Pilgrim Manor
52 Missionary Rd, Cromwell, CT 06416 · Non profit - Corporation · 60 certified beds · (860) 635-5511 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- a high payroll-based staffing rating (5/5)
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- a high number of inspection citations overall (16) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $12,048 in federal fines (most recent 2024-04-23)
- its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions
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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Location & what’s nearby
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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 | 5 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 5 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 19.4% | 18.0% | 15.4% | worse |
| Long-stay residents who lose too much weight | 8.5% | 6.5% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.5% | 0.7% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 1.1% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 1.1% | 22.3% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 1.6% | 3.5% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 25.1% | 16.4% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 22.2% | 17.6% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 93.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.0% | 4.0% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 21.1% | 24.7% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 5.5% | 17.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 95.1% | 69.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 22.1% | 24.3% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 4.7% | 10.7% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 0.97 | 2.06 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.30 | 1.46 | 1.80 | better |
‡ 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.
58.4% 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 119 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 73.5% 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 49 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 0.39 therapist hours per resident per day in 2026Q1 — more than 67% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 31% 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 58.4%CMS range 49.1–66.8 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 12.2%CMS range 8.0–17.1 | 10.7% | Oct 2022–Sep 2024 | no 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 discharge | 73.5% | 56.6% | Oct 2024–Sep 2025 | CMS 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 discharge | 55.1% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 55.1% | 50.0% | Oct 2024–Sep 2025 | CMS 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 identified | 98.1% | 98.7% | Oct 2024–Sep 2025 | CMS 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 setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS 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 discharge | not 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 stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 1.9% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.5%CMS range 3.8–10.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.93 | 1.02 | Oct 2022–Sep 2024 | CMS 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
How full it usually is: this home is certified for 60 beds and averages 54.3 residents a day — about 90% occupied, or roughly 6 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 3.94 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.86 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.42 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 3.66 hrs/resident/day on weekends vs 4.06 on weekdays — 10% thinner on weekends. RN hours go from 0.94 to 0.64 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 38% 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
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.
This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.
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.
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.
16 citations, most serious first. The 11 most serious are shown; the remaining 5 are one tap away and print in full.
- Actual harm · G2024-04-23 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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, review of facility documentation, and interviews for 4 of 5 residents (Resident #304) reviewed for accidents, the facility failed to appropriately supervise a resident resulting in a fall with a major injury. The findings include: Resident #304 's diagnoses included dementia, anxiety, history of a transient cerebral ischemic attack (TIA), atrial fibrillation, and blindness. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #304 was severely cognitively impaired and required extensive assistance for bed mobility, transfers, and personal hygiene. Additionally, Resident #304 had balance issues during transitions when moving from a seated to standing position and surface to surface transfers between the bed and chair or wheelchair. Review of the Resident Care Plan (RCP) in effect from 5/1/23 through 5/31/23 identified that Resident #304 was at risk for falls and required assistance with Activities of Daily Living (ADL's). Interventions 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.
- Potential for harm · D2025-05-01 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor 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 review of the clinical record, facility documentation, facility policy, and interviews for one (1) of two (2) residents (Resident #2) reviewed for abuse, the facility failed to ensure a resident was treated in a respectful and dignified manner. The findings include: Resident #2 had diagnoses that included anxiety, depression, fracture of the 7th rib, and hypertension. The quarterly [NAME] Data Set (MDS) assessement dated 1/31/2025 identified Resident #2 had a Brief Interview for Mental Status (BIMS) score of thirteen (13) indicative of intact cognition, was occasionally incontinent of bowel and bladder, required moderate assistance with ADLs, bed mobility, and transfers. The nurse's note dated 4/13/2025 at 3:47 P.M. written by Licensed Practical Nurse (LPN) #1 identified Resident #2 presented a complaint about disrespectful comments from Nurse Aide (NA) #1 and indicated Registered Nurse (RN) #1 spoke with Resident #2. The facility's reportable event form dated 4/14/2025 at 10:06 A.M. identified 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.
- Potential for harm · Dcited before2025-05-01 · tag F0609 — failed to report abuse allegations — isolatedTimely 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 review of the clinical record, facility documentation, facility policy, and interviews for one (1) of two (2) residents (Resident #1) reviewed for abuse, the facility failed to report an allegation of abuse to the state agency. The findings include: Resident #1 had diagnoses that included dementia with severe anxiety, depression, adult failure to thrive, weakness, difficulty walking, and unsteadiness on feet. The quarterly [NAME] Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of three (3) indicative of severely impaired cognition, was always incontinent of bowel and bladder, and dependent on staff for ADLs including bed mobility, transfers, was non ambulatory and dependent on staff for mobility in the wheelchair. The Resident Care Plan dated 2/20/2025 identified at times Resident #1 refused or was combative with care, refused medications with interventions that directed to notify the provider and family of refusals of care and showers…
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.
- Potential for harm · Dcited before2025-05-01 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
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 one (1) of two (2) residents (Resident #1) reviewed for abuse, the facility failed to conduct a complete and thorough investigation for an allegation of abuse. The findings include: Resident #1 had diagnoses that included dementia with severe anxiety, depression, adult failure to thrive, weakness, difficulty walking, and unsteadiness on feet. The quarterly [NAME] Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of three (3) indicative of severely impaired cognition, was always incontinent of bowel and bladder, and dependent on staff for ADLs including bed mobility, transfers, was non ambulatory and dependent on staff for mobility in the wheelchair. The Resident Care Plan dated 2/20/2025 identified at times Resident #1 refused or was combative with care, refused medications with interventions that directed to notify the provider and family 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.
- Potential for harm · Dcited before2025-05-01 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of two (2) residents (Resident #2) reviewed for abuse, the facility failed to ensure appropriate interventions were implemented following an allegation of staff-to-resident verbal abuse. The findings include: Resident #2 had diagnoses that included anxiety, depression, fracture of the 7th rib, and hypertension. The quarterly [NAME] Data Set (MDS) assessement dated 1/31/2025 identified Resident #2 had a Brief Interview for Mental Status (BIMS) score of thirteen (13) indicative of intact cognition, was occasionally incontinent of bowel and bladder, required moderate assistance with ADLs, bed mobility, and transfers. The nurse's note dated 4/13/2025 at 3:47 P.M. written by Licensed Practical Nurse (LPN) #1 identified Resident #2 presented a complaint about disrespectful comments from Nurse Aide (NA) #1 and indicated Registered Nurse (RN) #1 spoke with Resident #2. The facility's reportable event form 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.
- Potential for harm · Dcited before2024-05-24 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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 reviews, facility documentation, facility policies and interviews for one of three sampled residents (Resident #1) who was a re-admission and had a foot ulcer, the facility failed to develop a care plan that addressed a diabetic ulcer to ensure interventions were implemented for the prevention and treatment of wounds. The findings include: Resident #1 diagnoses included kidney failure, chronic heart failure, open wound right ankle, and type 2 diabetes mellitus with polyneuropathy. The admission physician's order dated 3/8/24 directed for wound treatments however, the orders failed to address the use of pressure relieving devices or protective boots to the feet. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 made reasonable and consistent decisions regarding tasks of daily life, was at risk of developing pressure ulcers, had an unhealed pressure ulcer Stage I or higher, a diabetic foot ulcer, and skin and ulcer treatments noted were pressure reducing device…
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.
- Potential for harm · D2024-04-23 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
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 interviews, review of the clinical record and facility policy for 1 of 4 residents (Resident #454) reviewed for accidents, the facility failed to include in the Resident Baseline Care Plan interventions to prevent falls for a resident who sustained a fall with injury prior to admission and for 1 of 3 residents (Resident #554) reviewed for pressure ulcers, failed to initiate a Resident Baseline Care Plan for a resident admitted with an unstageable pressure ulcer. The findings include: 1. Resident #454 was admitted to the facility on [DATE] with diagnoses that included a displaced fracture of the anterior wall of the left acetabular (broken hip), dementia, and difficulty walking. A physician's order dated 3/25/24 directed no ambulation and to transfer using a mechanical lift with a two person assist. The Resident, Baseline Care Plan dated 3/25/24 identified that Resident #454 was a fall risk and had weight bearing restrictions with goals to maintain safety and to be free from falls/injury, however, did…
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.
- Potential for harm · D2024-04-23 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 5 residents (Resident #304) reviewed for accidents, the facility failed to assess the resident's neurological status and failed to complete a fall assessment following a fall with head injury per the facility policy. The findings include: Resident #304 's diagnoses included dementia, anxiety, history of a transient cerebral ischemic attack (TIA), atrial fibrillation, and blindness. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #304 was severely cognitively impaired and required extensive assistance for bed mobility, transfers, and personal hygiene. Additionally, Resident #304 had balance issues during transitions when moving from a seated to standing position, and surface to surface transfers between the bed and chair or wheelchair. Review of the Resident Care Plan (RCP) in effect from 5/1/23 through 5/31/23 identified that Resident #304 was at risk for falls and required…
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.
- Potential for harm · D2024-04-23 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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, and interviews for the only sampled resident (Resident #19) reviewed for a change in condition, the facility failed to correctly transcribe physician's orders for a medication, Synthroid. The findings include: Resident #19 's diagnoses included hypothyroidism, metabolic encephalopathy, and Vascular Dementia. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #19 was moderately cognitively impaired and required, maximal assistance with bed mobility, moderate assistance with eating and was dependent with toileting hygiene. The Resident Care Plan dated 4/6/22 identified issues with Activities of daily living. Interventions included providing all nourishment and medication through the G-Tube. Interview with Person #3 on 4/17/24 at 1:40 PM indicated that in 2022 Resident #19 had been receiving Synthroid 125 mcg, however, should have received Synthroid 62.2 mcg (one half of the 125 mcg dose). Person #3 reported the facility had requested to change the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-04-23 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility policy, facility documentation, and interviews for 3 of 3 residents (Resident #554) reviewed for pressure ulcers, the facility failed to ensure a low air loss mattress was set at the appropriate setting for Resident #554's weight, and failed to assess and measure a community acquired pressure ulcer on admission. The findings include: Resident #554's diagnoses included hemarthrosis (bleeding into the joint cavity) of the right hip, unsteadiness on feet, and intervertebral disc disorder with radiculopathy (pinching of a nerve in the spinal column). The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #554 was cognitively intact and was dependent on staff for bed mobility and toileting. Additionally, the MDS indicated the resident was admitted to the facility on [DATE] with an unstageable community acquired pressure ulcer. Review of discharge summary paperwork from Hartford Hospital dated 4/8/24 identified that resident was followed by…
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.
- Potential for harm · D2024-04-23 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care 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 observation, interviews, review of the clinical record and facility policy for the only sampled resident (Resident #13) reviewed for respiratory care, the facility failed to provide oxygen therapy consistent with professional standards of practice. The findings include: Resident #13's diagnoses included chronic obstructive pulmonary disease, acute respiratory failure, and shortness of breath. A physician's order dated 3/19/24 directed to administer oxygen at 6 liters (L) via nasal cannula. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #13 was without cognitive impairment and required partial/moderate assistance with toileting, showering, dressing, and personal hygiene. Walking was not attempted due to Resident #13's medical condition or safety concerns. Additionally, the MDS identified that Resident #13 received oxygen therapy. The Resident Care Plan dated 3/27/24 identified a problem with respiratory status. Interventions included to assess and monitor respiratory…
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.
Show the remaining 5 citations
- Potential for harm · Dcited before2020-01-31 · tag F0609 — failed to report abuse allegations — isolatedTimely 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 a review of the clinical record, a review of facility documentation, staff interviews and a review of the facility policy for two of two sampled residents, (Resident #8 and #364), reviewed for abuse, the facility failed to report an alleged violation of abuse and misappropriation of resident property and failed to report the results of the investigation to the proper authorities within prescribed timeframe's. The findings include: a. Resident # 8's diagnoses included dysphagia, muscle weakness, difficulty walking and dysphagia. Physician's orders dated 7/2/19 directed the assistance of one staff for care. The admission Minimum Data Set (MDS) dated [DATE] identified severe cognitive impairment, absence of behavioral problems, extensive assistance of two staff for bed mobility, and assistance of one staff for dressing. The care plan dated 8/22/19 identified Resident # 8 required assistance for activities of daily living related to his/her advanced age. Interventions included the assistance of one 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.
- Potential for harm · Dcited before2020-01-31 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
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 review of facility documentation, a review of the clinical record and staff interviews, for one of two residents reviewed for abuse, Resident # 8, the facility failed to ensure a complete and thorough investigation of an allegation of abuse, and failed to protect residents by removing staff pending the outcome of an investigation. The findings include: Resident # 8's diagnoses included dysphagia, muscle weakness, difficulty walking and dysphagia. Physician's orders dated 7/2/19 directed the assistance of one staff member for care. The admission Minimum Data Set (MDS) dated [DATE] identified severe cognitive impairment, absence of behavior problems, required extensive assistance of two staff for bed mobility, and the assistance of one staff member for dressing. The care plan dated 8/22/19 identified the need for assistance with activities of daily living related to advanced age. Interventions included assistance of one staff member for toileting and dressing. Review of the nurses notes dated 9/9/19…
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.
- Potential for harm · Dcited before2020-01-31 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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 a clinical record review, staff interviews, and a review of the facility policy for one of five residents reviewed for unnecessary medications (Resident # 59), the facility failed to develop a comprehensive care plan with interventions that were individualized. The findings included: Review of the clinical record identified Resident #56 was admitted to the facility on [DATE] with diagnosis that included dementia, asthma, anxiety, depression, insomnia and pain disorder. Review of the physician's notes dated 9/26/19 indicated Resident #56 had an overall decline in his/her function. No adverse drug reactions, or tolerability issues were identified with the resident's medications. The note further indicated Resident #56 was stable on his/her current medication regime. Physician's orders dated 11/12/19 directed Amitriptyline 50 milligrams (mg) daily, Aricept 10 mg daily, and Remeron 7.5 mg daily. The Minimum Data Set (MDS) assessment dated [DATE] identified severe cognitive impairment, extensive assistance…
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.
- Potential for harm · E2019-03-07 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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 Dietary staff, review of facility policy, and staff interviews, the facility failed to follow safe sanitation practices regarding the use of beard restraints. The findings include: An observation on 3/4/19 at 11:40 AM identified Dietary Aide (DA) #1 had a full facial beard and DA #2 had a full goatee, both beards approximately 2 inches in length and both staff were observed in the food prep area of the kitchen. An interview on 3/4/19 at 11:40 AM with the Head Chef identified staff did wear beard restraints in the past but they stopped after attending a SerSafe training session where they were informed that a beard restraint was not required unless the length is greater than 2 inches. A subsequent observation on 3/6/19 at 6:15 AM identified DA #3 had a full mustache without the benefit of a beard restraint. An interview with DA #3 at that time identified he had not worn any sort of beard restraint in the 32 years he had worked in food service. An interview with the Food Service Director (FSD) on 3/6/18 at 1:15 PM identified dietary staff were wearing beard…
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.
- No harm found · B2020-01-31 · tag F0640 — patternEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a clinical record review, a review of facility documentation and staff interviews for 22 of 27 residents reviewed for Minimum Data Set assessment (MDS) transmissions (Resident #2, #4, #28, #29, #30, #31, #44, #45, #46, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #164, #216 and #217), the facility failed to transmit the MDS assessments to the state agency database within the required timeframe's. The findings included: a. Resident #2 was admitted to the facility on [DATE]. The resident's annual Minimum Data Set (MDS) assessment was completed on 12/19/19 however, was not transmitted to the state agency database as of 1/27/20, (29 days late). b. Resident #4 was admitted to the facility on [DATE]. The resident was discharged on 1/4/20. Review of the clinical record identified the discharge MDS was not transmitted to the state agency database as of 1/31/20, (13 days late). c. Resident #28 was admitted to the facility on [DATE]. The resident was discharged on 12/19/19. Review of the clinical record…
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.
“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.
- 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.
Fines & penalties
$12,048 in federal fines across 1 penalty.
- $12,048 — penalty dated 2024-04-23
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.
Part of a chain
This home belongs to COVENANT LIVING — 15 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 5 of 5 | 4.4 | +0.6 vs chain |
| Health inspection | 4 of 5 | 4.1 | ≈ chain avg |
| Staffing | 5 of 5 | 4.3 | +0.7 vs chain |
| Quality measures | 5 of 5 | 3.6 | +1.4 vs chain |
The other 14 homes this chain runs (chain average 4.4★, per CMS)
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 / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| COVENANT LIVING COMMUNITIES & SERVICES | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | 100% | since 01/03/2014 |
| CUNLIFFE, TERRI | Individual | W-2 MANAGING EMPLOYEE; CORPORATE OFFICER | — | since 03/19/2009 |
| HOLT, JODY | Individual | W-2 MANAGING EMPLOYEE; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 06/02/2017 |
| AAGAARD, JON | Individual | CORPORATE DIRECTOR | — | since 07/01/2013 |
| CHRISTENSEN, PAMELA | Individual | CORPORATE DIRECTOR | — | since 07/01/2013 |
| EASTBURG, MARK | Individual | CORPORATE DIRECTOR | — | since 07/01/2013 |
| ESPINOSA, MARC | Individual | CORPORATE DIRECTOR | — | since 07/01/2013 |
| HODGKINSON, DONALD | Individual | CORPORATE DIRECTOR | — | since 07/01/2013 |
| MANLOVE, MATT | Individual | CORPORATE DIRECTOR | — | since 07/01/2017 |
| OXENDALE, ROGER | Individual | CORPORATE DIRECTOR | — | since 07/01/2017 |
| STANTE, MARLENE | Individual | CORPORATE DIRECTOR | — | since 07/01/2013 |
| VINING, ANNE | Individual | CORPORATE DIRECTOR | — | since 07/01/2013 |
| ERICKSON, DAVID | Individual | CORPORATE OFFICER | — | since 01/31/2008 |
CMS files one row per role, so the 17 rows in the source record cover these 13 parties — each is shown once here with every role it holds. Nothing is omitted.
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.
This home reported $686K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
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
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
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.
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 075306. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-04-23, 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.