Greenwich Woods Rehabilitation
1165 King Street, Greenwich, CT 06831 · For profit - Limited Liability company · 217 certified beds · (203) 531-1335 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- lower-than-typical staff turnover (35% vs 45% nationally) — better care continuity
- it has an abuse, neglect, or exploitation citation (F0600), cited Jul 2022
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (31) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $130,496 in federal fines (most recent 2025-03-19)
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection rating is low (1/5)
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 | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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 | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 5 to 1 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 | 30.4% | 18.0% | 15.4% | worse |
| Long-stay residents who lose too much weight | 8.9% | 6.5% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 2.8% | 0.7% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 1.2% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.0% | 22.3% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 1.2% | 3.5% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 35.2% | 16.4% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 15.4% | 17.6% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 85.7% | 93.5% | 95.3% | worse |
| Long-stay residents with pressure ulcers | 11.3% | 4.0% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 24.1% | 24.7% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 19.5% | 17.8% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.6% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 62.5% | 69.7% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 26.9% | 24.3% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 5.5% | 10.7% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.77 | 2.06 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 0.75 | 1.46 | 1.80 | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ 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.
69.1% 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 343 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 72.8% 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 103 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 0.59 therapist hours per resident per day in 2026Q1 — more than 88% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 8% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 69.1%CMS range 63.6–74.8 | 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 | 13.1%CMS range 10.3–15.8 | 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 | 72.8% | 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 | 53.4% | 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 | 70.9% | 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 | 85.5% | 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 | 90.0% | 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 | 69.6% | 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 | 4.7% | 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 | 7.5%CMS range 5.0–10.5 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.04 | 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 217 beds and averages 77.5 residents a day — about 36% occupied, or roughly 140 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 3.83 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.60 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.43 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.44 hrs/resident/day on weekends vs 3.98 on weekdays — 14% thinner on weekends. RN hours go from 0.62 to 0.56 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 35% is below the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
31 citations, most serious first. The 12 most serious are shown; the remaining 19 are one tap away and print in full.
- Immediate jeopardy · L2025-03-19 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of facility documentation, and interviews, the facility failed to follow the manufacturers' recommendations for replacing the Nephros water filters which were in place since [DATE], following a presumptive positive case of Legionella in a resident at the facility, and the facility failed to ensure that a positive Legionella water sample was reported to the State Agency in a timely manner. These failures resulted in the finding of Immediate Jeopardy. The findings include: The daily census report dated [DATE] identified a resident census of 83. The facility's total capacity is 217. The facility's layout consists of two floors with resident units on both floors. There are three nursing units on the first floor and four nursing units on the second floor with three of the units closed (no residents residing on the units) and one resident unit (Redwood) with twenty-three residents residing on the unit. On [DATE] at 9:00 AM the Administrator was asked to provide documentation of all…
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 before2024-11-15 · 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, facility policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for accidents, (Resident #2), the facility failed to ensure a resident who is completely dependent on staff for transfers, wheelchair mobility, bed mobility and Activities of Daily Living (ADLs) remained free from significant injuries of unknown origin including bilateral (both sides) femur (bone in upper thigh) fractures. The findings include: Resident #2 had diagnoses that included vascular dementia, anxiety, depression, bipolar, and atrial fibrillation. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 had short-term and long-term memory impairment (not capable of completing a brief interview for mental status exam), severely impaired cognitive skills for daily decision making, was always incontinent of bowel and bladder, dependent on staff for all ADLs, including bed mobility, and transfers, was non ambulatory and dependent on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-03-19 · tag F0658 — failed to meet professional standards of care — patternEnsure 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 observations, review of clinical records, review of facility policy/procedures and interviews for two of three sampled residents (Resident #33 and Resident #336) observed with medications at the bedside, the facility failed to ensure that medications were administered according to acceptable standards of practice and the facility failed to ensure that medication was not left at the resident's bedside for a resident who is without an order or assessment for self-administration. The findings include: 1. Resident #33's diagnoses included chronic diastolic congestive heart failure, hypoxemia, and acute cough. The quarterly MDS assessment dated [DATE] identified Resident #33 had severe cognitive impairment, required moderate assistance with toileting hygiene, and supervision or touch assistance with dressing and personal hygiene. The assessment further identified the resident uses a walker with supervision for ambulation. The care plan dated 3/13/25 identified Resident #33 had a memory/recall problem related…
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 before2025-03-19 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure 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, review of facility documentation, review of facility policy, and interviews, the facility failed to ensure the second-floor windows contained mechanisms to prevent them from fully opening, presenting a safety hazard to residents residing on the unit (dementia unit). The findings include: Observation on 3/10/25 at 10:05 AM identified in room [ROOM NUMBER](a resident room), the window was fully opened, and did not contain a screen. The degree to which the window was opened presented a safety hazard to residents who were able to access the window. Interview with NA #2 on 3/10/25 at 10:10 AM indicated that she was providing care to a resident in that room with NA#1 and NA #1 opened the window because it was very hot in the room. Interview with NA #1 on 3/10/25 at 10:15 AM identified she had opened the window in room [ROOM NUMBER] because while providing care to the resident she had gotten hot. NA #1 indicated that she was aware that windows are only supposed to open a little…
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 · E2025-03-19 · tag F0726 — failed to have competent, trained nursing staff — patternEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documentation, facility policy, and interviews, the facility failed to complete license nurses and nurse aides education and competencies related to intravenous therapy (IV) therapy and the facility failed to ensure licensed nurses had intravenous therapy (IV) certificate. The findings included: 1. Review of the State Agency documentation identified the facility has a licensed bed capacity of 217 and an IV therapy program. Review of the census daily report dated 3/10/25 identified the facility census was 83 residents in the facility. A request was made on 3/17/25 for documentation of the annual licensed nurses and nurse aides IV competencies for 2023. The facility failed to provide any documentation regarding the completion of 2023 annual competencies. Review of the nursing IV competencies provided for 2024 identified only 15 of 29 licensed nurses received competency training in intravenous therapy (IV), and 17 of 43 nurse aides received competency training in intravenous therapy…
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 · E2025-03-19 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, review of facility documentation, review of facility policy, and interviews for four of four medication carts, the facility failed to ensure shift to shift controlled drug counts were consistently completed. The findings include: Based on observations, review of facility documentation, facility policy, and interviews for 4 of 4 medication carts, the facility failed to ensure shift to shift controlled drug counts were consistently completed. The findings include: Observations on 3/18/25 between 1:44 PM - 2:00 PM of the medication carts with LPN #9 (IP from another facility) identified the February 2025 and March 2025 narcotic drug change of shift audit sheet (the narcotic count that the on-coming and off-going nurses complete to ensure the narcotic medications are counted) were missing signatures on multiple dates on the 7:00 AM - 3:00 PM shift, 3:00 PM - 11:00 PM shift, and 11:00 PM - 7:00 AM shift on the following units: The [NAME] 1 unit was missing 21 signatures for the month of February 2025, and 9 signatures for the month of March 1, 2025 - March 18,…
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 · E2025-03-19 · tag F0883 — failed to offer flu and pneumonia vaccines — patternDevelop 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 clinical record reviews, review of facility documentation, review of facility policy, and interviews for 5 of 5 sampled residents (Resident #14, 16, 24, 56, and 73) reviewed for immunizations, the facility failed to offer and provide influenza vaccine as required and for 4 of 5 residents (Resident #12, 26, 37, and 61) reviewed for immunizations, the facility failed to offer and provide pneumococcal vaccine as required. The findings include: Interview and review of facility immunization documentation with RN #1 (Infection Preventionist) on 3/17/2023 at 12:37 PM identified the following: a) Resident #14 was admitted to the facility on [DATE] with diagnosis that included diabetes mellitus, hypertension, and hypothyroidism. The quarterly MDS assessment dated [DATE] identified Resident #14 had severe cognitive impairment. The assessment further identified that Resident #14 influenza vaccination was not up to date. Review of Resident #14 clinical record on 3/17/25 at 12:37 PM failed to identified that the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-03-19 · tag F0887 — patternEducate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
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 5 of 5 residents (Resident #2, 12, 19, 59, and 61) reviewed for immunizations, the facility failed to offer and provide Covid-19 immunizations as required. The findings include: Interview and review of facility immunization documentation with RN #1 (Infection Preventionist) on 3/17/2023 at 12:37 PM identified the following: 1) Resident #2 was admitted to the facility on [DATE] with diagnosis that included fracture of shaft of left femur, difficulty walking, and muscle weakness. The admission MDS assessment dated [DATE] identified Resident #2 had intact cognition. The assessment further identified that Resident #2 Covid-19 Booster vaccination was not up to date. Review of Resident #2 clinical record on 3/17/25 at 12:37 PM failed to identified that the Covid-19 Booster vaccine was offered and/or administered to the resident. Review of the Covid-19 immunization record identified Resident #2 had a consent for the vaccine.…
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 · D2025-03-19 · tag F0561 — failed to honor residents' choices — isolatedHonor 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 documentation, review of facility policy/procedures and interviews for two of two sampled residents (Residents #9 and #336) reviewed for choices, the facility failed to ensure the resident's choices were accommodated when the resident requested to go to bed, and staff did not assist the resident for four hours and failed to ensure menu choices were provided at mealtime. The findings include: 1. Resident #9 was admitted to the facility on [DATE] with diagnoses that included muscle weakness, difficulty walking, abnormal posture, pain, and peripheral neuropathy. The quarterly MDS assessment dated [DATE] identified Resident #9 had intact cognition, required partial to moderate assistance with personal hygiene, required total dependent with transfers (chair to bed/bed to chair), bed mobility, toileting, dressing, and utilized a wheelchair for mobility. The care plan dated 1/27/25 identified Resident #9 had an ADL (activities of daily living) function compromise and required substantial and maximal assist with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-19 · 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 clinical records, review of facility documentation, review of facility policy/procedure, and interviews for one of two sampled residents (Resident #335) reviewed for advanced directives, the facility failed to ensure consents were obtained regarding the resident's wishes regarding advance directives and decisions related to cardiopulmonary code status from the resident/responsible party. The findings include: Resident #335 was admitted to the facility in March/2025 with diagnoses that included chronic obstructive pulmonary disease (COPD), acute and chronic respiratory failure with hypoxia and cellulitis of the left lower limb. The admission MDS assessment dated [DATE] identified Resident #335 was moderately impaired cognition, required maximal assistance with dressing, toileting hygiene and bed mobility. The physician's order dated [DATE] directed full code (a full code means that if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided…
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 before2025-03-19 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, review of facility documentation, review of facility policy/procedure and interviews for one of two sampled residents (Resident #62) reviewed for Pre-admission Screening and Record Review (PASRR), the facility failed to ensure that a Level 2 determination was completed when the 30-day approval stay expired. The findings include: Resident #62 was admitted to the facility in January/2025 and had diagnoses that included anxiety disorder, type 2 diabetes mellitus, and squamous cell carcinoma The admission MDS assessment dated [DATE] identified Resident #62 was cognitively intact, independent with personal hygiene, and was dependent on care with toileting hygiene, lower body dressing, and transfers. Review of the PASRR screen level 1 dated [DATE] identified Resident #62 was approved for 30 days. The Psychiatric APRN note dated [DATE] identified Resident #62 has a history of bipolar disorder. Interview with the Social Worker (SW) on [DATE] at 12:20 PM identified she is responsible…
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 before2025-03-19 · 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 observation, review of clinical records, review of facility documentation, review of facility policy, and interviews for one of five sampled residents (Resident #62) reviewed for unnecessary medication the facility failed to ensure that physician's orders were implemented and completed as prescribed by the physician and one of seven residents (Resident #335) reviewed for accidents the facility failed to ensure that medications were administered as prescribed by the physician. The findings include: 1. Resident #62's diagnoses included anxiety disorder, type 2 diabetes mellitus, and squamous cell carcinoma. The admission MDS assessment dated [DATE] identified Resident #62 was cognitively intact, independent with personal hygiene, and was dependent on care with toileting hygiene, lower body dressing, and transfers. The assessment further identified the resident utilized antipsychotic (used for managing mental health disorders) medication which the assessment noted to be of the high-risk drug classes.…
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 19 citations
- Potential for harm · Dcited before2025-03-19 · 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 review of the clinical record, review of facility policy, and interviews for two of four sampled residents (Resident #36 and #286) reviewed for pressure ulcer/injury, the facility failed to ensure weekly skin audits were completed per the physician's order. The findings include: 1. Resident #36's diagnoses included dementia, and pressure ulcers on the right and left buttock. The quarterly MDS assessment dated [DATE] identified Resident #36 had severely impaired cognition, was always incontinent of bowel and bladder and required total assistance with eating, bed mobility, toileting, dressing, and personal hygiene. Additionally, Resident #36 had one stage 4 pressure ulcer. The care plan dated 12/10/24 identified Resident #36 had a coccyx pressure ulcer. Interventions included pressure reducing mattress and cushions and provide incontinent care with barrier cream as needed. Physician's orders dated 12/19/24 directed to perform weekly body audits on shower days Tuesday 3:00 PM to 11:00 PM shift and document…
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 · D2025-03-19 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
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, observations, review of facility policy/procedures and interviews for one sampled resident (Resident #24) reviewed for pressure ulcer/injury, the facility failed to ensure the bilateral hand rolls/rolled wash cloths were in place as ordered. The findings include: Resident #24's diagnoses included multiple sclerosis, deformity of the wrist, deformity of the hand and right sided weakness. The quarterly MDS assessment dated [DATE] identified Resident #24 was severely cognitively impaired, was dependent with bed mobility, transfers, bathing and personal hygiene. The care plan dated 2/1/25 identified Resident #24 was at risk for skin breakdown/redness related to bilateral hand deformities (contractures), with interventions that included the application of bilateral hand rolls or rolled wash cloths at all times. The nursing assistant (NA) care card identified left and right-hand rolls (can utilize wash cloths) to be worn at all times. Physician's orders for March 2024 directed 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 · D2025-03-19 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record reviews, facility policy review, and interviews for one sampled residents (Resident #51) for enteral feeding, the facility failed to ensure enteral feeding were properly labeled with date and time and discarded when appropriate in accordance to the facility policy. The findings include: Resident #51's diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant hand, dysphagia, and gastrostomy. The significant change MDS assessment dated [DATE] identified Resident #51 with intact cognition, required extensive assistance with eating and had an enteral feeding tube. The physician's orders dated 2/13/25 directed to administer Jevity 1.5 calories via enteral feeding at 30 centimeters (cc) per hours in which the enteral feeding will be stop every day at 6:00 AM and resume at 10:00 AM every day. The care plan dated 2/20/25 identified Resident #51 had an enteral feeding tube to supplement food intake. Care plan interventions directed 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.
- Potential for harm · D2025-03-19 · 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 review of the clinical record, review of facility policy, and interviews for one of three sampled residents (Resident #68) reviewed for pain management, the facility failed to ensure pain medication was administered in accordance with the physician's order. The findings include: Resident #68 was admitted to the facility on [DATE] with diagnoses that included wedge compression fracture of unspecified lumbar vertebra, malignant neoplasm of pancreas, and Myelodysplastic syndrome. The nurse's note dated [DATE] at 7:20 PM identified that Resident #68 was readmitted to the facility at 2:00 PM. Resident was alert and oriented to person, place, and time. The care plan dated [DATE] identified Resident #68 required an opioid medication to help with pain management. Interventions included providing opioid medication to manage pain and evaluate its efficacy. A physician's order dated [DATE] directed to administer Tramadol 50mg, 1 tablet by mouth, every 12 hours as needed (PRN) for pain, for 10 days. Interview with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-19 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, review of facility policy, and interviews for one of five sampled residents (Resident #65) reviewed for unnecessary medications, the facility failed to ensure target behavior monitoring was completed, per the physician's order. The findings include: Resident #65 was admitted to the facility on [DATE] with diagnoses that included depression, anxiety disorder, dementia in other diseases classified elsewhere, with other behavioral disturbances, and repeated falls. A physician's order dated 11/28/23 directed to administer Quetiapine (an antipsychotic medication) 50mg by mouth, at bedtime. A physician's order dated 9/13/24 directed to monitor target behaviors: hallucinations/aggression, every day, evening, and night shift. The annual MDS dated [DATE] identified Resident #65 had severely impaired cognition, had no changes in behavior status, care rejection, or wandering compared to the prior assessment, was receiving an antipsychotic on a routine basis, and a gradual dose…
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 before2025-03-19 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical records, review of facility policy, and interviews for two of three sampled residents (Resident #15 and #68) reviewed for pain management, the facility failed to ensure accurate administration documentation of pain medication. The findings include: 1. Resident #15 was admitted to the facility on [DATE] with diagnoses that included lower back pain, pain in the left upper arm, and dementia. The care plan dated 2/7/25 identified Resident #15 had activities of daily living (ADL) function compromised related to dementia, weakness, and advanced age. Interventions included referring to Resident #15's 24-hour positioning plan and to encourage him/her to do as much as possible before offering assistance. The quarterly MDS dated [DATE] identified Resident #15 had moderately impaired cognition, had pain with occasional frequency with a numeric rating scale of 3/10, and was not on a scheduled pain medication regimen. A physician's order dated 1/20/25 directed to administer Acetaminophen…
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 before2024-12-19 · 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
Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for wound care, the facility failed to ensure wound treatment recommendations were implemented. The findings include: Resident #1 had diagnoses that included metastatic malignant neoplasm of breast, fungating mass (tumor has broken through the skin) of right breast, secondary malignant neoplasm of bone, severe protein-calorie malnutrition, and adult failure to thrive. The nursing admission body audit dated 11/14/24 at 4:37 P.M. completed by RN #3 (wound nurse) identified Resident #1 has alterations in skin integrity with a cancerous wound to h/her right breast that is erythematous (red)with sanguineous drainage (clear fluid mixed with blood). A physician's order dated 11/14/24 directed to cleanse the right breast cancer wound with Dakins 0.125 % (an antimicrobial cleanser) , pat dry, apply Xeroform 4x4 gauze (a non adhesive dressing), cover with dry gauze, and abdominal pad secure with large stockinette like tube top change daily…
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 before2024-12-19 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for wound treatments, the facility failed to ensure the clinical record was complete and accurate to reflect wound treatments were administered. The findings include: Resident #1 had diagnoses that included metastatic malignant neoplasm of breast, fungating mass of right breast ( the mass has broken through the skin), pressure-induced deep tissue damage of sacral region, pressure-induced deep tissue damage to right and left buttock, secondary malignant neoplasm of bone, severe protein-calorie malnutrition, and adult failure to thrive. The nursing admission body audit dated 11/14/24 at 4:37 P.M. completed by RN #3 (wound nurse) identified Resident #1 has alterations in skin integrity with a cancerous wound to h/her right breast that is erythematous (red) with sanguineous drainage (drainage mixed with blood). RN #3 identified Resident #1 has ulcers to lower right lateral leg, right medial leg, and lower left medial leg and pressure…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2022-07-14 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure 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 2 residents (Resident #19) reviewed for transfers, the facility failed have a system in place to assess residents per manufacturer guidelines for the use of the correct size hoyer pads for residents being transferred utilizing a mechanical lift. The findings include: Resident #19 was admitted to the facility with diagnoses that included rheumatoid arthritis and morbid obesity. The quarterly MDS assessment dated [DATE] identified Resident #19 had intact cognition and required total dependence for transfers with 2 person physical assistance. Additionally, Resident #19's height was 62 inches (5 feet 1 inch) and weighted 241 lbs. The Resident Care Plan dated 5/10/22 identified Resident #19 required assistance with activities of daily living. Interventions included to provide assistance of 2 to transfer in and out of bed with a mechanical lift into an electric wheelchair (but failed to identify what…
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 · D2022-07-14 · 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 observation, review of the clinical record, facility documentation, facility policy, and interviews for 3 of 4 residents (Resident #21, Resident #34 and Resident #70) reviewed for resident to resident altercations, the facility failed to protect a resident (Resident #28) from abuse and failed to protect Resident #21 and Resident #70 from resident to resident altercations. The findings include: 1. Resident #21 was admitted to the facility with diagnoses that included dementia without behaviors, intellectual disorder, and multiple myeloma. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #21 had severely impaired cognition and required supervision for transfers and locomotion in wheelchair on the unit with one person. The Resident Care Plan dated 5/3/22 identified Resident #21 was verbally abusive towards staff. Interventions included to gently set limits on inappropriate behavior. Resident #70 was admitted to the facility with diagnoses that included major depression,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-07-14 · 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, facility documentation and interviews for one of three residents (Resident #25) reviewed for pressure ulcers, the facility failed to ensure the specialty air mattress was maintained on the appropriate setting according to the residents weight and as per the physicians orders. The findings included: Resident #25's diagnoses included chronic kidney disease, metabolic encephalopathy, anemia and dementia. The quarterly MDS assessment dated [DATE] identified Resident #25 was severely cognitively impaired, required extensive assistance with bed mobility, dressing and personal hygiene. The MDS assessment further identified Resident #25 was at risk for developing pressure ulcers and indicated Resident #25 had a pressure ulcer at the time of the assessment. The Resident Care Plan dated 5/9/22 identified Resident #25 with alternation in skin integrity and a community acquired pressure ulcer related to decreased mobility. Interventions included a low air loss mattress,…
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 · D2022-07-14 · 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 observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #85) reviewed for nutrition, the facility failed to ensure the accuracy of an admission dietary assessment to calculate fluid needs and obtain an admission weight timely. The findings include: Resident #85 was admitted to the facility on [DATE] with diagnoses that included vascular dementia, Type II diabetes, chronic kidney disease and recovering pneumonia secondary to Covid. A Hospital Intra-agency Referral Report dated 6/28/22 noted Resident #85's recorded weight as 100.6 kg (221 pounds/lbs). Labs dated 6/28/22 with a sodium (NA) of 138 (135-146 is normal range), Albumin 3.0 (3.6-5.1 is normal range), white blood cell count 11.4 (3.8-10.8 is normal range). A History and Physical dated 6/29/22 identified no complaints, somnolent but arousable, negative for abnormal findings and clinically stable. A Nutritional assessment dated [DATE] identified Resident #85's weight as…
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 · D2022-07-14 · tag F0770 — failed to provide lab services — isolatedProvide timely, quality laboratory services/tests to meet the needs of residents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #85) reviewed for nutrition, the facility failed to ensure laboratory blood work was completed timely as directed by the physician. The findings include: Resident #85 was admitted to the facility from the hospital on 6/28/22 with diagnoses that included vascular dementia, Type II diabetes, chronic kidney disease, and recovering pneumonia secondary to Covid. The Hospital Intra-Agency Referral Report dated 6/28/22 noted Resident #85's lab values dated 6/28/22 identified a Sodium (NA) of 138 (135-146 is the normal range), Albumin 3.0 (3.6-5.1 is the normal range), and white blood cell count 11.4 (3.8-10.8 is the normal range). A Resident Care Plan dated 6/29/22 identified Resident #85 was at nutritional risk due to compromised oral intake, Body Mass Index (BMI) of 15.4, underweight, multiple co-morbidities, therapeutic diet and decreased albumin. Interventions included 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.
- Potential for harm · D2022-07-14 · tag F0773 — isolatedProvide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
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 #85) reviewed for nutrition, the facility failed to notify the physician/Advanced Practice Registered Nurse (APRN) of abnormal lab values in a timely manner. Resident #85 was admitted to the facility from the hospital on 6/28/22 with diagnoses that included vascular dementia, Type II diabetes, chronic kidney disease, and recovering pneumonia secondary to Covid. The Hospital Intra-Agency Referral Report dated 6/28/22 noted Resident #85's lab values dated 6/28/22 identified a Sodium (NA) of 138 (135-146 is the normal range), Albumin 3.0 (3.6-5.1 is the normal range), and white blood cell count 11.4 (3.8-10.8 is the normal range). A Resident Care Plan dated 6/29/22 identified Resident #85 was at nutritional risk due to compromised oral intake, Body Mass Index (BMI) of 15.4, underweight, multiple co-morbidities, therapeutic diet and decreased albumin. Interventions included 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.
- Potential for harm · Dcited before2019-11-27 · tag F0644 — isolatedCoordinate 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 staff interview for the only resident in the survey sample reviewed for Pre-admission Screening and Resident Review( PASARR) (Resident # 62), the facility failed to ensure a resident with a Level I pre-screen which later identified with a mental disorder was referred to the appropriate state-designated authority for a Level II PASARR evaluation and determination. The findings include: Resident # 62 was admitted to the facility on [DATE] with diagnoses that included benign neoplasm of the brain and anxiety. A quarterly Minimum Data Set ( MDS) assessment dated [DATE] indicated Resident # 62 had moderately impaired cognition, no mood symptoms, no behaviors, and noted a diagnosis of bipolar disorder. A Resident Care Plan (RCP) dated 10/2019 identified a problem related to behavioral symptoms including physical aggression. Interventions included: to involve family, maintain routine and schedules, avoid confrontations, and to reproach as needed. A physician's order dated 10/26/19…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-11-27 · 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, staff interviews, and review of facility documentation for the only resident in the survey sample reviewed for choices (Resident #51), the facility failed to ensure specialized test were conducted in accordance to the physician's orders. The findings include: Resident #51's diagnoses included depression and a history of breast cancer with lumpectomy. The Annual Minimum Data Set (MDS) dated [DATE] identified the resident was moderately cognitively impaired and required extensive assistance with bed mobility, transfers and personal hygiene. A Nurse Practitioner (NP) note dated 3/7/19 at 11:11 A.M. identified that Resident #51 was concerned that he/she had not had a recent mammogram or ultrasound of his/her breasts. Resident #51 was told by his/her physician in the community that he/she should continue to be monitored. The plan identified a history of breast cancer of the left breast. A physician's order dated 3/7/19 directed to obtain a mammogram and ultrasound of breasts. 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 before2019-11-27 · 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 clinical record review, staff interview, review of facility documentation, and review of facility policies and procedures for one of three residents in the survey sample reviewed for pressure ulcers (Resident # 307), the facility failed to ensure interventions were implemented to ensure offloading and positioning/repositioning were performed to prevent the development of a pressure ulcer. The findings include: Resident #307's diagnoses included functional quadriplegia, osteoarthritis, vascular dementia, and anemia. The annual MDS assessment dated [DATE] identified the resident was moderately cognitively impaired , required extensive assistance of two people for bed mobility , total dependence for transfers, noted at risk for developing pressure ulcer/injuries and no unhealed pressure ulcer/injuries. Additionally, the annual MDS assessment dated [DATE] directed staff to provide a pressure reducing device for the chair and bed but failed to reflect the resident was on a turning and repositioning program.…
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 · B2025-03-19 · 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
Based on review of facility documentation, review of facility policy and interviews, the facility failed to ensure the Office of the Sate Long-Term Care Ombudsman was notified of resident transfers and discharges on a monthly basis. The findings include: Review of the facility's discharge report for the months of October 2024 - January 2025 identified the following: 1. For the month of October 2024, there were thirty-six residents discharged and/or transferred from the facility. 2. For the month of November 2024, there were forty-one residents discharged and/or transferred from the facility. 3. For the month of December 2024, there were twenty-six residents discharged and/or transferred from the facility. 4. For the month of January 2025, there were thirty-six residents discharged and/or transferred from the facility. A request for the monthly Ombudsman's report for transfers and discharges for the months of October 2024, November 2024, December 2024, and January 2025 identified that the monthly reports for October, November and December were sent to the Ombudsmen's office on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · B2025-03-19 · tag F0625 — patternNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, review of facility documentation, review of facility policy, and interviews for one of four sampled residents (Resident #66) reviewed for hospitalization and had multiple hospitalizations, the facility failed to ensure the resident and/or resident representative were provided with written information regarding the bed hold policy. The findings include: Resident #66 was admitted to the facility in December 2023 with diagnoses that included heart failure and dementia. The admission MDS assessment dated [DATE] identified Resident #66 had severely impaired cognition and required supervision/contact guard assistance with personal hygiene and maximum assistance with toileting and dressing. The physician's note dated 1/18/24 identified Resident #66 was admitted on [DATE] status post hospitalization for leg pain after a fall. The ombudsman's notification book for the month of January 2024 identified Resident #66 was transferred to the hospital on 1/31/24 and readmitted to the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“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
$130,496 in federal fines across 2 penalties.
- $122,478 — penalty dated 2025-03-19
- $8,018 — penalty dated 2024-11-15
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 |
|---|---|---|---|---|
| GREENWICH WOODS REHABILITATION LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 11/18/2014 |
| BERNSTEIN, MOSHE | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 03/01/2016 |
| BLASS, MORDECHAI | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 03/01/2016 |
| GREENWICH WOODS HOLDINGS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 68% | since 01/05/2015 |
| IK GREENWICH LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 7% | since 01/05/2015 |
| LYM GW LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 9% | since 01/05/2015 |
| SJJJ LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 16% | since 01/05/2015 |
| BROWN, NATALIE | Individual | W-2 MANAGING EMPLOYEE | — | since 09/13/2021 |
5 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 $2.2M paid to related parties — landlords or management companies under common ownership — equal to about 15% 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 075309. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-03-19, 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.