Complete Care At Glendale
4 Hazel Ave, Naugatuck, CT 06770 · For profit - Corporation · 120 certified beds · (203) 723-1456 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- lower-than-typical staff turnover (36% vs 45% nationally) — better care continuity
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (31) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
- 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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 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 2 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
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 | 5 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 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
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 | 37.7% | 18.0% | 15.4% | worse |
| Long-stay residents who lose too much weight | 3.1% | 6.5% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.4% | 0.7% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.6% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 45.7% | 22.3% | 6.5% | worse than 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 | 1.4% | 3.5% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 29.7% | 16.4% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 19.6% | 17.6% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 99.1% | 93.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.4% | 4.0% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 28.0% | 24.7% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 10.1% | 17.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.5% | 1.5% | 1.4% | typical |
| Short-stay residents given the seasonal flu vaccine | 84.6% | 69.7% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 15.6% | 24.3% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 5.5% | 10.7% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.10 | 2.06 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.49 | 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.
59.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than 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: 66.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 103 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 0.29 therapist hours per resident per day in 2026Q1 — more than 44% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 18% 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 | 59.6%CMS range 52.9–65.6 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 8.9%CMS range 6.3–12.0 | 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 | 66.0% | 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 | 59.2% | 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 | 55.3% | 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 | 100.0% | 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 | 100.0% | 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 | 100.0% | 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 | 0.0% | 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 | 3.2% | 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 | 7.2%CMS range 4.2–11.7 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.93 | 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 111.0 residents a day — about 92% occupied, or roughly 9 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 3.50 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.61 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.03 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 3.15 hrs/resident/day on weekends vs 3.64 on weekdays — 13% thinner on weekends. RN hours go from 0.74 to 0.31 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%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
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 unchanged from the previous inspection. 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.
31 citations, most serious first. The 11 most serious are shown; the remaining 20 are one tap away and print in full.
- Immediate jeopardy · Jcited before2024-01-04 · 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, facility documentation review, facility policy review, and interviews for one (1) of three (3) residents, (Resident #1), reviewed for accidents, the facility failed to ensure that a resident who had significant cognitive impairment did not leave the facility unescorted. Resident #1 was located by the police approximately 2 hours and 40 minutes after he/she was last seen by a staff and was transported to the hospital and treated for hypothermia. This resulted in a finding of Immediate Jeopardy. Resident #1 was admitted with diagnoses that included dementia, Parkinson's, anxiety, and psychotic disorder with delusions. The quarterly MDS assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) of six (6) indicative of severely impaired cognition, was independent with ambulation and activities of daily living. A care plan dated 11/27/2023 identified Resident #1 has a decline in cognitive function and impaired thought processes, short-and long-term…
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 · D2026-02-03 · 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 review of the clinical record, facility documentation/policies, and staff interviews, for one (1) of three (3) sampled residents (Resident #1) who required staff assistance for daily living skills, the facility failed to develop and implement a comprehensive care plan and physician orders to address the required use of a left arm sling following a humerus fracture. The findings included: Resident #1's diagnoses included fracture of the left humerus, chronic kidney disease, and type two diabetes. Review of the hospital discharge documents dated 11/21/25 identified Resident #1 was fitted for a left arm sling due to a humerus fracture. Review of physician's orders from 11/21/25 through 12/2/25 failed to identify an order for a left arm sling. The five (5) day Minimum Data Set assessment dated [DATE] identified Resident #1 was cognitively intact (Brief Interview for Mental Status (BIMS) score of 13) and was dependent on staff for dressing and transfers in and out of the bed and chair. 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.
- Potential for harm · Ecited before2026-01-14 · 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
Based on observations, facility documentation, facility policy, and interviews, the facility failed to ensure dry storage items were stored under sanitary conditions; and failed to ensure that the sanitizing solution was monitored for appropriate sanitizing levels; and failed to ensure food temperatures were monitored and logged for every meal; and failed to ensure that the nourishment refrigerator temperatures were checked and logged daily. The findings include:Observation on 1/11/26 at 8:24 AM during an initial tour of the kitchen with the Dietary Director in the dry food storage area identified a large, prepackaged bag that contained corn flake type cereal. The bag was not labeled or dated and there was a large tear in the bag (approximately 3 inches) with cereal open to the air. Additionally, a box of powered liquid thickener was observed fully opened at the top and had been placed in a plastic bag. The bag was open and nonsealable. Observation of the red sanitizing buckets identified that 2 of 3 buckets tested at 150 PPM. The Dietary Director identified these levels were low…
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 · D2026-01-14 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
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 3 residents (Resident #7, 117 and 119) reviewed for hospitalization and/or discharge, the facility failed to ensure the Office of the State Long-Term Care Ombudsman was notified in a timely manner when the residents were was transferred and admitted to the hospital and when a resident had left against medical advice (AMA). The findings include: 1. Resident #7 was admitted to the facility in February 2021 with diagnoses that included epilepsy, traumatic brain injury, and acute embolism. Review of the census form identified Resident #7 was transferred to the hospital and admitted on [DATE]. A nurse's note dated 6/9/25 at 8:26 PM identified Resident #7 was readmitted to the facility at 7:00 PM alert, nonverbal, and calm. Review of a notification details form dated 10/2/25 identified the routine monthly resident transfers dated between 6/1/25 – 6/30/25 were sent to the Office of the State Long-term Ombudsman (4 months…
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 · D2026-01-14 · 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, facility documentation, facility policy and interviews for 1 of 3 residents (Resident #1) reviewed for abuse, the facility failed to revise the care plan with interventions to reduce future injury after the resident sustained an injury of unknown origin. The findings include:Resident #1 was admitted to the facility in 6/2022 with diagnoses that included atherosclerosis of the native arteries, peripheral vascular disease (PVD) and dementia.The annual MDS dated [DATE] identified Resident #1 was moderately cognitively impaired, independent with bed mobility and required one person assist with transfers, toileting and locomotion using a wheelchair/walker. The care plan dated 11/18/25 identified Resident #1 had impaired cognition, was independent with transfers and ambulation with a walker, received antiplatelet therapy (medication used for PVD management that may increase risk for bleeding) and was at risk for skin breakdown. Interventions included to cue, supervise as needed,…
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 · D2026-01-14 · 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 Number of residents sampled: Number of residents cited: Based on observation, review of the clinical record, facility policies, and interviews for 1 of 5 residents (Resident #121) reviewed for accidents, the facility failed to ensure an RN assessment was completed timely following a change in the residents condition and failed to ensure antibiotics were administered timely after an x ray identified pneumonia. The findings include:Resident #121 was admitted to the facility in 12/2025 with diagnoses that included metabolic encephalopathy, neurocognitive disorder with Lewy Bodies, type 2 diabetes mellitus, Parkinson's Disease, and dysphagia.The physician's orders dated 12/15/25 directed for a cardiac, carbohydrate-controlled diet, dysphagia puree texture, honey consistency and directed for the administration of Albuterol Sulfate Inhalation Solution (2.5mg/3ml) 0.083% (a bronchodilator which works to relax the muscles of the airway to make breathing easier) 3ml inhale orally, via nebulizer every 6 hours, for…
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 before2026-01-14 · 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 observation, review of the clinical record, facility policies, and interviews for 1 of 4 residents (Resident #12) reviewed for pressure ulcers, the facility failed to complete a nutritional assessment for a resident with a newly re-opened pressure injury in a timely manner, and for 2 of 4 residents (Residents #60 and 121) reviewed for pressure ulcers, the facility failed to ensure a specialty mattress was set in accordance with a physician's order, and for Resident #121, the facility failed to ensure a comprehensive pressure ulcer assessment was completed on admission. The findings include: Resident #12 was admitted in 4/2025 with diagnoses that included Type II diabetes and atrial fibrillation. The quarterly MDS dated [DATE] identified Resident #12 had severely impaired cognition, required one person assist for bed mobility, transfers, was dependent for toileting needs, had no unhealed pressure ulcers and was at risk for developing a pressure ulcer. The care plan dated 10/22/25 identified Resident #12…
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 before2026-01-14 · 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 observation, review of the clinical record, facility documentation, facility policies, and interview for 1 of 5 residents (Resident #121) reviewed for accidents, the facility failed to ensure a resident at risk for aspiration was supervised during a meal. The findings include: Resident #121, during admission to an acute care hospital on [DATE], had a Clinical Bedside Swallow Evaluation. The Clinical Bedside Swallow Evaluation identified Resident #121 had mild oral phase dysphagia complicated by prolonged oral transit time/bolus manipulation across trial consistencies. No overt signs and symptoms (s/s) or airway compromise was noted at this time and no retention in the oral cavity post-swallow. Recommendations included the following: diet: puree/IDDSI-4 and mildly thick liquids/IDDSI-2, liquid administration via: cup and straw, supervision: total assist with feeding, compensation/maneuvers: slow rate, small bites/sips and check for pocketing, environmental considerations: upright 90 degrees and upright…
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 · D2026-01-14 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility policy, and interviews for 1 of 2 residents (Resident #33) reviewed for pain management, the facility failed to ensure pain assessments per the physician's order. The findings include: Resident #33 was admitted to the facility in April 2022 with diagnoses that included headache, polyosteoarthritis, chronic pain, schizoaffective disorder, borderline personality disorder, and repeated falls. A physician's order dated 5/1/24 directed to administer Acetaminophen 325mg, 2 tablets by mouth, every 4 hours as needed for mild pain. A physician's order dated 5/13/25 directed to administer Topiramate (an anticonvulsant also used to prevent migraines) 100mg, 1 tablet by mouth, twice daily for migraines, The quarterly MDS dated [DATE] identified Resident #33 had intact cognition and reported pain that rarely interfered with therapy activities, occasionally effected sleep and day-to-day activities, and over the past 5 days his/her worst pain rating was 3 (on a scale of 0…
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 before2026-01-14 · 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 observations, clinical record review, facility documentation, facility policy, and interviews for 1 of 5 residents (Resident #37) reviewed for unnecessary medications, the facility failed to ensure that a pharmacy recommendation was reviewed and addressed by the APRN/Physician. The findings include:Resident #37 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease, hypertension, and dementia.The quarterly MDS dated [DATE] identified Resident #37 had severely impaired cognition, was frequently incontinent of bowel, occasionally incontinent of bladder, and required supervision by facility staff with toileting, bathing, and dressing.The care plan dated 3/10/25 identified Resident #37 had altered cardiovascular status due to hypertension. Interventions included administering cardiac medications as ordered.A physician's order dated 5/15/25 directed for Metoprolol Tartrate (a medication for hypertension) 37.5 mg once daily.A pharmacy recommendation form dated 5/23/25…
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 · D2026-01-14 · 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 documentation, facility policy, and interviews for 1 resident (Resident #119) reviewed for discharge, the facility failed to ensure nursing staff documented when a resident left the facility against medical advice (AMA). The findings include: Resident #119 was admitted to the facility on [DATE] with diagnoses that included low back pain, diabetes, pneumonia, and abnormalities of gait and mobility.The nurse's note dated 8/29/25 at 9:57 PM identified Resident #119 arrived at the facility and was alert and oriented. Prior to admission Resident #119 had weakness and pain to the lower back and radiating to the left leg. Resident #119 denied shortness of breath and difficulty breathing. No edema noted to bilateral lower extremities. Resident #119 was on Levofloxacin 500mg every 48 hours for 5 days.Review of the census form identified Resident #119 had left the facility against medical advice (AMA) on 8/31/25.A nurse's note by the DNS dated 8/31/25 at 4:06 PM identified…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 20 citations
- Potential for harm · Dcited before2026-01-14 · tag F0880 — failed to prevent and control infections — isolatedProvide 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 observation, clinical reviews, facility documentation, facility policy and interviews for 1of 4 residents (Resident #12) reviewed for pressure ulcers, the facility failed to ensure hand hygiene was performed in accordance with infection control practices during wound care. The findings include:Resident #12 was admitted in 4/2025 with diagnoses that included Type II diabetes and atrial fibrillation and recent multidrug resistant organism (MDRO) of the urine.The quarterly MDS dated [DATE] identified Resident #12 was severely cognitively impaired and required one person assist for bed mobility, transfers, was dependent for toileting needs, had no unhealed pressure ulcers and was at risk for developing a pressure ulcer. The care plan dated 10/22/25 identified Resident #12 had an ADL deficit, actual moisture associated skin damage (MASD) and placed on enhanced barrier precautions after just completing treatment for a multidrug resistant organism in the urine. Interventions included dependent (two person)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-14 · tag F0925 — failed to control pests — isolatedMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, facility documentation, facility policy, and interviews, the facility failed to ensure that the kitchen was free of flying insects. The findings include: Observations on 1/11/26 at 8:24 AM during an initial tour of the kitchen with the Dietary Director identified 2 live flying insects at the interior entryway of the kitchen area. The insects appeared to be fruit flies. Additional observations of the grease trap area, also located near the interior entryway of the kitchen area, identified a significant amount of food debris and multiple dead winged insects directly on top of the grease trap, the gap between the wall and the grease trap, and along the wall surface directly next to the grease trap. The winged insects also appeared to be fruit flies. Interview with the Dietary Director immediately following these observations identified he only started working at the facility 2 weeks prior and had identified issues with the kitchen, sanitization, and the debris around the grease trap but had not noticed any active pest activity during that time. The Dietary…
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 · D2025-05-15 · 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 clinical records, interviews, facility documentation and facility policy for one (1) of three (3) residents (Resident #1) reviewed for a change of condition, the facility failed to notify the resident's family of a critical lab value result. The findings included: Resident #1 was admitted to the facility in March of 2025 with diagnoses that included cervicalgia, other spondylosis, and subluxation of the T2/T3 thoracic vertebra. The comprehensive Minimum Data Set assessment (MDS) dated [DATE] identified Resident #1 was moderately cognitively impaired (Brief Interview for Mental Status (BIMS) score of 11), required set-up assistance with eating and oral hygiene, and required supervision with personal hygiene. The Resident Care Plan (RCP) dated 3/18/25 identified a risk for malnutrition related to hyponatremia, dehydration, intravenous fluids, variable oral intake, mechanically altered diet, and oral nutritional supplements. Interventions directed to monitor for signs of dehydration and monitor…
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 before2025-05-15 · 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 review of clinical records, interviews, facility documentation and facility policy for one (1) of three (3) residents (Resident #1) reviewed for a change of condition, the facility failed to ensure follow-up labs were drawn in a timely manner for a resident with critical lab values. The findings included: Resident #1 was admitted to the facility with diagnoses that included cervicalgia, other spondylosis, and subluxation of the T2/T3 thoracic vertebra. The comprehensive Minimum Data Set assessment (MDS) dated [DATE] identified Resident #1 was moderately cognitively impaired (Brief Interview for Mental Status (BIMS) score of 11), required set-up assistance with eating and oral hygiene, and required supervision with personal hygiene. The Resident Care Plan (RCP) dated 3/18/25 identified a risk for malnutrition related to hyponatremia, dehydration, intravenous fluids, variable oral intake, mechanically altered diet, and oral nutritional supplements. Interventions directed to monitor for signs of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-01-26 · 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
Based on observation, review of facility documentation, facility policy, and interviews, the facility failed to maintain nourishment refrigerators in a clean and sanitary manner including labeling, dating and discarding food items as per the policy. The findings include: A tour of the resident's nourishment refrigerators with the Director of Dietary on 1/22/24 at 7:40 AM identified the following. Nourishment refrigerator #1. Brown liquid on the bottom in the freezer and the refrigerator had dried liquid on the bottom shelf and splatter marks on the inside walls. Ice cream partially eaten not labeled or dated in the freezer. Minestrone soup dated 8/4/23, not labeled with a name. Small container with sausage cubes and toothpicks in each piece of meat dated 1/17/24 not labeled with a name. A sandwich baggy with 4 cheese cubes dated 1/17/24 not labeled with a name. A chicken sandwich on a plate with saran wrap not labeled with a name or dated. A peanut butter and jelly sandwich in saran wrap with hard bread dated 1/18/24. A sandwich baggy with 5 cubes of cheese dated 1/18/24 not labeled…
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 · D2024-01-26 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of facility documentation and policy for 1 of 5 personnel files reviewed, the facility failed to conduct a required background for an LPN, according to policy, prior to hire. The findings include: LPN #2's hire date was 1/17/22. Review of LPN #2's personnel file identified that LPN #2 consented to a background check on 1/6/22, however, the file did not contain the state required ABCMS background check, including fingerprinting. Interview with the Director of HR on 1/26/24 at 1:00 PM identified LPN #2 did not have the required background check prior to hire. The Director of HR identified that she did not know why the background check was not done as it was prior to her employment at the facility. Review of the facility policy on background checks identified all offers of employment are contingent upon clear results of a thorough background check. Background checks will include social security verification, prior employment verification, personal and professional references, criminal history and state specific background checks, i.e. facilities operating in states that…
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 · D2024-01-26 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 9 residents (Resident #40) reviewed for PASSAR, the facility failed to submit a PASSAR when a resident received a new diagnosis. The findings include: 1. Resident #40 was admitted to the facility initially on 5/12/14 with a diagnosis that included mild or situational depression, myocardial infarction, and urinary tract infection. A PASARR Level 1 dated 5/1/14 identified Resident #40 had a diagnosis of mild or situational depression with no major mental illness and no diagnosis of dementia. The outcome from the assessment indicated a 120 day short term approval. Resident #40 was readmitted to the facility on [DATE] with diagnoses that included anxiety disorder, congestive heart disease, depression, and cerebral infarction. The care plan dated 3/25/23 identified Resident #40 was at risk for distressed and fluctuating mood symptoms related to diagnosis of depression. Interventions included to monitor for signs…
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 · D2024-01-26 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility policy, and interviews for the only sampled resident (Resident #83) reviewed for psychiatric medication side effects, the facility failed to ensure a status change Level 1 PASRR screen was completed. The findings include: Resident #83 was admitted to the facility on [DATE] with diagnoses that included neoplasm of the brain, anxiety, and major depressive disorder. Review of the Notice of PASRR Level 1 Outcome report dated 5/27/21 identified Resident #83 had situational low level behavioral health symptoms, a diagnosis of major depression with no indicators identified that would signify the need for further evaluation, at that time. The report further identified that if Resident #83's symptoms/behaviors did not improve or resolve within 30 - 60 days of the screen, then the nursing facility must submit an updated status change Level 1 screen to reevaluate the need for a PASSR Level 2 behavioral health evaluation. The annual MDS dated [DATE] identified Resident #83…
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 before2024-01-26 · 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 record, facility documentation, facility policy, and interviews for 1 resident (Resident #74) reviewed for positioning, the facility failed to ensure positioning in wheelchair per policy. The findings include: Resident #74 was admitted to the facility with diagnoses that included muscle weakness, difficulty in walking and dementia. An Occupational Therapy note dated 12/7/23 identified Resident #74 was a fall risk and dependent on staff to put on and take off footwear. Resident #74 utilized a wheelchair and could sit unsupported for 30 seconds with his/her feet flat on floor but was unable to stand unsupported with an assistive device. The quarterly MDS dated [DATE] identified Resident #74 had severely impaired cognition, was always incontinent of bowel and bladder and required maximum assistance for transfers from bed to chair and toilet transfers. Resident #74 was independent with self-propelling in a standard wheelchair at least 150 feet in hallway and 50 feet when…
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 before2024-01-26 · 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 observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 4 residents (Resident #29) reviewed for pressure ulcers, the facility failed to ensure that a low air loss mattress was applied timely for a resident admitted at risk of skin breakdown, and failed to ensure that an RN assessment was completed on a newly identified skin issue. The findings include: Review of the hospital Discharge summary dated [DATE] identified Resident #29 was discharged from the hospital to the facility with a wound vac in place at the right hip due to an abscess requiring surgical intervention. Resident #29 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction, osteomyelitis of the right femur, and insulin dependent diabetes. The care plan dated 11/23/23 identified Resident #29 was at risk for skin breakdown due to decreased mobility, incontinence, and actual skin breakdown related to a right hip pressure wound with wound vac. Interventions…
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 before2024-01-26 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #102) reviewed for respiratory care, the facility failed to follow the manufacturer recommendations in the cleaning and storage of a CPAP (continuous positive airway pressure is a machine that uses mild air pressure to keep breathing airways open while you sleep.) The findings include: Resident #102 was admitted to the facility on [DATE] with diagnoses that included obstructive sleep apnea and dependance on others for enabling machines and devices. The care plan dated 8/31/23 identified Resident #102 was at risk for respiratory complications related to sleep apnea. Interventions included maintaining CPAP per order. The admission MDS dated [DATE] identified Resident #102 had intact cognition and required supervision or touching assistance for bathing, upper and lower body dressing and required non-invasive mechanical ventilators such as Bi-PAP or CPAP. 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 · D2024-01-26 · tag F0711 — isolatedEnsure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #102) reviewed for respiratory care, the facility failed to have physicians' orders signed in a timely manner. The findings include: Resident #102 was admitted to the facility on [DATE] with diagnoses that included obstructive sleep apnea, stroke, heart disease, and epilepsy. The care plan dated 8/31/23 identified Resident #102 was at risk for seizures. Interventions included medicating resident per physician order and monitor effectiveness. Review of physician's orders dated 8/31/23 - 10/31/23 failed to reflect the physician/APRN had signed and dated the orders. The admission MDS dated [DATE] identified Resident #102 had intact cognition and required supervision or touching assistance for bathing, upper and lower body dressing. Additionally, required non-invasive mechanical ventilators such as Bi-pap or CPAP. Review of physician's orders dated 12/1/23 - 12/31/23 failed to reflect 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 before2024-01-26 · 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 review of the clinical record, facility documentation, facility policy, and interviews for 1 of 5 residents (Resident #65) reviewed for unnecessary medications, the facility failed to ensure the attending physician reviewed and responded to the pharmacy consultant's recommendations. The findings include: Resident #65 was admitted to the facility on [DATE] with diagnoses that included heart failure, bradycardia, and chronic atrial fibrillation. Review of the consultant pharmacist's medication regimen review dated 7/15/23 identified the resident is currently receiving Amiodarone 200mg twice daily. After initial dosing and steady state is achieved, the most recommended dose is 100mg once daily to minimize side effects. Please evaluate the current need for a higher dose. Consider tapering to standard maintenance dose of 100mg once daily, if appropriate. The facility responded as follows; (would defer to the consultant cardiologist to evaluate). A physician's order dated 9/29/23 directed to administer…
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 · D2024-01-26 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, review of the clinical record, facility documentation, facility policy, and interviews, the facility failed to ensure that medication storage refrigerator temperatures were monitored in accordance with facility policy. The findings include: Observation of the facility medication storage areas on 1/26/24 at 9:15 AM with RN #1 identified the medication refrigerator temperature logs for the L/M unit identified multiple missing daily temperatures. The observation further identified the medication refrigerators on the L/M and the SR units contained Insulin. A further review of the medication refrigerator temperature logs for the 2 medication refrigerators for the facility was completed for 11/2023 - 1/2024 (3 months). Review of the 11/2023 medication refrigerator temperature logs identified that for M/L unit refrigerator, no temperatures were recorded on 11/5 and 11/26/23. The review also identified 21 of 30 days only one temperature was recorded. Review of the 11/2023 refrigerator logs for the S/R unit identified that for 24 of 30 days, only one temperature was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-01-26 · tag F0880 — failed to prevent and control infections — isolatedProvide 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 observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 4 residents (Resident # 29) reviewed for pressure ulcers, the facility failed to ensure that facility staff maintained proper infection control technique and hand hygiene during a dressing change. The findings include: Review of the hospital Discharge summary dated [DATE] identified Resident #29 was discharged from the hospital to the facility with a wound vac in place at the right hip due to an abscess requiring surgical intervention. Resident #29 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction, osteomyelitis of the right femur, and insulin dependent diabetes. The care plan dated 11/23/23 identified Resident #29 was at risk for skin breakdown due to decreased mobility, incontinence, and actual skin breakdown related to a right hip pressure wound with wound vac. Interventions included completing weekly wound assessments to include measurements 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 · Fcited before2021-08-31 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, review of facility documentation and interviews for kitchen and food services, the facility failed to prepare and store food under sanitary conditions. The findings included: Observation and tour of the facility's kitchen on 8/23/2021 during the period of 9:40 A.M. to 10:12 A.M. identified the following concerns: a. A ceiling mounted return air ventilation system positioned over a food preparation area utilized for preparing vegetables and other food items, was noted as having louvers which were stained with a heavy accumulation of black dirt, thick layers of dust, and debris. The ceiling tiles surrounding or adjacent to the return air ventilation system were noted to be stained with black dirt, grime, debris, dust, grease splatter and mold. On 8/25/2021 at 8:52 A.M. during an additional tour of the kitchen, it was noted that the facility had removed the outer grille or louver of the return air vent system for cleaning. Upon further evaluation of the internal areas of the vent, it was noted that layers of packed dust-like matter, gray in color had accumulated…
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 · Ecited before2021-08-31 · tag F0695 — failed to provide proper breathing / tracheostomy care — patternProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility policy, and interviews for two of three residents (Resident #32 and #54) reviewed for respiratory care, the facility failed to ensure there was an order for oxygen therapy and that oxygen tubing was changed per facility policy. The findings include: 1. Resident #32's diagnoses included chronic obstructive pulmonary disease (COPD). The quarterly MDS dated [DATE] identified Resident #32 had intact cognition, was independent with ADLs, and utilized oxygen therapy. The care plan initially dated 5/28/2021 identified Resident #32 exhibited or was at risk for respiratory complications related to COPD. Interventions directed to provide oxygen as ordered via nasal cannula. Observation of Resident #32 on 8/24/2021 at 10:05 AM identified the resident was wearing oxygen 2 liters via nasal cannula. Review of the clinical record failed to identify a current physician order for oxygen use. Review of the facility Oxygen: Nasal Cannula Policy directed in part, 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 · Ecited before2021-08-31 · tag F0880 — failed to prevent and control infections — patternProvide 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 observation, clinical record review, facility policy review, manufacturer guidelines review, and interviews for one sampled resident (Resident #28) reviewed for medication administration, the facility failed to ensure staff disinfected the multi-use glucometer in accordance with manufacturer's guidelines after resident use. The findings include: Resident #28's diagnoses included type 2 diabetes. The quarterly MDS dated [DATE] identified Resident #28 was alert and oriented, and received insulin seven out of the last seven days. The care plan dated 8/18/21 identified diagnosis of diabetes. Interventions directed to obtain and record glucose levels as ordered. Physician's order dated 4/30/2021 directed to administer Humalog Solution (Lispro insulin) per sliding scale subcutaneously before meals. Observations on 8/25/2021 at 11:45 AM identified LPN #2 removed a glucometer labeled #2 from the medication cart and used an alcohol prep 2-ply 70% pad to cleanse the glucometer before using to obtain Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2021-08-31 · tag F0908 — failed to keep essential equipment working — patternKeep all essential equipment working safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, facility documentation review and interviews for kitchen and food services, the facility failed to ensure equipment was maintained in a safe operating condition. The findings included: During a tour of the kitchen on 8/24/21 at 9:40 A.M. to 10:12 A.M. the following concerns related to the facility's walk-in freezer were identified: a. A ceiling mounted return air ventilation system positioned over a food preparation area utilized for preparing vegetables and other food items, was noted as having louvers which were stained with a heavy accumulation of black dirt, thick layers of dust, and debris. The ceiling tiles surrounding or adjacent to the return air ventilation system were noted to be stained with black dirt, grime, debris, dust, grease splatter and mold. b. The floor of the walk-in freezer was coated with a thick patch of ice in the doorway. The ice was further noted to have dirt and debris and food matter frozen within the ice observed on the doorway floor. The other areas of the floors in the freezer were identified as being stained with black 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 before2021-08-31 · 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 clinical record review, facility documentation, facility policy and interview for two of four of residents reviewed for pressure ulcers (Resident # 82 and Resident #609), facility failed to ensure treatment orders were obtained timely for residents with pressure ulcers. The findings include: 1) Resident #82's diagnoses included dehydration and osteoarthritis. The nursing admission assessment dated [DATE] identified that Resident #82 had a stage II pressure ulcer on his/her buttocks and required assistance for mobility. A physician's order dated 8/17/2021 directed to monitor the wound site daily for surrounding tissue and wound pain, and to monitor the status of the dressing. A physician's order dated 8/19/2021 directed to cleanse the buttock wound with normal saline, apply Hydrogel Ag Gel (Silver) topically and cover with dry clean dressing daily for 14 days. The Resident Care Plan (RCP) dated 8/23/2021 identified a risk for skin breakdown due to decreased mobility. Interventions directed to turn 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.
“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 COMPLETE CARE — 85 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 | 4 of 5 | 3.1 | +0.9 vs chain |
| Health inspection | 3 of 5 | 2.7 | +0.3 vs chain |
| Staffing | 2 of 5 | 2.3 | -0.3 vs chain |
| Quality measures | 5 of 5 | 4.4 | +0.6 vs chain |
The other 84 homes this chain runs (chain average 3.1★, per CMS)
Showing 40 of 84; lowest-rated first.
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 |
|---|---|---|---|---|
| PC CT OPCOS LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 09/01/2021 |
| PC WTA OPCO HOLDCO LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 09/01/2021 |
| SMS 2021 TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 09/01/2021 |
| STEIN, SHALOM | Individual | INDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER; TRUSTEE OF THE SNF | — | since 09/01/2021 |
| WELLTOWER INC | Organization | 5% OR GREATER SECURITY INTEREST; ADP OF THE SNF | — | since 09/01/2021 |
| HOCH, ROBERT | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 09/01/2021 |
| KOLIANI, LEONARD | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2021 |
| LAGANA, KRISTIN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 09/01/2021 |
| SCHMITT, MELISSA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/25/2025 |
| TETREAULT, MARNIE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 09/01/2021 |
| AURORA GUARDIAN CT CO-BORROWER LLC | Organization | ADP OF THE SNF | — | since 09/01/2021 |
| AURORA GUARDIAN CT HOLDCO, LLC | Organization | ADP OF THE SNF | — | since 09/01/2021 |
| AURORA GUARDIAN CT MEZZ BORROWER LLC | Organization | ADP OF THE SNF | — | since 09/01/2021 |
| AURORA GUARDIAN CT REALTY, LLC | Organization | ADP OF THE SNF | — | since 09/01/2021 |
| AURORA GUARDIAN PARTNERS CT LLC | Organization | ADP OF THE SNF | — | since 09/01/2021 |
| GLENDALE CENTER REALTY, LLC (COMPLETE CARE AT GLENDALE) | Organization | ADP OF THE SNF | — | since 09/01/2021 |
| J & R FAMILY INVESTMENTS, LLC | Organization | ADP OF THE SNF | — | since 09/01/2021 |
| L FRIEDMAN 2018 FAMILY TRUST | Organization | ADP OF THE SNF | — | since 09/01/2021 |
| L FRIEDMAN FAMILY HOLDINGS LLC | Organization | ADP OF THE SNF | — | since 09/01/2021 |
| LANDAU FAMILY INVESTMENT TRUST | Organization | ADP OF THE SNF | — | since 09/01/2021 |
| M FRIEDMAN 2018 FAMILY TRUST | Organization | ADP OF THE SNF | — | since 09/01/2021 |
| PC WTA ACQUISITION LLC | Organization | ADP OF THE SNF | — | since 09/01/2021 |
| PC WTA CT LLC | Organization | ADP OF THE SNF | — | since 09/01/2021 |
| PEACE CAPITAL HOLDINGS LLC | Organization | ADP OF THE SNF | — | since 09/01/2021 |
| R&J FAMILY INVESTMENTS LLC | Organization | ADP OF THE SNF | — | since 09/01/2021 |
| REARDON, MICHELLE | Individual | ADP OF THE SNF | — | since 09/01/2021 |
CMS files one row per role, so the 36 rows in the source record cover these 26 parties — each is shown once here with every role it holds. Nothing is omitted.
19 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 $1.6M paid to related parties — landlords or management companies under common ownership — equal to about 12% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
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 075240. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-14, 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.