Pendleton Rehabilitation And Nursing Center
44 Maritime Drive, Mystic, CT 06355 · For profit - Limited Liability company · 120 certified beds · (860) 572-1700 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- lower-than-typical staff turnover (34% vs 45% nationally) — better care continuity
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has 1 actual-harm citation
- a high number of inspection citations overall (32) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
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 | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 5 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 11.0% | 18.0% | 15.4% | better |
| Long-stay residents who lose too much weight | 7.9% | 6.5% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.5% | 0.7% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.0% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 21.0% | 22.3% | 6.5% | typical for the state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 4.6% | 3.5% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 10.1% | 16.4% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 21.0% | 17.6% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 93.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.4% | 4.0% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 31.2% | 24.7% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 16.5% | 17.8% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 88.0% | 69.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 15.5% | 24.3% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 9.3% | 10.7% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.67 | 2.06 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 1.50 | 1.46 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
56.1% 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 194 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 48.7% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 117 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.52 therapist hours per resident per day in 2026Q1 — more than 82% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 31% 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 56.1%CMS range 47.8–62.8 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.6%CMS range 8.6–14.9 | 10.7% | Oct 2022–Sep 2024 | no 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 discharge | 48.7% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 47.0% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 45.3% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 98.1% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 97.5% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 90.1% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.9% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 1.2% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.6%CMS range 4.1–9.8 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.02 | 1.02 | Oct 2022–Sep 2024 | CMS 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
How full it usually is: this home is certified for 120 beds and averages 115.7 residents a day — about 96% occupied, or roughly 4 beds typically open. It runs essentially full — expect a waiting list. 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 3.75 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.72 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.16 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.35 hrs/resident/day on weekends vs 3.91 on weekdays — 14% thinner on weekends. RN hours go from 0.87 to 0.35 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 34% is below the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
32 citations, most serious first. The 11 most serious are shown; the remaining 21 are one tap away and print in full.
- Actual harm · Gcited before2019-12-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, review of facility documentation and interviews for 1 of 3 sampled residents (Resident #283) reviewed for accidents and required the assistance of two staff members for care, the facility failed to ensure that two staff were in place when care was being provided, resulting in a fall with an injury. The findings include: Resident #283 diagnoses included depression, cerebral infarction, hemiplegia, morbid obesity, osteoarthritis, diabetes mellitus and hypertension. The quarterly MDS assessment dated [DATE] identified moderately impaired cognition, no behavioral symptoms, required extensive assistance of at least two persons for all ADL care with the exception of eating, did not ambulate, was unsteady with surface to surface transfers and only able to stabilize with staff assistance, had range of motion limitations on one side of the upper and lower extremities, utilized a wheelchair for mobility and had not fallen in the last three months. The care plan dated 8/21/19…
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.
- Potential for harm · Dcited before2025-11-18 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, facility policy and interviews for two (2) of three (3) sampled residents (Residents #1 and #2) who were reviewed for an allegation of abuse, the facility failed to ensure a nursing assessment was completed and documented in the clinical record at the time the allegation and assessment was reported. The findings include:1.Resident #1's diagnoses included altered mental status, adjustment disorder with depressed mood and cerebral edema (swelling in the brain caused by an accumulation of excess fluid in the brain tissues). The annual Minimum Data Set assessment dated [DATE] identified Resident #1 had a staff assessment for mental status completed identifying both short and long-term memory problems, required supervision assistance with toileting and was independent with bed mobility, transfers and ambulation. The Resident Care Plan dated 10/9/25 identified Resident #1 could be non-compliant with medication administration, Activities of Daily Living (ADL)…
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.
- Potential for harm · Dcited before2025-08-06 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1), reviewed for accidents, the facility failed to revise to complete neurological checks as per facility standard. The findings include: 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 checks were completed after an unwitnessed fall, in accordance with facility policy. The findings include: Resident #1 was admitted with diagnoses that included non-traumatic subdural hematoma, atrial fibrillation (irregular heartbeat) right leg below the knee amputation. The Resident Care Plan (RCP) dated 5/13/2025 identified Resident #1 was at risk for falls due to confusion, disorientation and was on anticoagulation (blood thinner). Interventions directed Resident #1 was independent with transfers, and to remind resident to ask…
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.
- Potential for harm · Dcited before2025-01-23 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately 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 observations, review of the clinical record, review of facility policy/procedures and interviews for one sampled resident (Resident #88) who experienced a change in condition, the facility failed to ensure that the physician was notified when the resident experienced symptoms of pain and swelling of the left hand. The findings include: Resident #88 was admitted to the facility in October 2024 with diagnoses that included type 2 diabetes mellitus, gout, and atrial fibrillation. The admission MDS assessment dated [DATE] identified Resident #88 was cognitively intact, required maximum assistance with lower body dressing, bathing, and toileting. Physician's progress notes dated 11/19/24 identified the resident was seen for hand pain to the right hand and noted the resident had superficial thrombophlebitis to the Left hand while at the hospital and recommended that Coumadin be switched to Lovenox(anticoagulant) to minimize the pricks to the fingers required for blood testing as a result of being on Coumadin.…
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.
- Potential for harm · D2025-01-23 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, review of facility policy/procedures and interviews for one of five sampled residents (Resident #88) reviewed for unnecessary medications and was receiving anticoagulant medication, the facility failed to ensure the care plan addressed the monitoring of possible side effects of anticoagulant medication and actions to take in the event of the need for emergent care. The findings included: Resident #88 was admitted to the facility in October 2024 with diagnoses that included type 2 diabetes mellitus, gout, and atrial fibrillation. The admission MDS assessment dated [DATE] identified Resident #88 was cognitively intact, required maximum assistance with lower body dressing, bathing, and toileting. It further identified the resident received anticoagulant medication. Review of Resident #88's care plan dated 10/31/24 failed to identify the resident was receiving anticoagulant medication and failed to have interventions in place to address monitoring for possible side effects and…
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.
- Potential for harm · Dcited before2025-01-23 · tag F0658 — failed to meet professional standards of care — isolatedEnsure 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 observations, review of clinical records, review of facility policy/procedures and interviews for two of three sampled residents (Resident #22 and Resident #101) observed with medications at the bedside, the facility failed to ensure that medications were administered according to acceptable standards of practice. The findings include: 1. Resident #22's diagnoses included respiratory failure, chronic obstructive pulmonary disease (COPD), unspecified asthma, and dependence on supplemental oxygen. The quarterly MDS assessment dated [DATE] identified Resident #22 was cognitively intact, required moderate assistance for dressing, personal hygiene, and transfers, was independent with toileting hygiene, bed mobility and utilized a wheelchair for mobility. The care plan dated 10/1/24 identified Resident #22 had oxygen therapy related to COPD with interventions that included give medications as ordered by physician and monitor for signs and symptoms of respiratory distress and report to provider as needed. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-23 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, review of facility documentation, review of facility policy, and interviews for one of three sampled residents (Resident #44) reviewed for activities of daily living (ADL), the facility failed to ensure showers were provided as scheduled. The findings include: Resident #44's diagnoses included muscle weakness, difficulty walking, and abnormalities of gait and mobility. The annual MDS assessment dated [DATE] identified Resident #44 was moderately cognitively impaired, required supervision with bed mobility, supervision with toileting, required partial to moderate assistance with bathing and utilized a walker and wheelchair for mobility. The care plan dated 1/3/25 identified Resident #44 had an ADL self-care performance deficit with interventions that included: provide resident with level of care for bathing and showering, break tasks into sub tasks if needed, and shower and bath on specified day/shift. Interview with Resident #44 on 1/17/24 at 3:00 PM identified that in the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-23 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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 observation, review of the clinical records, review of facility policy, review of facility documentation, and interviews for one of four sampled residents (Resident #22) reviewed for accidents, the facility failed to ensure that medications were administered as prescribed by the physician. The findings include: Resident #22's diagnoses included respiratory failure, chronic obstructive pulmonary disease (COPD), asthma, and dependence on supplemental oxygen. The quarterly MDS assessment dated [DATE] identified Resident #22 was cognitively intact, required moderate assistance for dressing, personal hygiene, transfers, and independent with toileting hygiene and bed mobility. The assessment further identified the resident utilized a wheelchair independently for mobility. The care plan dated 10/1/24 identified Resident #22 had oxygen therapy related to COPD with interventions that included give medications as ordered by physician and monitor for signs and symptoms of respiratory distress and report 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.
- Potential for harm · D2025-01-23 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, review of facility policy, review of facility documentation, and interviews for one of five sampled residents (Resident #18), reviewed for immunizations, the facility failed to ensure that the pneumococcal vaccine was administered as requested by the resident upon admission. The findings include: Resident #18 was admitted to the facility in June of 2024 and had diagnoses that included cervical disc disorder with myelopathy, unspecified dementia, and chronic obstructive pulmonary disease (COPD) with exacerbation. The quarterly MDS assessment dated [DATE] identified Resident #18 was cognitively intact, and the assessment further identified Resident #18 pneumococcal vaccination was not up to date. Review of the Immunization Report identified Resident #18 received pneumococcal conjugate (PCV 13) historically (prior to admission to the facility) on 12/7/2015 and pneumococcal polysaccharide (PPV23) historical on 12/4/2017. Review of the Pneumococcal Immunization Informed Consent…
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.
- Potential for harm · Dcited before2024-09-18 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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 reviews, facility documentation, facility policy, and staff interviews for one of three sampled residents (Resident #1) who was a recent admission, the facility failed to follow the physician's order for proper medication dosing and failed to follow the warning on the Medication Administration Record alerting staff to improper medication dosing. The findings include: Resident #1's diagnoses included congestive heart failure, mitral valve insufficiency, and prostate cancer. The admission Medication Regimen Review note dated 5/13/24 at 7:56 AM identified a dose alert for the medication Relugolix. A physician's order dated 5/15/24 directed to administer Relugolix 120 milligram (mg) tablet, take 360mg once on day one (1), 5/16/24, and then 120mg daily thereafter. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 had no memory recall deficits and was oriented to person, place, and time. Review of the May, June, July, and August 2024 Medication Administration…
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.
- Potential for harm · Dcited before2024-05-14 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor 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 review, facility documentation review, facility policy review, and interviews for one of three residents (Resident # 1) reviewed for abuse or neglect, the facility failed to ensure care was provided with dignity and respect. The findings include: Resident #1 was admitted with diagnoses that included dementia with behavioral disturbance, dementia and nocturia. An admission MDS assessment dated [DATE] identified Resident #1 had severe cognitive impairment, can usually understand others, required limited assistance for transfers and bed mobility, and supervision for ambulation with a rolling walker. The RCP dated 6/2/2022 identified Resident #1 had impaired cognitive function and impaired thought processes due to dementia and a communication problem. The RCP directed for staff to ask yes/no questions to determine resident needs, cue/re-orient and supervise as needed, provide consistent caregivers to decrease confusion and to anticipate and meet needs validating resident's message by…
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.
Show the remaining 21 citations
- Potential for harm · Dcited before2023-11-29 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents, (Resident #1), reviewed for pressure ulcers, the facility failed to notify the physician of pressure injuries. The findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses that included fracture of the left tibia, diabetes type II and morbid obesity. The care plan dated 6/9/23 identified Resident #1 had a fracture of the left tibia shaft with interventions that included to checking circulation, sensation and motion of the affected extremity every shift. A skin check dated 6/9/23 identified no skin alterations and a left lower extremity cast in place for fractured tibia surgery. Physician's orders dated 6/9/23 directed to monitor skin integrity under/around the cast every shift, monitor circulation, mobility, sensation and pulse to Left Lower Extremity (LLE) every shift, and directed diabetic foot checks every evening shift. A physician's order 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.
- Potential for harm · Dcited before2023-11-29 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for pressure ulcers, the facility failed to assess, monitor, and treat the resident's pressure ulcer. The findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses that included fracture of the left tibia, venous insuffiency, diabetes type II and morbid obesity. The care plan dated 6/9/23 identified Resident #1 had a fracture of the left tibia shaft with interventions that included to check circulation, sensation and motion of the affected extremity every shift. A skin check dated 6/9/23 identified no new skin alterations and Resident #1 had a left lower extremity cast in place for fractured tibia surgery. Physician's orders dated 6/9/23 directed to monitor skin integrity under/around the cast every shift, monitor circulation, motion, sensation and pulse to Left Lower Extremity and diabetic foot checks every evening shift. 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.
- Potential for harm · E2022-12-01 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, facility policy review and interviews, the facility failed to label and store medications in accordance with professional standards. The findings include: 1. Observation on 11/30/2022 at 9/45 AM with LPN #5 indicated 1 opened insulin pen and 3 opened insulin vials without dates indicating when they were opened. Observation and interview with RN # 5 on 11/30/2022 at 9:50 AM identified insulin pens and insulin vials received and opened on 11/29/2022 should have been labeled by the nurse with the date the medication was opened. An interview with Pharmacist #1 on 11/30/2022 at 11:50 AM identified when insulin pens are opened it is the nurse's responsibility to write the date it was opened and to indicate the expiration date on the label. Interview with RN #5 on 11/30/2022 at 1:45 PM indicated the insulin was ordered and opened yesterday (11/29/2022) given once on the evening shift. RN # 5 also indicated agency nurse who has only worked in the facility a few times was on duty and did not label the insulin. RN #5 further indicated that she would provide in servicing…
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.
- Potential for harm · E2022-12-01 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations of the kitchen, review of policy and interviews, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner to prevent the spread of infection. The findings included: An observation of the kitchen on 11/28/22 at 10:20 AM identified the following: 1. Moderate amount gray matter buildup on knife holder. 2. Large amount of brown and gray matter buildup on the top of the utensil rack. 3. Moderate amount of dried brown spillage, green and orange crumb like debris, concentrated around the legs of the counters 4 bag ties under the food prep counter across from stove and center counter. 4. Large amount brown and white buildup on bottom shelf located on the far wall where the oven was located and on bottom shelf where serving containers were kept. 5. Moderate amount of brown spatter buildup along the face and beneath the stove vent. Cleaned [DATE], by outside contracted company. 6. Can opener with moderate amount congealed brown buildup around the blade. 7.(2) sanitation…
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.
- Potential for harm · E2022-12-01 · tag F0921 — failed to keep a safe, functional, sanitary building — patternMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on environmental observations and interviews for 6 of 7 residents reviewed for environment for (Residents # 2, # 4 and # 8, # 30 # 47 and # 63) bathrooms., the facility failed to maintain residents personal care items in a safe, sanitary, manner. The findings included: An in-service report titled Monthly N.A. Meeting dated 8/14/2022 identified under N.A. Responsibilities notes bedpans should be kept in a bag in the bathroom, labeled and not on the toilet or on the bathroom floor and basins should be labeled and placed in the bedside table of the resident it belongs to. Observations on 11/28/2022 at 10:30 AM of Residents #4 and #8 bathroom identified a urine leg bag without a label, draped over a towel rail with a small amount of urine within public view. Observations on 11/28/22 at 10:50 AM of Residents #30 and #47 bathroom identified a used urinal hung on the bathroom towel holder next to the sink with no name on it, personal care items were noted on a shelf above the toilet in a kidney shaped small basin with no name on it. Several basins noted to be piled on the floor left…
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.
- Potential for harm · Dcited before2022-12-01 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, observations, facility policy and interviews for one of two sampled residents (Resident #51) reviewed for a skin condition, the facility failed to provide care in a dignified manner and failed to ensure a privacy curtain was available. The findings include: Resident #51 ' s diagnoses included unspecified dementia with agitation, depressive episodes, and bipolar disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident # 51 was severely cognitively impaired and required extensive assistance dressing, toileting, and personal hygiene. The Resident Care Plan dated 11/7/22 identified Resident #51 had potential skin issues. Interventions included to provide preventative skin care and treatment as ordered. Physician ' s Order dated 10/31/22 directed to apply extra thick anti-fungal cream to bilateral buttocks with incontinent care every shift. 1. Observation on 11/29/22 at 12:25 PM identified Licensed Practical Nurse (LPN) #8 prepare to provide…
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.
- Potential for harm · D2022-12-01 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, and interviews for one of three sampled residents (Resident #42) reviewed for choices, the facility failed to provide a shower per the resident ' s preference. The findings include: Resident #42 ' s diagnoses included Cerebral Vascular Accident (CVA), hemiplegia, and aphasia. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #42 was moderately cognitively impaired, required the supervision of one staff with transfers, and was totally dependent on staff with bathing. The Resident Care Plan dated 9/27/22 identified Resident #42 had an Activities of Daily Living (ADL) self-care performance deficit related to a stroke. Interventions directed to encourage active participation in tasks, participate to the fullest extent possible, and praise all efforts. Observation on 11/28/22 at 12:10 PM, identified that Nurse Aide (NA) #8 offered Resident #42 a shower. Resident #42 declined and requested to have a shower the following day. NA #8 stated she could…
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.
- Potential for harm · D2022-12-01 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, facility policy, and interviews for the only sampled resident (Resident #21) reviewed for restraints, the facility failed to review and revise the care plan to include the use of a wheelchair lap belt and for (Resident #342) reviewed for neglect, the facility failed to implement the comprehensive care plan for a resident requiring two person assist with transfers using a mechanical lift and for 1 resident (Resident # 89) reviewed for closed record review, the facility failed to ensure the resident had a comprehensive care plan for discharge. The findings include: 1. Resident #21 ' s diagnoses included polyarthritis, morbid obesity, and narcolepsy. Observation on 11/28/2022 at 2:00 PM identified Resident #21 seated in wheelchair with a lap belt fastened in place. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #21 was moderately cognitively impaired, required the assistance of 2 staff with bed mobility and transfers, was unable 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.
- Potential for harm · Dcited before2022-12-01 · tag F0658 — failed to meet professional standards of care — isolatedEnsure 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 policy review and interviews for two of three residents (Resident #56 and Resident #64) reviewed for hospitalization, the facility failed to ensure that a registered nurse (RN) assessed the residents upon return from the acute care facility in accordance with the professional standard and facility practice. The findings included: 1. Resident #56's diagnoses included cerebral infarction, atrial fibrillation, type 2 diabetes mellitus, congestive heart failure, hyperkalemia, and chronic kidney disease stage 3. A nursing progress note dated 10/19/22 identified Resident #56 was sent to an acute care facility secondary to hyperkalemia and worsening of kidney function. A review of the census data dated 10/24/22 identified Resident #56 was re-admitted to the facility from acute care facility. The admission MDS assessment dated [DATE] identified Resident #56 had unknown cognitive status and required supervision with transfer, dressing, toileting, hygiene, and ambulation.…
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.
- Potential for harm · Dcited before2022-12-01 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the clinical record, facility documentation, facility policy, and interviews for one resident (Resident # 342) reviewed for neglect, the facility failed to ensure the resident was reproached after the resident refused ADL care. The findings include: Resident #342 was admitted on [DATE] with diagnoses that included malignant neoplasm of the of the lower third of the esophagus, liver and intrahepatic bile duct, dementia, and hypertension. Initial Care Plan dated 11/22/22 identified Resident #342 was cognitively impaired, incontinent of urine and bowel, required one-person physical assist with eating, personal hygiene, dressing, bed mobility and two-person physical assist for transfer. The physician's orders dated 11/22/22 directed activity as tolerated. The Activities of Daily Living (ADL) documentation received 11/29/22 for 11/27/22 failed to reflect documentation of ADL care for Resident #342 on the 3:00 PM to 11:00 PM shift and 11:00 PM to 7:00 AM shift (from 11/27/22 overnight…
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.
- Potential for harm · Dcited before2022-12-01 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility policy and interviews for 1 resident (Resident #60) reviewed for pressure ulcers, the facility failed to ensure a dietary follow up for a resident with a newly developed pressure ulcer within facility practice. The findings include: Resident #60 was admitted on [DATE] with diagnoses that included dementia, failure to thrive and hypertension. The care plan dated 10/6/22 identified Resident #60 was at risk for skin breakdown and at nutritional risk due to dementia, impaired mobility and mechanically altered diet. Interventions included to elevate legs as needed, provide heel poseys and to provide a dietitian consult as needed. An admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #60 had severe cognitive impairment, required extensive one person assist with bed mobility and personal care, two persons assist with transfers and noted the resident did not have any unhealed pressure ulcers. A Head-to-Toe Skin checks dated 10/23/22 noted a newly…
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.
- Potential for harm · Dcited before2022-12-01 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility policy and interviews for one resident (Resident # 342) reviewed for abuse, the facility failed to provide the necessary assistive devices to assist with ADL care to prevent a potential accident. The finding included: Resident #342 was admitted on [DATE] with diagnoses that included malignant neoplasm of the of the lower third of the esophagus, liver and intrahepatic bile duct, dementia, and hypertension. Initial Care Plan dated 11/22/22 identified Resident #342 was cognitively impaired, incontinent of urine and bowel, required one-person physical assist with eating, personal hygiene, dressing, bed mobility and two-person physical assist for transfer. The physician's orders dated 11/22/22 directed activity as tolerated. The Occupational Therapy (OT) Evaluation dated 11/23/22 identified Resident #342 required maximal assist with toileting, substantial maximal assist with lying to sitting on the side of the bed, and unable to stand without support and able 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.
- Potential for harm · D2022-12-01 · tag F0726 — failed to have competent, trained nursing staff — isolatedEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on, review of the clinical record, facility policy and interviews for 1 resident (Resident # 342) reviewed for neglect, the facility failed to ensure sufficient staffing to assist the resident with ADL care and failed to ensure nurse aides were competent in reporting resident refusal of care. The findings include: Resident #342 was admitted on [DATE] with diagnoses that included malignant neoplasm of the of the lower third of the esophagus, liver and intrahepatic bile duct, dementia, and hypertension. Initial Care Plan dated 11/22/22 identified Resident #342 was cognitively impaired, incontinent of urine and bowel, required one-person physical assist with eating, personal hygiene, dressing, bed mobility and two-person physical assist for transfer. The physician's orders dated 11/22/22 directed activity as tolerated. Physical Therapy (PT) Evaluation dated 11/23/22 noted Resident was able to roll left to right with partial moderate assist, sit to laying with substantial maximal assist, sit to stand with 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.
- Potential for harm · D2022-12-01 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure 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 clinical record review, review of facility documentation and interviews for one of five residents (Resident # 19) reviewed for unnecessary medications for utilization of psychotropic medication, the facility failed to ensure that pharmacy recommendations were reviewed and followed up by the physician. The findings include: Resident # 19's diagnoses included in part schizophrenia, dementia, hypomagnesemia, and hyperlipidemia. The quarterly MDS assessment dated [DATE] identified the resident with severe cognitive impaired, having trouble falling asleep, little or no energy, no behavioral symptoms and noted the utilization of antipsychotic medication within the last 7 days. The Pharmacy Consultation recommendation report dated 8/30/2022 noted to consider a trial dose reduction of one or more psychotropic medications listed to decrease Resident #19's risk for falls. The form indicated an area for the physician to respond and sign and date. However, no physician's response was indicated on the form as 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.
- Potential for harm · D2022-12-01 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility policy and interviews for one of five Residents (Resident # 295) reviewed for unnecessary medications, the facility failed to ensure a physician's order for a psychiatric referral per resident's request was followed and the facility failed to ensure a baseline AIMS was obtained for a resident with a newly prescribed antipsychotic medication. The findings include: Resident #295 was admitted with diagnoses that included alcohol dependence, generalized anxiety disorder and depressive episodes. The physician's orders dated 10/20/22 directed Cymbalta (Anti-depressant) 60 MG daily, to provide behavioral health services per a contracted agency that provided evaluation and treatment as needed. The care plan dated 10/24/22 identified Resident #294 had been prescribed an antidepressant medication related to mood disorder, depression, and anxiety. Interventions included to monitor/ document and report signs of depression, provide psychiatry/psychology consult as needed. 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.
- Potential for harm · Dcited before2022-12-01 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on, review of the clinical record, facility policy and interviews for 1 resident (Resident # 342) reviewed for neglect, the facility failed to ensure a complete and accurate regarding the resident's refusal of care. The findings include: Resident #342 was admitted on [DATE] with diagnoses that included malignant neoplasm of the of the lower third of the esophagus, liver and intrahepatic bile duct, dementia, and hypertension. Initial Care Plan dated 11/22/22 identified Resident #342 was cognitively impaired, incontinent of urine and bowel, required one-person physical assist with eating, personal hygiene, dressing, bed mobility and two-person physical assist for transfer. The physician's orders dated 11/22/22 directed activity as tolerated. The Activities of Daily Living (ADL) documentation received 11/29/22 for 11/27/22 failed to reflect documentation of ADL care for Resident #342 on the 3:00 PM to 11:00 PM shift and 11:00 PM to 7:00 AM shift (from 11/27/22 overnight to 11/28/22). The ADL documentation…
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.
- Potential for harm · D2019-12-12 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility documentation and interviews for one sampled resident (Resident #51) reviewed for advance directives, the facility failed to provide advance directive information following readmissions from the hospital. The findings include: Resident #51's diagnoses included acute embolism and thrombosis of right popliteal vein, systemic lupus erythematous and chronic myelomonocytic leukemia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #51 was without cognitive impairment. A physician's order dated [DATE] denoted the resident's code status as a Do Not Resuscitate, Do Not Intubate, and Nurse May Pronounce (DNR/DNI/NMP). The Advance Directive/Medical Treatment Decisions Acknowledgement of Receipt dated [DATE] and initialed by Resident #51 identified a status of Do Not Resuscitate.The Resident Care Plan (RCP) dated [DATE] identified the resident's code status as full code, with interventions which included to begin cardiopulmonary…
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.
- No harm found · B2025-01-23 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, review of facility documentation, review of facility policy and interviews for one sampled resident (Resident #12) reviewed for respiratory care, the facility failed to ensure nebulizer equipment was stored/labeled properly and discarded when not in use. The findings included: Resident #12's diagnoses included high blood pressure, obesity, and depression. The quarterly MDS assessment dated [DATE] identified Resident #12 was cognitively intact, had no behaviors, required max assistance with bathing, dressing, and transfers. The assessment further identified that the resident did not ambulate and utilized a wheelchair for mobility. The care plan dated 1/13/25 identified Resident #12 had an inability to perform self-care, related to impaired mobility with interventions that included: aiding in any assistance when needed, providing quarter/half-length enablers (side rails) to assist with bed mobility and providing female caregivers. Observation of Resident #12's…
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.
- No harm found · Bcited before2025-01-23 · tag F0641 — patternEnsure 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, review of facility documentation, review of facility policy/procedures and interviews for one sampled resident (Resident #67) reviewed for dialysis, the facility failed to ensure four Minimum Data Set (MDS) assessments were accurately coded for dialysis. The findings include: Resident #67's diagnoses included end stage kidney disease, heart failure and diabetes. A review of the physician's orders identified Resident #67 has had an order for hemodialysis from February 2024 through January 2025 for every Tuesday, Thursday, and Saturday in the afternoon at the dialysis center. Review of the following MDS assessments identified they did not reflect that the resident was receiving hemodialysis treatments. 1. admission MDS assessment dated [DATE] 2. Quarterly MDS assessment dated [DATE] 3. Quarterly MDS assessment dated [DATE] 4. admission MDS assessment dated [DATE] An interview on 1/23/25 at 12:33 PM with the MDS Coordinator (RN #3) indicated dialysis should have been coded on…
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.
- No harm found · C2022-12-01 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, review of facility documents and staff interview, the facility failed to ensure daily posted nurse staffing information reflected actual licensed and unlicensed nursing staff hours worked was accurate and posted daily. The findings include: On 11/29/22 at 8:00 AM observation with the Director of Nursing (DNS) of the posted nurse staffing information and actual staffing schedule identified that the posted nursing staffing information did not match for licensed nursing and NA hours for the evening shift (3-11 PM) 11/28/22. The posted daily nurse staffing form dated 11/28/22 for the 3-11 PM shift identified the total staffing hours for licensed staff (RN and LPN) was 51 hours and for unlicensed staff (NAs) was 59 hours. The actual staffing hours per the corrected staff schedule identified the total hours for licensed staff was 48 hours and for unlicensed staff was 55.25 hours. The posted daily nurse staffing form dated 11/28/22 for the 11-7 AM shift identified the total staffing hours for licensed staff (RN and LPN) as 34 hours and for unlicensed staff (NAs) as 44…
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.
- No harm found · Bcited before2019-12-12 · tag F0641 — patternEnsure 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 clinical record review, review of facility documentation and interviews for four of four sampled residents (Resident's #30 #40, #57 and #66) reviewed for Minimum Data Set (MDS) coding, the facility failed to ensure accurate coding. The findings include: 1. Resident #30 diagnoses included schizoaffective disorder, depressive disorder and anoxic brain injury. A level II preadmission screening and resident review summary of findings report (PASRR) dated 6/10/19 identified the resident was approved for long term care. An admission MDS assessment dated [DATE] identified Resident #30 was not considered by the state level II PASRR process to have serious mental illness and/or intellectual disability. The MDS further identified Resident #30 had severely impaired cognition and required extensive assistance to total dependence with Activities of Daily Living. Interview and clinical record review with the MDS Coordinator (RN #1) on 12/10/19 at 2:38 PM identified although Resident #30 had a positive level II PASRR…
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.
“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.
- 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.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to ATLAS HEALTHCARE — 29 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 5 of 5 | 3.6 | +1.4 vs chain |
| Health inspection | 4 of 5 | 3.1 | +0.9 vs chain |
| Staffing | 3 of 5 | 2.3 | +0.7 vs chain |
| Quality measures | 5 of 5 | 4.4 | +0.6 vs chain |
The other 28 homes this chain runs (chain average 3.6★, 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 / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| CT-2 OPERATIONS HOLDINGS LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 09/01/2022 |
| JMH FAMILY LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; LIMITED PARTNERSHIP INTEREST; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 09/01/2022 |
| JMH FAMILY TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; LIMITED PARTNERSHIP INTEREST; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 09/01/2022 |
| MLS FAMILY LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 09/01/2022 |
| MLS FAMILY TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; LIMITED PARTNERSHIP INTEREST; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 09/01/2022 |
| SGS FAMILY LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; LIMITED PARTNERSHIP INTEREST; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 09/01/2022 |
| SGS FAMILY TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; LIMITED PARTNERSHIP INTEREST; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 09/01/2022 |
| GOTTLIEB, MOSHE | Individual | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; LIMITED PARTNERSHIP INTEREST; ADP OF THE SNF | — | since 09/01/2022 |
| BAK, PINCHOS | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 09/01/2022 |
| CT-2 OPCO MANAGER LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/04/2025 |
| GOLDBERGER, SHLOMO | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 09/01/2022 |
| HENNESSEY, JOHN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 09/01/2022 |
| PEGLOW, SUSAN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 09/01/2022 |
| SHAW, LINDSAY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 09/01/2022 |
| SONNENSCHEIN, MOSHE | Individual | OPERATIONAL/MANAGERIAL CONTROL; TRUSTEE OF THE SNF; ADP OF THE SNF | — | since 09/01/2022 |
| MALT FAMILY TRUST | Organization | LIMITED PARTNERSHIP INTEREST | — | since 09/01/2022 |
| SGS 2010 FAMILY TRUST | Organization | LIMITED PARTNERSHIP INTEREST | — | since 09/01/2022 |
| TYH 2017 TRUST | Organization | LIMITED PARTNERSHIP INTEREST | — | since 09/01/2022 |
| ISAAC, CHAIM | Individual | TRUSTEE OF THE SNF | — | since 09/01/2022 |
| 44 MARITIME DRIVE REALTY LLC | Organization | ADP OF THE SNF | — | since 07/03/2025 |
| PENDLETON REALTY HOLDINGS LLC | Organization | ADP OF THE SNF | — | since 09/01/2022 |
CMS files one row per role, so the 44 rows in the source record cover these 21 parties — each is shown once here with every role it holds. Nothing is omitted.
13 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.
This home reported $266K 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
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
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.
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 075341. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-01-23, 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.