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Twin Maples Healthcare, INC

809 New Haven Road #r, Durham, CT 06422 · For profit - Corporation · 44 certified beds · (860) 349-1041 Medicare & Medicaid certified

Call the home — (860) 349-1041 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0609) — cited Aug 2024Behavioral-health or dementia-care citation — no harm found (F0758)1 actual-harm citation$24,928 in federal fines
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • a high payroll-based staffing rating (4/5)
  • lower-than-typical staff turnover (35% vs 45% nationally) — better care continuity
  • 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 (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $24,928 in federal fines (most recent 2025-10-09)

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.

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

Location & what’s nearby

Urgent care / clinic
900 Northrop Road
Pharmacy
321 Main St · (860) 349-3478 · Call to confirm hours
Grocery
238 Main St · (860) 788-3335 · Call to confirm hours
Park
50 Pickett Ln · Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 3 of 5
Long-stay residentspeople who live here 3 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 4 to 3 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 rating3★
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 increased12.7%18.0%15.4%better
Long-stay residents who lose too much weight4.7%6.5%5.4%better
Long-stay residents with a catheter left in their bladder3.6%0.7%0.9%worse
Long-stay residents with a urinary tract infection0.6%1.5%2.0%better
Long-stay residents with depressive symptoms0.6%22.3%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury9.1%3.5%3.3%worse
Long-stay residents whose ability to walk worsened15.4%16.4%16.1%typical
Long-stay residents on antianxiety or hypnotic medication15.5%17.6%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%93.5%95.3%typical
Long-stay residents with pressure ulcers2.0%4.0%4.7%better
Long-stay residents with worsening bladder/bowel control24.0%24.7%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table21.9%17.8%17.1%worse
Long-stay hospitalizations per 1,000 resident days2.362.061.67worse
Long-stay outpatient ER visits per 1,000 resident days0.721.461.80better

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.

9.7%U.S. median 10.7%
Went back to hospital
0.21U.S. median 0.31
Therapy hours / resident / day
0.01hours / resident / day
Physical therapy
0.14hours / resident / day
Occupational therapy
0.06hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.21 therapist hours per resident per day in 2026Q1 — more than 25% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 34% 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 SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.7%CMS range 6.6–16.410.7%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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identifiednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims for this measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims for this measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF staynot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.631.02Oct 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

0.80
RN hours/ resident / day
0.41
LPN hours/ resident / day
1.97
Aide hours/ resident / day
3.18
Total nurse hours/ resident / day
0.38
RN hoursweekends
35.3%
Total nursing turnover
33.3%
RN turnover

How full it usually is: this home is certified for 44 beds and averages 42.9 residents a day — about 98% occupied, or roughly 1 bed 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 3.18 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.80 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.97 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 2.77 hrs/resident/day on weekends vs 3.35 on weekdays — 17% thinner on weekends. RN hours go from 0.97 to 0.38 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 35% is below 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

7
deficiencies at the latest standard inspection (2025-05-22)
11
at the previous standard inspection (2023-06-22)

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.

27 citations, most serious first. The 11 most serious are shown; the remaining 16 are one tap away and print in full.

  • Actual harm · Gcited before2025-10-09 · 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 on interviews, review of the clinical record, facility documentation, and facility policy for 1 of 3 sampled residents (Resident #2), reviewed for falls, the facility failed to transfer the resident per the physician's order, rehabilitation screen, and nurse aide assignment card, which resulted in a fall with multiple fractures. The findings include:Resident #2's diagnoses included Erb's paralysis due to birth injury, hemiplegia affecting the right dominant side and paralytic gait.A review of the Interdisciplinary Therapy Screen conducted by Occupational Therapist (OT) #1 dated 6/23/25 identified Resident #2 was assessed for transfers and was an assist of 2 staff members for Stand, Pivot, Transfer (SPT). The Resident Care Plan dated 6/24/25 identified Resident #2 was at risk for falls related to decreased independent mobility. Interventions included Occupational Therapy to evaluate and treat as ordered or as needed and transfer with assistance of 1 staff to wheelchair. The admission Minimum Data Set (MDS)…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-19 · tag F0585 — failed to handle grievances — isolated
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility policy and interviews, for one (1) of three (3) residents (Resident #1) reviewed for grievances, the facility failed to ensure a complaint made by a resident regarding a staff member was referred to the designated grievance official, investigated, and documented with findings and resolution. The findings include:Resident #1's diagnoses included Traumatic Brain Injury (TBI), dementia with behavioral disturbances, conduct disorder, anxiety disorder and psychosis.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severely impaired cognition (Brief Interview for Mental Status (BIMS) score of 7), required substantial assistance with bed mobility and was dependent on staff for personal hygiene, toileting and transfers.The Resident Care Plan (RCP) dated 1/29/26 identified Resident #1 had impaired cognitive function/dementia or impaired thought processes due to a TBI/head injury, impaired decision making and made allegations and inappropriate…

    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 before2025-10-09 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, facility policies and interviews for one (1) of three (3) sampled residents (Resident #1) who had a history of wandering throughout the facility and self-ambulated with a walker, the facility failed to implement the Missing Person Policy when Resident #1 was not accounted for. The findings include:Based on clinical record reviews, facility documentation, facility policies and interviews for one (1) of three (3) sampled residents (Resident #1) who had a history of wandering throughout the facility and self-ambulated with a walker, the facility failed to implement the Missing Person Policy when Resident #1 was not accounted for. The findings include: Resident #1's diagnoses included vascular dementia, hemiplegia, and insomnia. The annual Minimum Data Set assessment dated [DATE] identified Resident #1 had short and long-term memory recall deficits and was independent with ambulation with the use of a walker. The Resident Care Plan dated 7/23/25 identified…

    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 · D2025-07-03 · tag F0808 — failed to follow doctor-ordered diets — isolated
    Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, facility policy, and interviews for one (1) of three (3) sampled residents (Resident #2) who had difficulty swallowing, the facility failed to follow the physician's recommended therapeutic diet which resulted in the resident choking. The findings include: Resident #2's diagnoses included cerebral vascular accident and dysphasia (difficulty swallowing). The Speech Therapy Treatment Encounter note dated 2/25/25 identified Resident #2's diet was downgraded to a Level 5 minced and moist diet after Resident #2 was observed coughing on a Level 6 diet. The barium swallow results dated 3/10/25 identified diet recommendations for the International Dysphagia Diet Standardisation Initiative (IDDSI) Level 5, minced and moist, regular dry bread and mixed consistency not allowed, alternate solids and liquids, and supervised feeding. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 had some slight memory recall deficits, required staff…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-05-22 · tag F0730 — pattern
    Observe each nurse aide's job performance and give regular training.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility documentation, facility policy and interviews, the facility failed to complete annual nurse aide performance evaluations. The findings include: Interview and review of facility documentation identified the facility employs a total of 25 nurse aides for all three shifts (7:00 AM - 3:00 PM shift, 3:00 PM - 11:00 PM shift, and 11:00 PM - 7:00 AM shift). Review of the personnel files of NA #1, NA #7, and NA #8 failed to reflect that annual performance evaluations had been completed. Interview with the DNS on 5/21/25 at 12:12 PM identified she has been employed by the facility for 7 years. The DNS indicated she has not completed nurse aide performance evaluations since she has been in the position. The DNS indicated annual nurse aide performance evaluations had not been completed in 2021, 2022, 2023, 2024, and 1/1/25 - 5/21/25. Interview with the Administrator on 5/21/25 at 12:20 PM identified he was not aware that the DNS had not completed nurse aide performance evaluations in 7 years. Review of the facility employee handbook identified performance…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-22 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy and interviews for 2 of 3 residents (Resident #5 and 36) reviewed for accidents, for Resident #5 the facility failed to implement the comprehensive care plan for a resident with a history of repeated falls and for Resident #36 the facility failed to develop a comprehensive care plan related to the resident's behavior of flailing arms. The findings include: 1. Resident #5 had diagnoses that included schizophrenia and bipolar disorder. The quarterly MDS dated [DATE] identified Resident #5 had moderate cognitive impairment and required one person assist with ambulation and toileting. The care plan dated 3/12/25 identified Resident #5 was at risk for falls related to a history of unsteady gait and noncompliance with asking for assistance. Interventions included ambulation with assist of one with a walker and do not leave the resident unattended when out of bed during the day. Physician's order dated 3/25/25 directed assist of one with…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-22 · 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, facility documentation, facility policy and interviews for 1 of 3 residents (Resident #5) reviewed for accidents, the facility failed to revise the care plan following a fall for a resident with a history of repeated falls. The findings include: Resident #5 had diagnoses that included schizophrenia, bipolar disorder and overactive bladder. The quarterly MDS dated [DATE] identified Resident #5 had moderate cognitive impairment and required one person assist with ambulation and toileting. The care plan dated 3/12/25 identified Resident #5 was at risk for falls related to a history of unsteady gait and noncompliance with asking for assistance. Interventions included ambulation with assist of one with a walker and do not leave the resident unattended when out of bed during the day. Physician's order dated 3/25/25 directed assist of one with two wheeled rolling walker for transfers and ambulation. A facility reported event dated 4/7/25 identified at 11:15 AM Resident #5 was…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-22 · tag F0678 — failed to provide CPR when needed — isolated
    Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
    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 #41) reviewed for quality of care, the facility failed to ensure staff maintained current CPR (cardiopulmonary resuscitation) certification. The findings include: Resident #41 had diagnoses that included Parkinson's disease, and hypertension. The quarterly MDS dated [DATE] identified Resident #41 had moderate cognitive impairment required two person assist with bed mobility, transfers and toileting. The care plan dated [DATE] identified Resident #41 had advance directives specifying full code status meaning all life saving measures were to be implemented in the event of a medical emergency. Physician's order dated [DATE] directed full code status. A late entry nurse's note dated [DATE] at 9:00 PM identified between 8:00 PM and 8:30 PM, Resident #41 vomited a large amount twice and had a large bowel movement. A nurse's note dated [DATE] at 9:53 PM identified RN #4 was notified by the medication…

    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 before2025-05-22 · tag F0726 — failed to have competent, trained nursing staff — isolated
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility documentation, the facility assessment, and interview, the facility failed to ensure intravenous (IV) therapy certifications and competencies were completed for 6 of 11 licensed nursing staff. The findings include: Review of the IV Therapy Certifications and Infusion Medications Administration Competencies binder failed to identify the following: RN #7 (hired on 5/2/15) was certified in IV therapy or had completed an Infusion Medications Administration Competency. RN #4 (hired on 4/24/18) was certified in IV therapy or had completed an Infusion Medications Administration Competency. RN #5 (hired on 11/29/21) was certified in IV therapy or had completed an Infusion Medications Administration Competency. RN #2 (hired on 5/27/22) was certified in IV therapy or had completed a 2024 annual Infusion Medications Administration Competency; competency was last completed on 8/8/23. RN #6 (hired on 7/6/22) was certified in IV therapy or had completed a 2024 annual Infusion Medications Administration Competency; competency was last completed on 8/12/23. LPN #4 (hired…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-05-22 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of facility documentation, facility policy, and interviews, the facility failed to discard Insulin 28 days after it was opened according to professional standards. The findings include: Observation on [DATE] at 10:43 AM of a medication cart with LPN #1 identified the following. A vial of Novolog Insulin 100 units/ml 10 ml approximately ¾ full with an open date of [DATE], and a sticker that the Insulin was good for 28 days once opened. A vial of Lantus Insulin approximately ¼ full with an open date of [DATE], and a sticker indicating to discard 28 days after opening. Two vials of Aspart Insulin 100 units/ml 10 ml approximately 1/3 full with an open date of [DATE], and a sticker that indicated discard 28 days after opening. A vial of Lantus Insulin 100 units/per ml approximately ¼ full with an open date of [DATE] and a sticker that indicated discard 28 days after opening. Interview with LPN #1 on [DATE] at 10:48 AM indicated that she was the full-time charge nurse and administered…

    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 · Dcited before2025-05-22 · 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 2 of 5 residents (Resident #15 and 78) reviewed for unnecessary medications, the facility failed to ensure pharmacy recommendations were addressed in a timely manner. The findings include: 1. Resident #15 was admitted to the facility in December 2024 with diagnoses that included dementia with mood disturbances, hyperlipidemia, and spiral fracture of arm. The care plan dated 12/17/24 identified Resident #15 had impaired cognition due to dementia. Interventions included cues, supervise, and reorient resident as needed. The admission MDS dated [DATE] identified Resident #15 had moderately impaired cognition and exhibited no hallucinations or delusions. Resident #15 did not show any physical or verbal behaviors directed towards others and had not rejected care. Resident #15 was receiving antipsychotic, antidepressant, and diuretic medications. A physician's order dated 1/31/25 directed to administer Seroquel…

    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
Show the remaining 16 citations
  • Potential for harm · E2024-11-12 · tag F0636 — pattern
    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, review of facility documentation, facility policies, and interviews for eight (8) of ten (10) sampled residents (Resident #2, #3, #4, #5, #6, #7, #8, and #10) who were reviewed for the completion of a current Minimum Date Set assessment, the facility failed to ensure the assessments were completed within the fourteen (14) day timeframe requirement. The findings include: Resident #2 had a quarterly Minimum Data Set, dated [DATE] with the status of in process. Resident #3 had an annual Minimum Data Set, dated [DATE] with the status of in process. Resident #4 had a quarterly Minimum Data Set, dated [DATE] with the status of in process. Resident #5 had an annual Minimum Data Set, dated [DATE] with the status of in process. Resident #6 had an annual Minimum Data Set, dated [DATE] with the status of in process. Resident #7 had an annual Minimum Data Set, dated [DATE] with the status of in process. Resident #8 had an admission Minimum Data Set, dated [DATE] with the status of in…

    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 · D2024-08-13 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, facility policies and interviews for one of three sampled residents (Resident #2) who required staff assistance with daily living skills and was reviewed for an allegation of mistreatment, a staff member failed to immediately report the allegation of mistreatment by another staff member while providing care to Resident #2 therefore the alleged perpetrator worked for three (3) days. The findings include: Resident #2's diagnoses included vascular dementia, hallucinations, blindness left eye and glaucoma right eye, depression, and incontinence. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 made poor decisions regarding tasks of daily life, experienced hallucinations, exhibited behaviors not directed towards others, and required maximum assistance for hygiene, dressing, and bathing. The Resident Care Plan dated 6/27/24 identified Resident #2 had a cognitive impairment, was hard of hearing, had periods of insomnia, had a…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-02 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of two (2) residents (Resident #1) who were reviewed for pressure ulcers, the facility failed to ensure complete and accurate documentation for a resident with a scheduled skin inspection who subsequently developed a pressure ulcer. The findings include: Resident #1's diagnoses included multiple sclerosis, neuromuscular dysfunction of the bladder and dementia. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 was moderately cognitively impaired, required extensive two person assist with bed mobility, transfers, total care with bathing, was at risk for the development of pressure ulcers and did not have any unhealed pressure ulcers. The Resident Care Plan dated 10/9/23 identified Resident #1 had a potential for impairment to skin integrity related to decreased mobility, incontinence (bowel) and muscle spasms of the lower extremities with interventions that directed to apply 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-02 · 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 clinical record reviews, observations, facility documentation, facility policy and interviews for one (1) of two (2) residents,(Resident #1), who were reviewed for pressure ulcers, the facility failed to ensure appropriate infection control practices were followed for a resident receiving a wound treatment. The findings include: Resident #1's diagnoses included multiple sclerosis, neuromuscular dysfunction of the bladder and dementia. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 was moderately cognitively impaired, required extensive two person assist with bed mobility, transfers, total care with bathing, was at risk for the development of pressure ulcers and did not have any unhealed pressure ulcers. The Resident Care Plan dated 11/5/23 identified Resident #1 had an unstageable pressure ulcer related to decreased mobility. Interventions directed to assess, record, monitor wound status and stage of healing weekly and provide treatment(s) as ordered. A physician's order…

    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 · E2023-06-22 · 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 during the kitchen tour, review of facility policy and interviews, the facility failed to ensure items were appropriately labeled and dated when opened and failed to discard expired foods prior to the expiration date. The findings include: Observations during a tour of the kitchen on 06/20/23 at 9:55 AM identified the following: Refrigerator #1 (white) A. Use by date of sour cream was 6/15/23. B. Feta shredded cheese lacked both an opened and expiration date. C. American shredded cheese lacking an opened date. D. Mozzarella shredded cheese lacking both an opened and expiration date. E. Parmesan cheese that expired on 5/11/23. Refrigerator #2 (double door stainless steel) Barbeque sauce that was transferred from the original container to a plastic container on 6/8/23 but lacked an expiration date. Interview with the Food Service Supervisor (FSS) on 6/20/23 at 10:14 AM, identified all food should have a date when opened and an expiration date. The FSS indicated that foods are generally good for 7 days once opened. Additionally, the FSS identified all cooks were…

    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 · D2023-06-22 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility policy, review of facility documentation and interviews for one of three sampled residents (Resident #16) who experienced severe pain and inability to bear weight (change in condition) and required hospitalization, the facility failed to ensure that the APRN/physician was consistently updated when the resident's symptoms of pain persisted, inability to bear weight and the ordered ultrasound was not administered. The findings include: Resident #16's diagnoses included dementia, anxiety, hypertension, benign prostatic hyperplasia, and abnormalities with gait. The resident care plan dated 3/12/23 identified Resident #16 had an ADL (activities of daily living) self-care performance deficit related to dementia with interventions that included: assistance of one person with dressing and personal hygiene/showering. A fall risk assessment dated [DATE] identified Resident #16 was at high risk for falls. The quarterly MDS assessment dated [DATE] identified Resident #16…

    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 before2023-06-22 · 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, review of facility policy, and interviews for three of four sampled residents (Residents #2, #13, and #35) with bathrooms in their rooms, the facility failed to ensure that the water temperatures in the resident bathrooms were maintained within the required range of 105.0 to 120.0 degrees Fahrenheit. The findings include: 1. Resident #2's diagnoses included schizoaffective disorder, bipolar disorder, dementia, adjustment disorder, and hypertension. The quarterly MDS assessment dated [DATE] identified Resident #2 was cognitively intact and required limited assistance for bed mobility, dressing, transfers, ambulation, toilet use and personal hygiene. The resident care plan (RCP) dated 6/5/23 identified a self-care deficit due to psychiatric symptoms with interventions that included: set up assistance for bathing and showering, remind and encourage resident to take showers at times and provide frequent checks for incontinence. Observation on 6/20/23 at 12:30 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-06-22 · tag F0726 — failed to have competent, trained nursing staff — isolated
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of the facility assessment and interview for the intravenous therapy program, the facility failed to identify that licensed and nurse aide staff had demonstrated competency or were educated related to intravenous therapy use. The findings include: Review of the Facility Assessment document dated 9/1/22 identified that the facility would provide intravenous medications and that education and testing of competency for intravenous line care would be provided. Interview with the DNS on 6/22/23 at 1:21 PM failed to identify documentation that licensed nursing or nursing assist facility staff had received education or competencies for intravenous line managment as indicated on the facility assessment and per the facility policy. Review of the Qualifications for Nurse Providing Infusion Therapy policy dated 8/2018 directed documented successful completion of infusion therapy education, documented completion of clinical competencies, and documented annual infusion education which could consist of in-servicing, formal infution therapy educationn programs and or clinical…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-06-22 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, review of facility narcotic records, clinical record review, and facility policy for 3 of 11 sampled residents (Resident #1, #6 and #16) who were reviewed for controlled substance records (narcotics), the facility failed to accurately reconcile controlled medication or identify the potential for diversion for controlled medications. The findings include: 1. Resident #1's diagnoses included cervical disc disorder, type 1 diabetes, and morbid obesity. 2. Resident #6's diagnoses included bipolar disorder and schizophrenia. 3. Resident #16's diagnoses included anxiety disorder, and unspecified dementia mild with anxiety. During a review of the controlled substance disposition records (narcotic sign out forms), irregularities for the correct number of medications administered to Resident #6 failed to match the physician's order at the top of the form. Further, for Resident #1 and Resident #16 the controlled substance disposition records identified that the medication had been distributed twice at the same time to Resident #1 and Resident #16, double the amount 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-06-22 · 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 clinical record review, facility policy review, and interviews for one of three residents (Resident #18) reviewed for unnecessary medication, the pharmacist failed to report a medication irregularity regarding a Gradual Dose Reduction (GDR) for Risperidone (anti-psychotic medication). The findings include: Resident #18's diagnoses included Wernicke's encephalopathy, asthma, depression, malignant left breast cancer. The resident 's physician's orders for the month of June/2023 directed to administer Risperidone tablet (antipsychotic medication) 0.25 milligrams (mg) by mouth twice a day. The origination date of the order was identified as 6/14/22. The psychiatric progress note dated 1/31/23 at 1:13 PM identified Resident #18 had good compliance with medication, no evidence of agitation or compulsive behaviors, and no sign of anxiety, hyperactive or attention difficulties. The note further identified Resident #18's behavior in session was cooperative and attentive with no gross behavioral abnormalities.…

    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 · D2023-06-22 · 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 clinical record review, facility policy review, and interviews for one of three residents (Resident #18) reviewed for unnecessary medication, the facility failed to ensure gradual dose reduction was attempted when a resident was receiving Risperdal (anti-psychotics medication). The findings include: Resident #18's diagnoses included Wernicke's encephalopathy, asthma, depression, malignant left breast cancer. The resident 's physician's orders for the month of June/2023 directed to administer Risperidone tablet (antipsychotic medication) 0.25 milligrams (mg) by mouth twice a day. The origination date of the order was identified as 6/14/22. The psychiatric progress note dated 1/31/23 at 1:13 PM identified Resident #18 had good compliance with medication, no evidence of agitation or compulsive behaviors, and no sign of anxiety, hyperactive or attention difficulties. The note further identified Resident #18's behavior in session was cooperative and attentive with no gross behavioral abnormalities. 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 · D2023-06-22 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interviews, and facility policy during an inspection of medication storage for the only medication cart in the facility, the facility failed to store ophthalmic medications appropriately to prevent cross contamination. The findings include: Observation with RN #1 on 6/21/23 at 11:10 AM of the medication cart identified that Resident #4's, Resident #10's, and Resident #20's Artificial Tears eye drops were stored together in one compartment without the use of dividers, plastic bags, or use of the individual boxes in which the medications were originally contained to prevent cross contamination. Interview with RN #1 on 6/21/23 at 11:10 AM identified the eye drops should have been kept in a plastic bag to separate for each resident. RN #1 further indicated that it was the responsibility of every nurse who used the medication cart to ensure eye drop containers were stored individually and separately. Subsequently to surveyor inquiry, RN #1 removed eye drops from the medication cart. Interview with the Pharmacy Consultant on 6/21/23 at 3:10 PM identified that…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-06-22 · tag F0791 — failed to provide routine dental services — isolated
    Provide or obtain dental services for each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, and interviews for one sampled resident (Resident #20) reviewed for dental services, the facility failed to provide routine dental services to meet the resident's needs. The findings include: Resident #20's diagnoses included obstructive and reflux uropathy, macular degeneration, and chronic atrial fibrillation. A dental consult dated 3/28/23 identified Resident #20 needed hygiene visits and x-rays. The quarterly MDS assessment dated [DATE] identified Resident #20 had intact cognition, required supervision with transfers and eating, and limited assistance with dressing and personal hygiene. The Resident Care Plan dated 4/13/23 identified the resident was at risk for oral/dental health problems and had his/her own teeth. Interventions identified to coordinate arrangements for dental care, transportation as needed and as ordered. Interview with the DNS on 6/21/23 at 10:16 AM identified that the dental consult dated 3/28/23 identified that the resident was seen by the dental…

    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 · D2023-06-22 · tag F0810 — isolated
    Provide special eating equipment and utensils for residents who need them and appropriate assistance.
    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, and interviews for one of thirty residents, (Resident #4), observed during the lunch meal, the facility failed to provide adaptive equipment according to the dietary slip and physician order. The findings include: Resident #4's diagnoses included cerebral vascular accident (stroke), arthritis, and heart failure. The change in condition Minimum Data Set assessment dated [DATE] identified, Resident #4 was without cognitive impairment, she/he required assist of 2 staff for bed mobility, dressing, and transfers. Additionally, she/he required the extensive assistance of 1 staff for meals. The care plan dated 5/25/23 identified that Resident #4 had an activities of daily living deficit, related to a cerebral vascular accident (stroke), and left arm contracture. Observation and review of the dietary slip, during the lunch meal, on 6/20/23 at 12:06 PM directed the use of cups with handles. Observation of Resident #4 identified that she/he had received his/her lunch…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-07-14 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 2 residents (Resident #5 and 24) reviewed for positioning, the facility failed to ensure physician orders were obtained for the use of a custom wheelchair with lap tray. The findings include: 1. Resident #5's diagnoses included Parkinson's disease and Lewy Body dementia. An Occupational Therapy note dated 11/6/20 identified Resident #5 utilized a custom wheelchair with a lap tray for optimal positioning. A physician's order dated 3/10/21 directed to transfer Resident #5 with the assistance of 2 staff to the custom wheelchair. The quarterly MDS dated [DATE] identified Resident #5 had severely impaired cognition, required extensive assistance of 2 staff for transfers, and used a wheelchair. The care plan dated 7/8/21 identified Resident #5 was at risk to fall related to confusion. Interventions included to transfer the resident out of bed to a custom wheelchair with a lap tray for pelvic positioning.…

    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
  • No harm found · C2023-06-22 · tag F0922 — failed to maintain the building's systems — widespread
    Have enough backup water supply for essential areas of the nursing home.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, review of facility policy and review of facility emergency water supply, the facility failed to ensure that there was an adequate amount of emergency potable and non-potable water available for each resident per the requirement. The findings include: Interview with the Administrator on 6/21/23 at 11:49 AM, identified that there was 50 gallons of water on hand for cooking, consumption, and the hygienic needs of all facility residents in the event of an emergency. Review of the provided entrance conference documentation information for the facility emergency water supply failed to indicate the facility had a current emergency water contract in place. Further, the facility failed to have sufficient emergency water storage on hand in the event of a water loss emergency. Review of the facility census (37) and the current water supply on hand, 50 gallons, identified that if the facility had an emergent loss of water, there would be 1.35 gallons of water for each resident for one day. Re-interview with the facility Administrator on 6/22/23 at 1:42 PM failed to identify…

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

    Environmental 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

$24,928 in federal fines across 1 penalty.

  • $24,928 — penalty dated 2025-10-09

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Who owns this facility

Owner / managerTypeRoleSince
JACKSON, SHELLEYIndividualDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/01/1997
JACKSON, THEODOREIndividualDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/01/1997
CARON, JOHNIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/06/2022
D'AMICO, MICHELEIndividualOPERATIONAL/MANAGERIAL CONTROLsince 01/13/1997
WALALIYADDA, ANURUDDHAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/25/2025

CMS files one row per role, so the 15 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$3.6M
Net patient revenuemost recent cost report
-4.9%
Operating marginrevenue minus expenses
$128K
Related-party expense3% of expenses
Who pays — share of resident-days
Medicaid 86%Medicare 4%Other / private 10%

About 86% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $128K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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

Cost & finances

$279per resident / day
operating cost
$8,480per month
≈ monthly operating cost
$266per 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 075431. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-22, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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