Amberwoods Of Farmington
416 Colt Highway, Farmington, CT 06032 · For profit - Limited Liability company · 130 certified beds · (860) 677-1671 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a middle-of-the-pack inspection score (3/5)
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (38) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $20,872 in federal fines (most recent 2024-09-11)
- its payroll-based staffing rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
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 | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 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 | 12.6% | 18.0% | 15.4% | better |
| Long-stay residents who lose too much weight | 4.5% | 6.5% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.7% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 1.2% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 6.0% | 22.3% | 6.5% | typical |
| 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 | 4.2% | 3.5% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 7.3% | 16.4% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 17.7% | 17.6% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 99.1% | 93.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.6% | 4.0% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 24.8% | 24.7% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 15.7% | 17.8% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 0.7% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 100.0% | 69.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 23.7% | 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 | 1.20 | 2.06 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.20 | 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.
56.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 107 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 71.4% 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 0.33 therapist hours per resident per day in 2026Q1 — more than 55% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 23% 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 | 56.5%CMS range 47.0–65.3 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.6%CMS range 7.6–16.4 | 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 | 71.4% | 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 | 76.5% | 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 | 58.8% | 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 | 99.3% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 98.5% | 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 | 0.7% | 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 | 3.9% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.2%CMS range 3.3–9.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.85 | 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 130 beds and averages 123.4 residents a day — about 95% occupied, or roughly 7 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.35 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.37 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.98 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 3.15 hrs/resident/day on weekends vs 3.44 on weekdays — 8% thinner on weekends. RN hours go from 0.42 to 0.25 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 44% 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 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.
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.
38 citations, most serious first. The 12 most serious are shown; the remaining 26 are one tap away and print in full.
- Actual harm · Gcited before2024-09-11 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, facility documentation and interviews for one (1) of three (3) residents, (Resident #3), reviewed for accidents, the facility failed to properly position the resident in bed during the provision of care resulting in the resident slipping out of bed and sustained bilateral femur fractures. The finding includes: Resident #3's diagnoses included Multiple Sclerosis (MS), morbid obesity, and muscle weakness. The Resident Care Plan (RCP) dated 6/10/24 identified that Resident #3 was at risk for falls with interventions that included a Hoyer lift for transfers. The annual Minimum Data Set assessment dated [DATE] identified Resident #3 was cognitively intact and required extensive assistance for bed mobility and had impaired range of motion on both sides of the upper and lower extremities. A care plan update dated 8/18/24 identified that the resident was to have 4 siderails during positioning. A physician's order dated 8/1/24 directed the resident to have assistance of two (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.
- Actual harm · Gcited before2023-11-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility documentation, review of facility policy and interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure care was provided safely to prevent a fall with fracture. The finding included: Resident #1 was admitted to the facility with diagnoses that included spinal stenosis, diabetes mellitus, morbid obesity, and anxiety disorder. An admission MDS dated [DATE] identified Resident #1 had moderate cognitive impairment, required moderate assistance for bed mobility, height was 60 inches (5 feet) and weight was 241 pounds. The Resident Care Plan (RCP) dated 10/9/2023 identified Resident #1 required assistance with ADLs and was a fall risk due to weakness, impaired safety awareness and impaired judgement. Interventions directed to assist as needed with ADLS, encourage the resident to call for help before getting up, assist with activities of daily living as needed, and provide a pressure relieving mattress. A facility…
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 before2026-02-17 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policies, and interviews, for 1 of 2 residents (Resident #1) reviewed for accidents, the facility failed to ensure a resident who was non-ambulatory and dependent on staff for care remained free from injury during a transfer.The findings include:Resident #1 had diagnoses that included multiple sclerosis, obsessive-compulsive disorder, personality disorder, anxiety, morbid obesity, edema, chronic kidney disease, low back pain, arthritis, displaced comminuted fracture of the right femur, and fracture of the left femur. The Resident Care Plan (RCP) dated 3/20/2022 identified Resident #1 is to get out daily of bed at 10:45 AM into an electric wheelchair with interventions that directed use of a mechanical lift with the assistance of two staff. The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #1 had intact cognition and was dependent on staff for transfers. Review of the facility Reportable Event Form dated 6/20/2022 at 2:20…
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 · D2026-02-17 · tag F0726 — failed to have competent, trained nursing staff — isolatedEnsure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, facility policy review, and interviews for 1 of 3 residents (Resident #1) reviewed for accidents, the facility failed to ensure staff were trained in the use of a mechanical lift. The findings include:Resident #1 had diagnoses that included multiple sclerosis, obsessive-compulsive disorder, personality disorder, anxiety, morbid obesity, edema, chronic kidney disease, low back pain, arthritis, displaced comminuted fracture of the right femur, and fracture of the left femur. The Resident Care Plan (RCP) dated 3/20/22 identified Resident #1 was to get out of bed at 10:45 AM daily into an electric wheelchair with interventions that directed use of a mechanical lift with the assistance of two staff.The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #1 had intact cognition and was dependent on staff for transfers. Review of the facility Reportable Event Form dated 6/20/22 at 2:20 PM identified during transfer Resident #1 had a fall 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.
- Potential for harm · Fcited before2025-08-26 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, review of facility documentation, review of facility policy/procedures and interviews, the facility failed to ensure food was labeled appropriately and temperatures completed prior to serving. The findings include:A tour of the kitchen on 7/24/25 at 10:15 AM with the Food Service Director identified a bottle of thousand island dressing that was half filled with a date of 12/31/24 located in the reach in refrigerator. Interview on 7/24/25 at 10:20 AM with the Food Service Director identified opened condiments such as salad dressing should be used within 3 months of opening and then discarded. Observation of the walk-in freezer on 7/24/25 at 10:30 AM identified a frozen apple pie in saran seal with no open date or expiration date. Interview on 7/24/25 at 10:35 Am with the Food Service Director identified she could not locate the open date or expiration date but believed it was from a recent event. Review of the food temperature log on 7/24/25 at 10:40 AM identified no record of food temperature completed on the following days/meals: On 6/1/25, 6/2/25, 6/3/25,…
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 · E2025-08-26 · tag F0835 — failed to run the facility competently — patternAdminister 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 review of facility documentation, review of facility policies and procedures and interviews for the facility reviewed for Administration, the facility administration failed to ensure that all contracted staff who provide direct or indirect care to residents met the training requirements or were provided the mandatory training as outlined in the facility assessment and per regulatory requirements prior to, and while providing ongoing services in the facility. The findings included: Review of the facility assessment dated [DATE] identified under the training plan section indicated a training mechanism for mandatory training of new and existing employees, contracted individuals, and volunteers, in all of the following required areas:Effective communicationResident RightsAbuse, Neglect, and Exploitation Quality Assurance and Performance ImprovementInfection ControlCompliance and EthicsNurse aide competencyBehavioral healthNon-pharmacological interventionsDementia CareOn 8/25/25 at 10:10 AM a request 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.
- Potential for harm · Ecited before2025-08-26 · 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
Based on observations, clinical record review, review of facility documentation, review of facility policy/procedures and interviews for 22 residents (Residents #3, #4, #6, #16, #17, #24, #29, #33, #37, #42, #47, #49, #52, #84, #85, #90, #94, #127, #128, #140, #145 and #146) who received podiatric care from one Podiatrist, the facility failed to ensure a contracted Podiatrist maintained standard precautions, and failed to ensure the podiatry medical equipment was cleaned and disinfected after each resident and prior to use on another resident to prevent cross-contamination and spread of infection. The findings include:Observations on 7/24/25 at 11:40 AM identified the Podiatrist exited Resident #146's room, and was wearing latex gloves, he proceeded to push a cart down the corridor. The cart contained a pair of soiled latex gloves, a small pile of unused gloves, a clear plastic container that contained about a fourth of an inch of bluish colored liquid, the container had a paper towel that covered the bottom of the container, and the container held three metal clipping tools. Two of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-08-26 · 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 observation, review of the clinical record, review of facility documentation, review of facility policy/procedures and interviews for 1 of 4 sampled residents (Resident #113) reviewed for pressure ulcers, the facility failed to ensure an assessment was completed upon identification of a pressure ulcer. The findings include:Resident #113 was admitted to the facility on [DATE] with diagnoses that included lack of coordination, type 2 diabetes mellitus with chronic kidney disease, and dementia. The care plan dated 7/9/25 identified Resident #113 was at risk for skin breakdown related to anticoagulant use with interventions that included: administer pressure relieving devices as ordered, apply house lotion as needed, apply treatments as ordered, dietary consult as needed, turn and reposition per facility policy, weekly skin checks by licensed nurse.The admission assessment dated [DATE] identified a new skin issue on the buttocks, denuded (the loss of the outermost layer of skin) skin wound measurements not…
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 before2025-08-26 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, facility policy review, and interviews for one of six sampled residents (Resident #53) reviewed for accidents, the facility failed to supervise a resident who exhibited wandering behaviors and was at risk for elopement. The findings include:Resident # 53's diagnoses included dementia, anxiety, depression, adjustment disorder, restlessness and agitation.The elopement evaluation dated 4/28/25 identified Resident # 53 was at risk for elopement.The care plan dated 5/27/25 identified Resident #53 was at risk for wandering and elopement with interventions that included: clearly identify the resident's room and bathroom, engage the resident in activity, and re-direct when noted self-propelling in the wheelchair outside the unit, supervision with wheelchair mobility. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #53 had moderate cognitive impairment, required supervision with wheelchair mobility and had not displayed…
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 · D2025-08-26 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy and interviews for one of five sampled residents (Resident #25) reviewed for vaccinations, the facility failed to offer or provide the pneumococcal #20 vaccination. The findings include: Review of the Infection Preventionist's (LPN #1) vaccine line list identified Resident #25 received the pneumococcal #23 on 10/31/20. There were no other noted pneumococcal vaccines listed as administered.A physician's order dated 12/24/24 directed to administer the pneumococcal vaccine. Resident #25's Pneumonia Vaccine Education Documentation Form, indicated the resident elected and agreed to receive the pneumococcal vaccine PVC #20, dated 12/29/24. A physician's order dated 1/21/25, directed to administer the Prevnar #20 intramuscular suspension prefilled syringe 0.5ml, inject 0.5ml intramuscularly as needed for vaccine. Resident #25 was readmitted (original admit date was 12/24/24) to the facility in March of 2025 and had diagnoses that included 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 · Fcited before2024-09-11 · tag F0657 — failed to keep the care plan current — widespreadDevelop 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 clinical record review, facility documentation review, facility policy review, and interviews for two (2) of three (3) residents, (Resident #1 and Resident #3), reviewed for care planning, the facility failed to ensure Resident Care Conferences in accordance with facility policy. The findings include: 1. Resident #1's diagnoses included down syndrome and personality disorder. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was severely cognitively impaired, exhibited behaviors and required maximal assistance with bed mobility and transfers. The Resident Care Plan dated 7/26/24 identified that Resident #1 required assistance with Activities of Daily Living (ADLs) with interventions that included transferring and ambulating with a hand held assist of one and a gait belt, encouraging the resident to do as much for themselves as possible and initiating a therapy consult as needed. Review of the clinical record for Resident #1 failed to identify any documented 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 · D2024-09-11 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation, interviews, and policy review, for one (1) of three (3) residents reviewed for abuse ( Resident #2), the facility failed to ensure that allegations of neglect and abuse were reported to the state agency in accordance with facility policy. The findings included: Resident #2 had diagnoses that included dementia. A quarterly Minimum Data Set assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with activities of daily living, and refused care on a daily basis. A care plan dated 2/28/24 identified that the resident refuses care with interventions that included to notify the family when the resident refuses care. a) Review of a concern/complaint form dated 1/30/24 identified that Resident #2's family member had concerns that on 1/30/24 the resident was found in the same clothes from the day before, pants and the incontinent brief were saturated with urine. The concern form further identified that NA…
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 26 citations
- Potential for harm · D2024-09-11 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation, interviews, and policy review, for one (1) of three (3) residents reviewed for abuse ( Resident #2), the facility failed to ensure that allegations of neglect and abuse were investigated in accordance with facility policy. The findings included: Resident #2 had diagnoses that included dementia. A quarterly Minimum Data Set assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with activities of daily living, and refused care on a daily basis. A care plan dated 2/28/24 identified that the resident refuses care with interventions that included to notify the family when the resident refuses care. a) Review of a concern/complaint form dated 1/30/24 identified that Resident #2's family member had concerns that on 1/30/24 the resident was found in the same clothes from the day before, pants and the incontinent brief were saturated with urine. The concern form further identified that NA #6 had…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-09-11 · 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 review of the clinical record, facility documentation, facility policy and interviews for one (1) of two (2) residents (Resident #1) reviewed for mistreatment, the facility failed to ensure the residents were provided social services support timely after an allegation of abuse/neglect. The findings include: 1. Resident #1's diagnoses included down syndrome, type II diabetes mellitus and congestive heart failure. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was severely cognitively impaired and required maximal assistance with bed mobility and transfers. The Resident Care Plan dated 7/26/24 identified that Resident #1 required assistance with Activities of Daily Living (ADLs). Interventions included transferring and ambulating with a handheld assist of one and a gait belt, encouraging the resident to do as much for themselves as possible and initiating a therapy consult as needed. Review of the facility Reportable Event Form dated 8/28/24 identified that Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-09-11 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation, interviews, and policy review for one (1) of three (3) residents reviewed for infection control, (Resident #2), the facility failed to ensure isolation precautions were put into place in a timely manner. The findings include: Resident #2 had diagnoses that included dementia. A quarterly Minimum Data Set assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with activities of daily living, and refused care on a daily basis. A care plan dated 9/4/24 identified that the resident was placed on Enhanced Barrier Precautions (EBP) related to a multi-drug resistant organism (MDRO) with interventions that included to follow precautions in accordance with facility policy and to ensure adequate hand washing. Observation of Resident #2's room failed to identify any signage to identify that the resident was on enhanced barrier precautions or any Personal Protective Equipment (PPE) was available. Interview…
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 · E2023-12-13 · tag F0561 — failed to honor residents' choices — patternHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the clinical record, facility policy, and interviews for 1 of 1 sampled resident (Resident #25) reviewed for choices, the facility failed to honor an out of bed time preference to attend scheduled morning recreational activities. The findings include: Resident #25 's diagnoses included multiple sclerosis, obesity, and low back pain. A Resident Care Conference note dated 10/11/23 indicated Resident #25 expressed the desire to be out of bed in time to attend morning activities. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #25 as cognitively intact and required extensive 2 person assistance with bed mobility and transfers. The Resident Care Plan dated 11/7/23 identified an activities problem. Interventions included informing Resident #25 of available activities, offering assistance with transportation to and from activities, and encouraging the resident to attend therapeutic recreation programs. Observation on 12/11/23 at 10:38 AM identified Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-12-13 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interviews, and policy review, the facility failed to ensure kitchen staff wore appropriate hair restraints and performed hand hygiene. The findings include: An initial tour of the facility kitchen on 12/6/23 at 10:45 AM with the Food Services Director. At 11:00 AM identified [NAME] #1 was standing in front of the stove, stirring a pot. [NAME] #1 had a hair net over her ponytail, but the top and front of their hair was not covered, exposing her hair. An interview with [NAME] #1 identified that she had forgotten to pull the hair net further forward to cover the rest of her hair. A review of the facility policy on hair coverings indicated that staff's hair should be covered entirely. Additionally, the facility policy indicated that if one hair covering is not enough to cover all of a staff member's hair, then the staff member can use a second hair covering. A second visit to the kitchen on 12/12/23 at 11:40 AM identified [NAME] #2 removing a tray of pork slices from the oven and placed the tray on a cart. [NAME] #2 took the temperature of the food and wiped…
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 · D2023-12-13 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility policy, and interviews for 1 of 1 sampled residents (Resident #95) receiving hemolytic (blood) treatments and who was on a fluid restriction, the facility failed to notify the medical provider when the fluid restriction exceeded physician orders. The findings include: Resident #95's diagnoses included end stage renal disease, hemolytic (blood) treatment, and diabetes. The admission Minimum Data Set assessment dated [DATE] identified Resident #95 was cognitively intact and required extensive assistance of 2 staff with bed mobility and transfers, and extensive assistance of 1 staff with eating. The Resident Care Plan dated 9/19/23 identified Resident #95 received hemolytic treatments. Interventions included providing treatment on Tuesdays, Thursdays, and Saturdays. The care plan failed to identify that Resident #95 was on a fluid restriction. A physician's order dated 11/1/23 through 12/13/23 directed to maintain a 1200 milliliter (ml) fluid restriction. Interview,…
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 before2023-12-13 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review and review of the facility policy for 1 of 2 sampled residents (Resident #62) reviewed for an alteration of skin condition, the facility failed to complete Braden scale assessments per policy. The findings include: Resident #62 was admitted to the facility on [DATE] with diagnosis that included pneumonia, heart failure, and cerebral vascular accident. The Resident Care Plan (RCP) dated 3/22/22 identified a problem with increased potential for skin breakdown and injuries related to incontinence. Interventions included providing an air mattress, ointment to testicles with each incontinent change, incontinent change every 2 hours to monitor bleeding until the area resolves. The RCP dated 1/27/23 identified Resident #62 may experience skin breakdown because of decreased mobility, and incontinence of bladder/bowel. Interventions included providing a pressure reduction mattress set at a weight for 250 pounds and a cushion for the chair, extensive assistance with bowel…
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 · D2023-12-13 · tag F0685 — isolatedAssist a resident in gaining access to vision and hearing services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, review of the clinical record, and interviews for 1 of 2 residents (Resident #14) reviewed for communication and sensory issues, the facility failed to ensure services to replace a broken hearing aide. The findings include: Resident #14's diagnoses included secondary multiple arthritis, right hand contracture and hyperlipidemia. A physician's order dated 1/22/22 directed to follow Resident #14 plan of care. The quarterly Minimum Data Set (MDS) assessments dated 7/13/23 and 10/2/23 identified Resident #14 was cognitively intact and required the use of a hearing aid. Additionally, Resident #14 required two person assistance with transfers and moderate assistance with showers and bathing. The Resident Care Plan dated 10/11/23 identified Resident #14 was hearing impaired. Interventions included providing assistance with cleaning, removing, and inserting hearing aids daily, and that hearing aids should be worn during waking hours. Interview with Resident #14 on 12/7/23 at 9:54 AM indicated that staff were assisting with care approximately 6 months ago and dropped…
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 before2023-12-13 · 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 staff interview, clinical record review and review of the facility policy for 1 of 2 sampled residents (Resident #36) reviewed for pressure ulcers, the facility failed to complete Braden scale assessments per policy. The findings include: Resident #36's diagnoses included dementia, type 2 diabetes, and hemiplegia (inability to move on left side). The Resident Care Plan (RCP) dated 9/14/23 identified Resident #36 was at risk for skin break down due to needing assistance with position changing and ability to respond to pressure. Interventions included to inspect skin during care, notify nurse of redness and irritation areas, offer to help with changing positions and offloading heels as needed. The RCP failed to indicate Resident #36 was refusing offloading. A physician order dated 9/14/23 directed to conduct a Braden scale for prediction of pressure scores risk to be completed weekly for four weeks. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #36 was moderately…
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 · D2023-12-13 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
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 2 sampled residents (Resident #59) reviewed for pain, the facility failed to ensure the Resident Care Plan (RCP) was comprehensive to include pain. The findings include: Resident #59 was admitted to the facility on [DATE] with diagnosis that included a disabling disease of the central nervous system, diabetes, and end stage renal disease. A physician's order dated 4/15/22 and currently in effect directed Acetaminophen (Tylenol) 325 milligrams (mg) take 2 tablets every 4 hours as needed for pain. A physician's order dated 6/23/22 and currently in effect directed Lidocaine cream (an anesthetic cream) 4% applied topically to lower back every morning. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #59 was cognitively intact, required assistance of 1 for bed mobility and eating, dependent and assist of 1 for personal hygiene, and transferring was not attempted. The MDS further…
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 · D2023-12-13 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility policy, and interviews for 1 of 1 sampled resident (Resident #95) receiving hemolytic (blood) treatments and who was on a fluid restriction, the facility failed to accurately identify total fluid intakes over a 24 hour period, failed to ensure fluid restriction parameter amounts for meals, medications, and by shift to abide with the fluid restriction, and failed to ensure an accurate fluid restriction amount in the Dietary Department. The findings include: Resident #95's diagnoses included end stage renal disease, hemolytic (blood) treatment, and diabetes. The admission Minimum Data Set assessment dated [DATE] identified Resident #95 was cognitively intact and required extensive assistance of 2 staff with bed mobility and transfers, and extensive assistance of 1 staff with eating. The Resident Care Plan dated 9/19/23 identified Resident #95 received hemolytic treatments. Interventions included providing treatment on Tuesdays, Thursdays, and Saturdays. The care…
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 · D2023-10-10 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility policy review, and interviews for one of three residents (Resident # 1) reviewed accidents, the facility failed to ensure a comprehensive care plan was developed timely to include impulsive behaviors for a resident with known polydipsia. The findings include: Resident #1 was admitted with diagnoses that included dementia with other behavioral disturbance, chronic obstructive pulmonary disease (COPD), hyponatremia (low blood sodium), and chronic kidney disease (CKD). An admission Minimum Data Set (MDS) dated [DATE] identified Resident #1 had moderate cognitive impairment, required assist of one (1) staff member to ambulate, and was independent with eating. A Resident Care Plan (RCP) dated 8/8/2023 identified Resident #1 had potential for alteration in nutrition and was at risk for dehydration. The interventions directed to encourage to drink fluids of choice. A facility Nurse Practitioner (NP) note written by NP #1 dated 8/15/2023 at 4:36 PM identified Resident #1 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.
- Potential for harm · E2021-10-26 · tag F0578 — failed to honor advance directives / code status — patternHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 24 residents (Resident #5) reviewed for advance directives, the facility failed to ensure the physician's order honored Resident #5's health care instructions for advanced directives. The findings include: Resident #5's diagnoses included vascular dementia with behaviors, alcohol abuse, and a terminal condition. The Advance Directive Communication Form signed by Resident #5's responsible person and dated [DATE] identified that in the event of cardiopulmonary arrest, Resident #5 did not want Cardiopulmonary Resuscitation (CPR) administered. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #5 was moderately cognitively impaired, was independent with bed mobility, required extensive assistance of 1 with dressing, toilet use and personal hygiene, and extensive assistance of 2 with transfers. The Resident Care Plan dated [DATE] identified Resident #5's advanced directive as do not…
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 before2021-10-26 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, clinical record review, and review of facility policy for 1 of 4 residents reviewed for a non pressure wound (Resident #338), the facility failed to monitor a wound. The findings include: Resident #338 diagnoses included dementia and diabetes. The Resident Care Plan dated 5/23/20 identified Resident #338 had a potential for impaired skin integrity. Interventions included to check condition of skin daily and report changes, check condition of skin weekly on shower day, and to utilize a pressure relief mattress and chair pad as ordered. The quarterly MDS assessment dated [DATE] identified Resident #338 had severe cognitive impairment and required extensive assistance for toilet use, dressing, and personal hygiene. A physician's order dated 10/17/20 directed to cleanse a right shoulder abrasion with Normal Saline followed by Bacitracin ointment twice daily for seven days, leave open to air, and check every shift until healed. Nurse's notes dated 10/17/20 at 5:50 PM identified 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.
- Potential for harm · E2021-10-26 · tag F0711 — patternEnsure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record and interviews for two of five residents reviewed for unnecessary medication (Resident #58 and Resident #78), the facility failed to ensure physician orders were signed, reviewed and dated timely. The findings include: 1. Resident #58's diagnoses included dementia. A significant change MDS assessment dated [DATE] identified Resident #58 had a severe cognitive impairment. Interview and record review with the DNS on 10/20/21 at 1:41 PM identified Resident #58's physician orders had not been signed since prior to 4/30/21. The DNS identified the orders should have been signed at least every 60 days, and the physician and nursing staff were responsible to ensure this. The DNS further identified the facility does not have a policy or procedure for the signing of physician's orders. 2. Resident #78 was admitted to the facility on [DATE] with diagnoses that included dementia, atrial fibrillation and osteoarthritis. The admission MDS assessment dated [DATE] identified Resident #78…
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 · E2021-10-26 · tag F0712 — patternEnsure that the resident and his/her doctor meet face-to-face at all required visits.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record and interviews for two of five residents (Resident #58 and Resident #78) reviewed for unnecessary medication, the facility failed to ensure Resident #58's and Resident #78's total program of care was reviewed by the physician and progress notes written at the required intervals. The findings include: 1. Resident #58's diagnoses included dementia. A significant change MDS assessment dated [DATE] identified Resident #58 had a severe cognitive impairment. Interview and record review with the ADNS on 10/19/21 at 3:10 PM failed to identify any physician visits and progress notes since 12/28/20. Interview and record review with the DNS on 10/20/21 at 1:41 PM identified the record did not reflect any physician visits since 12/28/20, and identified visits should be done on admission, at 30, 60 and 90 days of stay, and then every 60 days, which can be alternated with APRN visits. The DNS further identified the facility does not have a policy or procedure for ensuring timely…
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 before2021-10-26 · 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 — the official record, unedited, may be distressing
Based on observations, facility documentation and interviews the facility failed to ensure that foods were stored and prepared under sanitary conditions. The findings included: During tour and observation of the kitchen with the Food Service Director (FSD) on 10/18/21 at 10:15 AM it was identified that the floor was noted to be soiled with patches of black dirt and pieces of frozen mixed vegetables (peas and carrots) were scattered on the floor, two small Styrofoam containers of ice cream were also noted on the floor. On 10/18/21 at 1:45 PM an interview with the FSD identified the dirt and debris on the floor of the freezer and subsequent to surveyor inquiry, the FSD indicated the freezer floor would be cleaned.
- Potential for harm · D2021-10-26 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record and interviews for one of three residents reviewed for activities of daily living (Resident #72) the facility failed to ensure Resident #72 received assistance to maintain his/her dignity and for three residents (Resident #83, Resident #201, and Resident #337) who were in the vacinity during a NA to NA altercation, the facility failed to ensure 2 Nurse Aides conducted themselves professionally to provide a dignified environment for residents. 1. Resident #72's diagnoses included gastroesophageal reflux disease, dysphagia-oropharyngeal abnormal posture, mild cognitive impairment, and major depressive disorder. The Resident Care Plan (RCP) dated 10/15/21 identified Resident #72 as having a problem with alteration in health maintenance. Interventions included to maintain observation for complaints of abdominal pain, discomfort or vomiting. An annual MDS assessment dated [DATE] identified Resident #72 was moderately impaired for decision-making skills, had verbally…
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 · D2021-10-26 · tag F0659 — isolatedProvide care by qualified persons according to each resident's written plan of care.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, review of the clinical record and review of facility documentation for one of three residents (Resident #78) reviewed for accidents, the facility failed to provide assistance of one staff member for ambulation as per the plan of care. The findings include: Resident #78's diagnoses included dementia, atrial fibrillation and osteoarthritis. A fall risk assessment dated [DATE] identified Resident #78 was at a high risk for falls. Reportable Events from 8/5/21 to 10/18/21 identified: Resident #78 was found on the floor in the hallway on 8/5/21, had a fall in the dining room while trying to walk around a scale unassisted by staff on 8/16/21, had a witnessed fall while ambulating in the hallway on 8/25/21, was found on the floor in the hallway on 9/9/21 and sustained a bruise to the right hand, which was identified on 10/17/21 after the resident was observed independently pushing carts and wheelchairs in the hallway. A quarterly MDS assessment dated [DATE] identified Resident #78 had…
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 · D2021-10-26 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the clinical record, interviews and facility documentation for one of three residents (Resident #58) reviewed for Activities of Daily Living (ADLs), the facility failed to ensure staff supervision for meals was provided as per the plan of care. The findings include: Resident #58's diagnoses included dementia and tremor. A Speech Therapy Discharge summary dated [DATE] identified: Nursing staff was educated in compensatory strategies and demonstrating adequate carryover of skills. Reduced signs and symptoms of aspiration was facilitated by single sips, slow rate, small bolus size, in addition to safe swallowing strategies including upright positioning and feeding the resident when alert/interested. A physician's order dated 4/5/21 directed diet level of NDD2 (National Dysphagia Diet, Level 2), thin liquids, and directed single sips, slow rate, alternate solids/liquids, feed when alert/interested. The quarterly MDS assessment dated [DATE] identified Resident #58 had a severe…
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 · D2021-10-26 · 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 observation, interviews, review of the clinical record and facility documentation for two of two residents (Resident #58 and Resident #78) reviewed for nutrition, the facility failed to ensure beverage substitutions were of similar nutritive value and failed to ensure beverages were provided as per meal card/plan of care. The findings include: 1. Resident #58's diagnoses included dementia and tremor. A physician's order dated 4/5/21 directed diet level of NDD2 (National Dysphagia Diet, Level 2), with thin liquids. The quarterly MDS assessment dated [DATE] identified Resident #58 was severely cognitively impaired, required extensive assistance of one for eating and required a mechanically altered diet. The Resident Care Plan dated 9/13/21 identified a problem with having a potential for alteration in nutrition related to difficulty chewing/swallowing and dementia. Interventions included providing a diet as ordered. Observation on 10/20/21 at 9:17 AM identified Resident #58 eating breakfast in bed, 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.
- No harm found · C2025-08-26 · tag F0940 — failed to train staff — widespreadDevelop, 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 review of facility documentation, review of facility policies and procedures and interviews for the facility reviewed for training requirements, the facility failed to ensure that an effective training program was developed, implemented, and maintained for all individuals providing services under a contractual arrangements met the multiple training topic requirements prior to, and while providing ongoing services in the facility according to the facility assessment and regulatory guidance. The findings included:On 8/25/25 at 10:10 AM a request was made to the facility for the education/training documentation to include communication training, resident rights training, Abuse, neglect, and exploitation training, QAPI training, Infection control program training, Compliance and ethics training, nurse aide training, and behavioral health training for all individuals providing direct and indirect services under a contractual arrangements to facility residents. The facility was only able to provide education…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · B2025-08-26 · 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 clinical record review and interviews for one of five sampled residents (Resident #6) reviewed for Preadmission Screening and Resident Review (PASARR), the facility failed to obtain and complete the PASARR level II screen after the resident received a qualifying diagnosis. The findings include: Resident #6's diagnoses included paranoid schizophrenia, bipolar disorder, depression, and obsessive-compulsive disorder. The quarterly MDS assessment dated [DATE] identified Resident #6 had intact cognition and required extensive assistance for bed mobility, transfers, toileting and hygiene. Interview with SW #1 on 7/31/25 at 9:45 AM identified that the social workers are responsible for submitting requests for a Level II PASARR screening when there is a qualifying diagnosis that was not known when the resident was admitted to the facility. She identified that Resident #6 had new diagnoses of paranoid schizophrenia and bipolar disorder on 1/25/22, which would require a PASARR level II screening to be completed.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · Bcited before2023-12-13 · tag F0657 — failed to keep the care plan current — patternDevelop 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 record review, resident and staff interviews and facility policy for 1 of 3 sampled residents (Resident #2) reviewed for participation in care planning, the facility failed to ensure Resident #2 was invited to care plan meetings. The findings include: Resident #2 was admitted to the facility on [DATE] with a diagnosis of quadriplegic cerebral palsy, depression, and epilepsy. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #2 was cognitively intact, had adequate hearing, had clear speech, was able to make themselves understood, and was able to understand others. The MDS assessment also indicated that Resident #2 was dependent on two people for bed mobility. The quarterly Care Conference Report dated 4/19/23 identified Resident #2's family member attended the care conference. Resident #2 did not attend and the report failed to indicate if Resident #2 had been invited to the care conference. Facility documentation for resident activities dated 4/19/23 identified Resident #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.
- No harm found · B2021-10-26 · tag F0623 — patternProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal 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 clinical record review and interviews for two of two residents (Resident #12 and Resident #24) reviewed for hospitalization, the facility failed to ensure the Ombudsman was notified of a hospital transfer. The findings include: 1. Resident #12's diagnoses included dementia. The quarterly MDS assessment dated [DATE] identified Resident #12 was severely cognitively impaired. A physician's order dated [DATE] directed to send Resident #12 to the hospital. A Situation, Background, Assessment, Recommendation (SBAR) Communication Form dated [DATE] identified APRN #2 evaluated Resident #12 for altered respiratory status and directed to send Resident #12 to the emergency room (ER) for further evaluation. A nurse's note dated [DATE] identified Resident #12 was sent to ER for evaluation at 1:50 PM. A nurse's note dated [DATE] identified Resident #12's family came to collect resident belongings and informed the facility that Resident #12 expired at the hospital. 2. Resident #24's diagnoses included dementia. 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.
- No harm found · B2021-10-26 · tag F0732 — patternPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, a written statement, facility documentation and interviews for 6 of 24 nursing shifts, the facility failed to ensure daily nurse staffing information was posted consistently. On 10/14/21, Person #2 indicated that the facility had not been consistently completing and posting daily staffing sheets in entirety. Person #2 identified the facility was completing the staffing sheets on a shift by shift basis and not for a 24 hour period. Observation on 10/18/21 at 10:00 AM identified that the posted daily nurse staffing form only included the staffing level for the 7:00 AM to 3:00 PM shift and lacked nurse staffing hours for the 3:00 PM to 11:00 PM shift and 11:00 PM to 7:00 AM shift. Further observations of the daily nurse staffing forms from 10/11/21 through 10/17/21 identified a total of 6 shifts that did not have nurse staffing data posted. An interview with Person #2 on 10/20/21 at 2:45 PM identified that he/she visited the facility a couple of times and spoke with the DNS and Administrator to fill out the daily staffing sheets in entirety. Person #2 further…
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
$20,872 in federal fines across 2 penalties.
- $10,033 — penalty dated 2024-09-11
- $10,839 — penalty dated 2023-11-20
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 / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| STRASSER, REBECCA | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 25% | since 08/01/2023 |
| STRASSER, SOLOMON | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 75% | since 08/01/2023 |
| ZELLA HEALTHCARE CONSULTING LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/09/2025 |
| BAROCHIA, SANJAY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/09/2025 |
| COCOZZA, RENATA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 08/01/2023 |
| MUNDAKAL, BELLA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 08/01/2023 |
| APEX GLOBAL SOLUTIONS LLC | Organization | ADP OF THE SNF | — | since 08/01/2023 |
| GUARDIAN CONSULTING SERVICES | Organization | ADP OF THE SNF | — | since 08/01/2023 |
| LTC CONSULTING SERVICES LLC | Organization | ADP OF THE SNF | — | since 08/01/2023 |
| PHARMSCRIPT OF CT LLC | Organization | ADP OF THE SNF | — | since 08/01/2023 |
| PREFERRED THERAPY SOLUTIONS LLC | Organization | ADP OF THE SNF | — | since 08/01/2023 |
CMS files one row per role, so the 22 rows in the source record cover these 11 parties — each is shown once here with every role it holds. Nothing is omitted.
6 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $85K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in CT
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Connecticut Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 075419. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-26, 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.