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Curtis Home St Elizabeth Center, The

380 Crown Street, Meriden, CT 06450 · Non profit - Corporation · 60 certified beds · (203) 237-4338 Medicare & Medicaid certified

Call the home — (203) 237-4338 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0609, F0610) — most recent Mar 2025Behavioral-health or dementia-care citation — no harm found (F0758)1 actual-harm citation$10,358 in federal fines
Insights

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

Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 1 actual-harm citation
  • 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
  • the CMS record shows $10,358 in federal fines (most recent 2025-03-11)
  • its independent health-inspection rating is low (2/5)
  • it did not file the payroll staffing data CMS requires — its 1 of 5 staffing rating is the rating CMS assigns for not reporting, not a measure of how many nurses are on the floor
  • its facility-reported quality-measure rating is low (1/5)

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

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

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 1 of 5

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
12 Curtis St · (855) 962-3621 · Call to confirm hours
Pharmacy
153 Broad St · (203) 237-8997 · Call to confirm hours
Grocery
90 Olive St · (203) 440-2886 · Call to confirm hours
Park
83 Gale Ave · (203) 630-4259 · Typically dawn to dusk
Place of worship
399 S Colony St · (203) 599-0648

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 1 of 5
Long-stay residentspeople who live here 1 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 4 to 1 stars. From monthly CMS archive snapshots.

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

Overall rating1★
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 increased27.7%18.0%15.4%worse
Long-stay residents who lose too much weight5.4%6.5%5.4%typical
Long-stay residents with a catheter left in their bladder2.8%0.7%0.9%worse
Long-stay residents with a urinary tract infection2.5%1.5%2.0%worse
Long-stay residents with depressive symptoms6.5%22.3%6.5%typical
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 injury5.7%3.5%3.3%worse
Long-stay residents whose ability to walk worsened29.5%16.4%16.1%worse
Long-stay residents on antianxiety or hypnotic medication11.2%17.6%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%93.5%95.3%typical
Long-stay residents with pressure ulcers4.6%4.0%4.7%typical
Long-stay residents with worsening bladder/bowel control21.9%24.7%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table14.3%17.8%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine92.6%69.7%79.4%better
Long-stay hospitalizations per 1,000 resident days2.272.061.67worse
Long-stay outpatient ER visits per 1,000 resident days0.881.461.80better

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

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

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

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

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

0.32U.S. median 0.31
Therapy hours / resident / day
0.12hours / resident / day
Physical therapy
0.19hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.32 therapist hours per resident per day in 2026Q1 — more than 53% 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.

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 SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
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 identifiednot 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 next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims for this measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final 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 staynot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 SNFs0.741.02Oct 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

No payroll-based (PBJ) staffing hours are on file for this home — and the record suggests that is because it did not report them. Inspectors cited this home for failing to submit its staffing data to CMS (F0851) — see the citation below; CMS rates its staffing 1 of 5, which is the rating CMS assigns when a home does not report. Every Medicare-certified nursing home is required to submit its actual payroll data quarterly, and that submission is what makes staffing numbers auditable rather than a claim. A home that does not file is not the same as a home with no data yet: ask this home directly what its nurse-to-resident ratios and weekend RN coverage are, why its payroll data is not filed, and weigh the independent health-inspection score heavily in the meantime.

Inspection trend

14
deficiencies at the latest standard inspection (2025-03-11)
12
at the previous standard inspection (2023-08-01)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

29 citations, most serious first. The 11 most serious are shown; the remaining 18 are one tap away and print in full.

  • Actual harm · Gcited before2025-03-11 · 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 observations, review of clinical records, facility documentation, facility policies, and interviews for 1 of 4 residents (Resident #47) reviewed for accidents, the facility failed to provide adequate supervision to prevent a fall with injury and failed to follow the fall care plan interventions for injury prevention; and for the only sampled resident (Resident #36) reviewed for smoking, the facility failed to ensure a container being used for smoking materials was safe from potential fire hazard. The findings include: 1. Resident #47 was admitted to the facility in March 2024. Resident #47's diagnoses included dementia with behavioral disturbances, mood disturbance, anxiety, and large right cerebellar infarcts (stroke). The significant change Minimum Data Set (MDS) assessment dated [DATE] identified Resident #47 was severely cognitively impaired and required assistance of 1 for bed mobility, personal hygiene, and was a full mechanical lift for transfers. The Resident Care Plan dated 4/10/24 identified…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-03-11 · tag F0851 — widespread
    Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on facility documentation and staff interview regarding Payroll Based Journal (PBJ) submission, the facility failed to submit accurate PBJ staffing data for the 3rd quarter of 2024 (April 1, 2024, through June 30, 2024). The findings include: The PBJ 3rd quarter submission report for April 1, 2024, through June 30, 2024, triggered as having no Registered Nurse (RN) coverage for 8 consecutive hours a day, low weekend staffing, and no licensed nurses 24 hours a day. Interview with the Business Office Manager on 3/11/25 at 12:42 PM identified that she inadvertently submitted the incorrect data. She indicated that she reviewed the staff payroll list for the skilled nursing center and the Residential Care Home (RCH). She indicated that she unclicked (removed) the skilled nursing staff in error instead of the RCH nursing staff from the payroll list. She then submitted the data for PBJ that was for RCH nursing staffing and not the skilled nursing home staffing. She stated she realized that she unintentionally submitted the wrong data. Review of the mandatory submission of staffing…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-03-11 · tag F0561 — failed to honor residents' choices — pattern
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, observations, clinical record review, and facility policies for 1 of 5 sampled residents (Resident #8) reviewed for abuse, and for 2 of 2 residents (Resident #11 and Resident #45) reviewed for choices, the facility failed to ensure the resident right to choose was honored. The findings include: 1.Resident #8's diagnoses included anxiety, hypothyroidism, and asthma. The quarterly Minimum Set (MDS) assessment dated [DATE] identified Resident #8 as cognitively intact, independent with transfers, dressing, and personal hygiene. The Resident Care Plan dated 12/10/24 identified behavior/refusal of care issues. Interventions directed to provide emotional support as needed, explain potential negative outcomes, and provide positive reinforcement. Review of the nurse's note dated 12/16/24 identified that Resident #8's window had been screwed shut, Resident #8 verbalized being upset to staff, and he/she was anxious. Interview and observation with Resident #8 on 3/3/25 at 12:00 PM identified the window…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-03-11 · tag F0684 — failed to provide proper treatment and quality of care — pattern
    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 2 of 2 sampled residents (Resident #28 and Resident #58) reviewed for edema and with diagnoses of Congestive Heart Failure (CHF), the facility failed to consistently obtain and document daily weights per the physician's order, for Resident #58, the Registered Nurse (RN) staff and Advanced Practice Registered Nurse (APRN) failed to ensure documentation of an assessment when a significant weight gain occurred, and for 1 of 3 sampled residents (Resident #45), reviewed for nutrition the facility failed to obtain weekly weights on admission per the facility policy and monthly weights per the physician orders. The findings include: 1. Resident #28's diagnoses included chronic systolic CHF, non-rheumatic tricuspid valve insufficiency, and paroxysmal atrial fibrillation (irregular heartbeat). The admission Minimum Data Set assessment dated [DATE] identified Resident #28 was cognitively intact, required substantial/maximal…

    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 · Ecited before2025-03-11 · 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 the tour of the Dietary Department/Nourishment Rooms, staff interviews, and review of the facility policies, the facility failed to ensure food items were sealed, labeled and dated when opened and the only nourishment refrigerator/freezer temperatures were documented. The findings included: 1. Tour of the Dietary Department on 3/3/25 at 10:40 AM during the initial walk through with the Dietary Director identified the following: a. 3 bags (16 ounce) each Penne pasta bag #1 was 3/4/ full, bag #2 was ½ full, bag #3 ¼ full were opened and failed to include the date opened. b. An opened 5 pound bag of heart shaped pasta that was 1/4 full failed to include the date opened. c. An opened 5 pound bag of elbow pasta that was ½ full failed to include the date opened. d. A 32-ounce opened bag of powdered sugar that was 1/2 full failed to include the date opened. e. An opened 5 pound bag of sugar that was ¾ full failed to include the date opened. f. A package containing 2 frozen fish cakes was opened and failed to include the date opened. g. A 1 bag of romaine lettuce was opened, not…

    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 · D2025-03-11 · 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 interviews, review of the clinical record, and facility policy for 1 of 3 residents (Resident #45), reviewed for nutrition, the facility failed to notify the dietician and responsible party of a significant weight gain and significant weight loss. The findings include: Resident #45 was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm of the brain, moderate protein-calorie malnutrition, and Irritable Bowel Syndrome (IBS). The baseline Resident Care Plan (RCP) dated 3/1/24 identified Resident #45 was at risk for nutritional deficits related to cancer, IBS, and diabetes. Interventions included monitoring body weight, dietician consults as needed, and offering alternative choices with dislikes. An admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #45 had intact cognition, required set-up assistance with eating, used a manual wheelchair for mobility, and required moderate assistance with chair to bed and bed to chair transfers. A physician order…

    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 before2025-03-11 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, facility documentation, interviews, and facility policy for 2 of 5 sampled residents reviewed for abuse (Resident #15 and Resident #29) the facility failed to report allegations of abuse to the state agency in a timely manner. The findings include: 1. Resident #15's diagnoses included mild cognitive impairment, multiple sclerosis, and abnormalities of gait and mobility. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #15 was moderately cognitively impaired and required moderate assistance of 1 staff to transfer from the bed to the wheelchair, from lying to sitting on the side of bed, and for toilet transfers. Physician's orders dated 6/4/24 directed the assistance of 1 staff for transfers from the wheelchair and for activities of daily living. The Resident Care Plan dated 6/5/24 indicated mobility impairment was a concern. Interventions included transferring the resident per the physician's order to a custom wheelchair and administer pain…

    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 · D2025-03-11 · 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 clinical records, facility documentation, interviews, and facility policy for 2 of 5 sampled residents (Resident #15 and Resident #29) reviewed for abuse, the facility failed to investigate an allegation of abuse in a timely manner. The findings include: 1. Resident #15's diagnoses included mild cognitive impairment, multiple sclerosis, and abnormalities of gait and mobility. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #15 was moderately cognitively impaired and required moderate assistance of 1 staff to transfer from bed to wheelchair, from lying to sitting on the side of the bed, and for toilet transfers. Physician's orders dated 6/4/24 directed the assistance of 1 staff for transfers from the wheelchair for activities of daily living. The Resident Care Plan dated 6/5/24 indicated that mobility impairment was an area of concern. Interventions included transfer resident per physician order to a custom wheelchair and administer pain medications as…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-11 · tag F0656 — failed to write and follow a full care plan — isolated
    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 interviews and review of the clinical record for the only sampled resident (Resident #58) reviewed for hospitalization, the facility failed to implement interventions in the Resident Care Plan (RCP) for the completion of a respiratory assessment, each shift, for resident with Congestive Heart Failure (CHF). The findings include: Resident #58's diagnoses included congestive heart failure, atrial defibrillation, type 2 diabetes and coronary bypass surgery. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #58 had intact cognition and was independent with bed mobility, toilet transfers, and transfers from the chair to the bed and bed to the chair. The RCP dated 12/17/24 identified a potential for respiratory distress/respiratory failure. Interventions included observation for signs and symptoms of increasing distress, increase in respiration rate, dyspnea, tachycardia, restlessness, anxiety or change in mental status. Additional interventions included performing a respiratory…

    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 · D2025-03-11 · tag F0687 — failed to care for feet properly — isolated
    Provide appropriate foot care.
    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, interviews, and clinical record review for 1 of 3 residents (Resident #19), reviewed for activities of daily living, the facility failed to provide podiatry services to a diabetic resident. The findings included: Resident # 19's diagnoses included diabetes mellitus type 2 with neuropathy, gout, and Parkinson's disease. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #19 was cognitively intact, required substantial/maximal assistance from staff for personal hygiene, and was dependent on staff for lower body dressing and transfers. The Resident Care Plan dated 1/7/25 identified Resident #19 was at risk for alteration in the metabolic process secondary to diabetes. Interventions included good foot care daily, proper footwear, podiatry care as needed, and podiatry to cut toenails. A physician's order dated 12/24/24 and currently in effect, allowed Resident #19 to be seen and treated by podiatry. The Wound/Ostomy Advanced Practice Registered Nurse (APRN)…

    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 · D2025-03-11 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and clinical record reviews for 1 of 2 residents, (Resident #4), reviewed for pressure ulcers, the facility failed to follow infection control standards to identify and provide precautions for a resident with wounds, and for the only sampled resident (Resident #36) reviewed for blood glucose monitoring. The facility failed to clean and disinfect the glucose meter after use. The findings included: 1. Resident #4's diagnoses included a pressure ulcer of the sacral region, rheumatoid arthritis, and urge urinary incontinence. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #4 was severely cognitively impaired, and dependent on staff for hygiene, dressing, and transfers. The Resident Care Plan dated 2/18/25 identified Resident #4 had a stage 2 pressure area to her/his sacrum. Interventions included providing treatment as ordered, observing the area for good wound healing, and observing for signs and symptoms of infection. The Pressure Ulcer Progress…

    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
Show the remaining 18 citations
  • Potential for harm · Dcited before2023-08-01 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 Residents (Resident #10) reviewed for abuse, the facility failed to notify the State Agency of the allegation according to established timeframes. According to Appendix PP at §483.12(c)(1) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse. The findings include: Resident #10 was admitted [DATE] and readmitted [DATE] with diagnosis that included schizophreniform disorder, violent behavior, dementia, and ataxic gait (inability to walk in a straight line). The quarterly MDS dated [DATE] identified Resident #10 had impaired cognition, was totally dependent for 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-01 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    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 1 of 5 residents (Resident #32) reviewed for PASARR, the facility failed to ensure a Level II PASARR was completed. The findings include: A PASARR Level 1 screen dated 2/12/15 indicated Resident #32 met the conditions for an exempted hospital discharge to a nursing facility, and a physician had certified that he/she would likely require fewer than 30 days in the nursing facility. Accordingly, if the nursing facility thought more than 30 days in the facility would be required, a nursing facility representative must update the Level I screen by or before the 30th day after admission. At that time, a full PASARR Level II evaluation must be performed. No PASARR Level II evaluation was completed for Resident #32. Resident #32 was admitted to the facility on [DATE] with diagnoses that included Schizophrenia and Bipolar Disorder. The annual MDS dated [DATE] identified Resident #32 had intact cognition and received antipsychotic medications…

    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 before2023-08-01 · 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 policy, and interviews for 10 residents (2, 5, 7, 9, 11, 21, 24, 40, 48 and 255) who wore their call bell on a lanyard, the facility failed to complete an assessment of each resident prior to application of the lanyard, and for 1 of 5 residents (Resident #11) reviewed for unnecessary meds, the facility failed to ensure the licensed staff accurately edited the monthly physician's orders and monthly medication administration record and for the only sampled resident (Resident #48) reviewed for tube feeding, the facility failed to ensure weights were monitored and orthostatic blood pressures were completed, per the physician's order. The findings include: 1. Intermittent observations on 7/30/23 and 7/31/23 identified Resident's #2, 5, 7, 9, 11, 21, 24, 40, 48 and 255 wore a lanyard with a call bell around their neck. Interview with the DNS and Administrator on 7/31/23 at 1:00 PM identified that the call system for Resident's #2, 5, 7, 9, 11, 21, 24, 40, 48 and 255 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-01 · 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 the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #21) reviewed for pressure ulcers, the facility failed to implement a pressure relieving device on the resident's bed when the resident was readmitted to the facility with a stage II pressure ulcer. The findings include: Resident #21 was admitted to the facility in March 2023 with diagnoses that included atrial fibrillation, congestive heart failure, and post-traumatic stress disorder. Review of the RN assessment form dated 3/8/23 identified Resident #21's skin was intact except for slightly reddened Moisture-Associated Skin Damage (MASD) to the groin. The care plan dated 3/13/23 identified Resident #21 had a skin rash MASD to groin area. Interventions included to apply treatment as ordered. Assist with incontinent care every two hours. The admission MDS dated [DATE] identified Resident #21 had intact cognition, required extensive assistance with bed mobility and toilet use. Resident #21 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
  • Potential for harm · Dcited before2023-08-01 · 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 observations, review of the clinical record, facility documentation, facility policy and interview for 1 of 4 residents (Resident #22) reviewed for accidents, the facility failed to ensure that 1:1 supervision with meals was provided to a resident with an identified aspiration risk and for 1 of 5 residents (Resident #28) reviewed for smoking, the facility failed to supervise smoking while escorting a resident from the smoking area into the facility. The findings include. 1. Resident #22 was admitted to the facility on [DATE] with diagnoses that included advanced dementia, end stage renal disease without dialysis, and multiple myeloma. The quarterly MDS dated [DATE] identified Resident #22 had severely impaired cognition, was always incontinent of bowel and bladder and required the assistance of one staff member with eating, dressing, and toileting. The care plan dated 5/11/23 identified Resident #22 had a potential risk for aspiration due to pocketing food. Interventions included 1:1 supervision 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-01 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #21) reviewed for pressure ulcers, the facility failed to ensure the dietitian evaluated a resident in a timely manner who was readmitted with a pressure ulcer, and for 1 resident (Resident #50), who was on fluid restriction, the facility failed to monitor and document fluid Intake and Output (I&O). The findings include. 1. Resident #21 was admitted to the facility in March 2023 with diagnoses that included atrial fibrillation, congestive heart failure, post-traumatic stress disorder, and vitamin B-12 deficiency anemia. Review of the RN assessment form dated 3/8/23 identified Resident #21 skin was intact except for slightly reddened Moisture-Associated Skin Damage (MASD) to the groin. The nutritional admission assessment dated [DATE] identified Resident #21's diet order was regular, and the resident was at risk for weight fluctuation related to diuretic use. The care plan dated 3/13/23…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-01 · tag F0726 — failed to have competent, trained nursing staff — isolated
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, review of facility documentation, facility policy, and interviews the facility failed to ensure that a nurse aide was knowledgeable about the use of a flame-retardant blanket while supervising resident smoking. The findings include. Observation on 7/30/23 at 9:00 AM identified 5 residents (Resident #3, 20, 28, 36, and 44) were being supervised during smoking by NA #1 in the outdoor, designated, supervised smoking area. Interview with NA #1 regarding facility smoking protocols, identified she was knowlegable about the fire extinguisher, flame retardant apron, but failed to identify the use of the flame-retardant blanket. She further identified she was never trained in the use of the flame-retardant blanket which was hung on the wall in the corridor across from the smoking area door. Review of facility documentation identified NA #1 was trained on smoking protocols for the facility which included smoking times, use of smoking apron, location and use of the flame retardant blanket, and protocols to extinguish a fire utilizing a fire extinguisher. 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-01 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    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 1 of 5 residents (Resident #11) reviewed for unnecessary medications, the pharmacy failed to report to the Medical Director and DNS when the resident's medication regimen contained an as needed (prn) order for a psychotropic drug without a specific stop date. The findings include: Resident #11 was admitted to the facility on [DATE] with diagnoses that included schizophrenia, COPD, and atrial fibrillation. A physician's order dated 12/16/22 directed to administer Lorazepam 0.5mg every 6 hours, prn for 14 days and re-evaluate. Review of the December 2022, January 2023, February 2023 and March 2023 MAR's identified although the order for prn Lorazepam was active, the MAR's failed to document a stop date for the Lorazepam. Review of the Consultant Pharmacist Recommendation to Physician/Prescriber report dated 4/10/23 indicated Resident #11 had an active order for prn Lorazepam without a specified stop date, and to consider discontinuing or…

    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 · D2023-08-01 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility policy, and interviews for 1 of 5 residents (Resident # 11) reviewed for unnecessary meds, the facility failed to ensure a prn psychotropic medication was discontinued after 14 days according to the physician's order. The findings include: Resident #11 was admitted to the facility on [DATE] with diagnoses that included schizophrenia, COPD, and atrial fibrillation. A physician's order dated [DATE] directed to administer Lorazepam 0.5mg every 6 hours, prn for restlessness for 14 days and re-evaluate. The quarterly MDS dated [DATE] identified Resident #11 had severely impaired cognition and was receiving hospice care. The care plan dated [DATE] identified Resident #11 COP had chosen hospice services for Resident #11. Interventions included admitting Resident #11 to hospice services and administering Morphine Sulfate, Hyoscyamine, and Lorazepam as directed. Review of the MAR's dated [DATE] through [DATE] identified that although the physician's order 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-08-01 · 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, review of facility policy, and interviews the facility failed to discard opened Lorazepam after 90 days per the pharmacy recommendation. The findings include: Tour of the medication storage room with RN #2 on 8/1/23 at 7:53 AM identified a bottle Lorazepam Concentrate, for Resident #11, that was opened on 1/5/23, and last dispensed on 5/1/23. RN #2 indicated that she would remove the medication and bring it to the DNS for proper disposal and reconciliation. Interview with LPN #3 on 8/1/23 at 8:04 AM indicated that she recalled that the education she received was that liquid medications were good for one year, after they were opened. Interview with RN #2 at 8:06 AM, identified that she confirmed with the pharmacy that liquid Lorazepam is good 90 days after opening. RN #2 further indicated that she would in-service licensed staff about opened medication bottles, expiration dates, and their proper disposal. Interview with the DNS on 8/1/23 at 11:24 AM identified that the Lorazepam Concentrate opened on 1/5/23 should have been discarded after 90 days, and a new…

    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 · Dcited before2023-08-01 · tag F0812 — failed to store, cook, and serve food safely — isolated
    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 — the official record, unedited, may be distressing

    Based on observation, review of facility policy and interview, the facility failed to store food in accordance with professional standards. The findings include: Observation on 7/30/23 at 7:15 AM of the freezer identified a bag of frozen vegetables on the freezer floor, and 2 loaves of garlic bread exposed and partially uncovered on an upper shelf. Interview with the Director of Food Service at the time of the observation identified the exposed bread and frozen vegetables should not be stored in that manner and discarded the items. The policy for food storage indicated all food items will be stored above the floor on shelves, racks, dollies or other surfaces which facilitates through cleaning.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-01 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    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 the clinical record, facility documentation, facility policy and interview for 1 of 5 residents (Resident #3) reviewed for immunizations, the facility failed to ensure that the resident and/or resident representative was educated on and offered the pneumococcal vaccinations. The findings include: Resident #3 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder with psychotic features, emphysema, and muscle weakness. The care plan dated 5/16/23 identified Resident #3 was at risk for maladjustment due to new admission to the facility. Interventions included to administer medications as ordered, and to allow Resident #3 to verbalize feeling and concerns. The admission MDS dated [DATE] identified Resident #3 had intact cognition, was frequently incontinent of bladder, occasionally incontinent of bowel, and required the assistance of one staff member with dressing, toileting, and personal hygiene. A review of Resident #3's clinical record on 7/31/23 failed…

    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 · D2021-09-30 · 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, review of facility documentation and interviews for environmental review, for one observed room the facility failed to ensure the wallpaper and nightstand were in good repair, and for two observed shower rooms the facility failed to ensure the shower room and equipment was maintained in good repair. The findings include: a. Observations on 9/24/2021 at 1:28 PM identified the wallpaper in room [ROOM NUMBER] near the closet and on the left side of bed A was missing or was detached from the wall. Additional observations identified the middle drawer handle on the nightstand was detached and hanging from the drawer. Observation of room [ROOM NUMBER] and interview with the Director of Environment (DOE) on 9/28/2021 at 9:10 AM identified the detached wallpaper was caused by the resident's wheelchair. She further indicated that she was aware of the missing or detached wallpaper near the bed and the closet, and she was also aware of the drawer handle hanging from the middle drawer. Subsequent 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-09-30 · 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 documentation review, facility policy review and interviews for one of two residents (Resident #14) reviewed for pressure ulcers, the facility failed to ensure a dietician assessment was completed timely for a newly identified pressure ulcer. The findings include: Resident #14's diagnoses included dementia with behavioral disturbances, and muscle weakness. A quarterly MDS assessment dated [DATE] identified Resident #14 had severely impaired decision-making skills, required total staff assistance from staff ADLs, was at risk for pressure ulcers, had pressure relieving devices in place to his/her bed and chair, and had no pressure ulcers. The Resident Care Plan (RCP) dated 7/23/2021 identified a potential for pressure areas/actual as the problem. Interventions directed to provide hydrocolloidal dressing change every 3 days, assist with turning and repositioning, monitor skin for red areas with ADL Care, observe for good wound healing or s/s of infection. Additional…

    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 · C2025-03-11 · tag F0730 — widespread
    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 review of employee files and interviews for 2 of 4 Nurse Aides (NA) (NA #3 and NA #5) the facility failed to ensure annual employee performance evaluations were completed. The findings include: Review of NA #3 and NA #5 employee files and interview with the Human Resource Coordinator on 3/11/25 at 10:30 AM failed to identify performance evaluations in the employee files. NA #3 was hired by the facility on 9/11/11 and is a current full-time employee. NA #5 was hired by the facility on 4/30/20 and is a current per diem employee. The Human Resource Coordinator stated that if evaluations had been completed, they would be located in the employee file or might be with DNS. The Human Resource Coordinator indicated that she could not recall the last time she received an employee evaluation from the Nursing Department. Interview with the DNS on 3/11/25 at 11:30 AM identified that she had not completed any NA evaluations on any NA employed at the facility. The DNS stated she has worked for the facility for 11 years and had never completed any nursing staff evaluations. The DNS…

    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
  • No harm found · B2025-03-11 · tag F0641 — pattern
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, review of the clinical record, and review of facility policy for 2 of 3 residents (Resident #8 and Resident #45), reviewed for nutrition, the facility failed to accurately code the Minimum Data Set (MDS) assessment for significant weight changes. The findings include: 1. Resident #8's diagnoses included anxiety, hypothyroidism, and asthma. a. A quarterly MDS assessment dated [DATE] identified Resident #8 had intact cognition, was independent with oral hygiene, dressing and transfers. Additionally, the MDS identified Resident #8 required set up assistance with eating, weighed 153 pounds (lbs.), and had no significant weight loss or gain. The Yearly Weight Record identified Resident #8 weighed 156.2 lbs. in February 2024, 161.7 lbs. in March 2024, and weighed 148.6 lbs. in April 2024 which was 13.1 lbs., a 8.1 percent (%) loss in one month. A Resident Care Plan dated 4/27/24 identified Resident #8 was at risk for nutritional deficits related to weight loss. Interventions included providing 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
  • No harm found · Bcited before2025-03-11 · tag F0761 — failed to label and store drugs safely — pattern
    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 and interviews, the facility failed to ensure the medication room was clean and sanitary. The findings include: In an interview and observation with RN #2 on 3/6/25 at 11:10 AM, identified that the medication room floor was dirty with a brown substance and littered with paper. The medication room counter was cluttered with brown boxes and papers. RN #2 identified that it was the responsibility of the housekeeping staff to keep the floor clean of the observed substances. Additionally, RN #2 stated that it is the responsibility of the nurses who access the medication room to ensure that it is free of clutter. In an interview and observation with Housekeeper # 1 on 3/6/25 at 11:31 AM, it was identified that it is the responsibility of housekeeping to keep the medication room clean. After bringing Housekeeper #1 to the medication room, it was identified that it was not her responsibility to clean the medication room and that it was the responsibility of the housekeeper on A-wing to complete. In an interview and observation with Housekeeper # 2 on 03/06/25 at 11:34…

    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
  • No harm found · C2021-09-30 · tag F0582 — widespread
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical record review, facility documentation review, and interviews for five of five residents (Resident #19, #198, #199, #200 and #201) reviewed for Beneficiary Notification, the facility failed to ensure the notice provided included the Immediate Appeal contact information. The findings include: a. Clinical record review identified Resident #19 was admitted to the facility on his/her Medicare Part A benefit. Facility documentation review identified Resident #19's Medicare Part A benefit ended on 8/27/2021, and Resident #19 remained in the facility under an alternate payor source. Review of the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN) dated 8/25/2021, identified the form included three (3) options for the resident to choose. Option 1 described I want the care listed above. I want Medicare to be billed for an official decision on payment, which will be sent to me on a Medicare Summary Notice (MSN). I understand if Medicare doesn't pay, I'm responsible for paying, but I can appeal to Medicare by following the directions on the MSN.…

    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

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

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

Fines & penalties

$10,358 in federal fines across 1 penalty.

  • $10,358 — penalty dated 2025-03-11

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Who owns this facility

Owner / managerTypeRoleSince
MISLOW, ALBERTIndividualCORPORATE DIRECTORsince 02/15/2022
CANTOR, DAVIDIndividualCORPORATE OFFICERsince 12/02/2011
FLYNTZ, ROBERTIndividualCORPORATE OFFICERsince 12/02/2011
GRUBER, MICHAELIndividualCORPORATE OFFICERsince 12/02/2011
PENDRED, RICHARDIndividualCORPORATE OFFICERsince 06/01/2015
STEMPIEN, RONALDIndividualCORPORATE OFFICERsince 12/02/2011
MCDONNELL, PATRICKIndividualOPERATIONAL/MANAGERIAL CONTROLsince 06/24/2024

The source lists no ownership percentage for any party here — 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.

$6.9M
Net patient revenuemost recent cost report
-18.3%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 53%Medicare 2%Other / private 45%

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

$411per resident / day
operating cost
$12,499per month
≈ monthly operating cost
$348per 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 075365. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-03-11, 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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