No sales calls · nothing personal collected unless you ask us to · no facility pays to be here
Text size
Contrast

Autumn Lake Healthcare At Glen Hill

1 Glen Hill Rd, Danbury, CT 06811 · For profit - Individual · 100 certified beds · (203) 744-2840 Medicare & Medicaid certified

Call the home — (203) 744-2840 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0607) — cited Jun 2025Behavioral-health or dementia-care citation — no harm found (F0758)
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its payroll-based staffing rating is low (2/5)

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

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

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

Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
25 Tamarack Ave · (203) 798-6575 · Call to confirm hours
Pharmacy
95 Locust Ave # 100 · (203) 792-2044 · Call to confirm hours
Grocery
ShopRite0.4 mi
1 Padanaram Rd · (475) 329-6114 · Call to confirm hours
Park
33 Valerie Ln · (203) 438-0153 · Typically dawn to dusk
Place of worship
5 Padanaram Rd · (203) 501-6211

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 4 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 improved from 2 to 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.

Overall rating5★
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 increased16.7%18.0%15.4%typical
Long-stay residents who lose too much weight11.2%6.5%5.4%worse
Long-stay residents with a catheter left in their bladder0.3%0.7%0.9%better
Long-stay residents with a urinary tract infection1.1%1.5%2.0%better
Long-stay residents with depressive symptoms57.9%22.3%6.5%worse than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury3.9%3.5%3.3%worse
Long-stay residents whose ability to walk worsened15.5%16.4%16.1%typical
Long-stay residents on antianxiety or hypnotic medication24.4%17.6%18.9%worse
Long-stay residents given the seasonal flu vaccine93.9%93.5%95.3%typical
Long-stay residents with pressure ulcers1.2%4.0%4.7%better
Long-stay residents with worsening bladder/bowel control27.2%24.7%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table13.4%17.8%17.1%better
Short-stay residents who newly got an antipsychotic medication0.8%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine89.0%69.7%79.4%better
Short-stay residents rehospitalized after admission23.9%24.3%22.6%typical
Short-stay residents with an outpatient ER visit7.6%10.7%12.0%better
Long-stay hospitalizations per 1,000 resident days2.572.061.67worse
Long-stay outpatient ER visits per 1,000 resident days1.371.461.80better

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

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

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

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

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

63.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 317 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

63.0%U.S. median 51.5%
Got home and stayed home
11.2%U.S. median 10.7%
Went back to hospital
73.3%U.S. median 56.6%
Met the expected recovery
0.46U.S. median 0.31
Therapy hours / resident / day
0.15hours / resident / day
Physical therapy
0.24hours / resident / day
Occupational therapy
0.06hours / resident / day
Speech therapy

Met the expected recovery: 73.3% 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 101 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 0.46 therapist hours per resident per day in 2026Q1 — more than 77% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 16% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF63.0%CMS range 57.7–68.551.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.2%CMS range 8.9–14.210.7%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 discharge73.3%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 discharge51.5%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 discharge54.5%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 identified85.1%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge96.4%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 stay1.8%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.6%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 hospitalization7.5%CMS range 4.6–10.67.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.031.02Oct 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

0.71
RN hours/ resident / day
0.72
LPN hours/ resident / day
1.88
Aide hours/ resident / day
3.31
Total nurse hours/ resident / day
0.58
RN hoursweekends
40.0%
Total nursing turnover
37.5%
RN turnover

How full it usually is: this home is certified for 100 beds and averages 93.5 residents a day — about 94% 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 3.31 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.71 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.88 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 3.17 hrs/resident/day on weekends vs 3.37 on weekdays — 6% thinner on weekends. RN hours go from 0.76 to 0.58 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 40% is about the same as the national median of 45%. 1 administrator has left in the past year.

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

10
deficiencies at the latest standard inspection (2025-06-09)
16
at the previous standard inspection (2023-05-23)

Deficiencies are fewer than at the previous inspection — improving. 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.

30 citations, most serious first. The 10 most serious are shown; the remaining 20 are one tap away and print in full.

  • Potential for harm · Ecited before2025-06-09 · 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 of kitchen, facility policy and interview, the facility failed to ensure food was served in safe and sanitary conditions. The findings include: An observation of the noon meal plating service in the kitchen on 6/6/25 at 11:40AM identified an open industrial garbage can with trash filled to the top; opened with no lid to cover the garbage can while food was being plated from the steam table. The garbage can was to the right of the steam table and 15 feet (ft.) away. The garbage can was opened by steam table for a half hour of the serving time of food from the steam table until 12:10PM. An interview with the Dietary Manager on 6/6/25 at 12:00PM identified the garbage can should have been covered and not in proximity to the steam table while food was being plated. The Dietary Manager further indicated that all kitchen staff is responsibility for ensuring garbage cans are removed and covered during meal service. After surveyor inquiry, the Dietary Manger had a dietary aide cover and move the garbage can from the serving area. A review of the Environment Policy…

    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 · D2025-06-09 · 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, review of clinical records, facility policy and interviews for 2 of 2 residents reviewed for dignity (Resident # 41 and Resident # 71). The facility failed to ensure the residents were served lunch at the same time. The findings include: 1. Resident # 71 diagnoses included Alzheimer's disease, dysphagia and type 2 diabetes mellitus. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #71 as severally cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 3 and was independent with eating. The Resident Care Plan (RCP) dated 4/10/25 identified potential nutritional risk as an area of concern. Interventions included: to provide a ground diet as ordered, encourage fluids, honor food preferences for meals, monitor intake of all meals and offer alternatives as needed, and report any declines and inability to self-feed. The physician's orders dated 6/1/25 directed to provide regular diet with ground texture, allow ice cream, soft breads, cakes,…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-09 · tag F0607 — failed to have anti-abuse policies — isolated
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    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, interviews and facility policy for 1 of 3 residents (Resident #25) reviewed for abuse, the facility failed to conduct a thorough investigation regarding an allegation of injury of unknown origin. The findings include: Resident #25's diagnoses included dementia, involuntary movements and age-related osteoarthritis. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #25 as severely cognitively impaired and unable to participate in Brief Interview for Mental Status (BIMS) and noted totally dependent on staff for personal hygiene, transfers, toileting and bed mobility. The Resident Care Plan dated 1/25/24 identified Resident #25 as being dependent for activities of daily living as an area on concerns. Interventions included: to provide assist of 2 staff members for bed mobility, ¼ siderails to assist with bed mobility and positioning, provide cueing for safety and sequencing to maximize current level of functioning and…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-09 · 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 reviews, facility policy and interviews for 1 of 3 residents (Resident #25) reviewed for abuse, the facility failed to ensure the plan of care for assistance of 2 staff members for all care provided was followed and for the only sampled resident ( Resident #46), the facility failed to develop a comprehensive plan of care to address the residents respiratory and sensory needs. The findings included: 1.Resident #25's diagnoses included dementia, involuntary movements and age-related osteoarthritis. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #25 as severely cognitively impaired and unable to participate in Brief Interview for Mental Status (BIMS) and was totally dependent on staff for personal hygiene, transfers, toileting and bed mobility. The Resident Care Plan dated 1/25/24 identified Resident #25 as being dependent for activities of daily living as an area on concerns. Interventions included: to provide assist of 2 staff members for…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-09 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record interview and facility policy and interviews for the only residents (Resident # 50) reviewed for bladder and bowel incontinence, the facility failed to ensure staff revised the care plan to reflect the current resident status. The findings include: Resident #50's diagnosis included overactive bladder, urge incontinence and Congestive Heart Failure (CHF). The admission Minimum Data Set (MDS) assessment dated [DATE] indicated in part Resident #50 was cognitively intact and required substantial assistance with toileting, used a wheelchair and had a functional limitation with range of motion of one lower extremity. The MDS further indicated Resident #50 was frequently incontinent of urine and always incontinent of bowel, no trial of a toileting program (scheduled toileting, prompted voiding or bladder training and no toileting program was being used to manage the bowel incontinence. The care plan initiated 4/3/2024 indicated Resident #50 was incontinent of bowel and bladder and…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-09 · 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 clinical record review, review of policy and staff interviews for 1 of 2 residents (Resident # 13) reviewed for ADL, the facility failed to ensure a resident received incontinence care promptly. The findings include: Resident #13 was admitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease and heart disease. The admission MDS assessment dated [DATE] identified Resident #13 was cognitively intact, required partial/moderate assistance for toileting hygiene, and was frequently incontinent of the bladder. On 6/3/2025 at 1:49 PM, an interview with Resident #13 identified two weeks prior, the resident had to wait about 2 hours to get changed after an incontinence episode. Resident #13 indicated that although there were two male aides available, the resident preferred a female to help him/her with incontinence care. Resident #13 indicated she/he spoke to a female nurse and a female supervisor but was told to wait for the female aide to become available. On 6/4/2025 at 2:33 PM, an…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-09 · 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 review of the clinical record interview and facility policy and interviews for the only residents (Resident # 50) reviewed for bladder and bowel incontinence, the facility failed to ensure attempts were made to restore the residents bladder. The findings include: Resident #50's diagnosis included overactive bladder, urge incontinence and Congestive Heart Failure (CHF). The admission Minimum Data Set (MDS) assessment dated [DATE] indicated in part Resident #50 was cognitively intact and required substantial assistance with toileting, used a wheelchair and had a functional limitation with range of motion of one lower extremity. The MDS further indicated Resident #50 was frequently incontinent of urine and always incontinent of bowel, no trial of a toileting program (scheduled toileting, prompted voiding or bladder training and no toileting program was being used to manage the bowel incontinence. The care plan initiated 4/3/2024 indicated Resident #50 was incontinent of bowel and bladder and was unable 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 · Dcited before2025-06-09 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide 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 clinical record review, observation, facility policy and interviews for the only sampled resident (Resident #46) reviewed for Respiratory care, the facility failed to ensure oxygen physician's order were current. The findings include: Resident #46's diagnoses included acute respiratory failure with hypoxia, pneumonia, unspecified organism and insomnia, unspecified. The admission Minimum Data Set assessment dated [DATE] identified Resident #46 was cognitively intact and independent for eating, touching assistance for oral hygiene and personal hygiene. Review of Resident #46 care plan did not include interventions for respiratory care. The Resident care plan did not identify any behaviors of refusal of care. A physician's order dated 5/16/25 directed, Oxygen at 1 Liter per minute via Nasal Cannula continuously. The nurse's note from 5/28/25 through 6/5/25 did not indicate any refusal of treatment. Observation on 6/03/25 at 11:31 AM of Resident # 46 being assisted back to his/her room identified no oxygen…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-09 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the clinical record, facility documentation, facility policy and interviews for the only sampled resident (Resident #48) reviewed for foley catheters, the facility failed to ensure the foley catheter drainage bag was not touching the floor when in wheelchair. The findings included: Resident #48's diagnoses included congenital stricture of urethra, obstructive and reflex uropathy and urinary retention. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #48 was moderately cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 9 indicating the resident required moderate assistance for personal hygiene, dressing, transfers, utilizing a wheelchair for mobility and had an indwelling suprapubic urinary catheter (empties urine directly from the bladder from an opening in the abdomen). The Resident Care Plan dated 3/7/25 identified suprapubic catheter related to urinary retention as an area of concern. Interventions included: to change…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-09 · 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 clinical record review, observations, review of the clinical record and interviews for 1 of 6 residents (Resident #42) reviewed for accidents, the facility failed to provide adequate supervision to prevent a fall. The findings include: Resident #42's diagnoses included Parkinson's Disease, Cerebral Infarction (stroke) with Hemiplegia (paralysis on one side) and Hemiparesis (weakness on one side) affecting right dominant side, and vascular dementia. The Minimum Data Set (MDS) assessment dated [DATE] identified Resident #42 was severely cognitively impaired and required maximal assistance (helper does more than half the effort) with toileting hygiene, personal hygiene, and toilet transfers. The Resident Care Plan (RCP) dated 6/11/24 identified falls as an area of concern. Interventions included: to provide education to Resident #42's family on fall prevention and to not to leave the resident alone. The RCP was updated on 6/1/25 with a new intervention that aimed at gathering all items needed prior 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
Show the remaining 20 citations
  • Potential for harm · E2023-05-23 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation, review of facility documentation, facility policy, and interviews, the facility failed to maintain a home-like environment in the resident's dining room. The findings include: Observations on 5/21/23 at 7:00 AM identified the following in the resident's dining room: a multi-iPad charging station, 2 medication carts, and a resident weight scale. Interview with the DNS on 5/22/23 at 2:20 PM noted it is her expectation that the dining area is home like for the residents and the items should not be stored there. Although requested, a facility policy was not provided.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-05-23 · tag F0803 — failed to meet residents' dietary needs — pattern
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, review of facility documentation, facility policy and interview the facility failed to ensure that meals provided to the residents of the facility were based on the posted menu and failed to provide reasonable notification to the residents of any menu changes or substitutions. The findings include: Observation on 5/21/23 (Sunday) at 7:15 AM identified that the menus posted for residents in the unit common areas (Recovery, Nature Trail and Deerfield) did not correspond to the current day. The Recovery unit menus posted included Friday's breakfast specials, Saturday's lunch specials and Friday's dinner specials. On the Nature Trail and Deerfield units, the menus identified Friday's breakfast, lunch and dinner specials. No dates were identified on any of the menus posted. Interview with the Dietary Director on 5/21/23 at 9:19 AM identified it was the responsibility of the dietary staff to change the posted menus daily, but he was unsure if the staff had been trained about the menus as most of the dietary staff had started within the last 3 weeks. The Dietary…

    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 · E2023-05-23 · tag F0809 — failed to serve meals on a reasonable schedule — pattern
    Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, review of facility policy and interview for 8 residents (Residents #1, 6, 14, 22, 24, 48, 56 and 57) reviewed as part of the resident council task, the facility failed to consistently have available and offer an evening snack to all residents. The findings include: Interview with Residents #1, 6, 14, 22, 24, 48, 56 and 57 on 5/22/23 at 11:00 AM identified that evening snacks were not offered to residents. Resident #56 indicated an evening snack would be given upon request. Resident #48 further identified that occasionally facility staff have indicated that they do not have snacks available to offer the residents and facility residents were lucky to get an evening snack. Interview with the DNS on 5/22/23 at 12:50 PM indicated the expectation of facility staff is that a snack cart is wheeled through each unit and all residents would be offered an evening snack. Interview with the Dietitian on 5/22/23 at 4:12 PM identified the facility does not have an efficient program for evening snack distribution in place. The current practice is facility staff will go to 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-05-23 · 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 observation, review of facility documentation, facility policy and interview, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner, and failed to ensure cold food items were stored at appropriate temperatures, and failed to ensure dietary staff used hair nets and beard guards while in the kitchen, and failed to ensure food items were handled and distributed in a safe and sanitary manner, and failed to ensure kitchen preparation equipment was clean, and failed to ensure ice machines were maintained and in good working order, and failed to ensure food items in resident nourishment refrigerators were labeled and dated. The findings include: 1. During an initial tour of the facility kitchen on 5/21/23 at 7:20AM with Dietary [NAME] #1, the following was identified. a. Dietary [NAME] #1 was observed without a beard guard to cover his facial hair prior to the start of the kitchen tour. Dietary [NAME] #1 was observed to have a beard guard on, however positioned below the level of his face and chin and positioned at the level of his mid neck.…

    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 · Ecited before2023-05-23 · 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

    Based on review of the clinical record, facility documentation, facility policy, and interviews, the facility failed to maintain water treatment protocols to prevent the growth of opportunistic water pathogens. The findings include: Review of the facility documentation for antibiotic stewardship on 5/22/23 at 12:33 PM identified the water treatment protocols were delegated to the Maintenance Director. Interview and facility record review with the Maintenance Director on 5/23/23 at 2:15 PM indicated the water was tested 1/31/23 for Legionella, however the monthly safety meeting minutes from 1/2023 - 4/2023 identified only the amount of facility drinking water on hand and a commitment from a supplier to provide more drinking water on demand as needed. The facility's safety meeting minutes failed to identify an assessment of the building's water system, measures to prevent the growth of opportunistic waterborne pathogens such as visible inspections, disinfectant use, temperature controls, or in house testing. He also identified he was new to the position and unaware of water…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-05-23 · tag F0881 — failed to use antibiotics responsibly — pattern
    Implement a program that monitors antibiotic use.
    What the surveyor found here — the official record, unedited, 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, the facility failed to maintain comprehensive antibiotic stewardship logs for antibiotics prescribed in the facility. The findings include: Review of the facility documentation for antibiotic stewardship on 5/22/23 at 12:33 PM with the Infection Preventionist (RN #1), identified the Infection Control Monthly Line Listing dated [DATE] - May 2023 did not include the stop date for the antibiotics prescribed, a time out to determine the effectiveness of the antibiotic during the midpoint of the prescribed drug, clear documentation of the resolution of the initial problem identified, or if subsequent medication and or treatment was ordered to fully resolve the initial identified concern. The facility policy for antibiotic stewardship identified to monitor both antibiotic use practices and outcomes related to antibiotics in order to guide practice changes and track the impact of new interventions.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-05-23 · tag F0561 — failed to honor residents' choices — isolated
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility documentation, facility policy and interviews for 1 resident (Resident #30), reviewed for choices, the facility failed to ensure that the resident's meal preferences were honored. The findings include: Resident #30 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation, muscle weakness, and diabetes. A physician's order dated 5/4/23 directed Resident #30 be provided a consistent carbohydrate diet. The care plan dated 5/8/23 identified Resident #30 was at nutritional risk due to diabetes and the need for a therapeutic diet. Interventions included honoring Resident #30's food choices within the meal plan, and to offer and encourage food and fluids of choice with preferences on file. The nutritional assessment dated [DATE] identified Resident #30 enjoyed dietary preferences of diet ginger ale, vanilla yogurt, and cold cereal rather than oatmeal. The admission MDS dated [DATE] identified Resident #30 had intact cognition…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-05-23 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #21) reviewed for advance directive, the facility failed to provide information on advance directive to the residents Conservator of Person (COP) on admission and readmission to ascertain their wishes. The findings include: Review of a probate court document dated [DATE] identified Person #1 was appointed Resident #21's Conservator of Person (COP). Resident #21 was admitted to the facility in [DATE] with diagnoses that included dementia, chronic lymphocytic leukemia, and malignant neoplasm of esophagus. Review of the nursing admission documentation dated [DATE] identified Resident #21's mental status was alert. Review of the resident/patient health care instructions dated [DATE] identified the Resident #21 signed the advance directive form on [DATE] indicating do not attempt Cardiopulmonary Resuscitation (CPR): allow death to occur naturally Do Not Resuscitate (DNR). A facility staff signed…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-05-23 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for 3 residents (Resident #54, 68 and 80) reviewed for unnecessary medications and nutrition, for Resident #54, the facility failed to notify the physician when the resident developed abnormal movements, for Resident #68 the facility failed to notify the physician when the resident did not meet the estimated fluid needs, and for Resident #80, the facility failed to ensure the physician was notified when a weight loss was identified. The findings include: 1. Resident #54 was admitted to the facility with diagnoses that included dementia without behavioral disturbances, stroke, and schizophrenia disorder. A physician's order dated 10/17/19 directed to give Olanzapine (antipsychotic medication) 7.5 mg at bedtime. A physician's order dated 1/5/21 directed to add Olanzapine 2.5 mg every morning. The care plan dated 5/14/21 identified Resident #54 was at risk for complications related to use of psychotropic 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-05-23 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #33) reviewed for enteral feeding, the facility failed clarify a physician's order to ensure medications were administered according to professional standards of practice. The findings include: Resident #33 was initially admitted [DATE] with diagnosis for dementia, Alzheimer's, and a g tube. The quarterly MDS dated [DATE] identified Resident #33 as wheelchair bound, required 2 persons assist for ADLs, and has a feeding tube with 51% or more of nutrition from the tube feeding. The care plan dated 4/14/23 identified a focus for enteral feeding tube to meet nutritional needs secondary to Alzheimer's, dementia, malnutrition, and adult failure to thrive. Interventions included to administer medications as ordered and observe for effectiveness and side effects and report to physician as indicated. Physician's order dated 5/1/23 directed Resident #33 be NPO (nothing by mouth) and 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-05-23 · 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 observation, review of the clinical record, facility documentation, facility policy, and interviews for 4 residents (Resident #49, 67, 68, and 80) reviewed for nutrition and falls, for Resident #49 and 68, the facility failed to ensure follow-up consultations with outside providers were scheduled as recommended, and for Resident #67 and 80, the facility failed to follow the physician orders for weights. The findings include: 1. Resident #49 was admitted to the facility on [DATE] with diagnoses that included Parkinson's Disease, repeated falls, and a neurocognitive disorder with Lewy bodies. The quarterly MDS dated [DATE] identified Resident #49 had severely impaired cognition, was frequently incontinent of bladder, was always incontinent of bowel, and required extensive assistance with bed mobility and transfers. A neurology consultation dated 1/10/23 directed Resident #49 to return to care in one month. The care plan dated 1/11/23 identified Resident #49 was at high risk for falls. Interventions…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-05-23 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility documentation, facility policy and interview, for 1 of 2 residents (Resident # 85) reviewed for accidents, the facility failed to ensure that an elopement assessment was completed on admission to the facility. The findings include: Resident #185 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy, repeated falls, and gout. The care plan dated 5/11/23 identified Resident #185 was at risk for falls due to cognitive loss and lack of safety awareness. Interventions included to divert the resident by giving alternative objects or activities as needed. The 5/11/23 nursing admission assessment identified Resident #185 did not have a history of wandering behavior in the last 30 days, however, the nursing admission assessment lacked an elopement assessment. The admission (5-day) MDS dated [DATE] identified Resident #185 had severely impaired cognition and required the assistance of 1 staff member with transfers,…

    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 · D2023-05-23 · 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 observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #68) reviewed for hydration, the facility failed to ensure the resident had sufficient fluid intake to maintain proper hydration. The findings include: Resident #68 was admitted to the facility with diagnoses that included dysphagia, diabetes, and chronic pulmonary edema. The admission MDS dated [DATE] identified Resident #68 had intact cognition and required extensive assistance with bed mobility, dressing, toileting, and personal hygiene. The Hospital Discharge summary dated [DATE] identified Resident #68 had a BUN (a blood urea nitrogen (BUN) test is used to determine how well your kidneys are working) of 28 mg/dl (normal range was 6 - 23 mg/dl). A physician's order dated 4/28/23 directed to give Lasix 40 mg once a day. The nurse's note dated 4/28/23 at 9:40 PM identified that resident #68's lips appear healthy. Lab results dated 4/30/23 identified the resident's BUN was out 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-05-23 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide 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 review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #17) reviewed for respiratory care, the facility failed to ensure a sleep study was scheduled as ordered. The findings include. Resident #17 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included unspecified asthma, morbid obesity, and schizoaffective disorders. The hospital Discharge summary dated [DATE] identified that Resident #17 has obstructive sleep apnea, is mentally challenged, has Parkinson's, obesity, hypoventilation and needs one to one supervision for a sleep study and patient's representative agreed to stay with the resident for the testing. The admission MDS dated [DATE] identified Resident #17 had a serious mental illness, intellectual disability, with moderately impaired cognition, asthma, chronic obstructive pulmonary disease (COPD) or chronic lung disease, shortness of breath or trouble breathing when lying flat, and on oxygen…

    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 · D2023-05-23 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    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 #54) reviewed for unnecessary medications, the facility failed to follow up on pharmacy recommendations. The findings include: Resident #54 was admitted to the facility with diagnoses that included dementia without behavioral disturbances, stroke, and schizophrenia disorder. The quarterly MDS dated [DATE] identified Resident #54 had severely impaired cognition and had no hallucination, delusions, or behavioral symptoms. Resident #54 was on antipsychotic medications 7 days a week and a gradual dose reduction (GDR) had not been attempted. A physician's order dated 9/1/22 directed to give Olanzapine (antipsychotic medication) 2.5 mg every morning and Olanzapine 7.5 mg at bedtime. Pharmacy recommendation dated 10/10/22 identified that Resident #54 was on Olanzapine 2.5 mg every morning and 7.5 mg at bedtime. The last AIMS documented showed positive results, 23, as documented by LPN #5 on…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-05-23 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    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 #54) who was receiving an antipsychotic medication and was reviewed for unnecessary medications, the facility failed to attempt a gradual dose reduction (GDR). The findings include: Resident #54 was admitted to the facility with diagnoses that included dementia without behavioral disturbances, stroke, and schizophrenia disorder. A physician's order dated 10/17/19 directed to give Olanzapine (antipsychotic medication) 7.5 mg at bedtime. A physician's order dated 1/5/21 directed to add Olanzapine 2.5 mg every morning. The care plan dated 5/14/21 identified the resident was at risk for complications related to use of psychotropic medications. Interventions included to do AIMS (the Abnormal Involuntary Movement Scale (AIMS) is an assessment to detect the presence and severity of abnormal movements of the face, limbs, and body) testing per protocol and gradual dose reduction as ordered. 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2021-01-14 · tag F0684 — failed to provide proper treatment and quality of care — pattern
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a clinical record review, a review of facility documentation, staff interviews and a review of the facility policy, for 1 of 3 residents (Resident #14), reviewed for oxygen, the facility failed to obtain a physician's order for the administration of oxygen and for one sampled resident (Resident #56), reviewed for physician orders, the facility failed to follow physician orders for the use of hearing aides and ted stockings. The findings include: 1. Resident #14's diagnoses included chronic obstructive pulmonary disease (COPD), anxiety disorder, depressive disorder, transient ischemic attack and cerebral infarction. The quarterly Minimum Data Set (MDS) dated [DATE] identified intact cognition, limited assistance with activities of daily living (ADL) and the use of oxygen therapy. Resident #14's care plan dated 10/19/20 identified the resident had episodes of anxiety, incoherent statements, refusal of medication, self-adjusting his/her oxygen flow; makes false accusations that staff changed the oxygen…

    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 before2021-01-14 · 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 policy and procedures, review of facility documentation and interviews for 1 of 3 sampled residents (Resident #432) reviewed for pressure ulcers, the facility failed to ensure that the physician was notified of a significant change in condition related to the worsening of a wound. The findings include: Resident #432 was admitted to the facility on [DATE] with diagnoses that included, cellulitis of right lower limb, venous insufficiency, lymphedema crohn's disease, failure to thrive, morbid obesity and incontinence. The hospital Discharge summary dated [DATE] identified Resident #432 had moisture associated skin damage (MASD) with excoriation to the buttocks. Resident #432's care plan dated 12/22/20 identified Resident #432 was at risk for skin breakdown related to actual skin breakdown with interventions that included; evaluate for any localized skin problems, observe skin condition daily with ADL care and report abnormalities. The admission [NAME]…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-01-14 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, a review of the clinical record, staff interviews, a review of the facility documentation, and a review of the facility policy, for 1 of 3 Residents reviewed for pressure ulcers (Resident #55), the facility failed to conduct an evaluation by a dietician when a pressure ulcer and deep tissue injury occurred. The findings include: Resident # 55 was admitted to the facility in March of 2017 with diagnoses that included diabetes, heart failure, neuropathy, osteoarthritis, dementia, depression, and seizures. A care plan dated 8/13/20 identified diabetes as a problem with interventions that included a carbohydrate diet and to consult the dietician as needed. The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #55 was cognitively intact, frequently incontinent of bladder, and was independent with activities of daily living (ADL), no pressure ulcers, wounds or skin problems. The nurse's note for change of condition dated 11/3/20 at 9:22 PM identified a deep purple area to the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2025-06-09 · tag F0585 — failed to handle grievances — widespread
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, review of facility policy and interviews, the facility failed to ensure Grievance forms were readily available to residents, family members and visitors and the location of the forms. The facility failed to ensure the residents were made aware of the process for filing a grievance. The findings include: On 6/05/2025 at 9:58 AM a meeting with 12 residents who regularly attend the resident council meetings all agreed they were unaware of the grievance process and where the forms were located. An interview and observation on 6/05/25 at 10:38 AM with charge nurse RN #3 indicated the unit does not have any grievance forms. An observation and interview on 6/05/25 at 11:00 AM with Social Worker #1 while walking through the facility, identified no grievance forms located on the units only an empty folder in a file drawer. A policy regarding grievances and complaints was posted high above the State Ombudsman contact form and difficult for those in a wheelchair to see and read. The policy did not provide directions of how to obtain a form or who to contact. SW#1…

    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

No federal fines in the current CMS record.

Who owns this facility

Owner / managerTypeRoleShareSince
KC DERBY GH OPCO JV LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 09/01/2024
GLEN CT HOLDINGS LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST100%since 09/01/2024
SCHWARTZ, MARKIndividualOPERATIONAL/MANAGERIAL CONTROLsince 09/01/2024
ACCURATE STAFFING LLCOrganizationADP OF THE SNFsince 09/01/2024
BRAND SONNENSCHINE LLPOrganizationADP OF THE SNFsince 09/01/2024
PEREZ, RHEAIndividualADP OF THE SNFsince 09/01/2024
RUXIN, ROBERTIndividualADP OF THE SNFsince 09/01/2024
STERN, SAMUELIndividualADP OF THE SNFsince 09/01/2024

4 organizational owners 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.

$14.1M
Net patient revenuemost recent cost report
-0.1%
Operating marginrevenue minus expenses
$1.8M
Related-party expense13% of expenses
Who pays — share of resident-days
Medicaid 55%Medicare 23%Other / private 21%

This home reported $1.8M paid to related parties — landlords or management companies under common ownership — equal to about 13% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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

Cost & finances

$445per resident / day
operating cost
$13,539per month
≈ monthly operating cost
$445per 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 075031. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-09, 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.

What to do next