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Silver Springs Care Center

33 Roy St, Meriden, CT 06450 · For profit - Limited Liability company · 158 certified beds · (203) 237-8457 Medicare & Medicaid certified

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Flagged for abuseBehavioral-health or dementia-care citation — no harm found (F0758)3 actual-harm citations$24,150 in federal fines
Insights

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

In its favor
  • lower-than-typical staff turnover (36% vs 45% nationally) — better care continuity
Worth asking about
  • CMS has flagged it for abuse
  • it has abuse, neglect, or exploitation citations (F0600, F0602) — most recent Apr 2026
  • 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 3 actual-harm citations
  • a high number of inspection citations overall (36) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $24,150 in federal fines (most recent 2024-10-31)
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (2/5)

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

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

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's quality-measure rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

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

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 3 to 2 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 rating2★
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 increased17.6%18.0%15.4%worse
Long-stay residents who lose too much weight5.1%6.5%5.4%typical
Long-stay residents with a catheter left in their bladder0.5%0.7%0.9%better
Long-stay residents with a urinary tract infection0.5%1.5%2.0%better
Long-stay residents with depressive symptoms10.0%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 injury2.3%3.5%3.3%better
Long-stay residents whose ability to walk worsened14.7%16.4%16.1%typical
Long-stay residents on antianxiety or hypnotic medication24.2%17.6%18.9%worse
Long-stay residents given the seasonal flu vaccine99.3%93.5%95.3%typical
Long-stay residents with pressure ulcers2.3%4.0%4.7%better
Long-stay residents with worsening bladder/bowel control16.4%24.7%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table20.6%17.8%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.0%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine71.3%69.7%79.4%worse

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.

44.2% 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 25 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

44.2%U.S. median 51.5%
Got home and stayed home
9.9%U.S. median 10.7%
Went back to hospital
0.12U.S. median 0.31
Therapy hours / resident / day
0.05hours / resident / day
Physical therapy
0.06hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.12 therapist hours per resident per day in 2026Q1 — more than 8% 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 SNF44.2%CMS range 31.7–60.051.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.9%CMS range 6.6–17.210.7%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 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 — 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 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 SNFs0.631.02Oct 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

0.28
RN hours/ resident / day
0.86
LPN hours/ resident / day
1.97
Aide hours/ resident / day
3.11
Total nurse hours/ resident / day
0.19
RN hoursweekends
35.8%
Total nursing turnover
71.4%
RN turnover

How full it usually is: this home is certified for 158 beds and averages 148.2 residents a day — about 94% occupied, or roughly 10 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.11 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.28 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.97 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 2.71 hrs/resident/day on weekends vs 3.27 on weekdays — 17% thinner on weekends. RN hours go from 0.31 to 0.19 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 36% is below the national median of 45%. 1 administrator has left in the past year.

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

Inspection trend

6
deficiencies at the latest standard inspection (2024-12-20)
2
at the previous standard inspection (2022-07-12)

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.

36 citations, most serious first. The 13 most serious are shown; the remaining 23 are one tap away and print in full.

  • Actual harm · Gcited before2024-10-31 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and facility documentation review for two of three residents (Resident #2, Resident #3) review for abuse, the facility failed to ensure the residents were free from abuse. Residents #2 and #3 had a physical altercation, resulting in both residents with injuries to their faces, and were transferred to the hospital for treatment. The finding includes: 1. a. Resident #2 had a diagnosis of malignant neoplasm of the brain, bipolar disorder, and schizoaffective disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had a Brief Interview for Mental Status (BIMS) score of 13 indictive of an intact cognition and was independent with mobility and had no behaviors. The Resident Care Plan (RCP) dated 10/15/2024 identified Resident #2 had the potential for verbal aggression and accusatory behaviors and ambulated independently. Interventions directed to monitor for accusatory behavior and offer tasks to minimize disruptive behavior.…

    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
  • Actual harm · Gcited before2022-07-12 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #28) reviewed for abuse, the facility failed to ensure a resident was free from physical injury by another resident (Resident #133). The findings include: Resident #28 was admitted on [DATE] with diagnoses that included schizoaffective disorder and a fracture of the pelvis. Resident #28 was responsible for self. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #28 was without cognitive impairment and required physical assist of one with ambulation on and off the unit with wheelchair support. The care plan dated 3/31/22 identified Resident #28 had a concern with Activities of Daily Living (ADL) and fracture of pelvis and sacrum. Interventions included: Occupational Therapy (OT) Physical Therapy /(PT) as ordered, weight bearing as tolerated and toe touch weight bearing to right lower extremity and noted independence in the bedroom with the use of 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2019-10-31 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, facility policy and interviews for two of six resident's reviewed for accidents, (Resident #499 and Resident # 500), the facility failed to ensure that a resident was seated in the correct wheelchair and that staff was educated on how to maneuver a wheelchair on an even surface and failed to ensure that intervention were in place to supervise a resident who exhibited restless behaviors to prevent falls with major injuries. The findings included: 1. Resident # 499's diagnoses included a late effect Cerebral Vascular Accident (CVA), acute on chronic renal failure and bilateral carotid stenosis. A re-admission assessment dated [DATE] identified the resident was re-admitted with a diagnosis of a right middle cerebral artery infarct due to an embolism with left sided weakness, was alert and responsive, required total care with Activities of Daily Living ( ADL) and indicated the resident was a high risk for falls. The care plan dated [DATE] identified a risk…

    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 before2026-04-30 · tag F0602 — failed to protect residents from theft of their belongings — isolated
    Protect each resident from the wrongful use of the resident's belongings or money.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, review of facility documentation, facility policies, and interviews for one (1) of two (2) sampled residents (Resident #1) who had a family member as the Responsible Party and the Responsible Party managed Resident #1's finances, the facility failed to ensure an applied income payment (payment for services not covered by insurance) to the facility from Resident #1 dated 3/9/26 was not deposited into a staff member's personal banking account. The findings include: Resident #1's diagnoses included dementia, psychotic disturbance, mood disturbance, anxiety, bipolar disorder and muscle weakness. The admission Record identified a family member was Resident #1's Responsible Party and Power of Attorney. The annual Minimum Data Set assessment dated [DATE] identified Resident #1 had poor memory recall. The Resident Care Plan dated 2/18/26 identified Resident #1 had a diagnosis of dementia, and may need cues, reminders, prompting, and redirection. The facility Reportable Event form dated…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-03-06 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, interviews, and facility documentation/policies for two (2) of six (6) residents (Residents #1 and #2) reviewed for abuse, the facility failed to ensure a resident was free from abuse. The findings included:1.Resident #1 was admitted to the facility in December of 2014 and had diagnoses that included vascular dementia, schizophrenia, and anxiety disorder.The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severely impaired cognition (Brief Interview for Mental Status (BIMS) score of 4), was dependent for personal hygiene, toileting, and bathing, and utilized a wheelchair for transportation. The Resident Care Plan (RCP) dated 12/22/25 identified a history of engaging in non-consensual sexual advances by others. Interventions directed close observation levels applied as indicated per policy.2. Resident #2 was admitted to the facility in July of 2008 and had diagnoses that included vascular dementia, schizophrenia, and anxiety disorder.The quarterly…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-03-06 · 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 clinical record review, interviews, and review of facility documentation and policies for two (2) of six (6) residents (Resident #1 and Resident #2) reviewed for abuse, the facility failed to conduct a thorough investigation after a resident-to-resident abuse incident. The findings included:1.Resident #1 was admitted to the facility in December of 2014 and had diagnoses that included vascular dementia, schizophrenia, and anxiety disorder.The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severely impaired cognition (Brief Interview for Mental Status (BIMS) score of 4), was dependent for personal hygiene, toileting, and bathing, and utilized a wheelchair for transportation. The Resident Care Plan (RCP) dated 12/22/25 identified a history of engaging in non-consensual sexual advances by others. Interventions directed close observation levels applied as indicated per policy.2. Resident #2 was admitted to the facility in July of 2008 and had diagnoses that included vascular…

    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 before2025-12-16 · 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 three residents (Resident #1) reviewed for accidents, the facility failed to ensure neurological monitoring was completed timely after an unwitnessed fall in accordance with facility policy. The findings include:Resident #1's diagnoses included chronic obstructive pulmonary disease, morbid obesity and heart failure. The significant change in condition Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of fifteen out of fifteen, indicative of no cognitive impairment and used a wheelchair. The Resident Care Plan (RCP) dated 11/26/2025 identified limited physical mobility, non-ambulatory, and mobility by wheelchair. Interventions directed assist of one for wheelchair mobility. Review of facility reportable event dated 12/1/2025 at 6:45 PM identified Resident #1 was observed on the elevator floor after an unwitnessed fall from…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-08-04 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) who were reviewed for an allegation of abuse, the facility failed to ensure the resident was free from a physical altercation with a staff member that led to the resident falling. The findings include:Resident #1's diagnoses included severe dementia with agitation, mild cognitive impairment and muscle weakness. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of four (4) indicating severe impaired cognition, required supervision assistance when ambulating and was independent for bed mobility and transfers. The Resident Care Plan dated 6/18/25 identified Resident #1 may have limited insight into his/her illness and abilities and may wander on the unit at times which puts him/her at risk for unsafe situations. Interventions directed to offer to help the resident and ask questions about what…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-08-04 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) who were reviewed for abuse, the facility failed to notified the Administrator and/or designee of a physical altercation between a staff member and the resident at the time of the incident and therefore the incident was not reported to the State Agency for five (5) days. The findings include:Resident #1's diagnoses included severe dementia with agitation, mild cognitive impairment and muscle weakness. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of four (4) indicating severe impaired cognition, required supervision assistance when ambulating and was independent for bed mobility and transfers. The Resident Care Plan dated 6/18/25 identified Resident #1 may have limited insight into his/her illness and abilities and may wander on the unit at times which puts him/her at risk for unsafe…

    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 · D2025-08-04 · 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 reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) who had sustained a fall, the facility failed to ensure vital signs were obtained and recorded accurately. The findings include:Resident #1's diagnoses included severe dementia with agitation, mild cognitive impairment and muscle weakness. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of four (4) indicating severe impaired cognition, required supervision assistance with ambulation and was independent for bed mobility and transfers. The Resident Care Plan (RCP) dated 6/18/25 identified that Resident #1 may have limited insight into his/her illness and abilities and may wander on the unit at times which puts him/her at risk for unsafe situations. Interventions included offering to help him/her and ask questions about what the resident is trying to do if he/she appears to be…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-18 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for abuse, the facility failed to ensure an allegation of abuse/neglect was reported to the State Agency (SA). The findings include: Resident #1's diagnoses included multiple sclerosis, epilepsy, depression, anxiety and overactive bladder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severe cognitive impairment (Brief Interview for Mental Status (BIMS) score of three), was dependent with ADL care and frequently incontinent of bowel and bladder. The Resident Care Plan (RCP) dated 5/12/2025 identified Resident #1 had a communication problem related to progressive multiple sclerosis, interventions directed to anticipate and meet needs. Further review identified potential impairment to skin integrity related to fragile skin and dependence for mobility, interventions included pressure relief wheelchair cushion and pressure…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-18 · 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 clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for abuse, the facility failed to investigate an allegation of abuse/neglect. The findings include: Resident #1's diagnoses included multiple sclerosis, epilepsy, depression, anxiety and overactive bladder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severe cognitive impairment (Brief Interview for Mental Status (BIMS) score of three), was dependent with ADL care and frequently incontinent of bowel and bladder. The Resident Care Plan (RCP) dated 5/12/2025 identified Resident #1 had a communication problem related to progressive multiple sclerosis, interventions directed to anticipate and meet needs. Further review identified potential impairment to skin integrity related to fragile skin and dependence for mobility, interventions included pressure relief wheelchair cushion and pressure relieving/reducing mattress 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-18 · 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 facility documentation, the facility failed to follow infection prevention and control guidelines by failing to ensure resident room sink faucet filters were changed once expired. The findings include: Observation during tour of the facility on [DATE] at 9:05 AM identified dated resident room sink faucet filters in rooms [ROOM NUMBERS] were dated [DATE] (7 days past expiration date), rooms 204, 206, 208, 211, 214, and 217 filters were dated [DATE] (6 days past expiration date). Review of [NAME]-Aquasafe Water Filter manufacturer's instructions last updated [DATE] indicated the water filter is designed to be used for a maximum of one calendar month (31 days) following initial connection. Interview on [DATE] at 12:13 PM with facility Maintenance Director identified that the facility was following a water management program for an infectious agent, and filters were being used, maintained and replaced at faucet sites. He identified that he and the maintenance assistant were…

    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 23 citations
  • Potential for harm · Dcited before2025-03-03 · tag F0602 — failed to protect residents from theft of their belongings — isolated
    Protect each resident from the wrongful use of the resident's belongings or money.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, review of facility documentation, facility policies, and interviews for one (1) of eight (8) sampled residents (Resident #5) who were reviewed for misappropriation of personal property, the facility failed to ensure a controlled medication, Methadone, was properly stored to prevent the removal of six (6) bottles from the facility. The findings include: Resident #5's diagnoses included opioid dependence and other psychoactive substance abuse. The Resident Care Plan dated 11/11/24 identified Resident #5 was at risk for substance abuse related to the history of addiction and currently receiving medication assisted therapy. A physician's order dated 12/10/24 directed to give, the medication used to treat opioid use disorder, Methadone HCL oral solution 10 milligrams (mg) per 5 milliliters (ml), give 140 mg orally once a day. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #5 was alert and oriented to person, place, and time and received opioid 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
  • Potential for harm · D2025-03-03 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, review of facility documentation, facility policies, and interviews for one (1) of eight (8) sampled residents (Resident #5) who received Methadone (a controlled substance used to treat opioid addiction), the facility failed to ensure Resident #5's Methadone was stored per the facility policy to prevent the loss of the Methadone resulting in an omission of a dose and ensure the resident did not experience withdrawal symptoms. The findings include: Resident #5's diagnoses included opioid dependence and other psychoactive substance abuse. The Resident Care Plan dated 11/11/24 identified Resident #5 was at risk for substance abuse related to the history of addiction and currently receiving medication assisted therapy. A physician's order dated 12/10/24 directed to give, the medication used to treat opioid use disorder, Methadone HCL oral solution 10 milligrams (mg) per 5 milliliters (ml), give 140 mg orally once a day. The quarterly Minimum Data Set assessment dated [DATE]…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-03 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, review of facility documentation, facility policies, and interviews for one (1) of eight (8) sampled residents (Resident #5) who received a controlled medication, the facility failed to ensure a supply of Methadone (a controlled substance used to treat opioid addiction) was counted upon arrival to the facility and during the change of shift, and was stored in a secured cabinet per the facility's policy. The findings include: Resident #5's diagnoses included opioid dependence and other psychoactive substance abuse. A physician's order dated 12/10/24 directed to give, the medication used to treat opioid use disorder, Methadone HCL oral solution 10 milligrams (mg) per 5 milliliters (ml), give 140 mg orally once a day. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #5 was alert and oriented to person, place, and time and received opioid medications. The nurse's note dated 1/3/25 at 12:00 PM identified Resident #5 missed the daily dose of Methadone 140 mg,…

    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 · Past Non-Compliance
  • Potential for harm · Fcited before2024-12-20 · tag F0812 — failed to store, cook, and serve food safely — widespread
    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, staff interviews, and review of facility policy during a tour of the Dietary Department, the facility failed to ensure food was stored under clean conditions, failed to ensure facility prepared foods were discarded within 72 hours, and failed to ensure food items that had been removed from the original outer container had expiration or opened dates. The findings include: During a tour of the Dietary Department and interview with the Director of Food Service on 12/16/24 at 11:00 AM identified the following: A. A room described as the cold room contained 1 large refrigeration unit and 1 large freezer unit. The tile floor in the cold room was noted to be littered with a white, dusty, powdery, material. Shoe prints were visible throughout the cold room floor and an old green garden hose was stored on the floor. The Director of Food Services reported that sheetrock had recently been replaced. Further, the substance on the floor, where footprints were observed, was from sheetrock dust and debris that had dried following the work. Although the Director of Food…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-12-20 · tag F0756 — failed to review each resident's drug regimen — pattern
    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 interviews and record review for 1 of 5 residents (Resident #107) reviewed for unnecessary medications, the facility failed to follow pharmacy recommendations. The findings include: Resident #107's diagnoses included gastro esophageal reflux disease (GERD), Wernicke's encephalopathy, and anxiety. A physician order dated 4/1/24 directed Pantoprazole (a medication to treat GERD) 1 tablet be given daily. A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #107 had a short/long term memory problem and required set up with eating and upper body dressing. The MDS further identified Resident #107 required supervision with personal hygiene and maximal assistance with oral hygiene. Pharmacy Medication Regimen Review dated 9/10/24 identified Resident #107 was receiving crushed medications without an order to do so and Pantoprazole (a medication used to treat GERD) 40 milligrams (mg) which was enteric coated and cannot be crushed. Consultant Pharmacist recommendations included adding an…

    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 · E2024-12-20 · tag F0881 — failed to use antibiotics responsibly — pattern
    Implement a program that monitors antibiotic use.
    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 record review for 1 of 2 residents (Resident #112) reviewed for antibiotic use, the facility failed to monitor a resident on long term antibiotics per the facility antibiotic stewardship policy. The findings include: Resident #112's diagnoses included hemiparesis and hemiplegia affecting the left side, infection and inflammatory reaction due to internal left knee prosthesis, and epileptic seizures. The physician's order dated 9/30/24 directed to give Ciprofloxacin 500 milligrams (mg) 1 tablet twice a day (no end date was indicated). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #112 was cognitively intact, required set up help for eating and toileting, and was independent for transfers. The Resident Care Plan dated 11/5/24 identified Resident #112 had an infection of the left knee and was receiving antibiotic treatment. Interventions included administering the antibiotic per the physician orders and to follow the facility policy and procedure for line…

    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 · D2024-12-20 · 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 observations, review of the clinical record, facility policy, and interview for 1 of 4 sampled residents, (Resident #12) reviewed for positioning and mobility, the facility failed to implement siderail pads according to the care plan and for 1 of 1 sampled residents (Resident #121) reviewed for falls, the facility failed to implement a care plan intervention related to falls. The findings include:. The findings include: 1. Resident #12's diagnoses included dementia with behavioral disturbance, muscle weakness, and involuntary movements. The annual Minimum Data Set assessment dated [DATE] identified Resident #12 was severely cognitively impaired, had no limitation in range of motion, and was totally dependent on staff for bed mobility, transfers, and eating. The Resident Care Plan dated 11/13/24 identified Resident #12 was a fall risk related to a history of falls. Interventions included the use of padded siderails and that siderail pads and floor mats were in place. Observation on 12/16/24 at 11:20 AM,…

    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 before2024-12-20 · 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 observations, review of the clinical record, facility policy, and interviews for 1 of 4 sampled residents (Resident #12) reviewed for skin conditions, the facility failed to follow a physician's order for the application of bilateral foot boots and for 1 of 1 sampled residents (Resident #18) reviewed for positioning, the facility failed to accurately transcribe a provider's order for positioning. Additionally, for 3 of 3 residents (Resident #35, Resident #118 and Resident #129) reviewed for Methadone therapy, the facility failed to ensure Methadone was available for administration. The findings include: 1. Resident #12's diagnoses included dementia, muscle weakness, abnormal posture, reduced mobility, and involuntary movements. The annual Minimum Data Set assessment dated [DATE] identified Resident #12 was severely cognitively impaired, had no limitation in range of motion, and was totally dependent on staff for bed mobility, transfers, and putting on and taking off footwear. The Resident Care Plan…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-10-31 · 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, staff interviews, and facility documentation for one of three residents (Resident #1) reviewed for quality of care, the facility failed to ensure physician orders were transcribed accurately to ensure medication was administered in accordance with physician orders. The findings include: Resident #1 had a history that include an embolism and thrombosis of the right lower extremity. The significant change Minimum Data Set (MDS) dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition and identified Resident #1 received an anticoagulant during the prior seven (7) days. The Resident Care Plan (RCP) dated 9/12/2024 identified Resident #1 received an anticoagulant (Eliquis). Interventions directed to administer anticoagulant medications as ordered by physician. Physician order dated 8/9/24 directed staff to administer Eliquis (blood thinner) 5 milligrams (mg) twice a day. Nursing note dated 10/8/2024 at 6:48 AM…

    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 before2023-12-06 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, interviews, and facility policy review for one of three residents (Resident #2) reviewed for abuse, the facility failed to report an allegation of abuse to the State Agency timely. The findings include: Resident #1 was admitted to the facility with diagnoses that included opioid abuse, bipolar disorder, spinal disorder, seizures, and chronic pain. A quarterly Minimum Data Set assessment (MDS) dated [DATE] identified Resident #1 was alert and oriented, required set up help for personal hygiene and was independent for bed mobility, transfers, and wheelchair use. A Resident Care Plan (RCP) dated 10/1/2023 identified Resident #1 required assistance with ADLs. Interventions directed to allow Resident #1 to do as much as possible, and to explain what you are going to do before giving care. A nursing note written by RN #2 (evening supervisor), dated 11/9/2023 at 4:41 PM identified Resident #1 aggressively pushed the door to the supervisor's office shouting…

    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 · D2023-08-22 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation review, facility policies, and interviews for one of three sampled residents (Resident #5) who was reviewed for resident rights, the facility failed to ensure Resident #5's rights were not violated by taking away the resident's smoking privilege after Resident #5 was caught smoking in his/her room. The findings include: Resident #5's diagnoses included bipolar disorder, rhabdomyolysis, congestive heart failure, respiratory failure, and opioid dependence. The physician's order dated 7/1/23 directed supervised smoking per facility policy and Resident #5 was independent with transfers and ambulation. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #5 made consistent and reasonable decisions regarding tasks of daily life and was independent with ambulating off the unit. The Resident Care Plan dated 7/14/23 identified a substance abuse disorder. Interventions directed to provide individual and group substance abuse counseling,…

    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 before2023-08-22 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, facility policy, and interviews for two of three sampled residents (Residents #1 and #2) who were reviewed for a resident-to-resident altercation, the facility failed to monitor Resident #1 and Resident #2 to ensure they did not get into a physical altercation with each other after a verbal incident earlier in the morning. The findings include: Resident #1's diagnoses included bipolar disorder, borderline personality disorder, depression, and anxiety. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 made consistent and reasonable decisions regarding tsks of daily life and was independent with all activities of daily living. The resident care plan dated 6/13/23 identified Resident #1 had accusatory behaviors. Interventions included close observation levels applied as indicated, to observe resident's peer relation patterns and document significant dynamics or events quarterly and as otherwise indicated by facility policy,…

    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 before2022-07-12 · 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 documentation and interviews for one resident (Resident # 70) reviewed for specialized treatment, the facility failed to ensure medications were appropriate. The findings include: Resident # 70 was admitted to the facility on [DATE] with diagnoses that included End Stage Renal Disease (ESRD), required specialized treatment and chronic kidney disease stage 2. A physician's order dated 4/6/22 directed Milk of Magnesia 30 ml by mouth once daily as needed if no bowel movement in 3 days and Fleet Enema 1 rectally daily s needed if Bisacodyl suppository ineffective. The admission MDS assessment dated [DATE] identified Resident # 70 had intact cognition, was continent of bowel and bladder and required limited supervision with one person assist and received a specialized treatment in last 14 days. The care plan dated 4/22/22 identified end stage kidney disease and require hemodialysis. Interventions included: to arrange for follow up with nephrologist a needed and to be…

    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 · Ecited before2019-10-31 · 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 observation, interviews and review of the facility policy, the facility failed to store food in a sanitary manner and in accordance with professional standards for food service safety. The findings include: Observation with the Food Service Director on 10/28/19 at 10:30AM identified a rental refrigerator which contained a 12 inch block of 3.5 inch x 3.5 inch cheese slices wrapped in Saran Wrap and two opened and half-filled 4 pound jars of jelly without the benefit of a date on the containers. The Food Service Director was unable to identify any dates on the items listed. Interview with the Food Service Director at the time of the observation identified that all food items should be labeled and dated when opened. The Food Service Director further identified the Food Service Worker who opens or stores the food item is responsible to label the items. Review of the facility Food Storage Policy notes in part sliced cheese will be used within 7 days of opening and labeled with a use by date noting seven days from opening and refrigerated. The facility date marking quick…

    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 · Dcited before2019-10-31 · 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 review, facility documentation, and interviews, for one of three resident's reviewed for a change in condition, (Resident #500), the facility failed ensure a Power Of Attorney (POA) for health care was notified of a fall. The findings include: Resident #500 diagnoses included dementia, a left sided cerebral vascular accident, and Tourette syndrome. Review of the Durable Power of Attorney (POA) paperwork dated 9/26/2007 and face sheet identified Person #2 as the POA for health care. An admission assessment dated [DATE] identified the resident was alert, and confused, required assistance with activities of daily living, including transfer, and mobility. The care pan dated 9/18/19 identified the resident had fallen with interventions which included to have the resident sit next to the nurse's station while awake so staff can observe the resident.Review of the reportable event form dated 9/18/19 identified Resident #500 had an unwitnessed fall and was noted on the floor next to the bed 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-10-31 · 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, facility policy and interviews, for one of three resident's reviewed for a change in condition, (Resident #500), the facility failed to complete an assessment timely after a new onset of pain was identified, and failed to ensure a timely transport to the Emergency Department (ED) once a fracture was identified. The findings include: Resident #500 was admitted to the facility on [DATE] with diagnoses which included dementia, a left sided cerebral vascular accident, and Tourette's syndrome. An admission assessment dated [DATE] identified the resident was alert, and confused, required assistance with activities of daily living, including transfer, and mobility. The care plan dated 9/18/19 identified that the resident had a fall with interventions which included to have the resident sit next to the nurses station while awake so staff can observe the resident. A reportable event dated 9/18/19 identified Resident #500 experienced an unwitnessed fall with no…

    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 · D2019-10-31 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    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 interview for one sampled resident reviewed for urinary catheter, (Resident #47), the facility failed to ensure the urinary catheter was changed as direct by the physician orders. The findings include: Resident#47's diagnoses include neuromuscular dysfunction of the bladder. A quarterly MDS assessment dated [DATE] identified moderate impairment in cognition, requiring total assistance of one staff for ADLs, and an indwelling catheter. The September 2019 physician orders directed to utilize a 22 FR suprapubic tube with 30ml balloon, change every month and as needed for blockage/leakage. The nurse's notes dated 9/11/19 indicated Resident #47's suprapubic tube was clogged, unable to irrigate and tube changed. A physician order also dated 9/11/19 directs to change suprapubic tube 22 French with 30cc balloon every month and as needed for blockage/leakage. The October treatment [NAME] indicated the suprapubic tube was to be changed on 10/11/19 but was not signed off as being…

    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 · D2019-10-31 · tag F0742 — isolated
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
    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 interviews, for one of three resident's reviewed for behaviors, (Resident #500), the facility failed to ensure that all interventions were attempted to address behaviors. The findings include: Resident #500 was admitted to the facility on [DATE], with diagnoses which included dementia, a left sided cerebral vascular accident, and Tourette's syndrome. An admission assessment dated [DATE] identified the resident was alert, and confused, required assistance with activities of daily living. The care plan dated 9/17/19 identified the resident had a mental illness and takes an antipsychotic medication with interventions which included providing support and/or reassurance, and referral to psychiatric services as needed. The physician order dated 9/17/19 directed to administer Seroquel (an antipsychotic medication) 25 milligrams twice a day as needed (PRN) for agitation. A psychiatric evaluation dated 9/20/19 identified that when the resident yells out to use…

    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 before2019-10-31 · 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 documentation, facility policy, and interviews for one of five residents (Resident # 85) reviewed for unnecessary medications, the consultant pharmacist failed to identify and report irregularities related to orthostatic blood pressure monitoring for a resident receiving antipsychotic medication. The findings include: Resident #85 was admitted on [DATE] with diagnoses that included suicidal ideation, bipolar disorder and dyslipidemia.The quarterly minimum data set (MDS) assessment dated [DATE] identified Resident #85 was without cognitive impairment and required extensive assistance with personal care and received antipsychotic medication daily. The care plan dated 9/13/19 identified Resident had a risk for alteration in psychosocial wellbeing due to methadone maintenance and history of IV drug abuse, depression and a history of passive suicidal ideations. Interventions included psychiatric consultations as needed for severe coping or psychosocial complications…

    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 · D2019-10-31 · 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 observation, interviews, review of the clinical record and review of facility documentation for one of five residents (Resident # 85) reviewed for unnecessary medications, the facility failed to monitor orthostatic blood pressures for a resident receiving antipsychotic medications according to facility policy. The finding includes: Resident #85 was admitted on [DATE] with diagnoses which included suicidal ideation, bipolar disorder and dyslipidemia.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #85 was without cognitive impairment and required extensive assistance with personal care and received antipsychotic medications 7 days during the assessment reference period. The care plan dated 9/13/19 identified a risk for alteration in psychosocial wellbeing due to methadone maintenance and history of IV drug abuse, depression and a history of passive suicidal ideations. Interventions included psychiatric consultations as needed for severe coping or psychosocial complications…

    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 · B2025-03-03 · 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

    Based on clinical record reviews, review of facility documentation, facility policies, and interviews for seven (7) of eight (8) sampled residents (Residents #5, #6, #7, #8, #10, #11, and #12) who were reviewed for accurate documentation, the facility failed to ensure the Medication Administration Record (MAR) reflected documentation that the residents received the medication when administered. The findings include: 1. Resident #5 was admitted with the diagnosis of opioid dependence. A physician's order dated 12/10/24 directed to administer Methadone HCL oral solution (a medication to treat opioid addiction) 10 milligrams (mg) per 5 milliliters (ml), give 140 mg orally once a day. Review of the February 2025 MAR identified there was no documentation in the Electronic Medical Record (EMR) that the Methadone was administered on six (6) of twenty-five (25) days (2/1/25, 2/5/25, 2/10/25, 2/20/26, 2/22/25, and 2/23/25). 2. Resident #6 was admitted with the diagnosis of opioid dependence. A physician's order dated 1/21/25 directed to administer Methadone HCL oral Solution 5 mg/5 ml, give…

    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 before2024-12-20 · tag F0580 — failed to tell family and doctor about changes — pattern
    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 policy, and staff interviews for 1 of 1 residents (Resident #121) reviewed for falls, the facility failed to notify a resident's responsible party after multiple falls. The findings include: Resident #121's diagnoses include Parkinson's Disease, cognitive impairment, and fluency disorder. Review of the face sheet in the electronic record identified Person #1 was the responsible party/Power of Attorney for Resident #121. The Resident Care Plan dated 8/28/23 identified Resident #121 had a history of falls with injury. Interventions included education on call bell usage and not leaving him/her unattended while sitting on the side of the bed. Facility Reportable Events dated 1/1/24 through 12/19/24 identified Resident #121 had fallen twelve times (1/11/24, 1/27/24, 1/28/24, 4/2/24, 4/4/24, 4/14/24, 4/24/24, 6/2/24, 8/10/24, 9/6/24, 10/11/24, 11/22/24). The facility failed to notify Resident #121's responsible party/Conservator regarding the falls occurring on 4/2/24…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2019-10-31 · tag F0641 — pattern
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for four of five residents (Resident # 42, Resident #56, Resident #84 and Resident #107) reviewed for PASRR, the facility failed to ensure the accuracy of an MDS assessment. The findings included: 1. Resident #42 was admitted on [DATE] with diagnoses which included Diabetes Mellitus, schizoaffective disorder with psychotic features, bipolar disorder and depression. A review of the Hospital and Community Patient Review Instrument dated 3/25/96 identified Resident #42 had a serious mental illness and would require mental health services of a lower intensity with recommendations for a psychiatric evaluation within one week after admission or a written psychiatric plan of care. The annual minimum data set (MDS) assessment dated [DATE] identified Resident #42 was not considered by the state level II Preadmission Screening and Resident Review (PASRR) process to have a serious mental illness and or intellectual disability,…

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

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

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

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

Fines & penalties

$24,150 in federal fines across 1 penalty.

  • $24,150 — penalty dated 2024-10-31

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.

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 3 of 52.8+0.2 vs chain
Health inspection 2 of 52.7-0.7 vs chain
Staffing 2 of 53.0-1.0 vs chain
Quality measures 5 of 53.7+1.3 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
APEX ADVISORSOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST48%since 12/01/2003
EXECUTIVE ADVISORS, LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST48%since 12/01/2003
WRIGHT, CHRISTOPHERIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER5%since 12/01/2003
HACKLING, RAYMONDIndividualW-2 MANAGING EMPLOYEEsince 10/01/2015
I CARE MANAGEMENTOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 12/01/2003

CMS files one row per role, so the 6 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted.

3 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

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

$17.3M
Net patient revenuemost recent cost report
+1.3%
Operating marginrevenue minus expenses
$1.3M
Related-party expense8% of expenses
Who pays — share of resident-days
Medicaid 90%Medicare 1%Other / private 9%

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

$315per resident / day
operating cost
$9,568per month
≈ monthly operating cost
$319per 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 075337. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-12-20, 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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