Bel-Air Manor Nursing & Rehabilitation Center
256 New Britain Avenue, Newington, CT 06111 · For profit - Corporation · 71 certified beds · (860) 666-5689 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- it has an abuse, neglect, or exploitation citation (F0600), cited Jan 2025
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 2 immediate-jeopardy problems — the most serious level
- a high number of inspection citations overall (38) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $13,627 in federal fines (most recent 2024-02-23)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 3 to 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 19.4% | 18.0% | 15.4% | worse |
| Long-stay residents who lose too much weight | 6.2% | 6.5% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 1.6% | 0.7% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 5.3% | 1.5% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 6.2% | 22.3% | 6.5% | typical |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 3.6% | 3.5% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 25.4% | 16.4% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 29.9% | 17.6% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 98.1% | 93.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.5% | 4.0% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 26.5% | 24.7% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 10.4% | 17.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.1% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 54.9% | 69.7% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 21.7% | 24.3% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 14.9% | 10.7% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.42 | 2.06 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.05 | 1.46 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
65.1% 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 191 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 50.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 68 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 0.41 therapist hours per resident per day in 2026Q1 — more than 70% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 3% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 65.1%CMS range 57.4–72.1 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.5%CMS range 8.4–16.0 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 50.0% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 50.0% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 50.0% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 97.8% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 3.3% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 5.7%CMS range 3.5–8.7 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.82 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 71 beds and averages 73.0 residents a day — about 103% occupied, or roughly -2 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.44 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.87 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.93 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 3.17 hrs/resident/day on weekends vs 3.55 on weekdays — 11% thinner on weekends. RN hours go from 0.97 to 0.62 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 41% 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
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.
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.
38 citations, most serious first. The 12 most serious are shown; the remaining 26 are one tap away and print in full.
- Immediate jeopardy · Jcited before2024-02-23 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents, (Resident #1), reviewed for change in condition, the facility failed to ensure a resident, who was found unresponsive during the dinner meal, was promptly identified as a choking victim. The facility staff failed to administer the Heimlich maneuver. Upon Emergency Medical Service arrival, two whole grapes were suctioned from Resident #1's airway by EMS staff, the resident was subsequently hospitalized for a choking episode resulting in a finding of Immediate Jeopardy. Please cross reference F 805 The finding included: Resident #1 was admitted with diagnoses that included dysphagia, hemiplegia affecting right side dominant side, aphasia, and a cerebral infarction. The annual Minimum Data Set assessment dated [DATE] identified Resident #1 had severely impaired cognition, was on a mechanically altered diet, and required extensive assistance with Activities of Daily Living. The care…
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.
- Immediate jeopardy · J2024-02-23 · tag F0805 — failed to prepare food in a form residents can eat — isolatedEnsure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
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 a review of the clinical records, facility documentation, facility policy, and interviews for one (1) of three (3) residents, (Resident #1), reviewed for diet consistency, the facility failed to ensure the resident was served the physician ordered diet consistency with a subsequent choking episode resulting in a finding of Immediate Jeopardy. Please cross reference F 684 Resident #1 was admitted with diagnoses that include dysphagia, hemiplegia affecting right side dominant side, aphasia, and cerebral infarction. The annual Minimum Data Set, dated [DATE] identified Resident #1 had severely impaired cognition, was on a mechanically altered diet, and required extensive assistance with Activities of daily living. The care plan dated 10/26/2023 identified Resident #1 had dysphagia related to a cerebral vascular accident with interventions that directed to provide a mechanical soft diet with thin liquids and set up and assist as needed. A physician's order dated 1/1/2024 directed to provide Resident #1 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.
- Potential for harm · Ecited before2025-06-02 · tag F0658 — failed to meet professional standards of care — patternEnsure 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 review of clinical records, interviews, and facility documentation for three (3) of three (3) residents (Resident #1, #2, and #3) for medication administration, the facility failed to ensure residents blood glucose levels were obtained before meals and failed to ensure insulin was administered before meals according to provider order. The findings included: 1a. Resident #1 was admitted to the facility in April of 2025 and had diagnoses that included Type 2 diabetes mellitus, dementia, and chronic obstructive pulmonary disease. A physician's order dated 4/23/25 directed Lispro (a short-acting insulin) administration per sliding scale (two (2) units for a blood glucose level of 151-200, four (4) units for a blood glucose level of 201-250, six (6) units for a blood glucose level of 251-300, eight (8) units for a blood glucose level of 301-350, ten (10) units for a blood glucose level of 351-400, and to notify the provider of blood glucose levels greater than 400) before meals and at bedtime for diabetes.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-05-13 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on the tour of the Dietary Department, interview and facility documentation, the facility failed to identify expiration dates for dry stock and frozen items. The findings included: Tour of the Dietary Department on 5/9/25 at 12:05 PM with the Dietary Manager identified the following: a. The basement dry stock contained 16 individual bags of sliced white breads with no expiration date, 2 (1-gallon) coleslaw dressing jars with no expiration date and 4 (1-pound) cans of chicken base that lacked an expiration date. b. The walk-in basement freezer contained 12 packages of hot dog buns with no expiration date, 12 packages of hamburger buns with no expiration date, 2 plastic wrapped 5-pound beef chucks with no expiration dates, a 1 5-pound bag of chicken tenders with no expiration date and a 10-pound bag of chicken breast with no expiration date. Interview with the Dietary Director on 5/9/25 at 12:56 PM failed to identify the policy on expiration dates, and stated they were most likely on the boxes they were delivered in, but due to lack of room in the facility, items were removed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-05-13 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the clinical record, facility documentation, facility policy, and interviews for one of four residents (Resident #24) reviewed for pressure ulcers and one out of three residents (Resident #40) reviewed for nutrition, the facility failed to notify the Advanced Practice Registered Nurse (APRN) and family/responsible party of a significant weight loss. The findings include: 1. Resident #24 had diagnoses that included dysphagia, the presence of a cardiac pacemaker and dementia. The Resident Care Plan (RCP) dated 1/16/25 identified Resident #24 had a history of pressure wounds and was at risk for oral/nutritional problems with a goal to not have a weight loss. Interventions included weight as ordered and per facility protocol, and Registered Dietician (RD) evaluation as needed. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #24 was severely cognitively impaired, required substantial/maximal assistance with for eating and was dependent for personal…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-05-13 · tag F0609 — failed to report abuse allegations — isolatedTimely 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 observation, clinical record review, facility documentation review, facility policy review, and interviews for one resident (Resident #25) reviewed for grievances, the facility failed to notify state and local authorities of an allegation of neglect. The findings include: Resident #25 was admitted with diagnoses that included cancer that spread to the bone, major depression and post-traumatic stress syndrome. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #24 was alert and oriented and was independent for personal hygiene, ambulation with a walker and transfer. The Resident Care Plan (RCP) dated 3/25/25 identified Resident #25 had a history of anxiety and depression. Interventions included observing for periods of anxiety or sadness, provide a calm, quiet environment and encourage Resident #25 to verbalize thoughts and feelings related to anxiety. A facility grievance/concern form dated 4/15/25, noted Resident #25 reported that a call bell was ringing in another…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-05-13 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, observations, review of the clinical record and facility policy for 1 of 5 sampled resident (Resident #5) reviewed for side rails and for 1 of 3 sampled residents (Resident #53) reviewed for pressure ulcers, the facility failed to ensure the Resident Care Plan (RCP) was comprehensive to include side rail padding (Resident #5) and refusals for positioning (Resident #53). The findings include: 1. Resident #5's diagnoses included vascular dementia without behavioral disturbances, generalized muscle weakness and cachexia (irreversible weight and muscle loss). A physician's order dated 11/9/20 and currently in effect directed for quarter (¼) side-rails to be in place to both sides of the bed for mobility and transfer ability. A side rail evaluation dated 3/2/23 identified that a side-rail was indicated for enhancement of mobility and that the resident expressed a desire for a side-rail. It reported that side-rails were not indicated to provide safety for Resident #5 and that the resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-05-13 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 3 residents (Resident #23) reviewed for medication administration, the facility failed to ensure that the expiration date was checked on a narcotic medication prior to administration. The findings include: Resident #23's diagnoses included Parkinson's disease, chronic pain and type 2 diabetes mellitus with polyneuropathy. A physician's order dated 3/20/25 directed to administer Morphine Sulfate Extended Release (ER) 15 milligram (mg) oral tablet by mouth every eight (8) hours for chronic pain, as part of a 45 mg dose (received in combination with a 30 mg tablet) and to hold for sedation. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #23 had intact cognition and was independent with eating, personal care and bed mobility. The Resident Care Plan (RCP) dated 4/10/25 identified Resident #23 had pain related to cancer, a history of chronic pain and was receiving Morphine and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-05-13 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record and policy review for 1 of 3 residents (Resident #40) sampled for nutrition, the facility failed to follow a physician's order to obtain weekly weights and a reweight on a resident with a significant weight loss. The findings included: Resident #40 was admitted to the facility in April 2025 with diagnoses that included dysphagia, aphasia, and type 2 diabetes mellitus. A physician's order dated 4/21/25 directed to weigh Resident #40 weekly on his/her shower day. The Resident Care Plan dated 4/23/25 identified Resident #40 had impaired utilization of nutrients related to diabetes mellitus, stroke, no teeth, puree diet, and elevated blood pressure with risk for weight loss and unplanned weight loss, muscle loss related to diet texture dislike and refusing to eat puree meats. Interventions included diet and fluids as ordered, magic cup supplement with lunch, weights as ordered per facility protocol, registered dietician evaluation as needed, speech therapy as needed, monitor dietary…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-05-13 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, facility policy and interviews, the facility failed to ensure the medication carts and medication storage room were free from unlabeled and expired medications and non-medication items and that medications were stored properly. The findings include: 1. Observation and interview on 5/9/25 at 11:38 AM in the South Wing Medication room with the DNS, identified house stock medications including a box of 100 capsules of Diphenhydramine (an antihistamine and/or sedative medication) 25 milligram (mg) expired 11/2024, and a box of Beneprotein 0.25 ounce packets expired 7/2023. Opened, unlabeled and undated medications were identified as Miconazole Nitrate 2 percent (%) cream and Lactulose (a medication used as a laxative or to treat liver disease) 10 grams (g) in 15 milliliters (mL) solution. Food items were observed to be stored in the medication room cabinets alongside house stock medications included a basket of coffee creamers and sugar/sugar substitute packets, and a foam take out container with plastic utensils inside. Drawers of the medication room were…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-05-13 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility policy and interviews for 1 of 3 residents (Resident #1) reviewed for nutrition, the facility failed to ensure that meal percentages were consistently being documented for a resident with significant weight loss. The findings include: Resident #1's diagnoses included dementia without behavioral disturbances, dysphagia, severe protein-calorie malnutrition and type 2 diabetes mellitus. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was moderately cognitively impaired and required substantial assistance for bed mobility. Additionally, the MDS identified that Resident #1 had a weight loss of 5 percent (%) or more in the last month or a loss of 10 % or more in the last 6 months. The Resident Care Plan (RCP) dated 4/28/25 identified Resident #1 had severe protein calorie malnutrition related to severe weight loss, dysphagia, loss of muscle and fat, low Body Mass Index (BMI) and blood work indicating inflammation despite intake being…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-05-13 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, facility policy review, and interviews for 2 of 2 residents (Resident #23 and Resident #44) who transferred to the hospital and were reviewed for Multi-Drug Resistant Organisms (MDROs), the facility failed ensure at the time of transfer to an acute care hospital the MDRO colonization status, special instructions or precautions for ongoing care related to the MDRO were communicated to the receiving hospital. The findings include: 1. Resident #23 was admitted with diagnoses that included Parkinson's disease and chronic obstructive pulmonary disease (COPD). A lab result dated 6/24/24 identified Resident #23's sputum was positive for Extended- spectrum beta lactamase (ESBL-enzymes that identify antibiotic resistance) bacteria (Klebsiella) and Methicillin (antibiotic) resistance bacteria (staphylococcus) or MRSA. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #23 was alert and oriented and was independent for personal…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 26 citations
- Potential for harm · Dcited before2025-03-26 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #2) reviewed for change in condition, the facility failed to ensure the resident's Power of Attorney was notified timely of a hospital transfer and medication changes. The findings include: Resident #2's diagnoses included congestive heart failure, chronic kidney disease, tremors, and anxiety. Review of Resident #2's advance directives dated 12/4/2017 identified Person #2 was the medical Power of Attorney (POA). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had a Brief Interview for Mental Status (BIMS) score of fifteen out of fifteen (15/15), indicative of intact cognition and required set-up assistance for ADLs (activities of daily living). The Resident Care Plan (RCP) dated 8/23/2024 identified Resident #2 had ineffective airway clearance. Interventions directed to administer medications as ordered, monitor resident for signs and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-03-26 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure the clinical record was complete and accurate to include physician/APRN notification when an ordered x-ray was delayed. The findings include: Resident #1's diagnoses included Alzheimer's disease, dementia, and anxiety. The Resident Care Plan (RCP) dated 2/10/2024 identified a fall risk. Interventions directed to provide assistance/supervision with mobility and toileting, and two (2) assist for transfers. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of two out of fifteen (2/15), indicative of severe cognitive impairment, and maximum assistance with two (2) persons for transfers. APRN #1 note dated 3/10/2025 identified Resident #1 was seen due to a fall; Resident #1 resisted transfer with assist of two (2) for a weight and fell…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-22 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, review of facility policies and procedures, review of facility documentation, and interviews for one (1) of two (2) sampled residents (Resident #2) who were reviewed for an allegation of resident-to-resident sexual abuse, the facility failed to ensure Resident #2 was free from inappropriate touching by another resident. The findings include: Resident #1's diagnoses included depression and hemiplegia. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 was alert and oriented to person, place and time, had no memory deficits and was independent with self-propelling the wheelchair. Resident #2's diagnoses included unspecified dementia, and anxiety disorder. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 rarely or never made decisions regarding tasks of daily life and required supervision or touching assistance with most Activities of Daily Living (ADLs). The nursing progress note dated 1/8/25 identified Resident #1 was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-23 · tag F0726 — failed to have competent, trained nursing staff — isolatedEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) resident, (Resident #1), reviewed for a choking episode, the facility failed to ensure staff were able to act immediately to a choking incident with the necessary skills to adequately meet the needs of the resident resulting in a life-threatening situation for the resident. The findings include: Please cross reference F 684 and F 805 Resident #1 was admitted with diagnoses that include dysphagia, hemiplegia affecting right side dominant side, aphasia, cerebral infarction, and apraxia. The annual MDS dated [DATE] identified Resident #1 had severely impaired cognition, was on a mechanically altered diet, was frequently incontinent of bowel and bladder and required extensive assistance with dressing, bed mobility, transfers, personal hygiene, toilet use, and supervision with eating. The care plan dated 10/26/2023 identified Resident #1 has dysphagia related to a cerebral vascular accident with interventions…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-02-23 · tag F0730 — isolatedObserve each nurse aide's job performance and give regular training.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of employee files, interviews, and policy review for four (4) of six (6) Nurse Aides (Nurse Aide #1, Nurse Aide #6, Nurse Aide #7, and Nurse Aide #8) who were reviewed for annual performance evaluations, the facility failed to ensure that yearly performance evaluations were completed timely. The findings include: 1. Review of employee file identified NA #1 had a hire date of 2/6/1993. Review of the employee file identified that the last performance evaluation was completed on 4/2/2021. 2. Review of employee file identified NA #6 had a hire date of 2/15/2018. Review of the employee file identified that the last performance evaluation was completed on 4/2/2021. 3. Review of employee file identified NA #7 had a hire date of 5/2/2018. Review of the employee file identified NA #7 has not had any performance evaluation conducted since her hire date of 5/2/2018. 4. Review of employee file identified NA #8 had a hire date of 1/11/2018. Review of the employee file identified NA #8 has not had any performance evaluation conducted since her hire date of 1/11/2018. Interview…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-23 · tag F0802 — failed to prepare enough nourishing food — isolatedProvide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
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 review of dietary staffing, the facility failed to ensure sufficient dietary personnel were on duty to safely carry out all functions of food and nutrition services resulting in Resident #1 being served the wrong diet consistency and subsequently choking, The findings include: Resident #1 was admitted with diagnoses that include dysphagia, hemiplegia affecting right side dominant side, aphasia, and a cerebral infarction. The annual MDS dated [DATE] identified Resident #1 had severely impaired cognition, was on a mechanically altered diet, and required extensive assistance with Activities of Daily Living. The care plan dated 10/26/2023 identified Resident #1 had dysphagia related to a cerebral vascular accident with interventions that directed to provide a mechanical soft diet with thin liquids and set up and assist as needed. A physician's order dated 1/1/2024 directed to provide Resident #1 with a mechanical soft…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-09-13 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility policy review, and interviews for one sampled resident (Resident #16) reviewed for a medication error, the facility failed to notify the physician or APRN when the resident's medication was not administered as directed. The findings include: Resident #16's diagnoses included pseudobulbar affect, psychotic disorder with delusions, heart failure, dementia, Alzheimer's, hypertension, and anxiety. The significant change MDS assessment dated [DATE] identified Resident #16 had severe cognitive impairment, required extensive assistance with bed mobility, toileting, and personal hygiene, was non-ambulatory and required extensive assistance of two staff members for transfers. Physician's order dated 8/9/23 directed to administer Azithromycin (anti-bacterial) ophthalmic solution 1% instill 1 drop to both eyes twice per day for two days, then instill 1 drop once per day for five days (total of 9 doses). APRN #1's progress note dated 8/14/23 identified Resident #16 was evaluated for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-09-13 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility policy and interviews for one of three sampled residents (Resident #6) reviewed for dementia care, the facility failed to ensure the resident care plan addressed the resident's diagnosis of dementia and contained interventions to direct the resident's care and for one of five sampled residents (Resident #43) reviewed for unnecessary medications, the facility failed to ensure the care plan identified the use of an anticoagulant, side effects to observe for and precautions that needed to be taken. The findings include: 1. Resident #6's diagnoses included unspecified dementia, delusional disorders, and paranoid personality disorder. The quarterly MDS assessment dated [DATE] identified Resident #6 had moderately impaired cognition and required extensive assistance with bed mobility, dressing, personal hygiene, and required supervision with eating. The Resident Care Plan dated 8/10/23 identified impaired cognition with interventions that included encourage…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-09-13 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility policy, and staff interviews for one sampled resident (Resident #58) who died in the facility, the facility failed to ensure a physician's order for RN pronouncement of death was transcribed into the electronic medical record and failed to ensure the handwritten order contained the resident's name and date of birth . The findings include: Resident #58 had diagnoses that included dementia, acute kidney failure, metabolic encephalopathy, ischemic heart disease, protein calorie malnutrition, atrial fibrillation, and peripheral vascular disease. A physician's progress note dated [DATE] identified Resident #58 had failure to thrive due to dementia and hypoxic respiratory failure and had an overall poor prognosis. The admission MDS assessment dated [DATE] identified Resident #58 had severe cognitive impairment, required extensive assistance for bed mobility, dressing, personal hygiene, and required total assistance for transfers, and toileting. The facility's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-09-13 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility policy review, and interviews for one sampled resident (Resident #16) who had physician's orders for antibiotic therapy to treat acute infections, the facility failed to ensure that the resident received the complete course of antibiotic therapy as prescribed by the physician. The findings include: Resident # 16's diagnoses included pseudobulbar affect, psychotic disorder with delusion, heart failure, dementia, Alzheimer, hypertension, and anxiety. The significant change MDS assessment dated [DATE] identified Resident # 16 had severe cognitive impairment, required extensive assistance with bed mobility, transfers, toileting, and personal hygiene, and was non-ambulatory. Physician's order dated 8/9/23 directed to administer Azithromycin (anti-bacterial) ophthalmic solution 1% instill 1 drop to both eyes twice per day for two days, then instill 1 drop once per day for five days (total of 9 doses). APRN #1's progress note dated 8/14/23 identified Resident #16 was evaluated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-13 · tag F0687 — failed to care for feet properly — isolatedProvide appropriate foot care.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, facility documentation review, facility policy review, and interviews for one sampled resident (Resident #26) had diabetes mellitus and was reviewed for foot care, the facility failed to ensure podiatry services were offered and provided. findings include: Resident #26 admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus, lung cancer, Parkinson's, chronic respiratory failure, and chronic obstructive pulmonary disease (COPD). The Resident Care Plan (RCP) dated 3/30/23 identified Resident #26 was at risk for hypoglycemia/hyperglycemia related to type 2 diabetes mellitus with interventions that included: report any signs and symptoms of skin changes, discoloration, irritation of breakdown and address promptly, check blood glucose per physician order, endocrinology consult as needed, arrange podiatry consult as needed and diabetic foot care as needed. The physician's order dated 8/10/23 directed to provide diabetic foot care at bedtime…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-13 · tag F0804 — failed to serve food at safe, palatable temperature — isolatedEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, facility policy review, and interviews for one of eight sampled residents (Resident #311) reviewed for dining, the facility failed to ensure food was served within acceptable temperature ranges. The findings include: Resident #311's diagnoses included type 2 diabetes mellitus, Alzheimer's, and major depressive disorder. Interview on 9/6/23 at 1:30 PM with Resident #311 identified he/she was served scrambled eggs and oatmeal for breakfast that day and it was cold. Observation on 9/11/23 between 11:05 AM and 12:00 PM of the lunch meal preparation identified that the cook checked all the food temperatures in the steam table and all of the temperatures were within acceptable range per CMS guidance. The food is then placed in a metal cart, brought to the units and to the dining room and then served to the residents. The Food Service Director checked a test tray for food temperature at the end of service (last tray to be served off metal cart), the vodka pasta with chicken was 113.5 degrees Fahrenheit (F). The initial temperature of this dish when placed in the steam…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-09-13 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, review of facility policy, review of facility documentation, observations, and interviews one sampled resident (Resident #311) on transmission-based precaution (TBP), the facility failed to have the appropriate signage was placed outside of the resident's room indicating the resident was on transmission-based precautions and the specific personal protective equipment (PPE) required to be used by staff/visitors. The findings include: Resident #311 had a diagnosis of Covid-19. The nursing admission assessment dated [DATE] identified Resident #311 was alert and oriented to person, place, and time, and required limited assistance with bed mobility, transfers, and dressing. Resident #311's care plan dated 9/5/23 identified the resident tested positive for Coronavirus (COVID-19). Care plan interventions included: posting contact and droplet precaution signs outside the resident's door and placing an isolation cart outside the door containing gloves, gowns, goggles, masks and N95…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2021-09-17 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical records, review of facility policy and interviews for 2 residents (Resident #5 and Resident #45) reviewed for Activities of Daily Living (ADL), the facility failed to provide necessary services to maintain personal hygiene. The findings included: 1.Resident #5's diagnoses included dementia, anemia and bilateral heel pressure ulcers. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #5 was severely cognitively impaired and required extensive assist with one-person physical support for personal hygiene. The RCP identified the resident has a behavioral problem with refusal of personal care on occasion dated (4/11/19). Refusal to have nail trimming/cut/filing dated (12/27/20). Interventions include: to decrease visual or auditory stressors when over stimulated. Divert the resident with eating, drinking, talking or music. If agitated during activity, stop the activity, and try again later. Fluids encouraged. Introduce self to resident and explain what you…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-09-17 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, interviews, and review of policy for 6 of 21 sampled residents (Residents # 3, 8, 9, 27, 33 and 37) who were reviewed for Advanced Directives, the facility failed to ensure the Advanced Directive form was complete in the resident paper chart in accordance with the physician order. The findings included: 1.Resident # 3 diagnoses included Alzheimer's disease and unspecified dementia. The Resident Care plan (RCP) dated [DATE] identified Resident # 3 advanced care plan with Full Code and Registered Nurse Pronouncement of death. Additionally, identified code interventions included physician's order and documentation of the resident's code status and advance care planning in resident's clinical record. The physician order dated [DATE] directed Full Code and Registered Nurse Pronouncement of death if code failed. Interview with Licensed Practical Nurse (LPN # 2) the admission/discharge support (LPN) on [DATE] at 11:39 A.M. identified a completed Advanced Directive form was unavailable…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-09-17 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical record, and interview for one of sampled residents reviewed for accidents, the facility failed to ensure a comprehensive person-centered care plan to address the resident's impulsive behaviors. The finding include: Resident # 20 diagnoses included anxiety disorder, major depressive disorder, and unsteadiness on feet. The quarterly MDS assessment dated [DATE]identified Resident # 20 with the ability to make consistent and reasonable decisions regarding tasks of daily life. Interview with Nurse Aide (# 2) on 9/15/21 at 3:15 PM identified Resident # 20 was frequently impulsive, and the resident's behavior resulted in the residents fall on 4/21/21. A review of Resident # 20's care plans on 9/15/21 and 10/14/21 failed to reflect a comprehensive person-centered care plan to address the resident's impulsive behavior. Interview with the Assistant Director of Nurses on 10/14/21 at 12:20 P.M. identified the care plan for Resident # 20 failed to reflect the resident's behavior of impulsivity.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-09-17 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of clinical record, facility documentation and interviews for (Resident # 96) one of three sampled residents reviewed for medication administration, the facility failed to ensure a medication was administered in accordance with professional standards and the correct dosage form. The findings include: Resident # 96 admitted to the facility with diagnosis that included dementia and heart failure. The admission MDS assessment dated [DATE] identified Resident # 96 with severe cognitive impairment. The physicians' order dated 9/8/21 identified may crush appropriate medications and combine. The physician's order dated 9/8/21 identified Metoprolol ER 25 Milligrams (MG) po daily. The care plan dated 9/9/21 identified Resident # 96 with dysphagia. An intervention which includes to crush medications as indicated. Observation on 9/13/21 at 10:10 A.M. identified LPN# 1 to crush and combine 7 pills for Resident # 96 including Metoprolol ER, mix in applesauce and administer to Resident # 96. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-09-17 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical record, review of facility policy and interviews for one sampled resident for (Resident # 23), reviewed for nutrition, the facility failed to ensure weekly weights were completed per physician's order. The findings include: Resident #23's diagnoses included type 2 diabetes with hyperglycemia, dysphagia and adult failure to thrive. The Resident Care Plan dated 5/5/21 identified unplanned significant weight loss with an intervention which include to obtain weights as ordered. The quarterly Minimum Data Set assessment dated [DATE] identified Resident # 23 was severely cognitively impairment, required extensive two person assist for transfers, extensive one person assist for locomotion with a wheelchair and total dependence for activities of daily living and noted a weight loss of 10 % or more in 6 months without a physician prescribed weight loss regime. A physician's order dated 7/26/21 directed to obtain weekly weights on bath/shower day every Thursday evening shift. The Advanced…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-09-17 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide 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 policy and interviews for one of three residents (Resident #24) reviewed for nutrition, the facility failed to ensure the resident was evaluated by the dietician timely when the resident was noted with a significant weight loss. The findings include: Resident #24 was admitted to the facility with diagnoses that included dementia without behavioral disturbance, dysphagia, diabetes mellitus, gastric-esophageal reflux, and muscle weakness, An RCP initiated on 11/12/2020 identified a nutritional focus for Resident #24. Interventions included for aspiration precautions to elevate head of bed (HOB) 30 -45 degrees, to conduct weight as ordered and to provide a registered dietician evaluation as needed. A physician's order dated 3/12/21 directed to provide Resident #24 with a regular diet, ground texture and thin liquids consistency. A physician's order dated 5/22/21 directed to provide Resident #24 with ice cream one time a day as a supplement. An RCP dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-09-17 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and review of facility policy, the facility failed to store emergency medications in the Emergency Medication box (E-box) in a safe manner. The findings include: Observation with the Director of Nurses (DNS) on 9/15/21 at 11:45 A.M. of the facility Emergency Medication box (e-box) identified five (5) Calcium acetate 667 MG tablets that expired on 6/9/21, five (5) Lasix (Diuretic) 20 MG tablets that expired on 8/25/21 and two (2) Mirtazapine (Anti-depressant) 15 MG tablets that expired 8/3/21 stored in the e-box. Interview with the DNS on 9/15/21 at 12:00 P.M. identified that the contracted pharmacy service is responsible for checking the e-box and disposal of outdated medications. The DNS indicated the E box was checked last in August 2021and the outdated medications were missed. The facility policy: Emergency Service directs in part that the pharmacy supplies emergency medications including emergency drugs, antibiotics, controlled substances, products for infusion in an automated dispensing machine in compliance with state regulations. The policy…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-09-17 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record reviews, facility documentation, facility policy, and interviews for 3 of 5 sampled residents reviewed for Pneumococcal immunization (Residents #6, #13 and #15), the facility failed to track and monitor the resident immunization status to screen for eligibility and provide residents with education for pneumococcal vaccination. The findings included: 1.Resident #6 was admitted to the facility on [DATE]. Resident #6's diagnoses included plasma cell cancer, schizophrenia, coronary artery disease (CAD) and diabetes mellitus (DM). A physician's order dated 11/6/2020 directed to provide Resident #6 with pneumococcal vaccination unless previously vaccinated. A quarterly MDS assessment dated [DATE] identified that Resident #6 's pneumococcal vaccination was not up to date and the reason was that it was not offered. Interview and review of the Resident #6's medical record with RN #2 on 9/15/21 at 11:00 A.M. identified Resident #6's medical record lacked documentation…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · B2025-05-13 · tag F0553 — failed to let residents help plan their care — patternAllow resident to participate in the development and implementation of his or her person-centered plan of care.
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, record and policy review for 1 of 3 residents (Resident #40) sampled for nutrition, the facility failed to include a resident in the participation of the development and implementation of his or her person-centered plan of care. The findings include: Resident #40 was admitted to the facility in April 2025 with diagnoses that included dysphagia, aphasia, and Type 2 diabetes mellitus. The baseline Resident Care Plan (RCP) dated 4/19/25 identified Resident#40 had a decline in intellectual functioning characterized by a deficit in memory, judgement, decision making and thought process related to altered mental status. The facility admission Record Face Sheet dated 4/19/25 identified Resident #40 was the guarantor and care conference person and Person #1 was an alternate care conference contact. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #40 was severely cognitively impaired and required substantial/maximal assistance with eating, oral hygiene, and dressing.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · B2025-05-13 · tag F0645 — patternPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, review of facility policy and staff interviews for 1 of 5 sampled residents (Resident #25) reviewed for Pre-admission Screening and Resident Review (PASRR), the facility failed to ensure a Level 1 pre-screen of a new resident with a mental disorder diagnosis was completed. The findings included: Resident #25 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder, anxiety disorder, and post-traumatic stress disorder. A Preadmission Screening and Resident Review (PASRR) Level 1 Screen outcome dated 6/7/16 and from a previous long term care stay at another facility (completed by the State contracted agency for PASRR review) identified Resident #25 had no level 2 condition and that the PASRR Level 1 was negative. Review of the notice of action letter dated 6/15/17 identified that Resident #25's PASRR Level 1 screening was reviewed by the State contracted agency and showed that nursing facility placement was appropriate. Additionally, it…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2023-09-13 · tag F0572 — widespreadGive residents a notice of rights, rules, services and charges.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of facility documentation and interviews, the facility failed to ensure ongoing communication regarding resident rights was conducted. The findings include: Interview with the Recreation Director on 9/12/23 at 1:30 PM identified that she is responsible for facilitating the monthly resident council meetings with the residents. She further identified that when she reviews resident rights with the residents, she includes that in the meeting documentation. In addition, the Recreation Director identified that she was unaware that she should routinely review resident rights and could not provide documentation that identified the last time resident rights were reviewed during the resident council meeting. Review of the Resident Council minutes from March 2023 to August 2023 failed to identify documentation that that resident rights were reviewed with the residents during the monthly resident council meetings. Interview with the DNS on 9/12/23 at 2:00 PM identified that ongoing communication regarding resident rights are conducted at the monthly resident council meetings.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · Ccited before2023-09-13 · tag F0730 — widespreadObserve 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 facility documentation, facility policy, and interview for 5 of 6 nurse aides reviewed, the facility failed to complete annual performance evaluations. The findings include: Review of the personnel files for NA #1, #2, #3, #4, and #5, failed to reflect that yearly performance evaluations were completed. Interview with the DNS on 9/13/23 at 11:30 AM identified the yearly performance evaluations could not be found for the above NA's. The process followed would be that Human Resources would give her a list of evaluations to be completed and the DNS would complete them, and they should be done annually. The reason this was not done could not be identified as the DNS stated she and the HR were both new. Review of the Performance Evaluation policy directed first performance evaluation to be conducted after ninety days and annually thereafter.
- No harm found · Ccited before2023-09-13 · tag F0761 — failed to label and store drugs safely — widespreadEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, facility policy and interviews the facility failed to ensure expired medications were not stored in the medication storage room. The findings include: Observation on 9/12/23 at 6:20 AM in the South Medication room with the DNS, identified house stock; Ibuprofen 200mg tablets expired 8/2023, Bisacodyl 5mg tablets expired 7/2023, and Acetaminophen 650mg suppository expired 6/2023. Observation on 9/12/23 at 7:30 AM with LPN #1 of the Central/Main medication cart, identified multiple loose pills totaling at least a dozen in and around the blister packs. Observation on 9/12/23 at 9:00 AM with RN #4 at the South medication cart, identified at least two dozen loose pills located on the floor of the medication cart. Interview with the DNS on 9/12/23 at 6:20 AM, and 7:30 AM identified these medications should not be stored in the South medication room as the pharmacy consultant was in the facility last week and is responsible for going through the medications, and that the medications carts were just cleaned last week and that they are cleaned weekly. Med cart cleaning…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$13,627 in federal fines across 1 penalty.
- $13,627 — penalty dated 2024-02-23
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to RYDERS HEALTH MANAGEMENT — 7 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 1.7 | +1.3 vs chain |
| Health inspection | 3 of 5 | 1.7 | +1.3 vs chain |
| Staffing | 3 of 5 | 3.4 | -0.4 vs chain |
| Quality measures | 3 of 5 | 2.4 | +0.6 vs chain |
The other 6 homes this chain runs (chain average 1.7★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| DR. ROBERT SBRIGLIO 2009 TRUST | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 25% | since 07/17/2018 |
| MARTIN SBRIGLIO 2009 TRUST | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 25% | since 07/17/2018 |
| SBRIGLIO, MARTIN | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; 5% OR GREATER INDIRECT OWNERSHIP INTEREST; W-2 MANAGING EMPLOYEE | 50% | since 01/01/2005 |
| SBRIGLIO, ROBERT | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; W-2 MANAGING EMPLOYEE | 25% | since 05/04/2007 |
| FARMER, MICHELLE | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | — | since 11/14/2018 |
CMS files one row per role, so the 9 rows in the source record cover these 5 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.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $1.1M paid to related parties — landlords or management companies under common ownership — equal to about 10% 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. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in CT
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Connecticut Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 075393. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-13, 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.