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Autumn Lake Healthcare At New Britain

400 Brittany Farms Rd, New Britain, CT 06053 · For profit - Limited Liability company · 282 certified beds · (860) 224-3111 Medicare & Medicaid certified

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Abuse-prevention, restraint, or reporting citations — no harm found (F0609, F0610) — most recent Apr 20261 immediate-jeopardy citation
Insights

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

In its favor
  • a strong health-inspection score (5/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • 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.

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

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
38 Fenn Rd · (860) 436-4410 · Call to confirm hours
Pharmacy
475 Hartford Rd · (860) 348-9163 · Call to confirm hours
Grocery
ALDI0.2 mi
 
Park
2159 Stanley St · (860) 826-3360 · Typically dawn to dusk

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 4 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 4 stars. From monthly CMS archive snapshots.

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

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased15.3%18.0%15.4%typical
Long-stay residents who lose too much weight6.8%6.5%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%0.7%0.9%better
Long-stay residents with a urinary tract infection0.0%1.5%2.0%better
Long-stay residents with depressive symptoms45.5%22.3%6.5%worse than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury1.2%3.5%3.3%better
Long-stay residents whose ability to walk worsened11.2%16.4%16.1%better
Long-stay residents on antianxiety or hypnotic medication26.6%17.6%18.9%worse
Long-stay residents given the seasonal flu vaccine95.9%93.5%95.3%typical
Long-stay residents with pressure ulcers3.8%4.0%4.7%better
Long-stay residents with worsening bladder/bowel control23.3%24.7%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table10.2%17.8%17.1%better
Short-stay residents who newly got an antipsychotic medication1.1%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine54.9%69.7%79.4%worse
Short-stay residents rehospitalized after admission30.4%24.3%22.6%worse
Short-stay residents with an outpatient ER visit14.0%10.7%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.422.061.67worse
Long-stay outpatient ER visits per 1,000 resident days0.571.461.80better

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

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

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

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

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

63.6% 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 263 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

63.6%U.S. median 51.5%
Got home and stayed home
10.4%U.S. median 10.7%
Went back to hospital
70.5%U.S. median 56.6%
Met the expected recovery
0.29U.S. median 0.31
Therapy hours / resident / day
0.13hours / resident / day
Physical therapy
0.12hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 70.5% 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 139 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 45% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 15% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF63.6%CMS range 56.6–70.351.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.4%CMS range 8.0–12.910.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge70.5%56.6%Oct 2024–Sep 2025CMS 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 discharge48.2%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge43.2%50.0%Oct 2024–Sep 2025CMS 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 identified91.7%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS 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 discharge98.7%98.7%Oct 2024–Sep 2025CMS 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 stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened1.8%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.3%CMS range 4.9–11.47.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.181.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.32
RN hours/ resident / day
0.97
LPN hours/ resident / day
2.10
Aide hours/ resident / day
3.39
Total nurse hours/ resident / day
0.17
RN hoursweekends
48.1%
Total nursing turnover
33.3%
RN turnover

How full it usually is: this home is certified for 282 beds and averages 253.5 residents a day — about 90% occupied, or roughly 28 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 3.39 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.32 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.10 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 3.10 hrs/resident/day on weekends vs 3.50 on weekdays — 11% thinner on weekends. RN hours go from 0.38 to 0.17 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 48% is about the same as 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

4
deficiencies at the latest standard inspection (2026-04-24)
11
at the previous standard inspection (2024-05-10)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

25 citations, most serious first. The 11 most serious are shown; the remaining 14 are one tap away and print in full.

  • Immediate jeopardy · Kdisputed · IDR2026-04-24 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, observations, clinical record review, facility documentation, and facility policy, the facility failed to maintain a safe environment for residents in two distinct areas, resulting in the findings of Immediate Jeopardy. First, the facility failed to conduct adequate monitoring of hot water temperatures and to communicate and act upon documented temperatures exceeding 120 F, resulting in water temperatures ranging from 126.3 F to 145.4 F in 44 of 64 resident rooms on the second and third floors. Second, for one (1) of three (3) sampled residents (Resident #11) reviewed for respiratory care, the facility failed to maintain a safe environment for a resident receiving continuous oxygen therapy when Nurse Aide staff applied a petroleum-based ointment to Resident #11's nares and face without a physician's order, without proper assessment, and without recognition of the flammability risk; staff failed to remove the flammable material from Resident #11's room and the facility failed to educate staff…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-24 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy and interview for 1 of 8 residents (Resident #16) reviewed for accidents, the facility failed to report an injury of unknown origin (bruise above the left eyebrow) to the state agency within established timeframes. The findings include:Resident #16's diagnoses included dementia, cerebral infraction, and anxiety.The quarterly Minimum Data Set assessment dated [DATE] identified Resident #16 had severely impaired cognition, and was totally dependent on staff for transfers, changing positions in bed (rolling left to right and sitting to lying), and personal hygiene.The Resident Care Plan dated 12/4/25 identified Resident #16 had potential impairment to skin integrity related to inactivity. Interventions included using caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surfaces and to follow facility protocols for treatment of injury.Review of the January 2026 physician's orders…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-24 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy and interview for 1 of 8 residents (Resident #16) reviewed for accidents, the facility failed to thoroughly investigate an injury of unknown origin. The findings include:Resident #16's diagnoses included dementia, cerebral infraction, and anxiety.The quarterly Minimum Data Set assessment dated [DATE] identified Resident #16 had severely impaired cognition, and was totally dependent on staff for transfers, changing positions in bed (rolling left to right and sitting to lying), and personal hygiene.The Resident Care Plan dated 12/4/25 identified Resident #16 had potential impairment to skin integrity related to inactivity. Interventions included using caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surfaces and to follow facility protocols for treatment of injury.Review of the January 2026 physician's orders directed to transfer the resident via a hoyer lift (mechanical…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ddisputed · IDR2026-04-24 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility policy review and interview for 1 of 8 sampled residents (Resident #16) reviewed for accidents, the facility failed to update/ revise the resident's care plan for behaviors. The findings include: Resident #16's diagnoses included dementia, cerebral infraction, and anxiety.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #16 had a Brief Interview of Mental Status of 3 indicating severe cognitive impairment. The assessment also noted totally dependent on staff for transfers, changing positions in bed (rolling left to right and sitting to lying), and personal hygiene.The Resident Care Plan (RCP) dated 12/4/25 identified Resident #16 had potential impairment to skin integrity related to inactivity. Interventions included: using caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surfaces and to follow facility protocols for treatment of injury.A nurse progress note dated 1/22/26 at 7:30…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-24 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation, facility policy and interviews for 1 of 2 sampled residents (Resident #117) reviewed for Activities of Daily Living (ADL), the facility failed to ensure Resident #117 was ambulated per physician's orders. The findings include: Resident #117 was admitted in March 2026 with diagnoses that included congestive heart failure, respiratory failure and spinal stenosis. Physician's orders dated 3/23/26 directed, in part, physical and occupational therapy as indicated. Physician's orders did not address Resident #117's ambulation or transfer status.The Resident Care Plan (RCP) dated 3/24/26 identified activities of daily living (ADL) deficit and self-care performance related to decreased strength and endurance. Interventions included: assist of 1 ADL seated, assist of 1 ambulation to/from bathroom with rolling walker (RW), assist of 1 for transfers with RW, assist of 1 for bed mobility, assist of 1 with toileting and therapy as indicated.The admission Minimum Data…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-24 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, review of the clinical record, and review of facility policy for 1 of 1 resident (Resident #85) reviewed for blood glucose monitoring, the facility failed to maintain appropriate infection control practices during blood glucose monitoring. The findings include: Resident #85 was admitted to the facility in February 2014 with diagnoses that included type 2 diabetes, dementia, and depressive disorder. The annual Minimum Data Set (MDS) dated [DATE] identified Resident #85 had a Brief Interview for Mental Status (BIMS) score of three (3) indicative of severely impaired cognition and dependent with personal hygiene, dressing, and toileting. Additionally, the MDS identified Resident #85 received insulin 7 days a week.Physician's orders dated 3/12/26, directed to perform blood glucose monitoring twice a day, administer Toujeo Solostar (long-acting insulin used to lower blood sugar) 60 units subcutaneously (under the skin) once a day, and Tradjenta (medication used to control blood…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-18 · tag F0622 — isolated
    Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
    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 the one (1) of (3) three residents (Resident #1), reviewed for the discharge process, the facility failed to notify the homecare agency timely of a discharge delaying start of care. The findings include: Resident #1's diagnoses included sepsis (complications of an infection), low back pain, dyspnea (difficulty breathing), and orthostatic hypotension (low blood pressure that occurs when standing up from a sitting a lying position). The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1was moderately cognitively impaired and required supervision assistance with bed mobility, and moderate assistance with transfers and personal hygiene. The Resident Care Plan dated 2/16/23 identified that Resident #1had a self-care performance deficit related to decreased strength and endurance with interventions that included utilizing the assistance of 1 staff for dressing, bathing, bed mobility, 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-07-18 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy and interviews for the one (1) of three (3) residents reviewed for admission plan of care, (Resident #1), the facility failed to follow physician's orders regarding a medication. The findings include: Resident #1's diagnoses included glaucoma (an eye condition that damages the optic nerve) and type 2 diabetes mellitus. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was moderately cognitively impaired and required supervision assistance with bed mobility, and moderate assistance with transfers and personal hygiene. Review of the hospital Discharge summary dated [DATE] directed to continue taking Latanoprost (treats glaucoma) ophthalmic solution 1 drop to each eye daily at bedtime. A physician's order dated 2/8/23 directed to administer Latanoprost Ophthalmic Solution 0.005% one drop in both eyes at bedtime for glaucoma. A medication administration note dated 2/8/23 at 8:51 PM identified 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-06-11 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #2) reviewed for care planning, the facility failed to ensure care plan was comprehensive. The findings include: Resident #2 was admitted on [DATE] with diagnoses included laryngectomy (surgical removal of larynx (voice box), and had an intact laryngeal tube intact with oxygen via humidifier. A physician's order dated 1/11/2023 directed bedside tracheal humidification to be placed over laryngeal stoma every bedtime. The Resident Care Plan (RCP) dated 1/11/2023 identified Resident #2 had a laryngectomy tube. Interventions directed humidified oxygen as prescribed. The nurse's note dated 1/11/2023 at 7:51 AM laryngeal tube intact, oxygen via humidifier but resident consistently removes humidifier mask. The RPT (Respiratory Physical Therapist) note dated 1/12/2023 at 7:00 AM identified Resident #2 was educated on the importance of keeping humidification over his/her stoma a…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-05-10 · tag F0580 — failed to tell family and doctor about changes — pattern
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility policy review, and interviews for one of four sampled residents (Resident #87) reviewed for nutrition, the facility failed to notify the physician and resident representative regarding a significant weight loss. The findings include: Resident #87's diagnoses included type 2 diabetes mellitus, hypertension, anxiety, vascular dementia, and paranoid schizophrenia. The quarterly MDS assessment dated [DATE] identified Resident #87 had severe cognitive impairment, required set up assistance for eating, was non-ambulatory, had a height of 67 inches, a weight of 174 pounds, and did not have weight loss in the past six months. The annual MDS assessment dated [DATE] identified Resident #87 had severe cognitive impairment, required supervision for eating inclusive of verbal cues and touching assistance, was non-ambulatory, had a height of 67 inches, a weight of 174 pounds, did not have weight loss in the past six months, and had a mechanically altered therapeutic diet. 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-05-10 · tag F0656 — failed to write and follow a full care plan — pattern
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, review of facility documentation, review of facility policy and interviews for two sampled residents (Resident #81 and #160) receiving anticoagulant medication, the facility failed to ensure the care plan included interventions to address the possible side effects and the monitoring that should accompany the use of an anticoagulant. The findings include: 1. Resident #81's diagnoses included acute embolism and thrombosis (disruption of the blood flow in veins and arteries), fractured left femur, and chronic diastolic congestive heart failure. The quarterly MDS assessment dated [DATE] identified Resident #81 had severe cognitive impairment, required maximal assistance with personal hygiene, toileting, was non-ambulatory, and utilized anticoagulant medication (blood thinner) that the assessment noted to be a high-risk medication. The physician's orders for May/2024 directed to administer Apixaban/Eliquis (a blood thinner used to prevent blood clots) 5 milligram (mg) one…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
Show the remaining 14 citations
  • Potential for harm · E2024-05-10 · tag F0692 — failed to prevent malnutrition and dehydration — pattern
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility policy review, and interviews for one of four sampled residents (Resident #87) reviewed for nutrition, the facility failed to ensure the dietician assessed the resident for weight loss timely and failed to obtain the resident's monthly weight in accordance to facility policy. The findings include: Resident #87 's diagnoses included type 2 diabetes mellitus, hypertension, anxiety, vascular dementia, and paranoid schizophrenia. Review of Resident #87's weight records identified a weight of 174.2 pounds on 7/9/23, further review identified no documented weights from August 2023 through December 2023. The Resident Care Plan (RCP) dated 11/15/23 identified Resident #87 had a potential nutritional risk related to dysphagia, type 2 diabetes, dementia, and schizophrenia. Care plan interventions directed to monitor resident weight as ordered, provide, and serve diet as ordered, monitor/document signs and symptoms of dysphagia, and monitor for significant weight loss: 3 pounds…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-10 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of facility policy and interviews for one sampled resident (Resident #166) observed self-administering medications, the facility failed to ensure the resident was assessed for self-administration of medications. The findings include: Resident #166's diagnoses included chronic obstructive pulmonary disease, heart failure and chronic pain. The resident medication self-assessment forms dated 10/27/23 & 1/4/24 indicated Resident #166 expressed no desire to self-administer medications. The quarterly MDS assessment dated [DATE] identified Resident #166 was cognitively intact and was dependent for transfers, showering, toileting and required set up for meals. The care plan dated 2/29/24 identified a self-care deficit related to decreased strength and endurance, with interventions that included nursing assistants (NA's) to ensure foods are cut into bit sized pieces during each meal tray set up. Observation on 5/7/24 at 10:04 AM identified Resident #166 in bed by the window, with the privacy…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-10 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, review of facility documentation, review of facility policy and interviews for one sampled resident (Resident #126), the facility failed to ensure the physician's order and the resident's signed Advance Directives were congruent. The finding includes: Resident #126 's diagnoses included pulmonary fibrosis, asthma, and chronic cough. The physician's order dated [DATE] directed Resident #126's code status was Full Code (a full code means that if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive. This process can include chest compressions, intubation, and defibrillation and is referred to as CPR (cardiopulmonary resuscitation). Review of the clinical record identified an Advanced Directive form dated [DATE] that noted Resident #126 had elected a code status of Do No Resuscitate (DNR), which means that a person has decided not to have CPR attempted on them if their heart or breathing stops. 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-10 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of clinical records, review of facility documentation, review of facility policy and interviews for one sampled resident (Resident #42) reviewed for positioning and range of motion, the facility failed to ensure a physician's order was in place for the use of splints and for one sampled resident (Resident #213) who had orders for a compounded medication, the facility failed to ensure expired medication was not administered to the resident. The finding include: 1. Resident #42 was readmitted to the facility in January of 2024 with diagnoses that included quadriplegia, stiffness of unspecified joint, aphasia, and gastrostomy. The quarterly MDS assessment dated [DATE] identified Resident #42 had severe cognitive impairment, required maximal assistance with toileting, was dependent on staff for personal hygiene, transfers, was non-ambulatory, and had range of motion limitations of bilateral upper and lower extremities. The care plan dated 4/15/24 identified Resident #42 had 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-10 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical record, review of facility documentation, review of facility policy and interviews for one sampled resident (Resident #213) who had physician orders for a compounded medication, the facility failed to ensure the medicaion was administered as ordered. Resident #213's diagnoses included protein calorie malnutrition, gastro-esophageal reflux disease (GERD) without esophagitis, and end stage renal disease. The admission MDS assessment dated [DATE] identified Resident #213 had intact cognition and was dependent for eating, oral hygiene, toileting, showering/bathing, and dressing. The Resident Care Plan dated 3/20/24 identified the resident has a nutritional problem or related to advanced age, therapeutic diet, mechanically altered diet, fluid restriction, food allergy, tube feeding supplementation diet, poor by mouth intake, increased nutritional needs. Interventions directed to monitor weight, skin, labs, and oral intake per protocol or as needed. The physician's orders for May/2024 (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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-10 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, facility policy and interviews for one of three sampled medication rooms the facility failed to store medications appropriately. The findings include: Observation on [DATE] at 6:44am of Station 4 medication room with LPN #4 identified Ipatropium Bromide/Albuterol Sulfate 0.5mg & 3mg/3ml Rx#10754244 for Resident #16 was stored that expired 1/2024. Observation on [DATE] at 6:50am of Station 4 medication room with LPN#4 identified Ipatropium Bromide/Albuterol Sulfate 0.5mg & 3mg/3ml Rx#10903962 for Resident #394 stored that expired 2/2024. Observation on [DATE] at 6:53 am of Station 4 medication room with LPN#4 identified Ipatropium Bromide/Albuterol Sulfate 0.5mg & 3mg/3ml Rx# 10754244 for Resident #16 was stored that expired 1/2024. Observation on [DATE] at 6:55am of Station 4 medication room with LPN#4 identified Ipatropium Bromide/Albuterol Sulfate 0.5mg & 3mg/3ml Rx# 10728345 stored that expired 1/2024. Observation on [DATE] at 6:57am of Station 4 medication room with LPN#4 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-10 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of facility documentation, review of facility policy, and interviews, for 2 of 3 residents (Resident #42 and Resident #230) reviewed for infection surveillance, the facility failed to identify and maintain records of residents with known MDRO colonization and failed to appropriately cohort residents with a known MDRO colonization. The findings include: Resident #42's was admitted to the facility with diagnoses that included hemiplegia, MRSA, C-diff, aphasia, and gastrostomy. The quarterly MDS assessment dated [DATE] identified Resident #42 cognitive skills for daily decision making was severely impaired, required maximal assistance with toileting hygiene, bathing and dependent on care personal hygiene, transfers, and non-ambulatory. The care plan dated 4/15/24 identified Resident #42 had a history of MRSA and C-diff colonization with interventions that included: monitor for sign and symptom of C-diff and monitor or report to MD as needed for sign or symptom of MRSA infection every…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-27 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, policy, and interviews for one of three sampled residents (Resident #1) who were a new admission and received a medication to treat a low thyroid level, Levothyroxine, the facility failed to transcribe the medication on admission to ensure the resident was free of a significant medication error. The findings include: Resident #1's diagnoses included hypothyroidism. The Inter-Agency Referral Report dated 7/25/23 directed Levothyroxine (Synthroid) 100 micrograms (mcg) take one tablet by mouth daily. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 made consistent and reasonable decisions regarding tasks of daily life, required set up help only with eating, and had a thyroid disorder. The Resident Care Plan dated 8/10/23 identified Resident #1 had hypothyroidism. Interventions directed to give thyroid replacement therapy as ordered, to monitor and document for side effects and effectiveness. The Facility Reported Incident…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-27 · tag F0773 — isolated
    Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical record reviews, facility documentation, and interviews for one of three sampled residents (Resident #1) who were a new admission, the facility failed to implement the physician's order and obtain laboratory blood work. The findings include: Resident #1's diagnoses included malignant neoplasm of bladder, pancreatic adenocarcinoma, chronic anemia, hypomagnesemia, and hypokalemia. A physician's progress note dated 7/25/23 identified Resident #1 was evaluated today and the plan was to draw admission blood work. A physician's order dated 7/25/23 at 2:37 PM directed to obtain a Complete Blood Count (CBC) and Comprehensive Metabolic Panel (CMP) on 7/27/23. Review of the clinical record and facility documentation failed to identify the CBS and CMP had been obtained on 7/27/23. Interview with Advanced Practice Registered Nurse (APRN) #1 on 9/27/23 at 9:50 AM identified he would expect the CBC and CMP to be drawn per the physician's order. Interview with the Director of Nurses (DON) on 9/28/23 at 1:30 PM identified she could not locate the CBC and CMP results report 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-11-24 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, review of facility documentation, review of facility policy, and interviews for one of three sampled residents (Resident #538) reviewed for Advance Directives, the facility failed to ensure the physician's order reflected the resident written choice. The findings include: Resident #538's diagnoses included coronary artery disease, diabetes mellitus and stroke. The admission Advance Directive form dated [DATE] directed a Full Code. The admission History and Physical dated [DATE] identified Resident #538's cognitive status appeared intact, but evaluation was limited by slurred speech. The admission physician's order dated [DATE] directed an Advance Directive for a Full Code. The Advanced Practice Registered Nurse (APRN) progress note dated [DATE] identified the Advance Directive for a Full Code. The Advance Directive, Level of Treatment Option form dated [DATE] identified a change of Resident #538's Advance Directive to No Cardiopulmonary Resuscitation (CPR) and No Intubation.…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-11-24 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, and interviews for one sampled resident (Resident #539) who was a recent admission and exhibited behavioral symptoms, the facility failed to transcribe a physician's order from the discharging facility to include the indication of use directive for an as needed medication. The findings include: Resident #539's diagnoses included acute alcohol dependence and withdrawal, anxiety disorder, cerebrovascular attack, and hepatitis. The Nursing admission assessment dated [DATE] identified Resident #539 was had some difficulty making decisions regarding tasks of daily life. The Hospital Discharge summary dated [DATE] directed to administer Seroquel 25 milligrams (mg) as needed for breakthrough agitation. The admission physician's order dated 5/7/21 directed to administer Seroquel 25 milligrams (mg) as needed for tremors related to alcohol dependence with withdrawal delirium for fourteen (14) days. The physician's order failed to reflect documentation of the hospital's direction to…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-11-24 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #77) reviewed for respiratory care, the facility failed to provide necessary respiratory care consistent with professional practice. The findings include: Resident #77 was admitted to facility with the diagnosis of acute respiratory failure, pneumothorax, malignant neoplasm of lung, malignant neoplasm of main bronchus and centrilobular emphysema. The quarterly MDS dated [DATE] indicated Resident #77 was cognitively intact, was occasionally incontinent of bladder, always continent of bowel and required limited assistance of one staff member for bed mobility, transfers, toileting and required extensive assistance of one staff member with dressing and personal hygiene. A physician's order dated 9/24/21 directed for Budesonide Suspension 0.5 mg/2 ml 1 vial inhalation (nebulizer) twice a day with a discontinue date of 11/23/21. A physician's order dated 9/24/21 directed 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2024-05-10 · tag F0638 — pattern
    Assure that each resident’s assessment is updated at least once every 3 months.
    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, and interviews for three sampled residents (Residents #25, #104, and #170) reviewed for resident assessments, the facility failed to ensure quarterly MDS assessments were completed and submitted within prescribed timing parameters. The finding includes: Resident #25 had an admission MDS assessment dated [DATE](this date references the assessment reference date) with a completion date of 12/13/23 (the completion date indicates the completion of the MDS). Resident #25 had a quarterly assessment dated [DATE] (the quarterly should be no later than 92 days following the previous comprehensive MDS assessment), the deadline for the completion date of the MDS was 3/23/24. The actual completion date of the MDS was 5/2/24 making the completion of the MDS 40 days late. Resident #104 had an annual MDS assessment dated [DATE] with a completion date of 12/20/23 (eleven days late). Resident #104 had a quarterly assessment dated [DATE], the deadline for the completion date of the MDS 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2024-05-10 · tag F0730 — pattern
    Observe each nurse aide's job performance and give regular training.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on review of personnel files, review of facility policy, and interviews for two of three sampled nurse aides (NA #1 and #3) the facility failed to complete annual performance evaluations. The findings include: Interview with HR #1 on 5/10/24 at 8:50 AM identified that performance evaluations could be located for 2022 and 2023 for NA#1 (hired on 8/10/12) and NA#3 (hired on 7/7/99), and that typically they would be completed by the unit manager, however, there has been some turnover recently so annual reviews of the NA's have not been completed. Interview with the DNS on 5/10/24 at 10:00am identified there were no annual evaluations only annual competencies that were being completed and that in the policy entitled Competency of Nursing Personnel it directed evaluations to be done at any time interval determined by the Nursing Administration for reasons of performance issues and/or attendance. No policy speaking to the requirement of annual performance review of NA's could be provided when requested.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction

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

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to AUTUMN LAKE HEALTHCARE — 59 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 5 of 52.8+2.2 vs chain
Health inspection 5 of 52.5+2.5 vs chain
Staffing 2 of 52.4-0.4 vs chain
Quality measures 5 of 54.3+0.7 vs chain
The other 58 homes this chain runs (chain average 2.8★, per CMS)
1 of 5Autumn Lake Healthcare At Crystal SpringsElkins, WV 1 of 5Autumn Lake Healthcare At Glen BurnieGlen Burnie, MD 1 of 5Autumn Lake Healthcare At HomewoodBaltimore, MD 1 of 5Autumn Lake Healthcare At Long GreenBaltimore, MD 1 of 5Autumn Lake Healthcare at GreenfieldMilwaukee, WI 1 of 5Nella's At Autumn Lake HealthcareElkins, WV 2 of 5Ashbrook Care & Rehabilitation CenterScotch Plains, NJ 2 of 5Autumn Lake Healthcare At Arlington WestBaltimore, MD 2 of 5Autumn Lake Healthcare At Ballenger CreekFrederick, MD 2 of 5Autumn Lake Healthcare At Baltimore WashingtonGlen Burnie, MD 2 of 5Autumn Lake Healthcare At BridgeparkBaltimore, MD 2 of 5Autumn Lake Healthcare At CatonsvilleCatonsville, MD 2 of 5Autumn Lake Healthcare At Glade ValleyWalkersville, MD 2 of 5Autumn Lake Healthcare At Loch RavenBaltimore, MD 2 of 5Autumn Lake Healthcare At MadisonMadison, CT 2 of 5Autumn Lake Healthcare At Memorial BridgePenns Grove, NJ 2 of 5Autumn Lake Healthcare At NorwalkNorwalk, CT 2 of 5Autumn Lake Healthcare At OverleaBaltimore, MD 2 of 5Autumn Lake Healthcare At PikesvillePikesville, MD 2 of 5Autumn Lake Healthcare At RuxtonTowson, MD 2 of 5Autumn Lake Healthcare At Salem CountySalem, NJ 2 of 5Autumn Lake Healthcare At SouthgateCarneys Point, NJ 2 of 5King David Nursing And Rehabilitation CenterBaltimore, MD 2 of 5The Subacute At Autumn Lake HealthcareVoorhees, NJ 3 of 5Autumn Lake Healthcare At Alice ManorBaltimore, MD 3 of 5Autumn Lake Healthcare At Calvert ManorRising Sun, MD 3 of 5Autumn Lake Healthcare At Chesapeake WoodsCambridge, MD 3 of 5Autumn Lake Healthcare At Chevy ChaseChevy Chase, MD 3 of 5Autumn Lake Healthcare At Patuxent RiverLaurel, MD 3 of 5Autumn Lake Healthcare At Perring ParkwayBaltimore, MD 3 of 5Autumn Lake Healthcare At RiverviewEssex, MD 3 of 5Autumn Lake Healthcare At Silver SpringSilver Spring, MD 3 of 5Autumn Lake Healthcare At Spa CreekAnnapolis, MD 3 of 5Autumn Lake Healthcare At Summit ParkCatonsville, MD 3 of 5Autumn Lake Healthcare At VinelandVineland, NJ 3 of 5Autumn Lake Healthcare At VoorheesVoorhees, NJ 3 of 5Autumn Lake Healthcare At West HartfordWest Hartford, CT 3 of 5Autumn Lake Healthcare Post-Acute Care CenterBaltimore, MD 3 of 5Autumn Lake Healthcare at BeloitBeloit, WI 3 of 5Autumn Lake Healthcare at OceanviewOcean View, NJ

Showing 40 of 58; 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 / managerTypeRoleShareSince
NEW BRITAIN PARENT LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF100%since 01/01/2015
NEW BRITAIN ASSOCIATES INCOrganizationINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 01/01/2015
NEW BRITAIN REALTY LLCOrganization5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNFsince 01/01/2015
SCHWARTZ, MARKIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 01/01/2015
DAUPHINAIS, KARLIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2015
SCHECHTER, JOSHUAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2018
STERN, ARYEHIndividualADP OF THE SNFsince 01/01/2015

CMS files one row per role, so the 13 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

$33.2M
Net patient revenuemost recent cost report
+2.7%
Operating marginrevenue minus expenses
$3.6M
Related-party expense11% of expenses
Who pays — share of resident-days
Medicaid 65%Medicare 8%Other / private 27%

This home reported $3.6M paid to related parties — landlords or management companies under common ownership — equal to about 11% 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

$352per resident / day
operating cost
$10,708per month
≈ monthly operating cost
$362per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in CT

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Connecticut Medicaid page.

Typical monthly cost in Connecticut
$15,208/mo
Nursing home (semi-private)
$16,729/mo
Nursing home (private)
$9,118/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 075292. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-24, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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