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Complete Care At Groton Regency

1145 Poquonnock Rd, Groton, CT 06340 · For profit - Limited Liability company · 162 certified beds · (860) 446-9960 Medicare & Medicaid certified

Call the home — (860) 446-9960 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Jan 2026
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • 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
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Jan 2026
  • 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 (21) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing rating is low (2/5)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

5/5
CMS overall
5 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 5 of 5

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
85 Poheganut Dr · (860) 437-3737 · Call to confirm hours
Pharmacy
995 Poquonnock Rd · (860) 445-7719 · Call to confirm hours
Grocery
ALDI0.3 mi
 
Park
800 Long Hill Rd · (203) 453-8068 · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 5 of 5
Long-stay residentspeople who live here 5 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 held steady at 5 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating5★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased23.9%18.0%15.4%worse
Long-stay residents who lose too much weight2.0%6.5%5.4%better
Long-stay residents with a catheter left in their bladder0.2%0.7%0.9%better
Long-stay residents with a urinary tract infection0.7%1.5%2.0%better
Long-stay residents with depressive symptoms59.6%22.3%6.5%worse than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury3.7%3.5%3.3%typical
Long-stay residents whose ability to walk worsened14.2%16.4%16.1%better
Long-stay residents on antianxiety or hypnotic medication11.7%17.6%18.9%better
Long-stay residents given the seasonal flu vaccine99.1%93.5%95.3%typical
Long-stay residents with pressure ulcers2.2%4.0%4.7%better
Long-stay residents with worsening bladder/bowel control29.8%24.7%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table25.8%17.8%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.3%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine94.3%69.7%79.4%better
Short-stay residents rehospitalized after admission20.3%24.3%22.6%better
Short-stay residents with an outpatient ER visit11.1%10.7%12.0%typical
Long-stay hospitalizations per 1,000 resident days0.212.061.67better
Long-stay outpatient ER visits per 1,000 resident days0.181.461.80better

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

63.9% 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 126 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

63.9%U.S. median 51.5%
Got home and stayed home
8.9%U.S. median 10.7%
Went back to hospital
78.0%U.S. median 56.6%
Met the expected recovery
0.25U.S. median 0.31
Therapy hours / resident / day
0.09hours / resident / day
Physical therapy
0.11hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 78.0% 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 100 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 0.25 therapist hours per resident per day in 2026Q1 — more than 34% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 28% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF63.9%CMS range 56.1–72.551.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF8.9%CMS range 6.3–11.710.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge78.0%56.6%Oct 2024–Sep 2025CMS 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 discharge60.0%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge76.0%50.0%Oct 2024–Sep 2025CMS 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 identified100.0%98.7%Oct 2024–Sep 2025CMS 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 settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge100.0%98.7%Oct 2024–Sep 2025CMS 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 stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.1%CMS range 4.1–11.47.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.151.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.53
RN hours/ resident / day
0.90
LPN hours/ resident / day
2.11
Aide hours/ resident / day
3.54
Total nurse hours/ resident / day
0.30
RN hoursweekends
44.9%
Total nursing turnover
57.1%
RN turnover

How full it usually is: this home is certified for 162 beds and averages 121.5 residents a day — about 75% occupied, or roughly 40 beds typically open. It usually has some room. 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 0.53 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.11 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 3.20 hrs/resident/day on weekends vs 3.69 on weekdays — 13% thinner on weekends. RN hours go from 0.62 to 0.30 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 45% is about the same as the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

6
deficiencies at the latest standard inspection (2026-01-29)
5
at the previous standard inspection (2024-03-27)

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.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

21 citations, most serious first. The 10 most serious are shown; the remaining 11 are one tap away and print in full.

  • Potential for harm · Ecited before2026-01-29 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, review of facility documentation and interviews for two of three nursing units (C/D and E/F), the facility failed to ensure resident areas were kept in good repair. The findings include:Observations on all days of the survey, 1/21/26, 1/22/26, 1/27/26, 1/28/26 and 1/29/26 identified that many of the resident rooms on the C/D and E/F nursing units were noted with following:The frames of the drop ceilings contained an excessive amount of what appeared to be rust stains. The wallpaper and wallpaper borders at the top of the walls appeared discolored, ripped and/or hanging off the wall.Ceiling tiles that were bowed, bulged, or broken.Cove base molding that was not adhered to the wall and with dirt, debris or black growth observed behind the moldingThe thresholds to some resident rooms were missing.Chipped flooring tiles A tour of the nursing units with the Regional Maintenance Director on 1/28/26 and 1/29/26 identified that he wrote the specific rooms and areas where the environmental concerns were noted. Interview with the Regional Maintenance Director on 1/21/26…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-01-29 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect 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 review of clinical records, review of facility documentation, review of facility policy, and interviews for one of six sampled residents (Residents #98) reviewed for resident-to-resident abuse, the facility failed to ensure the resident was free from abuse. The findings include:Resident #15's diagnoses included schizoaffective disorder bipolar type, pseudobulbar affect, and post-traumatic stress disorder. The quarterly MDS assessment dated [DATE] identified Resident #15 was cognitively intact, had hallucinations, and delusions, exhibited verbal behavioral symptoms directed towards others and other behavioral symptoms not directed toward others. The assessment further identified Resident #15 required moderate assistance with toileting hygiene, lower body dressing, clean-up assistance with personal hygiene, was non-ambulatory and independently utilize a manual wheelchair. The care plan dated 2/19/25 identified Resident #15 exhibited or had the potential to demonstrate verbal behaviors related to cognitive…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-01-29 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, review of facility documentation, review of facility policy/procedures and interviews for 2 of 6 residents (Resident #4 and Resident #73) reviewed for involuntary seclusion, the facility failed to ensure the comprehensive care plan was reviewed and revised to reflect each resident's changing goals, preferences and needs of the resident including placement and continued placement on a secured unit. The findings included:Review of resident roster for the E/F secured nursing unit on 1/21/26 at 11:00 AM identified Resident #4 resided on the secured unit.Review of the clinical record on 1/22/26 identified a consent form for the secured unit (E/F) that identified Resident #4 had dementia and was a wandering risk and would only be allowed to leave the unit with supervision. The form identified that verbal consent was obtained from Resident #4's responsible party on 10/30/25 and was signed by facility staff.The physician's orders dated 1/26/26 directed Resident #4…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-29 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of clinical records, review of facility policy, review of facility documentation, and interviews for one of three residents (Resident #23) reviewed for pressure ulcer/injury, the facility failed to appropriately track and place a resident with an open wound on Enhanced Barrier Precautions (EBP) to ensure the appropriate PPE was utilized when providing wound care. The findings include:Resident #23's diagnoses included vascular dementia, non-pressure chronic ulcer of skin of other sites with fat layer exposed, anxiety disorder.The quarterly MDS assessment dated [DATE] identified Resident #23 had severely impaired cognition, was dependent on staff for bed mobility, personal hygiene, dressing, eating, transfers and was non-ambulatory. The assessment further identified Resident #23 had treatments for skin and ulcer/injury for pressure reducing device for chair and bed, application of non-surgical dressing other than to feet and applications of ointment/medications other than feet.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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-29 · tag F0887 — isolated
    Educate 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 review of the clinical record, review of facility documentation, review of facility policy/procedures, and interviews for 1 of 5 residents (Resident #4) reviewed for immunizations, the facility failed to ensure that the COVID-19 booster vaccination was offered or history assessed. The findings include:Resident #4's diagnoses included dementia, atrial fibrillation, and anxiety disorder. The quarterly MDS assessment dated [DATE] identified Resident #4 had severely impaired cognition. The assessment further identified that Resident #4 was not up to date with the COVID-19 vaccination.Review of the COVID-19 Vaccine Administration and Consent Form with the Infection Preventionist (RN #1) in the presence of the Clinical Manager (RN #3) on 1/28/26 at 10:49 AM identified Resident #4 Power of Attorney (POA) gave the facility permission on 10/20/25 to administer the COVID-19 vaccine and boosters. Further review of Resident #4 physician's orders, preventative health care report and progress notes with RN #1 and RN…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-11-14 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, interviews, facility documentation and policies for one (1) of three (3) residents (Resident #1) reviewed for resident rights, the facility failed to ensure the resident was treated with respect during medication administration. The findings included:Resident #1 was admitted to the facility in October of 2025 with diagnoses which included congestive heart disease, anxiety, and Type 2 diabetes mellitus.Review of the Nursing admission assessment dated [DATE] identified Resident #1 was alert and oriented to person, place, time, and situation, was verbally appropriate, and required extensive assistance with personal hygiene, bed mobility, and transfers.The Resident Care Plan (RCP) dated 10/25/25 identified Resident #1 required assistance/was dependent for activities of daily living which included bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, and toileting related to a recent hospitalization which resulted in fatigue, activity…

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

    Resident Rights Deficiencies · Past Non-Compliance
  • Potential for harm · D2025-11-14 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, interviews, facility documentation and policies for one (1) of three (3) residents (Resident #1) reviewed for medication administration, the facility failed to ensure the resident was not left unattended with administered medications. The findings included:Resident #1 was admitted to the facility in October of 2025 with diagnoses which included congestive heart disease, anxiety, and Type 2 diabetes mellitus.Review of the Nursing admission assessment dated [DATE] identified Resident #1 was alert and oriented to person, place, time, and situation, was verbally appropriate, and required extensive assistance with personal hygiene, bed mobility, and transfers.The Resident Care Plan (RCP) dated 10/25/25 identified Resident #1 required assistance/was dependent for activities of daily living which included bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, and toileting related to a recent hospitalization which resulted in fatigue, activity…

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

    Resident Assessment and Care Planning Deficiencies · Past Non-Compliance
  • Potential for harm · D2024-11-07 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #1) reviewed for falls, the facility failed to transport the resident to an orthopedic appointment per physician's order and failed to complete a fall risk assessment after a fall in accordance with facility policy. The findings include: Resident #1's diagnoses included repeated falls, right humerus fracture (a bone in the upper arm running from the shoulder to the elbow), bone density disorder, anxiety disorder and dementia with behavioral disturbances. The Resident Care Plan (RCP) dated 5/31/24 identified that Resident #1 is at risk for falls due to cognitive loss, lack of safety awareness and advanced Alzheimer's disease and had a history of falls and seizure like activity with interventions included to follow-up with the orthopedist for the right humerus fracture. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was severely cognitively…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-07 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #1) reviewed for falls, the facility failed to follow the plan of care to adequately supervise a resident who required assistance with ambulation resulting in falls. The findings include: Resident #1's diagnoses included repeated falls, right humerus fracture (a bone in the upper arm running from the shoulder to the elbow), right femur fracture (bone in the upper leg, spanning from the hip to the knee), bone density disorder, anxiety disorder and dementia with behavioral disturbances. The Resident Care Plan (RCP) dated 5/31/24 identified that Resident #1 is at risk for falls due to cognitive loss, lack of safety awareness and advanced Alzheimer's disease and had a history of falls and seizure like activity with interventions included to follow-up with the orthopedist for the right humerus fracture. The quarterly Minimum Data Set (MDS) assessment dated [DATE] 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-29 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect 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 reviews, facility documentation, facility policies and interviews for two of four sampled residents (Residents #1 and #2) who were reviewed for an allegation of resident-to-resident physical altercation, the facility failed to maintain the safety of Resident #1 who sustained bruises around the right forearm, wrist, and hand when facility staff intervened during the altercation. The findings include: Resident #1's diagnoses included dementia with behavioral disturbances, anxiety, abnormalities of gait, and history of stroke. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 rarely or never made decisions regarding tasks of daily life, was independent with dressing, transfers, and ambulation, and utilized a walker for mobility. The Resident Care Plan dated 2/16/24 identified Resident #1 exhibited verbal behaviors due to dementia, had anxiety, and was on an anticoagulant. Interventions directed to monitor medications, evaluate for trigger of verbal outbursts,…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
Show the remaining 11 citations
  • Potential for harm · D2024-05-29 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, facility policies and interviews for two of four sampled residents (Residents #1 and #2) who were reviewed for an allegation of resident-to-resident physical altercation, the Nurse Aide that witnessed the physical altercation and tried to intervene failed to report the altercation to licensed staff. The findings include: Resident #1's diagnoses included dementia with behavioral disturbances, anxiety, abnormalities of gait, and history of stroke. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 rarely or never made decisions regarding tasks of daily life, was independent with dressing, transfers, and ambulation, and utilized a walker for mobility. The Resident Care Plan dated 2/16/24 identified Resident #1 exhibited verbal behaviors due to dementia, had anxiety, and was on an anticoagulant. Interventions directed to monitor medications, evaluate for trigger of verbal outbursts, provide psych services as needed, explain care one…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-03-27 · tag F0561 — failed to honor residents' choices — pattern
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of facility documentation, review of facility policy, and interviews, the facility failed to ensure the Main ([NAME]) dining room was open and utilized for resident dining consistently on the weekends. The findings include: Observation of the resident dining on 3/21/24 at 12:30 PM identified approximately 30 residents eating in the [NAME] dining room. The Resident Council Interview on 3/25/24 at 1:00 PM with Resident #6, Resident #10, Resident #64, Resident #72, and Resident #102 identified that the [NAME] dining room had been closed on the weekend for several weeks. Interview with Dietary Aide (DA) #1 and Dietary Aide #2 on 3/26/24 at 12:00 PM identified that the [NAME] dining room was closed on weekends. The residents' meals are delivered to the residents' rooms on the weekends. DA #1 and DA #2 identified that the [NAME] dining room had been closed on the weekends for several weeks. They further identified that the nursing staff did not have enough staff to transport the residents…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-03-27 · tag F0725 — failed to have enough nursing staff — pattern
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    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, and interviews, the facility failed to ensure staff was available to transport residents to the [NAME] dining room on the weekends. The findings include: The Resident Council Interview on 3/25/24 at 1:00 PM with Resident #6, Resident #10, Resident #64, Resident #72, and Resident #102 identified that the [NAME] dining room had been closed on the weekend for several weeks. The facility Quality Assurance (QA) and Performance Improvement (PI) documentation dated 2/20/24 identified the issue of re-opening the [NAME] dining on the weekends and point of service. The goal was to re-open the [NAME] dining room by 5/1/24. The facility plan of action was to reach safe staffing levels by holding NA classes and training new NAs for dining procedures and transport. Review of staffing schedules on 3/16/24 (Saturday) identified there was 6 licensed nurses and 10 NA for the 7-3 shift and on 3/24/24 (Sunday) there was 6 licensed nurses and 9 NAs for the 7-3 shift. Interview with Dietary…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-03-27 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, review of facility policy and interviews, the facility failed to ensure expired food was dated and removed from the refrigerator. The findings include: Observation during the initial tour of the dietary department with the Food Service Director (FSD #2) on 3/20/24 at 9:54 AM identified 2 large plastic zip bags full of sliced ham with the date 3/11 handwritten on both bags. Two peaches in a plastic produce bag with two slices out of them that was undated. Interview with FSD #2 on 3/20/24 at 10:10 AM identified the two bags of sliced ham would be good for three days past the labeled date then should be discarded. The FSD #2 further identified that he did not know why the peaches were in an undated bag in the fridge. Interview with the Food Service Director (FSD #1) on 3/21/24 at 11:50 AM identified FSD #2 had told her about the expired foods, and she identified the ham would be good for seven days past the labeled date of 3/11/24. She noted that the ham should have been discarded by 3/18/24. She also could not explain why the peaches had been in an undated…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2021-11-19 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of facility documentation and interviews for 2 of 6 nursing units (A & E), the facility failed to ensure the environment was clean, comfortable and free from disrepair. The findings include: A. Observations on 11/16/21 at 9:30 AM with the Director of Maintenance of the A wing nursing unit identified the following: • Residents' rooms #1, #6, #10, #11, #12, and #16 contained wallpaper that had was peeled away from the wall. • Resident room [ROOM NUMBER]'s bathroom ceiling vent appeared to be coated with dust/debris and the bottom right corner of the wall located behind the toilet had cracked tiles and holes in the wall. • Resident room [ROOM NUMBER] contained a radiator that appeared rusted and dirty • Resident room [ROOM NUMBER] contained wall trim located behind the bed and dresser that was detached from the wall. Interview on 11/16/21 at the time the observations were made with the Director of Maintenance identified that although he conducts rounds once a week, he doesn't have 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2021-11-19 · tag F0657 — failed to keep the care plan current — pattern
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record, review of facility documentation, review of facility policy, and interviews for 1 sampled resident (Resident #55) reviewed for care plan development, the facility failed to ensure the comprehensive care plan was reviewed and revised by the IDT team as well as failed to ensure the resident's representative was given the opportunity to take part in the comprehensive care plan review and revision. The findings include: Resident #55's diagnoses included chronic congestive heart failure, dementia with behavioral disturbances, schizoaffective disorder, depression, diabetes mellitus, hypertension, anemia, abnormality of gait and muscle weakness. The quarterly MDS assessment dated [DATE] identified Resident #55 had severely impaired cognition, was frequently incontinent of bowel and bladder and required extensive assistance of 1 staff member for bed mobility, dressing, toileting and personal hygiene, it further identified the resident required limited assistance for transfers. A care plan…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-11-19 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, review of facility documentation, review of facility policy, and interviews for 1of 2 sampled residents (Resident #15) reviewed for ADL's, the facility failed to carry out necessary services to maintain good grooming/personal hygiene. The findings include: Resident #15's had diagnoses that included; malignant neoplasm of bladder, diabetes mellitus, atrial flutter, dysthymic disorder, obstructive sleep apnea, hypothyroidism, morbid obesity, major depressive disorder, vitamin D deficiency, hypertension, muscle weakness, anxiety disorder and asthma. The quarterly MDS assessment dated [DATE] identified Resident #15 was moderately cognitively impaired, required limited assistance for personal hygiene and was frequently incontinent of bowel and bladder. The care plan dated 10/15/21 identified Resident #15 required assistance and was dependent for ADL care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfers, locomotion, 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-11-19 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility policy and interviews for 1 of 4 sampled residents (Resident #314) reviewed for weight loss, the facility failed to ensure reweights were obtained after a significant weight loss was identified and failed to follow physician's orders related to weights. The findings include: Resident #314's diagnoses included anemia, severe sepsis and right buttock stage 4 pressure ulcer. The quarterly MDS assessment dated [DATE] identified Resident #314 was cognitively intact and required supervision with eating. Resident #314's care plan dated 7/27/21 identified he/she had a nutritional risk with interventions that included; weigh as ordered, alert dietitian and physician to any significant loss or gain, provide large portion diet, and provide house supplement twice daily and at bedtime. Review of Resident #314's weight record identified a weight of 137.2 pounds (lbs.) on 8/23/21. The next recorded weight on 9/8/21 was 128 lbs. indicating a 6.71% loss in sixteen days. Further…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2026-01-29 · tag F0641 — pattern
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, review of facility documentation, and interviews for one of two sampled residents (Residents #15) reviewed for Preadmission Screening and Resident Reviews (PASRR), the facility failed to ensure the comprehensive assessments were accurately coded to reflect the resident's positive Level II PASRR status and for three of three sample residents (Resident #12, Resident #14, and Resident #44) reviewed for resident assessment, the facility failed to ensure the Brief Interview for Mental Status (BIMS) (a screening tool to assess resident's cognitive function) was completed. The findings include: Resident #15's diagnoses included schizoaffective disorder bipolar type, pseudobulbar affect, and post-traumatic stress disorder. The PASRR level II screening dated 2/7/2023 identified Resident #15 had a positive level II PASRR. The annual MDS assessment dated [DATE] identified under the Preadmission Screening and Resident Review (PASRR) section a response of no to the question that asks if…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2024-03-27 · tag F0637 — pattern
    Assess the resident when there is a significant change in condition
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and interviews for one sample resident (Resident #12) reviewed for hospice care, the facility failed to complete a Significant Change in Status MDS assessment when the resident was admitted to hospice. The findings include: Resident #12's diagnoses included dementia, adult failure to thrive, bipolar disorder and malignant neoplasm of the colon. The quarterly MDS assessment dated [DATE] identified Resident #12 had severe cognitive impairment, required extensive assistance with toileting, hygiene, dressing, transfers, and was non-ambulatory. The physician's order dated 6/27/23 directed to refer Resident #12 for hospice services and treatment as appropriate for late-stage dementia. Review of the electronic health record (resident census) identified Resident #12 was admitted to hospice on 6/28/23. The Resident Care Plan (RCP) dated 6/28/23 identified Resident #12 was admitted to hospice care with interventions that identified: recognize and respect resident decision of no tube feeding…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2024-03-27 · tag F0842 — failed to keep accurate, complete medical records — pattern
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility policy, and interviews for one of two sampled residents (Resident #119) reviewed for advanced directives, the facility failed to ensure the clinical record contained accurate documentation pertaining to advanced directives. The findings include: Resident #119's diagnoses included cerebrovascular disease, type 2 diabetes mellitus, and aphasia. The admission MDS assessment dated [DATE] identified Resident #119 had intact cognition, required moderate assistance with bed mobility, toileting hygiene, lower body dressing, was non-ambulatory, and utilized a wheelchair for mobility. The care plan dated 12/26/23 identified the resident's cardiopulmonary status as full code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive) with interventions that included activate resident's advance directive as indicated. The physician's order dated 12/21/23 directed Resident #119 had full code status.…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to COMPLETE CARE — 85 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 →

RatingThis homeChain avg
Overall 5 of 53.1+1.9 vs chain
Health inspection 4 of 52.7+1.3 vs chain
Staffing 2 of 52.3-0.3 vs chain
Quality measures 5 of 54.4+0.6 vs chain
The other 84 homes this chain runs (chain average 3.1★, per CMS)
1 of 5Complete Care At Chestnut Hill LLCPassaic, NJ 1 of 5Complete Care At HagerstownHagerstown, MD 1 of 5Complete Care At Harston Hall LLCFlourtown, PA 1 of 5Complete Care At Kimberly Hall NorthWindsor, CT 1 of 5Complete Care At Laplata LLCLaplata, MD 1 of 5Complete Care At Milford Manor LLCWest Milford, NJ 1 of 5Complete Care At Wayne Hills Rehab & Resp CenterWayne, NJ 1 of 5Complete Care at Care AgeBrookfield, WI 1 of 5Complete Care at KensingtonWaukesha, WI 1 of 5Complete Care at Maple Grove LLCMadison, WI 1 of 5Complete Care at Margate ParkChicago, IL 1 of 5Complete Care at the BoulevardChicago, IL 2 of 5Complete Care At Brakeley ParkPhillipsburg, NJ 2 of 5Complete Care At Fox HillVernon, CT 2 of 5Complete Care At Harborage LLCNorth Bergen, NJ 2 of 5Complete Care At Harrington CourtColchester, CT 2 of 5Complete Care At HyattsvilleHyattsville, MD 2 of 5Complete Care At Inglemoor, LLCEnglewood, NJ 2 of 5Complete Care At Monmouth, LLCLong Branch, NJ 2 of 5Complete Care At Ocean Grove LLCOcean Grove, NJ 2 of 5Complete Care At Prospect Heights LLCHackensack, NJ 2 of 5Complete Care At Regent LLCHackensack, NJ 2 of 5Complete Care at Christian Home LLCWaupun, WI 2 of 5Complete Care at Grande PrairiePleasant Prairie, WI 2 of 5Complete Care at Heritage LLCDundalk, MD 2 of 5Complete Care at Linwood, LLCLinwood, NJ 2 of 5Complete Care at Nazareth LLCStoughton, WI 2 of 5Complete Care at Voorhees, LLCVoorhees, NJ 2 of 5Complete Care at Wall LLCWall, NJ 3 of 5Complete Care At Fair Lawn EdgePaterson, NJ 3 of 5Complete Care At Holiday CityToms River, NJ 3 of 5Complete Care At Lehigh LLCMacungie, PA 3 of 5Complete Care At Oak Ridge LLCCharleston, WV 3 of 5Complete Care At Orange ParkEast Orange, NJ 3 of 5Complete Care At Phillipsburg, LLCPhillipsburg, NJ 3 of 5Complete Care At Severna Park LLCSeverna Park, MD 3 of 5Complete Care At Shrewsbury LLCShrewsbury, NJ 3 of 5Complete Care At Silver Lake LLCDover, DE 3 of 5Complete Care At SpringbrookSilver Spring, MD 3 of 5Complete Care at Brick LLCBrick, NJ

Showing 40 of 84; lowest-rated first.

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 / managerTypeRoleShareSince
PC CT OPCOS LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 09/01/2021
PC WTA OPCO HOLDCO LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 09/01/2021
SMS 2021 TRUSTOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 09/01/2021
HOCH, ROBERTIndividualW-2 MANAGING EMPLOYEEsince 09/01/2021
STEIN, SHALOMIndividualCORPORATE OFFICERsince 09/01/2021

3 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.

$17.0M
Net patient revenuemost recent cost report
+4.7%
Operating marginrevenue minus expenses
$2.3M
Related-party expense14% of expenses
Who pays — share of resident-days
Medicaid 49%Medicare 5%Other / private 46%

This home reported $2.3M paid to related parties — landlords or management companies under common ownership — equal to about 14% 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.

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

$234per resident / day
operating cost
$7,118per month
≈ monthly operating cost
$246per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in CT

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Connecticut Medicaid page.

Typical monthly cost in Connecticut
$15,208/mo
Nursing home (semi-private)
$16,729/mo
Nursing home (private)
$9,118/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 075270. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-29, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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