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Grimes Center

1354 Chapel St, New Haven, CT 06511 · Non profit - Corporation · 114 certified beds · (203) 867-8300 Medicare & Medicaid certified

Call the home — (203) 867-8300 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Jan 2026Behavioral-health or dementia-care citation — no harm found (F0758)
Insights

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

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (5/5)
  • lower-than-typical staff turnover (23% vs 45% nationally) — better care continuity
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Jan 2026
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags

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

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

5/5
CMS overall
5 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 5 of 5
Quality measuresSelf-reported by the facility 4 of 5

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1308 Chapel St · (203) 865-5111 · Call to confirm hours
Pharmacy
1291 Chapel St · (475) 238-6473 · Call to confirm hours
Grocery
539 George St · (203) 789-0160 · Call to confirm hours
Park
Edgewood Ave · (203) 946-8028 · Typically dawn to dusk
Place of worship

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 4 of 5
Long-stay residentspeople who live here 4 of 5
Short-stay residentsrehab / post-hospital 5 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 4 to 5 stars. From monthly CMS archive snapshots.

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

Overall rating5★
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 increased21.0%18.0%15.4%worse
Long-stay residents who lose too much weight7.9%6.5%5.4%worse
Long-stay residents with a catheter left in their bladder0.4%0.7%0.9%better
Long-stay residents with a urinary tract infection1.9%1.5%2.0%typical
Long-stay residents with depressive symptoms3.7%22.3%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury1.9%3.5%3.3%better
Long-stay residents whose ability to walk worsened13.8%16.4%16.1%better
Long-stay residents on antianxiety or hypnotic medication11.7%17.6%18.9%better
Long-stay residents given the seasonal flu vaccine80.3%93.5%95.3%worse
Long-stay residents with pressure ulcers2.4%4.0%4.7%better
Long-stay residents with worsening bladder/bowel control13.1%24.7%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table13.2%17.8%17.1%better
Short-stay residents who newly got an antipsychotic medication2.0%1.5%1.4%worse
Short-stay residents given the seasonal flu vaccine90.3%69.7%79.4%better
Short-stay residents rehospitalized after admission28.6%24.3%22.6%worse
Short-stay residents with an outpatient ER visit8.4%10.7%12.0%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.

68.5% 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 213 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

68.5%U.S. median 51.5%
Got home and stayed home
10.1%U.S. median 10.7%
Went back to hospital
76.9%U.S. median 56.6%
Met the expected recovery
0.86U.S. median 0.31
Therapy hours / resident / day
0.43hours / resident / day
Physical therapy
0.35hours / resident / day
Occupational therapy
0.08hours / resident / day
Speech therapy

Met the expected recovery: 76.9% 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 78 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 0.86 therapist hours per resident per day in 2026Q1 — more than 95% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 25% 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 SNF68.5%CMS range 62.0–74.151.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.1%CMS range 7.5–13.010.7%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 discharge76.9%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 discharge73.1%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 discharge73.1%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 identified100.0%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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.6%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 worsened1.9%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 hospitalization7.1%CMS range 4.8–9.97.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.051.02Oct 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

1.11
RN hours/ resident / day
0.87
LPN hours/ resident / day
1.74
Aide hours/ resident / day
3.72
Total nurse hours/ resident / day
0.51
RN hoursweekends
23.2%
Total nursing turnover
15.0%
RN turnover

How full it usually is: this home is certified for 114 beds and averages 92.6 residents a day — about 81% occupied, or roughly 21 beds typically open. It usually has some room. 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 3.72 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.11 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.74 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.92 hrs/resident/day on weekends vs 4.04 on weekdays — 28% thinner on weekends — a notable drop. RN hours go from 1.34 to 0.51 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 23% is below the national median of 45%.

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

Inspection trend

9
deficiencies at the latest standard inspection (2026-01-30)
8
at the previous standard inspection (2024-04-09)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

22 citations, most serious first. The 10 most serious are shown; the remaining 12 are one tap away and print in full.

  • Potential for harm · D2026-01-30 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #7) reviewed for abuse, the facility failed to protect Resident #7 from verbal abuse and intimidation by Resident #6 after Resident #6 (who resides on a different unit), sat outside Resident #7's room and was verbally aggressive, intimidating and used sexually explicit profanity towards Resident #7. The findings include: a. Resident #6 was admitted to the facility on [DATE] with diagnoses that included dementia with agitation, adjustment disorder, and anxiety disorder.The annual MDS dated [DATE] identified Resident #6 had intact cognition, was independent with transfers and used a walker and a wheelchair for mobility. The care plan dated 8/14/25 identified Resident #6 was at risk for behavior issues related to history of mental illness and cognitive deficits. Interventions included to monitor behavior episodes, attempt to determine the underlying cause, and document the behavior 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-30 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #7) reviewed for abuse, the facility failed to immediately report when Resident #6 (who resides on a different unit), sat outside Resident #7's room and was verbally aggressive, intimidating and used sexually explicit profanity towards Resident #7. The findings include:a. Resident #6 was admitted to the facility on [DATE] with diagnoses that included dementia with agitation, adjustment disorder, and anxiety disorder.The annual MDS dated [DATE] identified Resident #6 had intact cognition. The care plan dated 8/14/25 identified Resident #6 was at risk for behavior issues related to history of mental illness and cognitive deficits. Interventions included to monitor behavior episodes, attempt to determine the underlying cause, and document the behavior and potential causes. Review of the census list identified Resident #6 resided on the 3rd floor unit on 9/7/25.A nurse's note dated 9/7/25 at…

    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 · D2026-01-30 · 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 interviews for 1 of 3 residents (Resident #7) reviewed for abuse, the facility failed to complete a thorough investigation and protect Resident #7 from further potential abuse by Resident #6 after Resident #6 (who resides on a different unit), sat outside Resident #7's room and was verbally aggressive, intimidating and used sexually explicit profanity towards Resident #7. The findings include:a. Resident #6 was admitted to the facility on [DATE] with diagnoses that included dementia with agitation, adjustment disorder, and anxiety disorder.The annual MDS dated [DATE] identified Resident #6 had intact cognition, was independent with transfers and used a walker and a wheelchair for mobility. The care plan dated 8/14/25 identified Resident #6 was at risk for behavior issues related to history of mental illness and cognitive deficits. Interventions included to monitor behavior episodes, attempt to determine the underlying cause, 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-30 · tag F0644 — isolated
    Coordinate 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 5 residents (Resident #7) reviewed for Pre-admission Screening and Resident Review (PASARR), the facility failed to incorporate the recommendations from the PASARR level II determination into the resident assessment and care plan for a resident with a history of harm directed behaviors and substance abuse. The findings include:Resident #7 was admitted to the facility in November 2024 with diagnoses that included borderline personality disorder, anxiety disorder, and bipolar disorder. The annual MDS dated [DATE] identified Resident #7 had intact cognition, was always continent of bowel and bladder, required set up with bathing, and was independent with toileting and transfers. The MDS further identified Resident #7 had active diagnosis that included bipolar disorder and psychotic disorder and required anti-psychotic medication daily. The MDS failed to identify the resident had a serious mental illness…

    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 before2026-01-30 · 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 review of the clinical record, facility policies, and interviews for 1 of 3 residents (Resident #63) reviewed for pressure ulcers, the facility failed to ensure the care plan was reflective of interventions to address pressure ulcers including a Deep Tissue Injury (DTI) and for 1 of 3 resident (Resident #38) reviewed for nutrition, the facility failed to ensure the care plan was reflective of interventions related to congestive heart failure (CHF). The findings include: Resident #38 was admitted to the facility in January 2026 with diagnoses that included bilateral humerus fractures, atrial fibrillation, and chronic diastolic congestive heart failure. The physician's orders dated 1/15/26 directed Congestive Heart Failure protocol as follows. Check oxygen saturation every shift. Obtain daily weights at 6:30 AM and notify the MD/APRN of weight gain of 3 lbs. or more in one day or 5 lbs. in a week. Monitor edema to the abdomen, legs, ankles, and feet every shift. Monitor fatigue every shift. Monitor 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-30 · tag F0678 — failed to provide CPR when needed — isolated
    Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
    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 interview for 1 resident (Resident #2) reviewed for death, the facility failed to utilize a hard surface (backboard) beneath the resident while performing cardiopulmonary resuscitation (CPR) according to the American Heart Association current guidelines. The findings include:Resident #2 was admitted to the facility in 6/2025 with diagnoses that included malignant neoplasm of glottis (region of the larynx or voice box containing vocal cords) and history of acute and chronic respiratory failure with a tracheostomy placement.The quarterly MDS dated [DATE] identified Resident #2 was cognitively intact, independent with bed mobility, transfers and ambulation without assistance and received tracheostomy care.The care plan dated [DATE] identified Resident #2 had a potential for altered respiratory status secondary to having a tracheostomy (trach) and history of respiratory failure. Interventions included monitoring…

    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 · D2026-01-30 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interview for 1 of 3 residents (Resident #38) reviewed for nutrition, the facility failed to ensure that daily weights were obtained and documented per the physician's order. The findings include:Resident #38 was admitted to the facility in January 2026 with diagnoses that included bilateral humerus fractures, atrial fibrillation, and chronic diastolic congestive heart failure. The physician's order dated 1/15/26 directed to obtain daily weights at 6:30 AM and notify the MD/APRN of weight gain of 3 lbs. or more in one day or 5 lbs. in a week.The admission MDS dated [DATE] identified Resident #38 had severely impaired cognition, was frequently incontinent of bowel, occasionally incontinent of bladder and was dependent on facility staff to assist with eating, bathing, and toileting.Review of the care plan failed to identify interventions related to congestive heart failure or the need for daily weights. Review of the clinical…

    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 · D2026-01-30 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    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 #11) reviewed for range of motion, the facility failed to ensure an adaptive device for limited mobility of the right hand was applied according to physician's orders. The findings include.Resident #11 was admitted to the facility in 10/2024 with diagnoses that included cerebral infarction and disorders of the automatic nervous system.The quarterly MDS dated [DATE] identified Resident #11 was severely cognitively impaired, had limited range of motion in the upper and lower extremities and required two person assist for bed mobility, transfers, and dressing.The care plan dated 1/3/26 identified Resident #11 required ADL assistance related to decreased mobility with cognitive deficits. Interventions included providing supportive care, assistance with mobility as needed and PT/OT referral, evaluation and treatment as ordered.A physician's order dated 1/4/26 (original date 4/11/25)…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-01-30 · 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 review of the clinical record, facility documentation, facility policy, and interviews for the only sampled resident (Resident #8) reviewed for antibiotic use, the facility failed to ensure the resident with an indwelling medical device and chronic wound was placed on Enhanced Barrier Precautions (EBP), and for the only sampled resident (Resident #16) reviewed for dialysis, the facility failed to ensure a resident with an indwelling medical device was placed on EBP.1. Resident #8 was admitted to the facility on 12/2025 with diagnoses that included a non-pressure chronic ulcer of the left and right heel and left and right midfoot with bone involvement.A physician's order dated 12/26/25 directed to change the dressing to the right foot wound daily, every shift, and to change the wound vac (125 mmHg) dressing to the left foot every Monday, Wednesday, and Friday. The physician's orders identified that Resident #8 had a single lumen Peripherally Inserted Central Catheter (PICC) to the right upper chest with…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-12-05 · 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 review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for the plan of care , the facility failed to ensure a comprehensive care plan with appropriate interventions was implemented for a resident at risk for bruising. The findings include: Resident #1 had diagnoses that included Waldenstrom macroglobulinemia, myeloproliferative disease ( blood disorders) , lymphoplasmacytic lymphoma (a type of cancer), anemia, amyloidosis, post-traumatic stress disorder, delirium, and depressive disorder. Review of the nursing admission assessment dated [DATE] completed by RN #6 identified Resident #1 had a fading bruise to the left side of forehead, bruising to both arms, and dark purple discoloration to the peri area extending to the inner buttocks. The care plan dated 10/19/24 identified Resident #1 at risk for impaired skin integrity related to decreased mobility and incontinence. Interventions directed preventative treatments…

    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 12 citations
  • Potential for harm · D2024-12-05 · 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 review, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for abuse, the facility failed to ensure the charge nurse was notified when it was identified that the resident had purple discoloration to the groin and upper inner thighs. The findings include: Resident #1 had diagnoses that included Waldenstrom macroglobulinemia (a blood disorder), myeloproliferative disease (a blood disease), lymphoplasmacytic lymphoma (a type of cancer), amyloidosis, ( a systemic diease) post-traumatic stress disorder, delirium, and depressive disorder. The admission MDS dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) of ten (10) indicative of moderately impaired cognition, was frequently incontinent of bowel and bladder, was dependent with transfers, and required substantial assistance with ADLs and bed mobility. The physician's order dated 11/11/24 directed to administer Brukinsa (antineoplastic medication…

    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 · E2024-04-09 · tag F0882 — pattern
    Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on facility documentation review, and interviews, the facility failed to ensure a certified Infection Preventionist was employed by the facility. The findings include Review of RN #4 (Infection Control Nurse) certification documentation on 4/8/24 at 9:30 AM identified a certificate of achievement from Infection Control Training dated 4/4/22 and the course topics included: Introduction, Transmission, Prevention and Control, Hand Hygiene, Personal Protective Equipment, Environmental Controls, Sharps and Injection Safety, Occupational Health and Safety, Sepsis, Final Exam. The course was 4 hours long, and the certification expires after 2 years. RN #4 also identified she took also took several courses in the CDC/Infection Control Training site which was is 19 hours long and consists of 23 modules, however RN#4 did not complete the final exam associated with the CDC/Infection Control Training and as a result did not have a certificate of completion. The courses were taken June 2022. Interview and Infection Control curriculum review with RN #4 on 4/9/24 at 9:40 AM identified RN #4…

    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 · D2024-04-09 · 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 and interviews for 3 of 3 residents (Resident #53, #58, and #70) reviewed for advanced directive, the facility failed to ensure the advanced directive form was completed. The findings include: 1. Resident #53 was readmitted to the facility on [DATE] with diagnoses which included dementia, end stage renal disease, and anxiety. The hospital Discharge summary dated [DATE] did not identify a code status for Resident #53. A nurses' note dated [DATE] at 10:09 PM identified Resident #53 was admitted to the facility and was alert and oriented times 3. The resident representative was called identified he/she wanted Resident #53 to be a full code. The facility consent form for the administration or withdrawal of cardiopulmonary resuscitation (CPR) identified on [DATE] that 1 nurse had signed a telephone verbal consent from the resident's representative as a full code. The witness line was blank. Review of the nurse's notes dated [DATE]-[DATE] did not…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-09 · tag F0623 — isolated
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical records ,review of facility documentation, and interviews for 3 of 5 residents (Resident #1, 18 and 71), reviewed for hospitalization, the facility failed to ensure the Office of the State Long-Term Care Ombudsman was notified when the residents were transferred to the hospital. The findings include. 1a. Resident #1 was admitted to the facility in February 2024 with diagnoses which included chronic kidney disease, myocardial infarction, and atherosclerotic heart disease. The nurse's note dated 2/17/24 at 1:48 PM identified Resident #1 was transferred to the hospital. The nurse's note dated 2/29/24 at 2:41 PM identified Resident #1 was readmitted to the facility. Review of the Action Summary dated 2/1/24 - 2/29/24 failed to reflect the Office of the State Long-Term Care Ombudsman had been notified when Resident #1 was transferred to the hospital on 2/17/24. b. The nurse's note dated 3/16/24 at 6:22 AM identified Resident #1 was transferred to the hospital. The nurse's note 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-09 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, review of facility documentation, and interviews for 2 of 4 residents (Resident #40, Resident #37) reviewed for accidents, the facility failed to provide adequate supervision to prevent a fall resulting in a fracture and the facility failed to ensure appropriate observation and monitoring was conducted for a resident with multiple recurrent falls.The findings include: 1. Resident #40 was admitted to the facility with diagnoses which included schizophrenia, emphysema, bilateral lower extremity neuropathy, and multiple malignant neoplasms. The quarterly MDS assessment dated [DATE] identified intact cognition and required supervision with transfers, bed mobility, walking in room and corridor, dressing, toilet use, and personal hygiene. The care plan dated 3/23/23 identified Resident #40 was at risk for falls related to cancer diagnosis and anticipated decline in functional status with a progressive terminal disease. Interventions included to cue for safety awareness, keep…

    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 · D2024-04-09 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, review of facility documentation, and interviews for 1 of 2 residents (Resident #17) reviewed for nutrition, the facility failed to ensure the dietitian had followed up on weight loss. The findings include: Resident #17 was admitted to the facility with a diagnosis which included Alzheimer's disease, dementia, dysphagia, and diabetes. The quarterly MDS assessment dated [DATE] identified Resident #17 had severely impaired cognition and required set up with meals. Resident #17's height was 70 inches, weighed of 236 lbs. and did not have a weight gain or loss. Resident #17 was on a therapeutic diet. The care plan dated 12/13/23 identified nutrition and dehydration risk with a weight gain this quarter ending on 12/13/23. Interventions included to provide diet as ordered. The dietitian quarterly progress note dated 12/13/2023 at 9:36 AM identified Resident #17's diet was no added salt and no concentrated sweets. On 12/11/23 residents' weight was 235.9 lbs. Resident continues 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-09 · tag F0725 — failed to have enough nursing staff — isolated
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    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 4 residents (Resident #37) reviewed for accidents, the facility failed to ensure adequate nursing staff was available to provide close monitoring for a resident with multiple falls per facility policy. The findings include: Resident # 37 was admitted to the facility on [DATE] with diagnoses which included repeated falls, muscle weakness, and dementia. The admission MDS assessment dated [DATE] identified Resident # 37 had severely impaired cognition, was always continent of bowel and bladder, required substantial assistance from staff with bathing and moderate assistance with toileting and transfers. The MDS further identified Resident #37 had a history of falls in the month prior to admission to the facility and had at least one following admission to the facility. The care plan dated 11/26/23 identified Resident # 37 was at risk for falls due to functional decline and a history of repeated falls 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-09 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, review of facility documentation, and interviews for 1 of 5 residents (Resident #16) reviewed for unnecessary medications, the facility failed monitor targeted behaviors for antipsychotics use. The findings include: Resident #16 was admitted to the facility with diagnoses which included bipolar disorder, dementia, depressive episodes, and anxiety. The quarterly MDS assessment dated [DATE] identified Resident #16 had intact cognition, did not display physical or verbal behaviors towards others, no hallucinations or delusions, no rejection of care or wandering. Resident #16 receives antipsychotics and antidepressants in the last 7 days. The care plan dated 2/7/24 identified daily use of psychotropic medication related to bipolar disorder with anxiety and depression. Interventions included to administer medications as ordered, monitor for side effects including movement disorder, discomfort, hypotension, gait disturbance, constipation or cognitive/behavioral impairment, 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-09 · 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, facility documentation, facility policy and interviews, the facility failed to ensure the glucometer was sanitized after use and hand hygiene performed per policy and professional standards of care. The findings include: Resident #245 was admitted to the facility on [DATE] with diagnosis which included Type 2 Diabetes, muscle weakness, and congestive heart failure. The nursing assessment dated [DATE] identified Resident #245 was alert, forgetful, and confused and oriented to person and place. The care plan for Resident #245 dated 4/1/24 identified a focus on both nutrition and hydration with interventions that included to provide diet as ordered, and labs as ordered. The physician's orders dated 4/1/24 identified Resident #245's blood sugar should be monitored before meals and at bedtime, and to administer Lispro (insulin) via a sliding scale based upon blood sugar level. Observation on 4/7/24 at 7:45AM identified LPN #1 obtaining a blood sugar level for Resident #245. LPN #1 obtained 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-09 · 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 review of the clinical record, review of facility documentation, and interviews for 1 sampled resident (Resident #145) reviewed for medication error, the facility failed to ensure a laboratory test was obtained per physician's order for a resident receiving an anticoagulant medication which resulted in a significant medication error as the anticoagulant medication was not administered for 13 days. The findings include: Resident #145 was admitted to the facility in January 2023 with diagnoses which included prosthetic heart valve, endocarditis, atherosclerotic heart disease, and congestive heart failure. The admission MDS assessment dated [DATE] identified Resident #145 had severely impaired cognition and required extensive assistance with personal hygiene. The January 2023 care plan dated identified Resident #145 was at risk for abnormal bleeding related to use of anticoagulation status-post Surgical Aortic Valve Replacement (SAVR). Interventions included administering anticoagulant as ordered, schedule…

    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 · F2021-12-13 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations during a tour of the Dietary Department, review of facility policy and interviews, the facility failed to ensure foods were dated when opened, refrigerator/freezer temperature logs were completed and trash receptacles were covered. The findings include: a. On 12/6/21 at 10:40 AM, tour of the Dietary Department with the Dietary Manager identified the Cook's Reach-in refrigerator was observed with an opened half gallon container of half and half and an opened half gallon container of organic milk without a date which identified when the containers were opened. The walk-in refrigerator identified an opened half gallon container of half and half, two opened 32-ounce containers of almond milk, a 32-ounce opened container of thickened apple juice without the benefit of a date in which it was opened. Additionally, an 8 pound pouch of Italian wedding soup with meatballs was observed in the walk-in refrigerator with a date to be used by date 11/27/21 (10 days old). Additionally, three 32 gallon garbage containers/bins in the kitchen were observed without the benefit 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-12-13 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical records, facility policy, and interviews for 1 of 2 residents (Resident #33) reviewed for pressure ulcers, the facility failed to ensure a Registered Nurse (RN) assessed the wound when a pressure ulcer to the left heel was identified. The findings include: Resident #33's diagnoses included unspecified dementia with behavioral disturbances, peripheral vascular disease, unspecified other deformities of the toe, foot and Type II diabetes with diabetic chronic kidney disease. Physician orders dated 5/16/20 and renewed monthly through 11/29/21 directed to monitor both heels for pressure areas every shift. The Resident Care Plan dated 5/25/21 identified a problem with being at risk for impaired skin related to immobility and incontinence. Interventions included monitoring of affected areas for changes and report as needed, assure adequate nutritional amounts at meal times, place a pillow between legs to prevent legs rubbing together. The quarterly Minimum Data Set (MDS)…

    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

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

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

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

Owner / managerTypeRoleShareSince
YALE NEW HAVEN HOSPITALOrganization5% OR GREATER DIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 07/29/2012
YALE-NEW HAVEN HEALTH SERVICES CORPORATIONOrganization5% OR GREATER DIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 09/12/2012
WORK, CAROLIndividualW-2 MANAGING EMPLOYEEsince 07/29/2012
PAYNE, DOUGLASIndividualCORPORATE DIRECTORsince 04/01/2019
BALCEZAK, THOMASIndividualCORPORATE OFFICERsince 07/29/2012
TAMMARO, VINCENTIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 01/04/2016

CMS files one row per role, so the 7 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted.

2 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.

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 075275. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-30, 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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