Avery Nursing Home/Noble Building

Location & what’s nearby

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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

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.

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.

58.3% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 97 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 70.0% 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 70 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 0.23 therapist hours per resident per day in 2026Q1 — more than 29% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 6% 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.

Staffing

How full it usually is: this home is certified for 194 beds and averages 169.2 residents a day — about 87% occupied, or roughly 25 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.40 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.64 is at or above 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 3.24 hrs/resident/day on weekends vs 3.46 on weekdays — 6% thinner on weekends. RN hours go from 0.71 to 0.48 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 25% is below the national median of 45%.

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

Inspection trend

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

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

43 citations, most serious first. The 15 most serious are shown; the remaining 28 are one tap away and print in full.

• Immediate jeopardy · J2023-12-12 · 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 review, facility documentation review, facility policy review and interviews for one of three residents (Resident #1) reviewed for mechanical lift transfers, the facility neglected to utilize two staff members while operating the mechanical lift in accordance with physician orders and facility policy resulting in Resident #1 falling from the lift on [DATE] and [DATE]. The failures resulted in a finding of Immediate Jeopardy. The findings include: Resident #1's diagnoses included quadriplegia (partial or total loss of function in the arms, legs, trunk, and pelvis) due to a history of right cerebellar infarct stroke and right femoral neck fracture. a. Physician orders dated [DATE] directed (2) assist with mechanical lift transfers. The quarterly minimum data set (MDS) dated [DATE] identified Resident #1 was confused and was dependent on staff for transfers. Facility incident report dated [DATE] identified Resident #1 sustained a fall during a mechanical lift transfer. The report noted 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
• Immediate jeopardy · Jcited before2023-12-12 · 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 clinical record review, facility documentation review, facility policy review and interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure adequate assistance was provided when operating a mechanical lift in accordance with the plan of care and facility policy, resulting in the resident falling to the floor on [DATE] and [DATE]. The failures resulted in a finding of Immediate Jeopardy. The findings include: Resident #1 diagnoses included quadriplegia (partial or total loss of function in the arms, legs, trunk, and pelvis) due to a history of right cerebellar infarct stroke and right femoral neck fracture. a. Physician orders dated [DATE] directed (2) assist with mechanical lift transfers. The quarterly minimum data set (MDS) dated [DATE] identified Resident #1 was confused and was dependent on staff for transfers. Facility incident report dated [DATE] identified Resident #1 sustained a fall during a mechanical lift transfer. The report noted one NA had…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-10-06 · 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 review, facility documentation, and facility policy, and interviews for one of three residents (Resident #1) reviewed for wandering, the facility failed to ensure adequate supervision for a resident with known wandering behaviors to ensure Resident #1 could not leave the unit without staff knowledge resulting in a fall outside the building (last seen 2 hours prior to observed outside). The findings include: Based on review of the clinical record review, facility documentation, and facility policy, and interviews for one of three residents (Resident #1) reviewed for wandering, the facility failed to ensure adequate supervision for a resident with known wandering behaviors to ensure Resident #1 could not leave the unit without staff knowledge resulting in a fall outside the building (last seen 2 hours prior to observed outside). The findings include: Resident #1 had a history of dementia, muscle weakness, legally blind, and disorder of bone density. The annual Minimum Data…

  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
• Actual harm · Gcited before2025-04-08 · 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 with major injuries, the facility failed to ensure a timely assessment pertaining to bed mobility during provisions of care. As a result, Resident #1 sustained a fall out of bed resulting in multiple subsequent fractures. The findings include: Resident #1's diagnoses included muscle weakness, repeated falls, anxiety disorder and type 2 diabetes with neuropathy (nerve damage affecting the feet and legs that can cause numbness, tingling, pain and loss of sensation). The significant change in status Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Mental Interview for Mental Status (BIMS) assessment was conducted and identified both short-term and long-term memory problems indicative of moderately impaired cognition and was dependent on staff for bed mobility and transfers. Review of the Fall Risk Scale dated 2/14/25 identified Resident…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2023-08-08 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide 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, observation, facility policy review, and interviews for one of two sampled residents (Resident #105) reviewed for facility acquired pressure ulcers, the facility failed to ensure interventions were implemented to prevent the development and worsening of a pressure ulcers/injury. The findings include: Resident #105 had diagnoses that included dementia, venous insufficiency, mood disturbance, dysphagia, anxiety, and type II diabetes mellitus. The admission MDS assessment dated [DATE] identified Resident #105 had severe cognitive impairment, required extensive assistance for bed mobility and eating, was non-ambulatory, required total assistance for transfers, hygiene, and toilet use. The assessment further identified Resident #105 was at risk for the development of pressure ulcers but did not have the presence of a pressure ulcer. The Braden Scale assessment (used to predict risk for pressure ulcer development) dated 2/21/23 identified the resident had a score of 15 which is…

  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 · E2025-05-19 · tag F0603 — failed to not confine residents against their will — pattern
  Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
  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/procedure, review of facility documentation and interviews for thee sampled residents (Residents #34, #38 and #158) residing on a secured unit, the facility failed to assess, care plan, demonstrate that the secured unit was the least restrictive setting, and obtain consents for residents who were selected to reside on the secured unit. The findings include: Observations on all days of the survey: 5/12/25, 5/13/25, 5/14/15, 5/15/25, 5/16/25 and 5/19/25 identified the secured unit was identified as Station 2 and noted that all doors that could be used to exit the unit required a code to be punched in to a key pad located on the wall by the egress doors. Resident #34 was admitted to the facility in 2018 with diagnoses that include schizophrenia, osteoarthritis, bipolar disorder, major depressive disorder, agoraphobia with panic disorder. In 2020 the diagnoses of dementia and anxiety were added. The quarterly MDS assessment dated [DATE]…

  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 · Ecited before2025-05-19 · tag F0880 — failed to prevent and control infections — pattern
  Provide and implement an infection prevention and control program.
  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 interview, the facility failed to provide documentation that environmental rounds were conducted on a quarterly basis. The findings include: Review of the environmental rounds documentation for the period of August 2023 through April 0f 2025 with the Infection Preventionist (RN #6) on 5/16/25 at 11:39 AM failed to identify any documentation that the environmental rounds were completed for the first quarter of 2024 which includes the months of January, February and March. Interview with RN #6 on 5/16/25 at 11:39 AM identified that environmental rounds are completed quarterly by the infection control nurse. She identified it was the responsibility of the previous infection control nurse to ensure that the environmental rounds were completed, as she had only started working in the role of the Infection Preventionist nurse in June of 2024. RN #6 further identified that she was unable to locate any documentation of the environmental rounds for the first quarter in 2024 that was completed. Review of 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 · E2025-05-19 · tag F0883 — failed to offer flu and pneumonia vaccines — pattern
  Develop and implement policies and procedures for flu and pneumonia vaccinations.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, review of facility policy, review of facility documentation, and interviews for five of five sampled residents (Residents #29, #36, #46, #91, and #161) reviewed for immunizations, the facility failed to ensure that the pneumococcal vaccine was assessed/and administered and failed to offer the influenza vaccine. The findings include: Resident #29 was admitted to the facility in February of 2025 and had diagnoses that included anemia, hypertension, and hyperlipidemia. The admission MDS assessment dated [DATE] identified Resident #29 had moderately impaired cognition. The assessment further identified Resident #29 had not received the pneumococcal vaccine. Review of the immunization consent form provided on admission under Pneumococcal vaccine consent section indicated that Resident #29 had received the pneumococcal vaccine 23 (PPSV23) in 2020 in the past and signed by responsible party on 2/20/25. Review of Resident #29's clinical records with the Infection Preventionist (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 · D2025-05-19 · tag F0578 — failed to honor advance directives / code status — isolated
  Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, review of facility documentation, review of facility policy, and interviews for one sampled resident (Resident #127) reviewed for advance directives, the facility failed to ensure there was a physician's order indicating the resident's wishes related to cardiopulmonary code status, hospitalization, and intravenous fluids. The findings include: Resident #127's diagnoses included dementia, hypertension, and muscle weakness. The annual MDS assessment dated [DATE] identified Resident #127 had severely impaired cognition and required maximal assistance with toileting hygiene, bathing dressing, personal hygiene and bed mobility. The care plan dated [DATE] identified Resident #127 had advance directives to be honored by staff per resident/family election of full code status with interventions that included CPR (Cardiopulmonary Resuscitation). A review of the clinical record identified an Advance Directive Consent Form that was signed by Resident #127's responsible party and 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-05-19 · tag F0657 — failed to keep the care plan current — isolated
  Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, review of facility documentation, review of facility policy, and interviews for one sampled resident (Resident #427) who was a new admission, the facility failed to ensure an interdisciplinary care plan meeting was held and failed to develop the comprehensive care plan. The findings include: Resident #427 was admitted to the facility on [DATE] with diagnoses that included heart failure, peripheral vascular disease and gout. The baseline care plan dated 4/14/25 identified the following care plan focused areas: nutritional status, return to community referral and psychosocial well-being along with approaches for each identified area. The admission MDS assessment dated [DATE] identified Resident #427 was cognitively intact, dependent on staff for toileting hygiene, required moderate assistance with personal hygiene, upper body dressing, bed mobility and bathing, was occasionally incontinent of bladder and always continent of bowel. The assessment further 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.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-05-19 · tag F0658 — failed to meet professional standards of care — isolated
  Ensure services provided by the nursing facility meet professional standards of quality.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical records, review of facility policy/procedures and interviews for one of four sampled residents (Resident #149) reviewed for accidents, the facility failed to ensure medications were administered according to professional standards. The findings include: Resident #149's diagnoses included muscle weakness, primary open angle glaucoma bilateral, hypertensive heart and chronic kidney disease with heart failure and chronic kidney disease. The quarterly MDS assessment dated [DATE] identified Resident #149 was cognitively intact, had no behaviors, was independent with eating, was dependent for toileting, utilized a wheelchair for mobility, and received anticoagulant, antiplatelet, and hypoglycemic medications. The care plan dated 5/9/25 identified Resident #149 was at risk for pain related to limited mobility with interventions that included administer medications as ordered. The physician's order dated 5/1/25 directed Amlodipine 5mg 1 tablet every morning, Aspirin delayed…

  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 · Dcited before2025-05-19 · 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, review of facility policy/procedures and interviews for one sampled resident (Resident #26) reviewed for skin conditions, the facility failed to administer a treatment/medication as ordered. The findings include: Resident #26's diagnoses included heredity syndrome of bilateral lacrimal glands, dry eye disorder, and malignant melanoma of right upper eyelid. The quarterly MDS assessment dated [DATE] identified Resident #26 was cognitively intact, had no behaviors, required substantial/maximal assist with toileting, and was independent with eating. The care plan dated 4/24/25 identified Resident #26 was at risk for impaired skin integrity related to right upper eye lid malignant melanoma with interventions that included treatments as ordered with monitoring per protocol and as needed, and extremities to be assessed by the licensed staff daily on the 3pm -11pm shift. The physician's orders dated 5/1/25 directed Artificial Tears 1%, 1 drop to each eye twice daily; 8AM-11AM; 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-05-19 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, review of facility policy/procedures, and interviews for two of three sampled residents (Residents #114 & #128) reviewed for pressure ulcers, the facility failed to ensure the necessary proper documentation of a pressure injury consistent with professional standards and failed to provide the necessary treatment and services to promote the healing of a pressure ulcer. The findings included: 1. Resident #114 has a diagnosis of Parkinson's disease. The significant change MDS assessment dated [DATE] identified Resident#114 had intact cognition, did not have behaviors, did not have range of motion impairments, required set up assistance with eating, required partial to moderate assistance with toileting hygiene, required substantial to maximal assistance with rolling to the left or right while in bed, did not ambulate, was at risk for the development of pressure ulcers but did not have any pressure ulcers. The assessment further identified that the resident weighed…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-05-19 · 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, review of facility documentation, review of facility policy/procedures and interviews for one of four sampled residents (Resident #10) reviewed for accidents, the facility failed to ensure Resident #10 was free from accidents when transported in a shower chair. The findings included: Resident #10 was admitted to the facility in March 2023 with diagnoses that included heart failure, unspecified osteoarthritis, left hand contracture, muscle weakness and hemiplegia and hemiparesis following cerebral infarction. The quarterly MDS assessment dated [DATE] identified Resident #10 had intact cognition, had impairment on one side to the upper extremity, required extensive assistance with bed-mobility, and transfers and had a weight of 213 pounds (lbs.). The care plan dated 10/31/23 identified Resident #10 had a self-care deficit with interventions that included: extensive assist of one with personal hygiene, and bathing, independent with transfers with a walker, and ambulates…

  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 · D2025-05-19 · tag F0761 — failed to label and store drugs safely — isolated
  Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, review of facility policy and procedures, and interviews, the facility failed to ensure medication carts were secured when not in use. The findings include: Observation on 5/15/25 at 6:03 AM on Station 2 (the secured unit), identified the 2 South medication cart located in the hallway had the lock in the unlocked position and the top drawer slightly opened. There were oxygen tubing packets on the top of the cart. The 2 North medication cart's lock was also in the unlocked position. Additionally, one resident was wandering the North hallway near the common area approximately 10 feet from the medication cart. The charge nurse was in the nurses' office and could not see the carts. Interview on 5/15/25 at 6:10 AM with LPN #15 identified that the carts should be locked when not in use and not within the line of sight of the nurse. Interview on 5/15/25 at 6:15 AM with the night shift Nursing Supervisor (RN #15) identified that the medication carts should always be locked when not in use. RN#15 indicated that if the nurse is passing medications and the cart is facing…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction

“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.

Fines & penalties

$69,928 in federal fines across 3 penalties.

• $10,358 — penalty dated 2025-10-06
• $14,505 — penalty dated 2025-04-08
• $45,065 — penalty dated 2023-12-12

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

CMS files one row per role, so the 19 rows in the source record cover these 13 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

Follow the money — this home’s finances

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

About 73% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.2M paid to related parties (affiliated landlords or management companies) in its most recent cost report. 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