Westview Health Care Center
150 Ware Rd, Dayville, CT 06241 · For profit - Corporation · 103 certified beds · (860) 774-8574 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- no federal fines or payment denials on record
- a high payroll-based staffing rating (5/5)
- it has an abuse, neglect, or exploitation citation (F0602), cited Nov 2025
- 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 payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection 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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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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 | 4 of 5 |
| Long-stay residentspeople who live here | 3 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 fell from 5 to 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
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 | 16.9% | 18.0% | 15.4% | typical |
| Long-stay residents who lose too much weight | 7.0% | 6.5% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 4.1% | 0.7% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 1.0% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 59.4% | 22.3% | 6.5% | worse 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 | 5.2% | 3.5% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 8.9% | 16.4% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 18.8% | 17.6% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 98.8% | 93.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.9% | 4.0% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 20.1% | 24.7% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 12.6% | 17.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.1% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 93.0% | 69.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 23.5% | 24.3% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 13.6% | 10.7% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.68 | 2.06 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 1.38 | 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.
63.5% 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 236 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 78.2% 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 119 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 1.07 therapist hours per resident per day in 2026Q1 — more than 97% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 8% 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 | 63.5%CMS range 58.2–69.1 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.9%CMS range 8.4–13.7 | 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 | 78.2% | 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 | 64.7% | 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 | 77.3% | 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 | 100.0% | 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 | 97.4% | 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 | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS 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 stay | 0.6% | 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 | 0.6% | 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 | 9.5%CMS range 5.9–12.7 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.05 | 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 103 beds and averages 100.1 residents a day — about 97% occupied, or roughly 3 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.98 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.95 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.32 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 3.44 hrs/resident/day on weekends vs 4.20 on weekdays — 18% thinner on weekends. RN hours go from 1.07 to 0.66 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 41% 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.
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.
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 · D2025-11-26 · tag F0602 — failed to protect residents from theft of their belongings — isolatedProtect each resident from the wrongful use of the resident's belongings or money.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for abuse, the facility failed to ensure the resident was free from misappropriation of resident property. The findings include:Resident #1 was admitted to the facility for short term rehabilitation stay on 8/16/2023 with diagnoses that included diabetes, anxiety, and heart failure. The quarterly MDS assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of fifteen out of fifteen, indicative of no cognitive impairment, required assistance with personal care, and was independent with meals. The RCP dated 6/1/2025 identified an alteration in ADL function and a history of hallucinations which resident is able to verbalize as not real. Interventions directed assist with personal care, one to one with the social services as needed, and monitor for psych/social needs. Review of facility Reportable Event Form dated 6/27/2025…
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 · E2025-02-03 · tag F0550 — failed to protect resident dignity and rights — patternHonor 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 the clinical record, facility documentation, facility policy and interviews for 12 of 12 residents (Resident #5, Resident #7, Resident #8, Resident #15, Resident #22, Resident #25, Resident #46, Resident #55, Resident #73 Resident #75, Resident #83, Resident #89) reviewed for dining, the facility failed to provide a dignified dining experience. The findings include: 1. Resident #5 was admitted to the facility in January of 2022 with diagnoses that included Dementia with agitation, anxiety disorder, Parkinson's disease, and dysphagia. A Resident Face Sheet identified Resident #5's current diet order was a mechanical soft with moist chopped meat and thin liquids. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #5 was severely cognitively impaired (Brief Interview for Mental Status (BIMS) score of 2) and required supervision or touching assistance for eating, and total dependence with toileting, bed mobility, and transfer. The Resident Care Plan 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 · E2025-02-03 · tag F0644 — patternCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy/procedures and interviews for 3 of 3 sampled residents (Resident #35, Resident #65, and Resident #71) reviewed for Pre-admission Screening and Resident Review (PASARR), the facility failed to ensure that residents with PASARR Level II recommendations were provided services to meet the resident's needs. The findings include: 1. Resident #35 was admitted to the facility in August of 2022 and had diagnoses that included generalized anxiety disorder, auditory hallucinations, delusional disorders and vascular dementia with behavioral disturbances. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #35 had intact cognition, did not exhibit inattention, disorganized thinking, or altered level of consciousness, did not exhibit hallucinations or delusions, indicated that antipsychotics were received on a routine basis and that a gradual dose reduction had not been attempted. The quarterly MDS assessment 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 · E2025-02-03 · tag F0726 — failed to have competent, trained nursing staff — patternEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of the clinical record, facility documentation, facility policy and interviews the facility failed to provide trained and competent nursing staff for monitoring resident skin conditions and failed to provide trained and competent nursing staff for changing oxygen tubing and cleaning oxygen concentrator filters. 1. Review of Healthcare Academy (online education platform) Course Status Reports for all staff for 2023 and 2024 identified a course assigned to NA's titled Skin Care Basics for Nursing Assistants which included education on skin tears, pressure injuries and reporting of skin problems to the nurse. Review of the completion rate for the Skin Care Basics course identified 32 out of 75 (42.6%) actively employed NA's did not complete this assigned course for 2024. Interview with Registered Nurse (RN) #1 on 1/21/2025 at 11:00 AM identified the licensed nurses did not conduct preventative weekly skin assessments for facility residents, that residents skin was monitored by the NA's during care and if the NA observed a change in skin integrity they would notify a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-02-03 · 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 observations, staff interviews, and review of facility documentation, the facility failed to dispose of condiments and beverages with an open date greater than (3) three days in 2 of 3 nourishment room refrigerators and 2 of 3 medication room refrigerators. The findings include: Observation of the North/West medication room refrigerator on 1/24/25 at 11:43 AM identified: (1) 46- fluid ounce prune juice container ¾ full with an open date of 1/20. (1) 60- fluid ounce cranberry juice container 50% full with no open date. Interview with RN #1 on 1/24/25 at 11:43 AM identified that the juices stored in the medication room refrigerator are used for the medication pass and that the kitchen stocks and cleans out the refrigerator. She indicated she would call the kitchen to confirm how long the juices could be stored in the refrigerator once opened. Interview with RN #1 on 1/24/25 at 11:45 AM identified that the kitchen has a 3-day rule for all open food and drinks and that both juices needed to be disposed of. Tour of the Nourishment room on the North/West Wing on 1/24/25 at 12:50…
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 · D2025-02-03 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 2 residents (Resident #16) reviewed for pressure injuries, the facility failed to provide wound assessments by a qualified clinician. The findings include: Resident #16 was admitted to the facility in August of 2024 with diagnoses that included adult failure to thrive, repeated falls, diabetes mellitus without complications and generalized muscle weakness. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #16 was cognitively intact (Brief Interview for Mental Status (BIMS) score of 15) and required set up assistance for personal hygiene, supervision or touching assistance for bed mobility and transfers and was occasionally incontinent of stool. The MDS identified Resident #16 as not at risk for developing pressure injuries and failed to identify the presence of pressure ulcers. The Resident Care Plan (RCP) dated 11/14/24 identified Resident #16 with an alteration in skin integrity. It…
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 before2025-02-03 · tag F0657 — failed to keep the care plan current — isolatedDevelop 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 observation(s), review of the clinical record, facility documentation, facility policy and interviews for 1 of 2 residents (Resident #16) reviewed for pressure injuries, and 2 of 2 residents (Resident #18 and Resident #87) reviewed for suicidal ideations, the facility failed to revise the resident care plan (RCP) for a resident who developed a facility acquired pressure injury and failed to revise the RCP for residents who made expressions of suicidal ideations (SI). The findings include: 1. Resident #16 was admitted to the facility in August of 2024 with diagnoses that included adult failure to thrive, repeated falls, diabetes mellitus without complications and generalized muscle weakness. The admission assessment dated [DATE] identified a 1.5 centimeter (cm) by 1.5 cm pressure injury to the upper back, a debrided/open area to the right wrist measuring 4 cm by 2 cm by 0.5 cm, and a skin tear measuring 5 cm by 5 cm by 0.1 cm to the left upper arm. The admission assessment did not identify toe…
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 · D2025-02-03 · 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 observations, review of the clinical record, facility documentation, facility policy and interviews for 1 of 2 sampled residents (Resident #16) reviewed for pressure injuries, the facility failed to conduct a registered nurse (RN) assessment after the identification of a new wound and failed to complete weekly wound assessments to monitor the status of an existing wound and prevent infection and failed to initiate preventative skin integrity monitoring for a resident with a history of pressure injuries and with a current a current pressure injury and failed to initiate new preventative pressure injury interventions after the development a pressure injury to prevent worsening of the pressure injury and the development of a new pressure injury. The findings include: Resident #16 was admitted to the facility in August of 2024 with diagnoses that included adult failure to thrive, repeated falls, diabetes mellitus without complications and generalized muscle weakness. The admission assessment on 8/10/24…
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 before2025-02-03 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide 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 clinical record review, review of facility policy, and interviews for 1 of 5 residents (Resident #31) reviewed for nutrition, the facility failed to obtain weekly weights according to physician order. The findings include: Resident #31 was admitted to the facility in September of 2024 with diagnoses that included diabetes, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD) and anxiety disorder. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #31 was cognitively intact (Brief Interview for Mental Status (BIMS) score of 15), required partial/moderate assistance for toileting hygiene and was dependent for personal hygiene, bed mobility and transfers. A Resident Care Plan dated 10/4/24 identified Resident #31 was at risk for nutritional deficit. Interventions included encourage Resident #31 with feeding, offer substitutes for dislikes, maintain intake and output and obtain weekly weights. A Physician's order dated 10/4/24 directed to obtain weekly…
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 · D2025-02-03 · tag F0741 — failed to have staff trained for behavioral health — isolatedEnsure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
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(s), review of the clinical record, facility documentation, facility policy and interviews for 1 of 3 residents (Resident #87) reviewed for mood/behavior, the facility failed to provide a behavioral health assessment by a qualified clinician for a resident with suicidal ideations. The findings include: Resident #87 was admitted to the facility in February of 2024 with diagnoses that included unspecified dementia, anxiety disorder, chronic kidney disease and diabetes. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #87 was severely cognitively impaired (Brief Interview for Mental Status (BIMS) score of 6) and required set up assistance for eating, was dependent for toileting and required partial/moderate assistance with bed mobility and transfers. Resident #87 had no limits on range of motion for upper and lower extremities and used a walker and wheelchair for mobility. A Clinical note dated 11/15/24 at 3:57 PM by Advanced Practice Registered Nurse (APRN) #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.
Show the remaining 20 citations
- Potential for harm · D2025-02-03 · tag F0742 — isolatedProvide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
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, review of facility documentation, and interviews for 1 of 2 residents (Resident #87) reviewed for mood/behavior, the facility failed to provide appropriate treatment and services to attain the highest practicable mental and psychosocial well-being for a resident who expressed suicidal ideation (SI).The findings include:Resident #87 was admitted to the facility in February of 2024 with diagnoses that included unspecified dementia, anxiety disorder, chronic kidney disease and diabetes.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #87 was severely cognitively impaired (Brief Interview for Mental Status (BIMS) score of 6) and required set up assistance for eating, was dependent for toileting and required partial/moderate assistance with bed mobility and transfers. Resident #87 had no limits on range of motion for upper and lower extremities and used a walker and wheelchair for mobility.A Clinical note dated 11/15/24 at 3:57 PM…
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 · D2025-02-03 · tag F0745 — failed to provide medically-related social services — isolatedProvide medically-related social services to help each resident achieve the highest possible quality of life.
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 2 of 2 residents (Resident #18 and Resident #87) reviewed for suicidal ideation, the facility failed to provide social services for residents who expressed suicidal ideations. The findings include: 1. Resident #18 was admitted to the facility in September of 2017 and had diagnoses that included Alzheimer's disease, bipolar disorder, depression, and suicidal ideations. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #18 was severely cognitively impaired (Brief Interview for Mental Status (BIMS) score of 5), had moderate depression (PHQ-2 to 9 (resident mood interview) severity score of 11), required substantial/maximal assistance with eating, and was dependent for bed mobility and transfers. The Resident Care Plan (RCP) dated 10/4/2024 identified Resident #18 was at risk for alteration of mood/behaviors related to diagnoses of dementia, bipolar disorder and depression.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-03 · tag F0835 — failed to run the facility competently — isolatedAdminister the facility in a manner that enables it to use its resources effectively and efficiently.
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 facility documentation, facility policy and interviews, the facility failed to ensure the Administrator updated the facility assessment to identify the services the facility provided and failed to ensure the Administrator facilitated a method of communciation between disciplines (coordinated interdisciplinary communication and approach to care) and failed to ensure the Administrator contracted the facility with behavioral health services and failed to ensure Administrator oversight of the facility staff education department to ensure compliance. The findings include: 1. Review of the Annual Facility assessment dated [DATE] through September 30, 2024, completed on 10/10/2024 (annual update due 10/1/2025) identified the Facility Assessment was not updated after the dissolution of the facility contracted behavioral health service in 2020. Review of facility staff education files identified a failure of compliance with the required staff training and competencies as stated in the Facility Asessment. 2.…
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 · D2025-02-03 · tag F0838 — failed to assess facility resources and resident needs — isolatedConduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
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 Facility Assessment the facility failed to update the facility assessment after the dissolution of the facility contracted behavioral health service in 2020 and failed to ensure compliance of required staff training and competencies. The findings include: 1. Review of the Annual Facility assessment dated [DATE] through September 30, 2024, completed on 10/10/2024 (annual update due 10/1/2025) identified services and care offered based on Resident's needs included mental health and behavior services. Management of medical conditions and medication related issues causing psychiatric symptoms and behavior, identification and implementation of interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/PTSD, other psychiatric diagnosis, 1:1 visit with social services designee for the purpose of allowing verbalization of feelings and issues surrounding SNF placement, and coping with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-03 · tag F0840 — isolatedEmploy or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.
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 use of outside resources, the facility failed to provide behavioral health services including psychotherapy as identified in the facility assessment. The findings included: Review of the Annual Facility assessment dated [DATE] - September 30, 2024, completed on 10/10/2024 identified services and care offered based on Resident's needs included mental health and behavior services. Management of medical conditions and medication related issues causing psychiatric symptoms and behavior, identification and implementation of interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/PTSD, other psychiatric diagnosis, 1:1 visit with social services designee for the purpose of allowing verbalization of feelings and issues surrounding SNF placement, and coping with grief and loss. Additionally,…
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 · D2025-02-03 · tag F0841 — isolatedDesignate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documentation, facility policy and interviews the facility failed to ensure the Medical Director's responsibility in the coordination of behavioral health services for residents in need of behavioral health treatment and the oversight of a current and complete policy for management and treatment of residents with suicidal ideations. The findings include: Review of the Annual Facility assessment dated [DATE] through September 30, 2024, completed on 10/10/2024 (annual update due 10/1/2025) identified services and care offered based on Resident's needs included mental health and behavior services. Management of medical conditions and medication related issues causing psychiatric symptoms and behavior, identification and implementation of interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/PTSD, other psychiatric diagnosis, 1:1 visit with social services designee for 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 · Dcited before2025-02-03 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, review of the clinical record, facility documentation, facility policy and interviews for one sampled resident observed with transmission based precaution signage (Resident #87), the facility failed to provide clear and accurate signage for transmission based precautions. The findings include: Observation on 2/3/25 at 11 AM of signage outside of Resident #87 ' s room identified 3 separate signs: Contact Precautions sign directing: hand hygiene, dedicated patient equipment, gloves, and a gown; Droplet Precautions sign directing: hand hygiene, eye protection, procedure mask, dedicated patient equipment, gloves, and a gown; Airborne Respirator Precautions sign directing: hand hygiene, dedicated patient equipment, CAPR/PAPR or fitted N95 mask, keep door closed, and notify maintenance to add a fan to room. Interview with the IP on 2/3/25 at 12:49 PM identified that all 3 precautions signs are posted outside of resident rooms with potential or confirmed cases of Covid-19 because staff need to utilize a portion of each precaution to achieve Transmission Based…
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 · D2025-02-03 · tag F0940 — failed to train staff — isolatedDevelop, implement, and/or maintain an effective training program for all new and existing staff members.
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 facility documentation, facility policy and interviews the facility failed to maintain an effective training program for all new and existing staff based on the facility assessment. Review of the Annual Facility assessment dated [DATE] through 9/30/2024 identified 19 areas of mandatory education for all staff upon hire and annually to include: resident rights, abuse prevention and reporting, confidentiality/Health Insurance Portability and Accountability Act (HIPAA), emergency preparedness, fire safety, infection prevention and control, tuberculosis, COVID-19, exposure control, bloodborne pathogens (BBP), hazardous chemicals, personal protective equipment (PPE), transmission based precautions (TBP), enhanced barrier precautions (EBP), corporate compliance/ethics, quality assurance and performance improvement (QAPI), effective communication, dementia-specific strategies (communication), and trauma informed care (TIC). The facility assessment failed to include annual mandatory education for workplace…
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 · D2025-02-03 · tag F0941 — isolatedDevelop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on facility documentation, facility policy and interviews the facility failed to ensure staff compliance with communication training. The findings include: Review of Healthcare Academy (online education platform) reports dated 1/29/2025 through 1/30/2025 for 2023 and 2024 staff education course completions identified 73 out of 227 (32.1%) facility staff members did not complete communication training in 2024. Review of Healthcare Academy reports dated 1/29/2025 through 1/30/2025 for 2023 and 2024 staff education course completions identified 32 out of 75 (42.6%) Nurse Aides did not complete communication training in 2024. Review of Healthcare Academy reports dated 1/29/2025 through 1/30/2025 for 2023 and 2024 staff education course completions identified 15 out of 44 (34%) Licensed Nurses did not complete communication training in 2024. Interview with the Director of Education Services (RN #4) on 2/3/2025 at 11:33 AM identified she assigned facility staff required in-service courses through Healthcare Academy and checked completion of courses monthly. RN #4 identified after…
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 · D2025-02-03 · tag F0942 — isolatedEnsure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on facility documentation, facility policy and interviews the facility failed to ensure staff compliance with resident rights training. Review of Healthcare Academy (online education platform) reports dated 1/29/2025 through 1/30/2025 for 2023 and 2024 staff education course completions identified 44 out of 227 (19.3%) facility staff members did not complete resident rights training in 2024. Review of Healthcare Academy reports dated 1/29/2025 through 1/30/2025 for 2023 and 2024 staff education course completions identified 28 out of 75 (37.3%) Nurse Aides did not complete resident rights training in 2024. Review of Healthcare Academy reports dated 1/29/2025 through 1/30/2025 for 2023 and 2024 staff education course completions identified 9 out of 44 (20.4%) Licensed Nurses did not complete resident rights training in 2024. Interview with the Director of Education Services (RN #4) on 2/3/2025 at 11:33 AM identified she assigned facility staff required in-service courses through Healthcare Academy and checked completion of courses monthly. RN #4 identified after checking course…
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 · D2025-02-03 · tag F0943 — isolatedGive their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on facility documentation, facility policy and interviews the facility failed to ensure staff compliance with abuse, neglect, and exploitation training and the facility failed to ensure staff compliance with dementia management training. 1. Review of Healthcare Academy (online education platform) reports dated 1/29/2025 through 1/30/2025 for 2023 and 2024 staff education course completions identified 35 out of 227 (15.4%) facility staff members did not complete abuse, neglect, and exploitation training in 2024. Review of Healthcare Academy reports dated 1/29/2025 through 1/30/2025 for 2023 and 2024 staff education course completions identified 22 out of 75 (29.3%) Nurse Aides did not complete abuse, neglect, and exploitation training in 2024. Review of Healthcare Academy reports dated 1/29/2025 through 1/30/2025 for 2023 and 2024 staff education course completions identified 7 out of 44 (15.9%) Licensed Nurses did not complete abuse, neglect, and exploitation training in 2024. 2. Review of Healthcare Academy (online education platform) reports dated 1/29/2025 through 1/30/2025…
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 · D2025-02-03 · tag F0944 — isolatedConduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on facility documentation, facility policy and interviews the facility failed to ensure staff compliance with Quality Assurance and Performance Improvement (QAPI) (framework used to improve resident safety and the quality of their services) training. Review of Healthcare Academy (online education platform) reports dated 1/29/2025 through 1/30/2025 for 2023 and 2024 staff education course completions identified 60 out of 227 (26.4%) facility staff members did not complete QAPI training in 2024. Review of Healthcare Academy reports dated 1/29/2025 through 1/30/2025 for 2023 and 2024 staff education course completions identified 33 out of 75 (44%) Nurse Aides did not complete QAPI training in 2024. Review of Healthcare Academy reports dated 1/29/2025 through 1/30/2025 for 2023 and 2024 staff education course completions identified 13 out of 44 (29.5%) Licensed Nurses did not complete QAPI training in 2024. Interview with the Director of Education Services (RN #4) on 2/3/2025 at 11:33 AM identified she assigned facility staff required in-service courses through Healthcare Academy…
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 · D2025-02-03 · tag F0945 — failed to train staff on abuse prevention — isolatedInclude as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on facility documentation, facility policy and interviews the facility failed to ensure staff compliance with their infection control program (infection prevention and control, tuberculosis, COVID-19, bloodborne pathogens, personal protective equipment, transmission based precautions, and enhanced barrier precautions) training. A. Review of Healthcare Academy (online education platform) reports dated 1/29/2025 through 1/30/2025 for 2023 and 2024 staff education course completions identified 53 out of 227 (23.3%) facility staff members did not complete infection prevention and control training in 2024. Review of Healthcare Academy reports dated 1/29/2025 through 1/30/2025 for 2023 and 2024 staff education course completions identified 30 out of 75 (40%) Nurse Aides did not complete infection prevention and control training in 2024. Review of Healthcare Academy reports dated 1/29/2025 through 1/30/2025 for 2023 and 2024 staff education course completions identified 11 out of 44 (25.0%) Licensed Nurses did not complete infection prevention and control training in 2024. B.…
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 · D2025-02-03 · tag F0946 — isolatedProvide training in compliance and ethics.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on facility documentation, facility policy and interviews the facility failed to ensure staff compliance with corporate compliance and ethics training. Review of Healthcare Academy (online education platform) reports dated 1/29/2025 through 1/30/2025 for 2023 and 2024 staff education course completions identified 52 out of 227 (22.9%) facility staff members did not complete corporate compliance and ethics training in 2024. Review of Healthcare Academy reports dated 1/29/2025 through 1/30/2025 for 2023 and 2024 staff education course completions identified 29 out of 75 (38.6%) Nurse Aides did not complete corporate compliance and ethics training in 2024. Review of Healthcare Academy reports dated 1/29/2025 through 1/30/2025 for 2023 and 2024 staff education course completions identified 10 out of 44 (22.7%) Licensed Nurses did not complete corporate compliance and ethics training in 2024. Interview with the Director of Education Services (RN #4) on 2/3/2025 at 11:33 AM identified she assigned facility staff required in-service courses through Healthcare Academy and checked…
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 · D2025-02-03 · tag F0947 — failed to train nurse aides adequately — isolatedEnsure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on facility documentation, facility policy and interviews the facility failed to ensure Nurse Aides (NA) completed at least 12 hours of education for 2024. Review of Healthcare Academy (online education platform) reports dated 1/29/2025 through 1/30/2025 for 2023 and 2024 staff education course completions identified 37 out of 75 (49.3%) nurse aides did not complete at least 12 hours of education in 2024. Facility handwritten read and sign inservices for 2023 and 2024 were additionally reviewed, and with the addition of read and sign inservices, 12 hours of education was not met. Interview with RN #4 on 2/3/2025 at 11:33 AM identified that she was responsible for assigning education courses to all staff in Healthcare Academy, that she monitored their completion monthly, and notified facility department heads of any staff within their department who did not complete their courses. RN #4 indicated that she notified the DNS of nursing staff who had not completed their courses. Interview with the Director of Nursing Services (DNS) on 2/3/25 at 12:15 PM identified RN #4 notified…
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 · D2025-02-03 · tag F0949 — failed to train staff on dementia and abuse — isolatedProvide behavior health training consistent with the requirements and as determined by a facility 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 facility documentation, facility policy and interviews the facility failed to ensure staff compliance with behavioral health training. A. Review of Healthcare Academy reports dated 1/29/2025 through 1/30/2025 for 2023 and 2024 staff education course completions identified 96 out of 227 (42.2%) facility staff members did not complete behavioral health-trauma informed care (TIC) training in 2024. Review of Healthcare Academy reports dated 1/29/2025 through 1/30/2025 for 2023 and 2024 staff education course completions identified 47 out of 75 (62.6%) Nurse Aides did not complete behavioral health-TIC training in 2024. Review of Healthcare Academy reports dated 1/29/2025 through 1/30/2025 for 2023 and 2024 staff education course completions identified 20 out of 44 (45.4%) Licensed Nurses did not complete behavioral health-TIC training in 2024. B. Review of Healthcare Academy reports dated 1/29/2025 through 1/30/2025 for 2023 and 2024 staff education course completions identified 34 out of 227 (14.9%)…
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 · Ecited before2022-10-03 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
FACILITY Infection Control Based on observation, facility documentation, facility policy, and interviews reviewed for infection control, the facility failed to transport linens appropriately in a clean and sanitary manner. The findings include: Review of facility documentation identified that the facility had 4 units. Review of infection control documentation indicated that 2 of the 4 units, the North and Rehabilitation units, housed a total of 11 COVID-19 positive residents. Observations on 9/29/22 at 1:15 PM on the North (partially COVID-19 positive) Unit identified Laundry Staff #1 distributing clean laundry from an uncovered, large metal rack, 4 tiers high, approximately 6 feet tall by 2 feet wide by 5 feet long. Laundry Staff #1 was taking linens from the 4 tiered, uncovered, cart and placing the items on a smaller covered cart. Interview and observation on the Rehabilitation (partially COVID-19 positive) Unit with Laundry Staff #1 on 9/29/22 at 1:29 PM identified she was taking clean linen from the large 4 tiered cart and distributing it onto a smaller covered cart. Laundry…
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 before2019-12-05 · tag F0657 — failed to keep the care plan current — isolatedDevelop 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 observations, clinical record review, review of facility documentation, and interviews for one sampled resident (Resident #34) reviewed for falls, the facility failed to review and revise the care plan following four falls. The findings include: Resident #34's diagnoses included, advance dementia, history of falls and fracture of right hip on 6/17/19. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #34 was severely cognitively impaired, required extensive assistance of two with bed mobility, transfers, ambulation and had sustained two falls since admission with injuries. Resident #34's care plan dated 09/25/19 identified that the resident had impaired mobility and was a fall risk. Care plan interventions identified that the resident was to ambulate with a rolling walker with assistance of two in the hallway only on straight path with the wheelchair to follow. It also noted to transfer with the assistance of two and that the resident utilized a wheelchair with an alarmed…
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 before2019-12-05 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, review of facility documentation and staff interviews for 1 of 4 sampled residents (R#17) reviewed for nutrition, the facility failed to ensure that the dietician and the physician were notified of a weight loss in a timely manner. The findings include: Resident #17 was admitted on [DATE] with diagnosis that included Lewy Body Dementia, Lyme disease and hypertension. A physician's order dated 6/10/19 directed to obtain weight every week on Friday and a physician's order dated 7/9/19 directed to administer carnation instant breakfast 8 ounces (oz.) twice per day. A dietary consultation report dated 9/8/19 identified Resident #17 weighed 169 pounds (lbs.) and had fair to good oral intake of meals and ate 50%-75% of most meals in a seven day period. The quarterly MDS dated [DATE] identified Resident #17 had severe cognitive impairments and required extensive assistance of one for eating. The care plan dated 10/4/19 identified a problem with nutrition and indicated 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 · D2019-12-05 · tag F0806 — failed to honor food preferences — isolatedEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
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 1 of 4 sampled residents (Resident #196) reviewed for accidents, the facility failed to ensure that a resident with food allergies received the appropriate diet. The findings include: Resident #196 was admitted to the facility on [DATE] with diagnoses that included dementia, dairy and gluten allergies. A nutrition assessment dated [DATE] identified Resident #196 had a food intolerance/allergies to dairy and gluten. Resident #196's care plan dated 11/18/19 identified a nutritional concern with an intervention dated 11/19/19 that noted to change the resident's diet to gluten and dairy free. The care plan interventions further identified that the resident could feed him/her self. A physician's order also dated 11/19/19 directed to change the resident's diet to gluten free and dairy free. A 7:00 AM to 3:00 PM shift nurse's note dated 11/26/19 identified that Resident #196 had an exposure to gluten at lunch time and noted 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.
“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
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| CZERMAK, CHAIM | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR | 50% | since 07/18/1974 |
| CZERMAK, MARVIN | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR | 25% | since 07/18/1974 |
| KATZ, ISABELLE | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR | 13% | since 07/18/1974 |
| KATZ, MAURICE | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR | 13% | since 07/18/1974 |
| PANTELEAKOS, DAVID | Individual | W-2 MANAGING EMPLOYEE; CORPORATE DIRECTOR; CORPORATE OFFICER | — | since 07/18/1974 |
CMS files one row per role, so the 11 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted.
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 $1.0M paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
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 075078. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-02-03, 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.