Civita Care Meadowbrook
350 Salmon Brook Street, Granby, CT 06035 · For profit - Corporation · 90 certified beds · (860) 653-9888 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- lower-than-typical staff turnover (21% vs 45% nationally) — better care continuity
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0600), cited Jan 2024
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 3 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 | 4 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 3 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 | 18.4% | 18.0% | 15.4% | worse |
| Long-stay residents who lose too much weight | 9.0% | 6.5% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.3% | 0.7% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 1.7% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 6.6% | 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 | 3.3% | 3.5% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 18.1% | 16.4% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 23.6% | 17.6% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 95.3% | 93.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.8% | 4.0% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 28.0% | 24.7% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 5.7% | 17.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 3.9% | 1.5% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 91.2% | 69.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 27.4% | 24.3% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 9.5% | 10.7% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.70 | 2.06 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 1.44 | 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.
67.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 158 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 54.7% 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 75 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 0.34 therapist hours per resident per day in 2026Q1 — more than 57% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 20% 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 | 67.6%CMS range 58.8–74.4 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.7%CMS range 6.9–13.2 | 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 | 54.7% | 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 | 40.0% | 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 | 66.7% | 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 | 90.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 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 | 97.3% | 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 | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 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 | 6.8%CMS range 4.2–10.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.97 | 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 90 beds and averages 83.1 residents a day — about 92% 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 3.54 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.43 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.07 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 3.29 hrs/resident/day on weekends vs 3.64 on weekdays — 10% thinner on weekends. RN hours go from 0.46 to 0.36 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 21% is below the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
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.
30 citations, most serious first. The 10 most serious are shown; the remaining 20 are one tap away and print in full.
- Potential for harm · Dcited before2026-03-10 · 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 policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for activities of daily living (ADL) care, the facility failed to ensure a safe environment and protect a non-ambulatory, cognitively impaired resident who was totally dependent on staff for transfers from injury. This failure resulted in Resident #1 sustaining a femur fracture and displaced tibia and fibula fractures requiring surgical intervention. The findings include:Resident #1 was admitted to the facility with diagnoses that included dementia and osteoarthritis. Resident #1 had a power of attorney for health decisions. The Fall Risk assessment dated [DATE] identified Resident #1 was at risk for falls.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severely impaired cognition (Brief Interview for Mental Status (BIMS) score of 0) and was always incontinent of bowel and bladder.The Resident Care Plan (RCP) dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-10 · 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, and interviews for one (1) of two (2) residents (Resident #1) reviewed for medically-related social services, the facility failed to ensure medically-related social services were provided and documented.The findings include: Resident #1 was admitted to the facility with diagnoses that included dementia and schizoaffective disorder. Resident #1 had a power of attorney (POA) for health decisions. The Social Work (SW) Annual assessment dated [DATE] identified Resident #1 was alert to self primarily with observed cognition deficits related to place and times as well as confusion. The note identified the SW was available for emotional support as well as concerns or complaints.The Social Service Quarterly assessment dated [DATE] identified Resident #1 continued to present with severe cognitive impairment due to advanced dementia. Resident #1's mood remained stable and continued to appear calm and friendly with poor insight and judgement. The note…
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 before2025-12-02 · tag F0578 — failed to honor advance directives / code status — isolatedHonor 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, review of facility policy and interviews for one of twenty-three sampled residents (Resident #4) reviewed for advance directives, the facility failed to ensure the physician's order matched the wishes of the resident/responsible party. The findings include: Resident #4's diagnoses included atrial flutter, Type 1 diabetes mellitus with hyperglycemia, and mild intellectual disability. The quarterly MDS assessment dated [DATE] identified Resident #4 had intact cognition, required moderate assistance with personal hygiene, was independent with bed mobility and utilized a walker for mobility. Resident #4's clinical record (physical) identified a folded Advanced Directives Declaration Code Status form that identified Resident #4 had elected a code status of Do Not Resituate (DNR) which means if the resident stops breathing or if the resident's heart stops beating, cardiopulmonary resuscitation will not be provided. It also identified that the election of Do Not intubate (DNI)…
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 before2025-12-02 · 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 clinical record reviews, review of facility documentation, and review of facility policy for one of three sampled residents (Resident #40) reviewed for medication reconciliation, the facility failed to ensure the medications from the hospital discharge instructions were accurately transcribed to the facility electronic physician's orders to prevent medication error and for one sampled resident (Resident #88) reviewed for bowel function, the facility failed to ensure the bowel regimen was followed as per physician order and facility policy. The findings include:1. Resident #40's was admitted to the facility on [DATE] with diagnoses that included multiple fractures of the ribs, wedge compression fracture of 4th lumbar vertebrae, delirium, glaucoma, Gastro-Esophageal Reflux Disease (GERD), depression and dementia. Review of Resident #40's hospital Discharge summary dated [DATE] identified the following medication instructions: continue taking cyanocobalamin 100 microgram (mcg) (vitamin) by mouth once 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 · Dcited before2025-12-02 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, review of facility policy and interviews for one sampled resident reviewed for hydration (Resident #88), the facility failed to ensure a resident's hydration needs were assessed and did not ensure that intake and output were consistently documented as per facility policy. The findings include: A hospital discharge summary report dated 8/28/2025 identified Resident #88 may have been dry with a creatinine that had increased from 1.2 to 1.5 on 8/24/2025 and that there were no concerns that would necessitate hospitalization. Resident #88 was then admitted to the facility on [DATE] with diagnoses that included fusion of the cervical spine, cognitive communication deficit, and weakness. A nursing admission assessment dated [DATE] at 9:30 AM identified Resident #88 was alert and oriented to person, place, and time. The resident's abdomen was soft, non-tender, and had normal bowel sounds, and the last bowel movement was on 8/28/2025. The admission assessment also indicated…
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 before2025-12-02 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, review of facility policy/procedures and interviews for 1 of 2 medication carts reviewed for medication storage (unit 3), the facility failed to ensure control drugs were secured under double lock. The findings include:Observation on 12/1/25 at 11:10AM with LPN#3 identified the unit 3 medication cart identified LPN #3 used a key to unlock the medication cart and once opened she was able to lift the door to the compartment that contained the controlled medications (the controlled medications were not double locked).Interview on 12/1/25 at 11:15 AM with LPN#3 identified that sometimes due to the cards in the drawer the drawer does not click shut. However, the drawer closed and locked when LPN#3 attempted to secure the lock and identified the lock does work and is not broken. Interview on 12/2/25 at 1:30 PM with the DNS identified that control drugs should be secured under double lock in the medication cart. The nurse should have had the lock box inside the cart secured. She had not heard of any issue with the medication cart having any difficulty locking. Review…
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 before2025-12-02 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, review of facility policy and interviews, the facility failed to ensure expired food items stored in the first-floor nourishment room, were removed. The findings include:Observation on 11/25/25 at 1:08 PM identified the first-floor nourishment room refrigerator contained; 14-(4) ounce individual containers of orange juice with an expiration date of 11/7/25, 3-(4) ounce individual containers of orange juice with an expiration date of 11/19/25, and a container of yogurt with an expiration date of 11/15/25.Interview on 11/25/25 at 1:30 PM with the Food Service Director (FSD), identified the prep cook is responsible for checking the refrigerators daily and removing any expired items and restocking the refrigerators. The orange juice and yogurt should have been removed. All expired orange juice and yogurt were removed by the FSD and discarded. An attempt to interview the Prep [NAME] on 11/26/25 at 11:42 AM was unsuccessful. The Personal Food Policy directed that the dietary aides were responsible for checking nourishment refrigerator's daily. Food Brought in From…
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 · D2024-07-03 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a clinical record review, review of facility documentation and staff interviews for one of three sampled residents reviewed for hospitalization (Resident #1), for the newly admitted resident, the facility failed to ensure a baseline care plan was developed and implemented to address the residents fractured (broken) ribs. The findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses that included diabetes, hypertension, metabolic encephalopathy and dementia with behavioral disturbances. Review of Resident #1's Chest CT (computed tomography) performed at Hospital #1 on 4/15/23 (prior to admission to the long term care facility) identified the resident with an acute/subacute nondisplaced left posterior, 10th rib fracture. Further review of hospital documentation identified the resident with pleural effusion and a malignancy was suspected. Review of Hospital #1's Discharge summary dated [DATE] (printed on 7/3/24) identified the resident with recurrent falls and an acute/subacute…
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 · D2024-06-05 · 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 documentation, facility policy, and interviews for one of three residents (Resident #1) reviewed for quality of care, the facility failed to notify the physician of critical lab values timely. The findings include: Resident #1's diagnoses included methicillin resistant staphylococcus aureus infection, urinary tract infection, dysphagia, and depression. The RCP dated 1/21/2024 identified Resident #1 was receiving intravenous (IV) therapy (Vancomycin) for recurrent UTI's (urinary tract infection). Interventions directed to monitor intake and output every shift, and to administer IV Vancomycin as ordered. A physician order dated 1/21/2024 directed to obtain lab work for CBC (complete blood count) with differential, CMP (comprehensive metabolic panel), ESR (erythrocyte sedimentation rate), CRP (c-reactive protein), and a Vancomycin trough weekly on Mondays. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 had severely impaired cognition…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-06-05 · 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 clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for quality of care, the facility failed to ensure IV antibiotics were administered timely in accordance with physician orders. The findings include: Resident #1's diagnoses included methicillin resistant staphylococcus aureus infection, urinary tract infection, dysphagia, and depression. The RCP dated 1/21/2024 identified Resident #1 was receiving intravenous (IV) therapy (Vancomycin) for recurrent UTI's (urinary tract infection). Interventions directed to monitor intake and output every shift, and to administer IV Vancomycin as ordered. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 had severely impaired cognition and received IV antibiotics. a. A physician order dated 1/21/2024 directed to administer Vancomycin HCI Intravenous Solution 1500 mg/300 ml, every 18 hours, IV. Review of the January 2024 eMAR (electronic medication…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 20 citations
- Potential for harm · Dcited before2024-06-05 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for hydration, the facility failed to ensure intake and output was monitored in accordance with physician orders, and failed to perform a dehydration evaluation timely for a resident not meeting their estimated daily fluid needs. The findings include: Resident #1's diagnoses included methicillin resistant staphylococcus aureus infection, urinary tract infection, dysphagia, and depression. A physician order dated 1/20/2024 directed to monitor intake and output (I & O), every shift for 72 hours, upon admission/readmission, and to document on I & O paper flowsheet. Review of Resident #1's Nutrition Evaluation dated 1/20/2024 identified Resident #1's estimated daily fluid needs totaled 1875 milliliters (mls). The care plan dated 1/25/2024 identified Resident #1 as at risk for malnutrition related to severe cognitive changes, variable oral intake, slight weight loss,…
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 before2024-01-23 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation of the kitchen and nourishment room and interview for 1 of 2 nourishment rooms, the failed to failed provide a safe and sanitary ice maker and ensure safe nourishment room cabinet without in disrepair. The findings include: Observation on 1/16/24 at 11:16 AM of second floor, Unit II nourishment room, identified the door was open and accessible to residents. The ice maker dispensing machine was streaked with a large amount of whitish colored scale-like build-up and rusted black/gray grates on the ice maker machine's catch tray. The catch tray also contained brown-reddish colored areas, the countertop edge and door were flaking with lifting or missing laminate, brownish streaks were observed dried and dripping down inner side of cabinet door, and the cabinet area under and in the sink's cabinet wood was lumpy and swollen. On 1/16/24 at 11:21 AM interview and observation of second floor, Unit II nourishment room with LPN #1 identified the ice machine was not cleaned. She indicated that the ice maker had been cleaned on 1/15/24, as per paper hanging on the machine…
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 · D2024-01-23 · 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 reviews, facility documentation, facility policy and interviews for 2 of 2 residents reviewed for abuse (Resident #75 and Resident #333), the facility failed to ensure timely reporting of allegations of abuse and/or threats to the state facility. The findings included: 1. Resident #75's diagnosis' included diabetes mellitus, chronic kidney disease, acute kidney failure and anxiety. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #75 was cognitively intact. The Resident Care Plan (RCP) dated 12/18/2023 indicated Resident #75 had a history of anxiety Interventions included in part to provide a calm quiet environment and to offer support and reassurance. An Admissions Progress Note dated 1/21/2024 at 10:44 AM indicated in part, while speaking with a family member it was identified that the person did not want to hold Resident #75's bed while hospitalized secondary to Resident #75 was yelled at by a nurse. The resident was unable to identify the staff member.…
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 · D2024-01-23 · tag F0636 — isolatedAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, and interviews for 1 of 1 resident (Resident #54) reviewed for Communication-Sensory, the facility failed to ensure a resident's ability to hear was comprehensively assessed prior to coding the Minimum Data Set (MDS) assessment. The findings include. Resident #54's diagnosis' included fall with hip fracture, depression, and generalized anxiety disorder. The admission nursing assessment dated [DATE] indicated minimal difficulty hearing with no hearing aid. The Recreation assessment dated [DATE] indicated Resident #54's hearing was poor. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #54's ability to hear was adequate, could understand others and indicated the resident was cognitively intact. The Care plan dated 12/19/2023 indicated in part, Resident #54 had a history of anxiety. Interventions included encouraging participation in activities of interest and encourage verbalizing thoughts and feelings. An observation on 1/17/2023 at 9:23…
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 · D2024-01-23 · 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, observation, and interviews for 1 of 1 resident (Resident #54) reviewed for Communication-Sensory, the facility failed to ensure the resident had comprehensive person-centered care plan to address the resident's hearing needs. The finding include: Resident #54's diagnosis' included fall with hip fracture, depression, and generalized anxiety disorder. The admission nursing assessment dated [DATE] indicated minimal difficulty hearing with no hearing aid. The Recreation assessment dated [DATE] indicated Resident #54's hearing was poor. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #54's ability to hear was adequate, could understand others and indicated the resident was cognitively intact. The Care plan dated 12/19/2023 indicated in part, Resident #54 had a history of anxiety. Interventions included encouraging participation in activities of interest and encourage verbalizing thoughts and feelings. An observation on 1/17/2023 at 9:23 AM indicated…
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 · D2024-01-23 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, policy review and interview for 1 of 5 residents (Resident #184) reviewed for unnecessary medications, the facility failed to review and revise the residents care plan related to Activities of Daily Living (ADL) and feeding. The findings include: Resident #184 diagnoses include Alzheimer's disease, dementia, and generalized weakness. The physician's orders dated 1/1/24 directed regular diet. The admission MDS assessment dated [DATE] indicated Resident #184 was moderately cognitively impaired and required partial/moderate assistance in eating, toileting, and hygiene. The occupational orders dated 1/9/24 indicated Resident #184 was a total assistance self-feed. The rehabilitation screening dated 1/9/24 failed to screen Resident #184 for feeding abilities. The Resident Care Plan (RCP) dated 1/9/24 indicated Resident #184 has an ADL deficit related to generalized weakness and recent hospitalization for seizures with goals for the resident to participate in ADLs as able times 90 days.…
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 before2024-01-23 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, policy review and interviews for 1 of 1 resident (Resident #78) reviewed for death, the facility failed to obtain a physician's order for the release of the resident's body resident and for 1 of 1 resident (Resident #184) reviewed for nutrition, the facility failed to obtain a physician's order to clarify the resident's feeding abilities. The findings included. 1. Resident #78's diagnoses included atherosclerotic heart disease and heart failure. A physician's order dated [DATE] directed Resident #78's code status as Do Not Resuscitate (DNR), Do Not Intubate (DNI), and directed an RN may pronounce at the time of death. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #78 was cognitively intact. The care plan dated [DATE] identified Resident #78 for advanced directives included DNR and DNI. The progress note labeled RN Pronouncement of Death dated [DATE] at 2:27 PM for a completion on [DATE] at 2:20 PM by the Assistant Director of Nursing Services…
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 · D2024-01-23 · tag F0660 — isolatedPlan the resident's discharge to meet the resident's goals and needs.
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 1 resident (Resident #80) reviewed for discharge, the facility failed to follow their policy regarding an unplanned discharge, provide an Inter-Agency Referral Report and notify the Ombudsman with correct information regarding of discharge. The findings included: Resident #80's diagnoses included: orthostatic hypotension (low blood pressure), diabetes mellitus, and anemia. An admission MDS assessment dated [DATE] indicated the resident was cognitively intact and required supervision or touching assistance with personal hygiene, dressing, bathing, transfers, ambulation and was independent with rolling side to side, sitting and standing up and eating. a. An RCP dated 10/20/23 identified Resident #80 had not been care planned for discharge within 48 hours of the resident's admission to present. The hospital discharge Inter-Agency Patient Referral Report form dated 10/20/23 indicated the resident had a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-01-23 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, policy review and interviews for 1 of 1 resident (Resident #78) reviewed for death, the facility failed to obtain a physician's order for the release of the resident's body resident and 1 of 4 sampled residents (Resident #4) reviewed for Nutrition, the facility failed to follow the physician's order for 1:1 supervision during meals. The findings included: 1. Resident #78's diagnoses included atherosclerotic heart disease and heart failure. A physician's order dated 7/6/2022 directed Resident #78's code status as Do Not Resuscitate (DNR), Do Not Intubate (DNI), and directed an RN may pronounce at the time of death. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #78 was cognitively intact. The care plan dated 11/28/2023 identified Resident #78 for advanced directives included DNR and DNI. The progress note labeled RN Pronouncement of Death dated 12/21/2023 at 2:27 PM for a completion on 12/21/2023 at 2:20 PM by the Assistant Director of Nursing…
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 before2024-01-23 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, observations, review of policy and interviews for 2 of 4 residents (Residents #56 and #184) reviewed for nutrition, the facility failed to ensure weights were obtained per the physician order. The findings included: 1. Resident #56's diagnoses included aortic stenosis, atherosclerotic heart disease and diabetes mellitus. The physician's orders dated 1/4/2024 directed to provide a controlled carbohydrate diet of regular consistency texture with thin liquids and to obtain a weight on admission and for 4 consecutive weeks post admission then reassess the need to obtain every Tuesday for 4 weeks (admission 1/4/2024, Tuesday 1/9/24, 1/16/24 and 1/23/24). The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #56 was cognitively impaired, required a set up for feeding and was dependent of staff for transfer from bed to chair and back and did not ambulate. A physician's note dated 1/14/2023 identified the resident was examined due to fever and vomiting with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-23 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record, observations, review of policy and interviews for 2 of 2 residents (Resident #15 and #32) reviewed for respiratory care, the facility failed to post cautionary and safety signs indicating the use of oxygen outside a resident's room and failed to ensure oxygen was infusing at an appropriate concentration. The findings included: 1. Resident #15's diagnoses include congestive heart failure (CHF), persistent asthma, and chronic respiratory failure with hypoxia (Hypoxemia is a below-normal level of oxygen in your blood, specifically in the arteries). The RCP dated 10/16/23 identified the resident had COPD (chronic obstructive pulmonary disease) with interventions directing to administer oxygen and monitor effectiveness by checking saturation as indicated. The MDS assessment dated [DATE] identified Resident #15 as moderately cognitively impaired and required maximum assistance with personal hygiene and noted the resident was completely dependent for assistance with bathing and toileting.…
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 before2024-01-23 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, review of facility policy and interview for 1 of 2 medication carts. The facility failed to ensure a medication cart was not unlocked in a resident area to ensure a safe environment. The finding include: Observation on 1/18/24 at 12:05 PM on second floor, Unit III, identified a medication cart was located outside a resident's room in 232, the cart was observed to be unlocked and unattended while residents were noted to be sitting in hall area near nursing station not within eyesight of a licensed staff. Interview with charge nurse, LPN #5 identified she thought the medication cart was locked. She further indicated that there were cognitively impaired residents on this unit and that it was the facility practice to leave a medication cart unlocked. LPN # 5 then proceeded to immediately lock the cart. The 1/3/24 policy titled Medication Storage Room/Medication Cart Policy notes, the facility provides pharmaceutical services that are conducted in accordance with ethical and professional standards of practice and that meet applicable Federal, State and Local Laws,…
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 · D2024-01-23 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — the official record, unedited, may be distressing
Based observation, review of the facility policy and interview for 1 of 5 residents reviewed for Medication Administration (Resident #22), the facility failed to perform hand hygiene following glove removal. The findings include: Observation and interview with LPN #6 on 1/19/24 at 6:27 AM identified s/he failed to perform hand hygiene following glove removal after performing a blood glucose test. LPN #6 identified s/he was supposed to perform hand hygiene following glove removal, policy directed to perform hand hygiene following glove removal. Interview with DNS on 1/19/24 at 7:55 AM indicated staff is directed to follow policy and perform hand hygiene following glove removal. Review of the Hand Hygiene Policy revised on 1/3/24, directed to utilize hand sanitizer before putting on gloves and after removing gloves.
- Potential for harm · D2024-01-23 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility policy and interviews for 1 of 2 residents reviewed for abuse (Resident #333), the facility failed to ensure administration was notified immediately of the resident's threatening statement about NA # 9 per facility practice. The findings include: Resident #333's diagnoses included diabetes mellitus, Type 2, Benign Prostatic Hyperplasia (BPH), and adjustment disorder. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #333 was moderately cognitively impaired and required extensive assistance with toilet use, dressing and personal hygiene. A nursing note dated 10/3/22 at 4:18 PM by the Director of Nursing Services (DNS) identified Resident #333 expressed concerns related to care received during the 11:00 PM to 7:00 AM shift. Resident #333 indicated his/her sweatpants were removed and placed on the bedside chair while care was given. The DNS explained the standard of care to the resident, the rounding process, and how hygienic care 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 · Dcited before2021-10-26 · tag F0578 — failed to honor advance directives / code status — isolatedHonor 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 2 residents (Resident #38) who was reviewed for advance directives, the facility failed to establish the resident's wishes regarding code status, (what measures to take if the resident experiences cardiopulmonary arrest) and ensure those wishes were documented in the clinical record. The findings include: Resident #38 diagnoses included urinary tract infection, seizure disorder, and cognitive communication deficit. The care plan dated 9/4/21 failed to reflect the residents wishes regarding advance directive or living will. Physician's orders dated 9/4/21 failed to address Resident's #38's code status. The admission MDS dated [DATE] identified Resident #38 had moderately impaired cognition, no potential indicators of psychosis, had indwelling Foley catheter and feeding tube, did not ambulate and was totally dependent requiring extensive assistance with all activities of daily living. The MDS also identified…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-10-26 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, review of facility policies, and interviews for one of three sampled residents (Resident #278) who were reviewed for medication administration, the facility failed to clarify the strength of a medication and failed to enter a medication onto the Medication Administration Record on admission. The findings include: Resident #278's diagnoses included recurrent depressive disorder and anxiety. a. The Smoking Evaluation and Safety Screen dated 10/23/19 identified Resident #278 was a current smoker, did not wish to smoke and two (2) weeks ago was the last time Resident #278 smoked. The hospital discharge instructions dated 10/23/19 directed to administer Nicotine 14 milligrams (mg) per 24 hours place one (1) patch onto the skin daily. A physician's order dated 10/23/19 directed Nicotine Kit 21-14-7 milligrams/24 hours apply one (1) patch transdermally one (1) time a day for tobacco use and remove per schedule. Review of the October 2019 Medication Administration Record identified that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-10-26 · 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 observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #8) reviewed for accidents, the facility failed to ensure a safe environment and that interventions were put into place for the resident's safety after an elopement. The findings include: Resident #8 was admitted with diagnoses that included dementia without behavioral disturbance, vertigo, repeated falls, and anxiety disorder. A care plan dated 4/7/21 identified Resident #8 was at risk for wandering and was occasionally exit seeking. Interventions included to provide specific diversional activity such as magazines, socializing with peers and staff, and to place wander-guard to left ankle (device to trigger exit alarm), checking function every night, and checking placement every shift. An elopement risk assessment dated [DATE] identified Resident #8 was at risk for elopement and wandering. The quarterly MDS dated [DATE] identified Resident #8 had moderately impaired…
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 F0694 — isolatedProvide for the safe, appropriate administration of IV fluids for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility's documentation, facility's policy and interviews for 1 resident (Resident #66) who was reviewed for intravenous infusion (IV) therapy, the facility failed to provide care according to professional standard regarding the resident's central line. The findings include: Resident #66's diagnoses included diabetes and congestive heart failure. The admission MDS dated [DATE] identified Resident #66 had no cognitive impairment with no behavioral indicators of psychosis, required extensive assistance of 1 or more persons to complete activities of daily living, and used a wheelchair or walker. Further, the MDS indicated Resident #66 was status post repair of the pelvis/hip. The hospital Discharge summary dated [DATE] identified a tunneled catheter, double lumen was placed in the residents right internal jugular on 9/15/21 at 2:56 PM. The care plan dated 9/16/21 to 10/1/21 identified Resident #66 is receiving IV antibiotic therapy for hip infection via PICC.…
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 · B2025-12-02 · tag F0628 — patternProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, review of facility documentation, review of facility policy, and interviews for two sampled residents (Resident #86 and #88) reviewed for hospitalization and discharge to the community, the facility failed to ensure the Ombudsman's office was provided with the required notification of the transfer and the discharge. The findings include: 1. Resident #86's diagnoses included malignant neoplasm of brain and unspecified part of bronchus or lung, hypertensive heart disease with heart failure, and aphasia. The admission MDS assessment dated [DATE] identified Resident #86 had moderate cognitive impairment. RN #2's progress note dated 9/3/25 at 9:00 PM identified that on 9/2/25 Resident #86 was observed in respiratory distress had oxygen saturation rates in the 70's, was placed on a non-rebreather oxygen mask at 6 liters and was sent to the acute care hospital. The Director of Social Service's (SW #1) progress note dated 9/3/25 at 9:58 AM identified Resident #86 was transferred out to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · B2025-12-02 · tag F0730 — patternObserve each nurse aide's job performance and give regular training.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of facility documentation, review of facility policy/procedures and interviews for 2 of 3 Nurse Aides (NA #1 and NA #2) reviewed for annual performance evaluations, the facility failed to ensure they were completed and available for review. The findings include:Based on review of facility documentation, review of facility policy/procedures and interviews for 2 of 3 Nurse Aides reviewed for annual performance evaluations, the facility failed to ensure they were completed and available for review. The findings included: Review of personnel records for Nurse Aide performance reviewed identified NA#1 had an evaluation 11/20/24 and was due to have one completed 11/2025. No evaluation was available to review in the personnel record or could be located for NA#1. NA#2 had an evaluation completed 10/9/25 and no 2024 evaluation was available in the personnel record or could be located to review.Interview on 11/26/25 at 9:30AM with Human Resources identified he started in May of 2025 and was unable to locate the missing reviews. It was his understanding that the DNS 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.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to ATHENA HEALTHCARE SYSTEMS — 22 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 1.5 | +2.5 vs chain |
| Health inspection | 4 of 5 | 1.7 | +2.3 vs chain |
| Staffing | 3 of 5 | 2.1 | +0.9 vs chain |
| Quality measures | 4 of 5 | 2.5 | +1.5 vs chain |
The other 21 homes this chain runs (chain average 1.5★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| CHAKALOS-SANTILLI, VALERIE | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 6% | since 06/07/2012 |
| CURTIS, DIANE | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 5% | since 06/07/2012 |
| MOSIER, MICHAEL | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; W-2 MANAGING EMPLOYEE | 7% | since 06/06/1990 |
| SANTILLI, LAWRENCE | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 73% | since 12/31/2018 |
| ATHENA HEALTH CARE ASSOCIATES, INC. | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 01/01/2012 |
CMS files one row per role, so the 6 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $1.5M paid to related parties — landlords or management companies under common ownership — equal to about 11% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in CT
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Connecticut Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 075367. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-02, 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.