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Touchpoints At Manchester

333 Bidwell St, Manchester, CT 06040 · For profit - Corporation · 127 certified beds · (860) 533-3086 Medicare & Medicaid certified

Call the home — (860) 533-3086 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0610) — cited Aug 2025Resident-funds citation (F0565)
Insights

The public record raises real questions here. Weigh the concerns below carefully.

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
  • lower-than-typical staff turnover (21% vs 45% nationally) — better care continuity
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has a citation for mishandling residents’ money or property (F0565)
  • a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags

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

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

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 4 of 5

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
394 W Center St · (860) 647-7831 · Call to confirm hours
Pharmacy
455 Hartford Rd · (860) 649-9946 · Call to confirm hours
Grocery
425 Broad St · (860) 645-1913 · Call to confirm hours
Park
795 Center St · 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 4 of 5
Long-stay residentspeople who live here 4 of 5
Short-stay residentsrehab / post-hospital 4 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 4 stars. From monthly CMS archive snapshots.

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

Overall rating4★
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 increased12.3%18.0%15.4%better
Long-stay residents who lose too much weight3.0%6.5%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.7%0.9%better
Long-stay residents with a urinary tract infection0.0%1.5%2.0%better
Long-stay residents with depressive symptoms11.7%22.3%6.5%better 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 injury1.6%3.5%3.3%better
Long-stay residents whose ability to walk worsened9.2%16.4%16.1%better
Long-stay residents on antianxiety or hypnotic medication21.5%17.6%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%93.5%95.3%typical
Long-stay residents with pressure ulcers3.2%4.0%4.7%better
Long-stay residents with worsening bladder/bowel control7.6%24.7%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table17.9%17.8%17.1%typical
Short-stay residents who newly got an antipsychotic medication0.0%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine93.2%69.7%79.4%better
Short-stay residents rehospitalized after admission30.1%24.3%22.6%worse
Short-stay residents with an outpatient ER visit8.8%10.7%12.0%better

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

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

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

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

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

55.8% 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 45 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

55.8%U.S. median 51.5%
Got home and stayed home
10.6%U.S. median 10.7%
Went back to hospital
0.18U.S. median 0.31
Therapy hours / resident / day
0.08hours / resident / day
Physical therapy
0.08hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.18 therapist hours per resident per day in 2026Q1 — more than 18% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 15% 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 SNF55.8%CMS range 38.1–68.551.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.6%CMS range 6.5–15.810.7%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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified90.9%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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.121.02Oct 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

0.49
RN hours/ resident / day
0.65
LPN hours/ resident / day
1.81
Aide hours/ resident / day
2.95
Total nurse hours/ resident / day
0.41
RN hoursweekends
20.7%
Total nursing turnover
20.0%
RN turnover

How full it usually is: this home is certified for 127 beds and averages 118.7 residents a day — about 93% occupied, or roughly 8 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 2.95 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.49 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.81 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 2.61 hrs/resident/day on weekends vs 3.08 on weekdays — 15% thinner on weekends. RN hours go from 0.53 to 0.41 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 21% is below the national median of 45%.

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

Inspection trend

3
deficiencies at the latest standard inspection (2025-08-13)
16
at the previous standard inspection (2023-07-25)

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.

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.

29 citations, most serious first. The 10 most serious are shown; the remaining 19 are one tap away and print in full.

  • Potential for harm · Dcited before2025-09-02 · tag F0842 — failed to keep accurate, complete medical records — isolated
    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 review of clinical records, interviews, and review of facility documentation and policies for one of three residents (Resident #1) reviewed for change of condition, the facility failed to ensure the clinical record was complete and accurate to include timely notification of a change in condition. The findings included: Based on review of clinical records, interviews, and review of facility documentation and policies for one of three residents (Resident #1) reviewed for change of condition, the facility failed to ensure the clinical record was complete and accurate to include timely notification of a change in condition. The findings included: Resident #1 had diagnoses that included anxiety disorder, and chronic systolic heart failure. Review of the medical record on 9/2/2025 identified Person #1 was the court appointed Conservator of Person (COP). Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Mental Interview for Mental Status (BIMS) score of…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-08-13 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of facility documentation, review of facility policy and procedures, and interviews, the facility failed to ensure that an accurate accounting of all controlled medications were maintained and reconciled periodically, to ensure the accurate disposition of the controlled medications. The findings include: A review of the narcotic reconciliation process on 8/11/25 at 12:35 PM with the DNS identified that the narcotic audits are completed twice per month and include counting the narcotic medications on each medication cart, reviewing the signatures on the shift-to-shift count sheet to ensure that the count is being conducted and signed for and inspecting the packs of medications (blister) to ensure they have not been tampered with, and she reviews narcotic medications that were ordered on an as needed basis but were not administered. Additionally, the DNS identified that when the pharmacy delivers narcotic medications, the medications come with a white and yellow controlled substance…

    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
  • Potential for harm · E2025-08-13 · 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/procedures and interviews, the facility failed to ensure refrigerated food items were dated, labeled, discarded within set time frames and failed to ensure staff did not store personal food items in the commercial reach in refrigerator designated for resident food storage. The findings include:Observation during the brief initial kitchen tour on 8/6/25 at 10:30 AM with the Dietary Manager identified six carafes of orange juice, six carafes of apple juice, two pitchers of white cranberry juice, and two pitchers of fruit punch with no preparation date. Interview on 8/6/25 at 10:35 AM with Dietary Manger identified the carafes and pitchers should be labeled with the preparation date and usually they are prepared the day before for the next day and there is a piece of parchment paper put on top of them with the date, however the person who prepared them did not put the label there. Observation on 8/6/25 at 10:42 AM with the Dietary Manager identified the walk-in refrigerator contained five plastic containers of apple sauce and six plastic…

    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 · Ddisputed · IDR2025-08-13 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, review of facility documentation, review of facility policy and interviews for one sampled resident (Resident #107) with a fracture to the right ankle of unknown origin and who required the use of a total mechanical lift for transfers, the facility failed to complete a thorough investigation inclusive of determining that two staff members were utilized when the resident was transferred. The findings include:Resident #107 's diagnoses included dementia, stiffness in bilateral knees, and reduced mobility.The quarterly Minimum Data Set assessment dated [DATE], identified Resident #107 was severely cognitively impaired, had no behaviors and was dependent for activities of daily living and transfers.A nurses note dated 12/23/24 at 2:43 PM identified Resident #107 complained of right ankle pain with movement, swelling and mild bruising around the outer ankle, and a yellow discoloration noted to the left shin. The APRN was updated, evaluated the resident and ordered x-rays. 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-20 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, facility policies and interviews for one (1) of four (4) sampled residents (Resident #2) who had a witnessed fall with no initial injuries noted, the facility failed to notify the physician after a change in condition was identified. The findings include: Resident #2's diagnoses included malignant neoplasm of the oropharynx, anxiety, and depression. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 had poor short- and long-term memory recall. The nurse's note dated 1/9/25 at 3:08 PM identified Resident #2 had a witnessed fall at 2:45 PM in the hallway. Resident #2 was ambulating in the hallway, lost his/her balance and fell. Resident #2 complained of right hip and knee pain, there were no bruises or discoloration seen at that time and Resident #2 had positive range of motion (ROM) to all extremities. The note identified the Advanced Practice Registered Nurse (APRN) #1 was updated and directed a stat x-ray order for the right…

    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 before2025-02-28 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #2) reviewed for medication administration, the facility failed to notify the Advanced Practice Registered Nurse (APRN) timely of medication omissions. The findings include Please cross reference F 684. Resident #2's diagnoses included cellulitis (bacterial skin infection) and spondylosis of the lumbar region (degeneration of the bones and disks in the lower spine). The Resident admission Profile dated 8/16/24 identified that Resident #2 was alert and oriented to person, place and time and was independent with eating and required assistance with transfers and mobility. Review of Resident #2's Face sheet identified that the resident was admitted to the facility on [DATE] at 6:30 PM. Review of Resident #2's admission orders dated 8/16/24 directed that the resident was to be administered: 1) Tylenol (pain reliever) 500 milligrams (mg), 2 tablets (1000 mg) by mouth three times…

    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 plan of correction
  • Potential for harm · D2025-02-28 · 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, facility policy, and interviews for the one (1) of three (3) residents (Resident #1) reviewed for diabetes management, the facility failed to revise the care plan to include the resident's diagnosis and concerns related to his/her diabetic plan of care. The findings include: Resident #1's diagnoses included Congestive Heart Failure (CHF) and Chronic Kidney Disease (CKD). The 5-day Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Mental Interview for Mental Status (BIMS) of fifteen (15) indicative of intact cognition and required moderate assistance with showering/bathing self, bed mobility and transfers. Review of Resident #1's hospital Discharge summary dated [DATE] identified that Resident #1 had a diagnosis of diabetes mellitus, type II and was discharged to the facility on insulin glargine (lantus) 100 units per milliliter (mL) directing to inject 12 units under the skin at bedtime. A physician's order dated 1/25/25 directed to continue…

    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 plan of correction
  • Potential for harm · Dcited before2025-02-28 · 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

    Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #2) reviewed for medication administration, the facility failed to ensure that a newly admitted resident was provided with medications in accordance with hospital discharge summary directions and physician's orders. The findings includePlease cross reference F 580Resident #2's diagnoses included cellulitis (bacterial skin infection) and spondylosis of the lumbar region (degeneration of the bones and disks in the lower spine).The Resident admission Profile dated 8/16/24 identified that Resident #2 was alert and oriented to person, place and time and was independent with eating and required assistance with transfers and mobility.Further Review of the Resident admission Profile identified that RN #1 completed Resident #2's admission assessment on 8/16/24 at 6:16 PM.Review of Resident #2's admission orders dated 8/16/24 directed that the resident was to be administered:1) Tylenol (pain reliever) 500 milligrams (mg), 2 tablets (1000 mg) by mouth…

    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 plan of correction
  • Potential for harm · E2023-07-25 · tag F0550 — failed to protect resident dignity and rights — pattern
    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

    Based on review of facility smoking policy and Leave of Absence (LOA) policy and staff interviews, the facility failed to ensure that facility policies honored the resident's rights. The findings included: 1. On 7/21/2023 at 1:00 PM an interview and policy review with the Administrator, the [NAME] President of Operations, Registered Nurse (RN #6), and the Director of Nursing Services (DNS) identified the smoking policy and smoking agreement signed by the resident/responsible party indicated in part a potential removal of smoking privileges from a resident who was not complied with the facility smoking rules. The Administrator and [NAME] President of Operations further indicated the smoking rules were in place to ensure that residents who smoke adhere to the rules to prevent a potential emergent situation of all residents if a fire was started by a resident who was not following the rules, kept smoking items in their own possession and started a fire in the facility. The Administrator further indicated to his knowledge smoking privileges have yet to be taken away from any 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 · E2023-07-25 · tag F0656 — failed to write and follow a full care plan — pattern
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation, and policy review and interviews for 1 of 1 sampled resident (Resident #33) reviewed for specialized treatment, the facility failed to ensure the resident's care plan for weight monitoring was followed. The finding include: Resident # 33's diagnoses included: Acute and Chronic Respiratory Failure, diabetes mellitus, depression, Heart Failure, Congestive Heart Failure (CHF), COPD, End Stage Renal Failure, and Kidney Transplant with Rejection. An admission MDS assessment dated [DATE] identified Resident #33 as alert and cognitively intact, the resident required limited assistance of one for transfers, dressing, toilet use, and personal hygiene, supervision with assistance of one for bed mobility, and independent with set-up for eating. The Treatment Administration Record (TAR) for the month of June 2023 indicated daily weights per CHF/COPD guidelines, if over 2 pounds in 24 hours or 5 pounds in 1 week, notify MD. A physician's order dated 7/10/23 indicated…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
Show the remaining 19 citations
  • Potential for harm · D2023-07-25 · tag F0565 — failed to support the resident council — isolated
    Honor the resident's right to organize and participate in resident/family groups in the facility.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, review of facility documentation and staff interviews, the facility failed to act on recommendations from Resident Council concerns. The findings include: Review of Resident Council meeting minutes dated 4/27/23 indicated the residents requested to receive silverware and drinks before getting their meals. Facility's response indicated they would communicate to Nurse Aides (NAs) and kitchen staff to improve timing and that silverware and drinks would be passed earlier to ensure residents receive them before the meal. Observation of dining on the first floor A Wing on 7/18/23 at 11:20 AM identified a steam table was brought to the unit by Dietary staff, food was plated and served to residents eating in their room (by Dietary staff). Additionally, a NA was observed to be passing juices from a cart and another NA was passing out silverware, however, residents had to wait to receive juices/silverware because they were not delivered with the meal. Interview with the Food Service Director on 7/18/23 at 11:40 AM identified that NAs are responsible for passing out…

    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 before2023-07-25 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    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 observations, review of facility documentation, and staff interviews, the facility failed to ensure the environment was maintained in good repair and in a homelike manner. The findings include: Observations on 7/21/23 at 1:04 PM through 1:45 PM with the Administrator, Director of Operations, Director of Maintenance and the Regional Director of Housekeeping identified the following issues: a. A curtain rod was observed to be bent causing the [NAME] to sag in the second floor East lounge. b. Approximately 24 tiles were observed with linear zigzag cracking located from the doorway to the far wall in the second floor East lounge. c. The ceiling between 2 windows were noted with a black stain and drip marks, paint was observed to be peeling on the wall below the drip marks in the second floor East lounge. d. The second floor Social dining room was observed missing the cove base molding on all 5 walls, exposing peeling, chipped sheetrock. Debris and dust was noted where tile meets the wall. In addition, 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 · D2023-07-25 · 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 clinical record review and interviews for 1 of 2 sampled residents (Resident # 79) reviewed for Accidents, the facility failed to ensure physician's orders were verified for daily weights to meet professional standards and facility practice. The findings include: Resident # 79's diagnoses included heart disease, pulmonary hypertension, and dementia. The annual Minimum Data Set assessment dated [DATE] identified Resident # 79 was severely cognitively impaired and required one-person limited assistance with bed mobility and locomotion on the unit, and one-person extensive assistance with dressing, toilet use, and personal hygiene. The Resident Care Plan dated 6/4/23 identified a diagnosis or history of coronary artery disease and pulmonary hypertension, nutritional risk secondary to medical condition, and need of more assistance with activities of daily living related to diagnosis, decline in mobility and right hip fracture. Interventions directed weight as ordered and to monitor status for any changes. 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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-07-25 · 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 clinical record review, facility policy review and interviews for 1 of 1 sampled resident (Resident # 120) who was reviewed for death, the facility failed to ensure licensed staff were CPR Certified, obtain a physician order to release a body to a funeral home, failed to date and time a physician's order for IV therapy and staff failed to transcribe a physician's order. The findings included: 1 a. Resident #120 was admitted on [DATE], diagnoses included Type 2 diabetes mellitus, sepsis, and pressure ulcer of the sacral region. The admission MDS assessment dated [DATE] identified the resident was severely cognitively impaired, required extensive to total care with ADLs and noted the resident utilized 6 antibiotics in the last 7 days. The care plan dated [DATE] indicated in part for Resident #120 at risk for alteration in nutritional status with interventions that included: to monitor diet tolerance, assist with meals as needed/accepted and to obtain weights and laboratory blood work as ordered. The care…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-25 · 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 review of clinical records, review of facility policy and interviews for 1 of 2 residents (Resident #222) reviewed for pressure ulcers, the facility failed to ensure a resident's air mattress was set at the appropriate settings. The finding include: Resident #222's diagnoses included atrial fibrillation, patella fracture, arthritis, osteoporosis, anxiety, anemia, and unstageable pressure ulcer of the coccyx. The resident was admitted to the facility on [DATE]. The admission Minimum Data Set assessment dated [DATE] indicated the resident was alert with moderately impaired cognition, and required extensive assistance of two for bed mobility, limited assistance of one for transfers, dressing, toilet use, personal hygiene, and independent with set-up for eating. Additionally, the assessment indicated the resident weighed 110 pounds. The baseline care plan dated 7/1/23 for at risk for skin breakdown secondary to incontinence and wound on coccyx, heels, and right buttocks. Interventions directed to apply 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-25 · tag F0694 — isolated
    Provide for the safe, appropriate administration of IV fluids for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observations and interviews for 1 of 1 sampled resident (Resident #221) reviewed for intravenous therapy the facility failed to follow professional standards of practice of assessing and maintaining parenteral access. The findings include: Resident #221's diagnoses included: heart failure, respiratory failure, peripheral vascular disease, diabetes mellitus, and osteomyelitis. A Resident Care Plan dated 7/5/23 indicated the resident had a chronic disease process that required a continuous intravenous infusion of medication to sustain organ function and was at risk for worsening symptoms of organ failure. Interventions included monitoring his/her level of shortness of breath, swelling, increased tiredness, weight changes, providing education regarding signs and symptoms of organ failure, what to do if signs and symptoms occurred, and directed facility staff to report symptoms to the clinic. However, the RCP failed to identify care planning interventions specific for intravenous…

    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 before2023-07-25 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observations, review of facility documentation, review of facility policy and interviews for 1 of 2 sampled residents (Resident #2) reviewed for oxygen therapy, the facility failed to assess the resident for competency to apply/remove oxygen independently and failed to ensure a physician's order identified the frequency for monitoring oxygen saturation levels. The findings include: Resident #2 's diagnoses included chronic respiratory failure with hypoxia, acute and chronic systolic (congestive) heart failure and morbid obesity with alveolar hypoventilation. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had intact cognition, and required supervision of 1 for bed mobility, transfers, dressing, toilet use and personal hygiene. The MDS further identified Resident #2 utilized oxygen while in the facility. A Resident Care Plan (RCP) dated 4/27/22 identified a problem with respiratory status with interventions that included to provide oxygen per…

    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 · D2023-07-25 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation, policy review and staff interviews for o1 of 1 sampled resident (Resident #33) reviewed for specialized treatment, the facility failed to ensure that treatment site monitoring, weight monitoring, and communication with the treatment center was consistent and within the plan of care. The findings included: Resident # 33's diagnoses included: Acute and Chronic Respiratory Failure, diabetes mellitus, depression, Heart Failure, Congestive Heart Failure (CHF), COPD, End Stage Renal Failure, and Kidney Transplant with Rejection. An admission MDS assessment dated [DATE] identified Resident #33 as alert and cognitively intact, the resident required limited assistance of one for transfers, dressing, toilet use, and personal hygiene, supervision with assistance of one for bed mobility, and independent with set-up for eating. The Treatment Administration Record (TAR) for the month of June 2023 indicated daily weights per CHF/COPD guidelines, if over 2 pounds in 24…

    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 · D2023-07-25 · tag F0730 — isolated
    Observe each nurse aide's job performance and give regular training.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews and employee record review, the facility failed to complete annual performance evaluations for 1 of 3 sampled Nurses Aides (NA #3) reviewed. The findings include: NA #3's date of hire was 3/12/15. One performance evaluation was present in the employee record dated 3/16/23. Although requested, the facility was unable to provide annual evaluations prior to 2023 for NA #3. Interview with the Administrator on 7/20/23 at 1:30 PM indicated that administration provides the Nursing Supervisors an evaluation form to complete with the NAs being evaluated. Once completed, the form is returned to the DNS and Administrator for signatures. The Administrator was unable to indicate a reason for the absence of evaluations prior to 2023 for NA #3 and indicated that follow up to incomplete evaluations for NAs is done by the DNS. Interview with the DNS on 7/20/23 at 1:40 PM indicated that performance evaluations are completed yearly on the date of hire. The DNS was not able to indicate a reason for the absence of evaluations prior to 2023 for NA #3. The DNS identified that there 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-25 · 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 observation and staff interview for 2 of 2 units, the facility failed to ensure staff ensure that treatment carts were secure. The findings included. 1. Observations on 7/17/23 6:15 AM on the first floor, noted the treatment cart located on left side of hall across from the nursing station was unlocked and unattended Interview with the charge nurse, LPN # 8 indicated the treatment cart should have been locked and proceeded to immediately lock the cart. LPN #8 further indicated a staff member had just been in it a few minutes ago. Observation further identified no other staff member or resident in the vicinity of the unsecured treatment cart. 2. Observations on 7/17/2023 at 6: 25 AM on the second floor identified the treatment cart was found unlocked and unattended to the right side of the nurse's station in the hall leading to resident rooms. The charge nurse LPN# 7 was noted sitting at the opposite side of the nurse's station using the computer. LPN # 7 indicated the treatment cart should have been locked and s/he did not know who left the cart unlocked and proceeded to…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-25 · 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

    Based on observation, review of the facility infection control program and interviews, the facility failed to perform hand hygiene following glove removal and failed to properly label, cover, and store a bedpan to prevent the spread of infection. The findings included: 1. Observation and interview with RN #4 on 7/17/23 at 11:42 identified failure to perform hand hygiene after removing his/her gloves following a blood glucose test. RN#4 indicated she did not perform hand hygiene after removing her gloves, policy directed to perform hand hygiene following glove removal, and she forgot to perform hand hygiene following glove removal. Interview with the Director of Education and the Director of Nursing Services on 7/20/23 at 2:48 PM indicated the nurse should perform hand hygiene following the removal of his/her gloves. Review of the Hand Hygiene Policy directed to utilize hand sanitizer after removing gloves. 2. Observation and interview with Nurse Aid (NA) #8 on 7/20/23 at 7:45 AM identified an unlabeled and uncovered bedpan in Resident # 15, 47, 70, 102, and 117's shared bathroom…

    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 · D2023-07-25 · tag F0908 — failed to keep essential equipment working — isolated
    Keep all essential equipment working 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 observations, review of facility documentation, and staff interviews, the facility failed to maintain resident equipment in a safe operating condition. The findings include: Observations on 7/21/23 at 1:04 PM through 1:45 PM with the Administrator, Director of Operations, Director of Maintenance and the Regional Director of Housekeeping identified resident beds in room [ROOM NUMBER] B, room [ROOM NUMBER] A and room [ROOM NUMBER] B had all four bed wheels propped on top of wooden blocks, which rendered the bed incapable of moving. Interview with the Director of Operations on 7/19/23 at 1:00 PM identified that he was unaware beds were risen on blocks, and would inquire with the Director of Maintenance. Interview with the Director of Operations on 7/19/23 at 2:30 PM identified the Director of Maintenance placed the beds on wooden blocks in order to prevent them from moving because the wheel locks did not function well. Subsequently, he directed the Director of Maintenance to order new beds. Interview with…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-25 · tag F0921 — failed to keep a safe, functional, sanitary building — isolated
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and interviews the facility failed to ensure the resident lounge on the second-floor unit was clean and odor free. The findings include: Observations on 7/17/2023 at 6:02 AM while walking up the staircase to the second floor identified strong odor of urine. Upon entering the locked unit, the smell of urine was present a short distance across the hall from the staircase doorway to the resident lounge where two residents were noted: one lying down on the couch and the other sitting on another small couch. The strong odor of urine was noted in the lounge and neither resident was noted to have soiled clothing, no trash cans that contained any trash would account for the smell. Additionally, there were a few food wrappers under the couch but without smell. Observation and interview with the Administrator on 7/17/2023 at 7:30 AM of the second-floor lounge area indicated the lounge needed a deep cleaning. The Administrator further indicated that cleaning of the lounge was done as needed. However, the Administrator could not provide a date when the deep cleaning was…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-25 · tag F0943 — isolated
    Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
    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 the therapy department staff received mandatory annual training that included in part abuse and dementia training. The findings included: The Facility assessment dated [DATE] indicated in part the facility training plan upon on hire and annually staff training which included: Effective Communication, Resident Rights, Abuse, Neglect, and Exploitation (part of the annual in-service and a test is completed), Infection Control, Compliance with Ethics, Nurse Aide Competency, Behavioral Health, and Non-pharmacological Interventions. Interview with the Director of Rehabilitation PT#1, on 7/18/2023 at 8:30 AM identified the therapy department staff has 53 licensed staff who follows, the facility in servicing schedule of mandatory in-service training that is provided by the facility for staff in all other departments. Review of the in-service binders and signature sheets for 2021, 2022, and 2023 with the staff development nurse, LPN…

    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 · E2021-06-30 · tag F0578 — failed to honor advance directives / code status — pattern
    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 of three sampled residents (Resident #42) reviewed for advanced directives, the facility failed to ensure monthly physician's orders corresponded with the resident's wishes and advanced directive documents. The findings include: Resident #42's diagnoses included arthritis, osteoporosis, adult failure to thrive, dysphagia, dementia and depression. The annual MDS assessment dated [DATE] identified Resident #42 had intact cognition, was independent with walking, and required supervision with personal hygiene. The quarterly MDS assessment dated [DATE] identified Resident #42 had moderately impaired cognition, was independent with transfers and ambulation, required supervision with bed mobility, eating and toilet use, and required limited assist with dressing and hygiene. The Advance Directives/Code Status Consent forms dated [DATE] and [DATE] were signed by the resident's Conservator of Person…

    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 · D2021-06-30 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the clinical record, review of facility policy and procedures and interviews for one of six sampled residents (Resident #26) reviewed for unnecessary medications the facility failed to ensure the resident was assessed to self-administer a medication. The findings included: Resident #26's diagnoses included auditory hallucinations, schizoid personality disorder, mild cognitive impairment, bipolar disorder and history of ETOH dependence. An annual MDS assessment dated [DATE] identified the resident as cognitively intact and required supervision to limited assistance from staff for activities of daily living. The RCP updated on 4/20/21 identified concerns with risk for skin breakdown with an intervention of treatment as indicated. Physician's order dated 6/22/21 at 3:35 PM directed to apply antifungal powder to affected area under bilateral breasts twice daily for ten days. On 6/24/21 at 12:29 PM a medication cup with a white powdery substance was observed on the Resident #26's over…

    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 before2021-06-30 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    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 observations, facility documentation and interviews for 1 of 14 resident rooms (room [ROOM NUMBER]) on the E-wing, the facility failed to ensure the bathroom was in good repair and failed to ensure electrical equipment located in a resident's room was utilized safely. The findings include: Observations with the Physical Plant Manager (PPM) on 6/29/21 at 12:44 of room [ROOM NUMBER] identified that the lower areas at the base of the door frame of the bathroom door was marred and rusty. There were also missing bathroom tiles and the ceiling tile was detached and out of alignment. Subsequent to surveyor's inquiry, the PPM indicated, he/she would replace the bathroom tiles and touch up the rusted areas with paint. The PPM was further observed adjusting the ceiling tile causing it to fall back into alignment. Further observations of room [ROOM NUMBER] identified an electrical outlet located to the right of Resident #105's bed. The outlet contained a surge protector/power strip that had the cable television…

    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 before2021-06-30 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, review of facility documentation, review of facility policy and interviews for 1 sampled resident (Resident #32) reviewed for respiratory care, the facility failed to maintain infection control measures related to the cleaning and storage of a nebulizer mask. The findings include: Resident #32 was admitted to the facility with the diagnosis of chronic obstructive pulmonary disease (COPD), dementia and depression. The quarterly MDS assessment dated [DATE] identified Resident #32 had moderately impaired cognition, required limited assistance of one staff member for personal hygiene, supervision for bed mobility, ambulation, toileting and eating. In addition, the MDS further identified Resident #32 required extensive assistance with assistance of one staff member for dressing. Physician's order dated 5/23/21 directed to administer Pulmicort (corticosteroid medication) 0.5 mg/2 ml respule, 1 vial via nebulizer every 12 hours, DuoNeb (used to prevent bronchospasm…

    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 · Bcited before2025-08-13 · 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 review of clinical records, review of facility documentation, review of facility policy, and interviews for three sample residents (Residents #2, #29 and #123) with incomplete medical records, the facility failed to ensure timely documentation of a physician's medical evaluation and failed to ensure the signed pharmacy recommendation was available in the resident's clinical record. The findings include:1. Resident #2's diagnoses included schizophrenia, bipolar disorder, and major depressive disorder. The quarterly MDS assessment dated [DATE] identified Resident #2 had severely impaired cognition, required maximal assistance with dressing, personal hygiene, bed mobility and transfers. Review of Resident #2's clinical record from January 2025 through August 2025 failed to identify physician evaluations/notes from MD #1. Subsequent to surveyor's inquiry, MD #1's evaluations/notes dated 1/25/25, 3/15/25. 5/24/25, and 7/26/25 were added to the electronic medical record Interview with the DNS on 8/11/25 at…

    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.

“Disputed” is CMS’s own flag, not our reading: the CMS deficiency file records whether the home has formally contested a citation, and we reproduce that. IDR is Informal Dispute Resolution, run by the state survey agency that wrote the citation; IIDR is Independent Informal Dispute Resolution, a separate process before an outside entity, available when CMS has proposed a civil money penalty. They are different processes and we mark them differently. Two things to hold at once. A disputed citation is still a citation — it was written by a surveyor, it stands on the record unless and until it is changed, and we neither hide it nor discount it. And we cannot tell you how the dispute came out: CMS publishes that a citation is under dispute, not the outcome, so a tag marked here may since have been upheld, reduced, or deleted, and an unmarked tag may have been disputed and resolved before this file was cut. Ask the home what it disputed and why — it is entitled to tell you, and the answer is often the most informative thing on this page.

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 ICARE HEALTH NETWORK — 12 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 4 of 52.8+1.2 vs chain
Health inspection 4 of 52.7+1.3 vs chain
Staffing 3 of 53.0≈ chain avg
Quality measures 4 of 53.7+0.3 vs chain
The other 11 homes this chain runs (chain average 2.8★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
BIDWELL CARE CENTER, LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL100%since 12/01/2003
APEX ADVISORSOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 12/01/2003
EXECUTIVE ADVISORS, LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 12/01/2003
PLAZA INVESTMENT TRUSTOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 12/01/2003
NEAGLE, PATRICKIndividualW-2 MANAGING EMPLOYEEsince 01/18/2019
WRIGHT, CHRISTOPHERIndividualCORPORATE OFFICERsince 12/01/2003

CMS files one row per role, so the 7 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted.

4 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.

$13.9M
Net patient revenuemost recent cost report
-4.0%
Operating marginrevenue minus expenses
$1.3M
Related-party expense9% of expenses
Who pays — share of resident-days
Medicaid 90%Medicare 1%Other / private 8%

About 90% 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 $1.3M paid to related parties (affiliated landlords or management companies) in its most recent cost report.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$348per resident / day
operating cost
$10,592per month
≈ monthly operating cost
$335per 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 075314. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-13, 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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