities resulting in a medication error rate of 8.57%). The findings include: Resident #16 was admitted to the facility in November of 2024 with diagnoses that included fracture of thoracic vertebrae 9-10, thrombocytopenia, and severe protein calorie malnutrition. The admission Minimum Data Set assessment dated [DATE] identified Resident #16 was cognitively intact (Brief Interview for Mental Status (BIMS) score of 13) and required set up assistance with eating, oral hygiene, personal hygiene, substantial maximum assistance to dependence with dressing, toileting and mobility. The Resident Care Plan dated 11/26/24 identified Resident #16 had potential for impaired nutritional status due to anemia, myelodysplastic syndrome, low…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-06 · 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 two residents (Resident #4) reviewed for abuse, the facility failed ensure the resident was free from mistreatment. The findings include: Resident #4 was admitted with diagnoses that included dementia and amyloidosis. An admission MDS assessment dated [DATE] identified Resident #4 had a BIMS of 8 indicating moderately impaired cognition, required assistance for personal hygiene, was occasionally incontinent of urine and frequently incontinent of bowel. The RCP dated 11/5/2024 identified Resident #4 required assistance for ADLs. The RCP directed provide care. A facility incident report dated 11/14/2024 at 1:30 PM identified Resident #4's roommate (Resident #5) reported to social services about 6 AM a NA came into the room when Resident #4 had a bowel movement and stated to Resident #4 to get your s a up. When Resident started moving, the NA said no, no, don't touch me with your s leg, I…

    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 before2022-09-13 · 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 — the official record, unedited, may be distressing

    Based on observations, review of facility documentation, review of facility policy, and interviews, the facility failed to ensure that the temperature logs of the refrigerators, dishwasher and meals were maintained on a consistent basis to ensure the safe storage, preparation, and cleanliness of the dishes to prevent foodborne illness. The findings include: Observations made during the initial inspection of the kitchen on 9/6/22 indicated that food temperature logs were incomplete as well as the temperature logs for the refrigerator and the dishwater. An interview with the Food Services Director on 9/6/22 at 10:06 AM indicated that the responsibility for log completion is that of the cook on duty and noted that the cook was currently in training. The Food Service Director provided no explanation as to why the temperature logs were incomplete. The policy for logging food temperatures identified that food temperatures are to be taken for each food item during each meal service and recorded on a temperature monitoring log.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-09-13 · 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 observation, review of the clinical record, review of facility documentation, review of facility policy, and interviews for one sampled resident, (Resident #13) who experienced a significant weight loss, the facility failed to notify the physician of the significant weight loss in a timely manner. The findings include: Resident #13's diagnoses included multiple sclerosis, dysphasia, chronic respiratory failure, and pressure ulcer. The quarterly MDS assessment dated [DATE] identified Resident #13 had intact cognition, required extensive assistance of two persons for bed mobility, was independent with eating once set up and was totally dependent for toileting and bathing. The care plan dated 6/16/22 identified Resident #13was at risk for impaired nutrition due to dysphagia and multiple sclerosis. Care plan interventions included, provide a regular puree diet dysphagia level 1 diet with extra gravy/sauces with meals and nectar thick liquids, allow resident adequate time to consume meals, provide aspiration…

    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 before2022-09-13 · 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, review of facility documentation, and interviews for one sampled resident (Resident #77) with a vision deficit, the facility failed to ensure that the resident's vision deficit was addressed within the plan of care. The findings include: Resident #77's diagnoses included diabetes, general anxiety disorder, depression, and dementia. The admission MDS assessment dated [DATE] identified Resident #77 was cognitively intact, had moderately impaired vision, required limited assistance for bed mobility and transfers, was independent with eating once set up. The assessment further identified that vision triggered as a care plan area and that the team (IDT) would proceed with care planning for the vision deficit. Review of the Nurse Aide care card dated 8/11/22 failed to reflect Resident #13's vision deficit. The care plan dated 8/23/22, indicated resident #77 required assistance with activities of daily living (ADLs) and mobility. Further review of the care plan failed to identify…

    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 · D2022-09-13 · 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 review of the clinical record, review of facility documentation, and interviews for one sampled resident (Resident #77) reviewed for activities of daily living, the facility failed to ensure that Resident #77's was offered and given a weekly shower. Resident #77's diagnoses included diabetes, general anxiety disorder depression and dementia. The admission MDS assessment dated [DATE] indicated that Resident #77 had moderately impaired vision, had intact cognition, required limited assistance of one person for bed mobility and transfers, and required assistance for bathing. The Nurse Aide care card date 8/11/22 indicated Resident #77's shower schedule was every Friday on the 3:00 PM to 11:00 PM shift with the assistance of one person. The care plan dated 8/23/2022, indicated resident #77 required assistance with activities of daily living (ADL's) and mobility with interventions that included, provide assistance of one person for transfers to wheelchair, provide assistance or cueing to maximize current…

    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 before2019-11-18 · 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 a clinical record review, staff interviews and a review of the facility documentation for one sampled resident (Resident #34), the facility failed to notify the responsible party when there was a change in medication regimen. The findings include: Resident #34 was admitted to facility on 08/09/19 with diagnoses that included non-Alzheimer's dementia, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD) and generalized anxiety disorder . The resident care plan dated 8/9/19 identified anxiety as a problem with interventions that included to observe behaviors for periods of anxiety, provide a calm environment, diversional activities, psychiatric evaluations as needed for medication management, administration of anxiolytics and monitor their effectiveness, provide support and reassurance to the resident and the family. Physician's admission orders dated 8/13/19 directed to administer Trazadone 25 milligrams (mg) every twenty four hours as needed for sleep and to administer Clonazepam…

    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 before2019-11-18 · 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 a clinical record review and interview for one sampled resident (Resident # 34), the facility failed to follow physician's diet orders prior to a medical procedure. The findings include: Resident #34 was admitted to facility on 08/09/19 with diagnoses that included non-Alzheimer's dementia, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and generalized anxiety disorder. An admission Minimum Data Set (MDS) assessment dated [DATE] identified moderate cognitive impairment, extensive assistance with activities of living and a mechanically altered diet . A resident care plan dated 8/16/19 identified impaired nutritional status due to dysphagia with interventions that included monitor intake at meals, assist and allow the resident adequate time to consume meals, nutritional assessments and education, assess and monitor for the presence of factors interfering with nutritional status, and document consumed fluids and foods. Physician's orders dated 09/27/19 directed Resident #34…

    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 · C2024-12-23 · tag F0565 — failed to support the resident council — widespread
    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

    Based on review of facility Resident Council meeting minutes (formal records documenting discussions to address concerns and collaborations on facility-related matters affecting the residents), interviews, and facility policy, the facility failed to adequately respond to resident grievances. The findings include: 1. Review of Resident Council minutes dated September 2024 identified the following concerns: A. Several concerns related to the number of agency staff (temporary healthcare workers hired through an agency to fill vacancies) in the building and agency staff not introducing themselves. 2. Review of the Resident Council meeting minutes dated October 2024 identified the following: A. Several concerns related to the number of agency staff in the building and lack of staff overall, concerns with overall care and staff knowledge of individual resident needs. B. Concerns regarding distractions such as earbuds and cell phones being used by staff. 3. Review of Resident Council meeting minutes dated November 2024 identified the following: A. Several concerns related to the number of…

    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 · B2024-12-23 · tag F0625 — pattern
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    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 sampled residents (Resident #14 and Resident #36) reviewed for hospitalizations, the facility failed to provide the required notification of a bed hold to the resident and the resident representative. The findings include: 1. Resident #14 was admitted to the facility in September of 2024 and had diagnoses that included chronic obstructive pulmonary disease (COPD), diabetes, and Covid-19. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #14 was moderately cognitively impaired (Brief Interview for Mental Status (BIMS) score of 9), required substantial/maximal assistance with oral hygiene and bed mobility, and was dependent for transfers. The Resident Care Plan (RCP) dated 10/1/2024 identified Resident #14 was at risk for complications of diabetes. Interventions included to monitor for signs of hypoglycemia (low blood sugar) which may include clammy skin, shallow respirations, and mental status…

    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

“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

$11,175 in federal fines across 1 penalty.

  • $11,175 — penalty dated 2026-01-28

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
BOJANOWSKI, KRISTINIndividualCORPORATE DIRECTORsince 01/01/2015
COHEN, JASONIndividualCORPORATE DIRECTORsince 09/19/2023
GIRARD, CHRISTOPHERIndividualCORPORATE DIRECTORsince 01/01/2015
GROSS, GARYIndividualCORPORATE DIRECTORsince 01/01/2015
HINCKS, DANIELIndividualCORPORATE DIRECTORsince 01/01/2015
JENNINGS, MICHAELIndividualCORPORATE DIRECTORsince 01/01/2015
LONGLEY, LAURENIndividualCORPORATE DIRECTORsince 01/14/2025
MCDOUGAL, MARISSAIndividualCORPORATE DIRECTORsince 06/30/2021
MYERS, CARMENIndividualCORPORATE DIRECTORsince 06/30/2021
NEVERS, ROBERTIndividualCORPORATE DIRECTORsince 01/01/2015
SCHAEFER-REID, ANNAIndividualCORPORATE DIRECTORsince 03/08/2022
WALKER, JOSEPHIndividualCORPORATE DIRECTORsince 01/10/2023
FITZGERALD, CAROLIndividualCORPORATE OFFICERsince 04/27/2015
CAMPUTARO, BETHANYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/13/2024
MILLER, GARYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/27/2025

CMS files one row per role, so the 17 rows in the source record cover these 15 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.

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.

$11.6M
Net patient revenuemost recent cost report
-11.5%
Operating marginrevenue minus expenses
$675K
Related-party expense5% of expenses
Who pays — share of resident-days
Medicaid 75%Medicare 6%Other / private 19%

About 75% 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 $675K paid to related parties (affiliated landlords or management companies) in its most recent cost report. 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

$423per resident / day
operating cost
$12,858per month
≈ monthly operating cost
$379per 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 075396. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-12-23, 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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