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Jefferson House

1 John H Stewart Dr, Newington, CT 06111 · Non profit - Corporation · 104 certified beds · (860) 667-4453 Medicare & Medicaid certified

Call the home — (860) 667-4453 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0602) — cited Dec 2024
Insights

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

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (5/5)
  • lower-than-typical staff turnover (31% vs 45% nationally) — better care continuity
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0602), cited Dec 2024
  • 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
  • a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags

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

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

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

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
100 Market Sq · (860) 978-1535 · Call to confirm hours
Pharmacy
1181 Main St · (860) 667-1888 · Call to confirm hours
Grocery
2190 Berlin Tpke · (860) 924-9289 · Call to confirm hours
Park
(860) 665-8666 · Typically dawn to dusk
Place of worship
155 Lowrey Pl · (860) 268-9993

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 5 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 5 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 5 stars. From monthly CMS archive snapshots.

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

Overall rating5★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased13.5%18.0%15.4%better
Long-stay residents who lose too much weight2.9%6.5%5.4%better
Long-stay residents with a catheter left in their bladder0.2%0.7%0.9%better
Long-stay residents with a urinary tract infection2.7%1.5%2.0%worse
Long-stay residents with depressive symptoms0.6%22.3%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury0.9%3.5%3.3%better
Long-stay residents whose ability to walk worsened9.3%16.4%16.1%better
Long-stay residents on antianxiety or hypnotic medication15.7%17.6%18.9%better
Long-stay residents given the seasonal flu vaccine84.4%93.5%95.3%worse
Long-stay residents with pressure ulcers2.4%4.0%4.7%better
Long-stay residents with worsening bladder/bowel control27.5%24.7%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table9.1%17.8%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine89.6%69.7%79.4%better
Short-stay residents rehospitalized after admission17.0%24.3%22.6%better
Short-stay residents with an outpatient ER visit7.8%10.7%12.0%better
Long-stay hospitalizations per 1,000 resident days1.642.061.67typical
Long-stay outpatient ER visits per 1,000 resident days0.811.461.80better

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

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

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

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

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

60.1% 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 183 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

60.1%U.S. median 51.5%
Got home and stayed home
10.1%U.S. median 10.7%
Went back to hospital
68.2%U.S. median 56.6%
Met the expected recovery
0.42U.S. median 0.31
Therapy hours / resident / day
0.22hours / resident / day
Physical therapy
0.17hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 68.2% 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 66 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 0.42 therapist hours per resident per day in 2026Q1 — more than 72% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 20% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF60.1%CMS range 53.5–65.951.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.1%CMS range 6.7–14.710.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge68.2%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge56.1%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge66.7%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified78.7%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting92.6%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims for this measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.5%CMS range 3.6–9.77.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.091.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

1.98
RN hours/ resident / day
0.35
LPN hours/ resident / day
2.85
Aide hours/ resident / day
5.17
Total nurse hours/ resident / day
1.36
RN hoursweekends
31.0%
Total nursing turnover
19.6%
RN turnover

How full it usually is: this home is certified for 104 beds and averages 98.3 residents a day — about 95% occupied, or roughly 6 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 5.17 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.98 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.85 is at or above 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 4.53 hrs/resident/day on weekends vs 5.43 on weekdays — 16% thinner on weekends. RN hours go from 2.23 to 1.36 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 31% is below the national median of 45%.

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

Inspection trend

9
deficiencies at the latest standard inspection (2025-01-28)
9
at the previous standard inspection (2023-09-29)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

25 citations, most serious first. The 10 most serious are shown; the remaining 15 are one tap away and print in full.

  • Potential for harm · F2025-01-28 · tag F0851 — widespread
    Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview and review of Payroll Based Journal (PBJ) submissions for Quarter 1 (October 1, 2024 through December 31, 2024) and Quarter 2 (January 1, 2024 through March 31, 2024) the facility failed to ensure the PBJ data was submitted on time. The findings include: PBJ submissions for Quarter 1 of 2024 and Quarter 2 of 2024 identified the facility as a 1-star rating and excessively low weekend staffing metric was suppressed for the facility for Quarter 1 and Quarter 2 of 2024. On 1/28/25 at 2:21 PM an interview with Administrator identified that the staff member who was responsible for submitting the PBJ reports had left and then came back per diem, she did not submit the PBJ on time for Quarter 1 and therefore Quarter 2 was also triggered. The Administrator further identified that she was responsible at this time for reporting the PBJ and no further issues have been identified. Review of the Mandatory submission of staffing information based on payroll data in a uniform format. The facility must submit direct care staffing information on the schedule specified by CMS,…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-01-28 · tag F0684 — failed to provide proper treatment and quality of care — pattern
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the clinical record, facility documentation, facility policy and interviews for 1 of 4 sampled residents, (Resident #57) reviewed for accidents, the facility failed to implement a physician's order for the application of padded side rails. Additionally, for 1 of 1 sampled resident (Resident #63) reviewed for choices, the facility failed to schedule an appointment with a specialist per provider recommendations and resident request, and for 1 of 3 residents (Resident #87) reviewed for general concerns, the facility failed to schedule a hematology consult per physician's order. The findings include:1. Resident #57's diagnoses included cognitive decline, osteoarthritis, and acute embolism and thrombosis (blood flow blockage) of the deep veins in the lower extremities. The annual Minimum Data Set assessment dated [DATE] identified Resident #57 was cognitively intact, had limited range of motion on both sides of the lower extremities, and was totally dependent on staff for bed mobility…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-01-28 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the tour of the Dietary Department, interviews, review of facility policy and facility documentation, the facility failed to ensure that beard restraints were worn appropriately, perform hand hygiene when appropriate, ensure open food items were properly closed/dated and not near debris on the floor and failed to discard expired food items. The findings include: During observations of meal service on 1/23/25 at 11:45 AM with the Director of Food Services, the following was identified: 1a. Dietary Aide #1 (DA) was observed at the tray line placing plated food on residents' trays wearing a beard restraint that covered only the lower half of his facial hair with the sides of his beard exposed. Subsequent to surveyor inquiry, the Director of Food Services (who was also observing the meal service) informed DA #1 that his beard was exposed around the beard restraint and that his beard restraint needed to be readjusted. DA #1 proceeded to walk away from the plating area, removed his gloves, removed his beard…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-01-28 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the clinical record, facility policy, and staff interviews for 5 of 5 residents (Resident #10, #32, #66, #73, and #83) reviewed for blood glucose testing, the facility failed to clean and disinfect a glucometer device per the manufacturer's instructions for use. 1. Resident #10's diagnoses included Type 2 Diabetes, Alzheimer's disease, and chronic obstructive pulmonary disease (COPD). A physician's order dated [DATE] directed to obtain a blood glucose level every Tuesday at 6:00 AM. A chart review identified that Resident #10 had blood glucose checks performed per physician order on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #10 had moderately impaired cognition, required maximal assistance with his/her personal hygiene, and was dependent with chair/bed-to-chair transfers and rolling left and right. The Resident Care Plan (RCP) dated [DATE] identified Resident #10 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-28 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility documentation, facility policy and interviews for 2 of 3 residents (Resident #87 and Resident #353) reviewed for transmission-based precautions, the facility failed to ensure privacy related to having the posted isolation sign identify the type of infection/reason for the resident's isolation. The findings include: 1. Resident #87's diagnoses included current herpes zoster/shingles, chronic obstructive pulmonary disease and congestive heart failure. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #87 was cognitively intact and required partial to moderate assistance with toileting, transfers, and bed mobility. The Resident Care Plan dated 1/3/25 indicated a rash related to herpes zoster and antiviral medication for a diagnosis of shingles. Interventions included treatments and medications as ordered and to inform medical staff as needed. A physician's order dated 1/23/25 directed contact precautions, place a contact…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-28 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of clinical records, facility documentation, facility policy and interviews for 2 of 5 residents (Resident #9 and Resident #64) reviewed for unnecessary medications, the facility failed to follow professional standards for medication administration. The findings include: 1. Resident #9 was admitted to the facility in August of 2022 with diagnoses that included infection and inflammatory reaction due to internal right knee prosthesis (chronic infection of knee replacement), peripheral vascular disease, and Factor VIII disorder (increase bleeding disorder). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #9 as being cognitively intact and required maximum assistance with personal hygiene, dressing, showering and totally dependent for toileting and independent with eating. The Resident Care Plan dated 1/2/25 identified behavioral symptoms with interventions to administer medications per physician orders and monitor for any side effects or adverse…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-04 · tag F0602 — failed to protect residents from theft of their belongings — isolated
    Protect each resident from the wrongful use of the resident's belongings or money.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for abuse, the facility failed to ensure the resident was free from mistreatment. The findings include: Record review identified Resident #1 was admitted to the skilled nursing facility during 5/2024 and had an emergency contact listed as a Durable Power of Attorney (POA). Resident #1's diagnoses included depression, anxiety and cerebral infarction (stroke). The annual Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #1 had a Brief Interview for Mental Status (BIMS) score of fifteen out of fifteen, indicative of no cognitive impairment, and required assistance with ADLs. The Resident Care Plan (RCP) dated 8/27/2024 identified a risk for loneliness due adjustment to change in living situation related to placement for long term care. Interventions directed to allow to express feelings, and visits with social services. Review of facility…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-09-29 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on a tour of the kitchen and staff interview, the facility failed to ensure that kitchen equipment was maintained in a sanitary manner. The findings include: A tour of the kitchen on 9/25/23 at 10:27 AM with the Food Service Director identified the following: The ice machine in the kitchen was observed to have a black and pink substance on the inside of the ice machine. Subsequent to inquiry, the ice machine was emptied and cleaned. Interview on 9/25/23 at 10:30 AM with the Food Service Director identified the ice machine should be cleaned by kitchen staff in the evening at the end of meal service. Interview on 9/26/23 at 8:10 AM with System Director identified there is no specific cleaning schedule other than the expectation that the ice machine is cleaned at the end of the day.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-09-29 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, observations, facility policy review and interviews for for four residents (Resident #19, #29, #52 and #77) requiring assistance to eat in 2 of 4 dining rooms, the facility failed to provide a dignified dining experience. The findings included: 1. Resident #19's diagnoses included Alzheimer's disease, anxiety, schizoaffective disorder, anemia, dysphagia, and cerebral infarction. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #19 had severe cognitive impairment, had no signs and symptoms of possible swallowing disorder, and required extensive assistance with eating. The Resident Care Plan (RCP) dated 7/28/23 identified Resident #19 at risk for loneliness. Interventions directed staff to allow the resident to express feelings, offer emotional support, keep topics of conversation light and cheerful, and allow the resident to participate in daily care and decision-making or in establishing goals. Further review identified the resident was at risk…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-29 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy and interviews for 2 of 2 sampled residents (Resident #1 and Resident #22), the facility failed to ensure advanced directives in the paper clinical record matched advanced directives in the electronic health record (EHR). The findings include: 1. Resident #1 was admitted to the facility on [DATE] with diagnoses that include heart failure, chronic kidney disease, coronary artery disease with angina pectoris, and cognitive impairment. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had intact cognition and required extensive assistance of 2 for bed mobility, was totally dependent on 2 for transferring, dressing and toilet use, and dependent on 1 for personal hygiene. The Resident Care Plan (RCP) dated [DATE] identified Resident #1 needed assistance and guidance in management of disease/illness. Interventions included the resident's code status was do not resuscitate (DNR), do not Intubate (DNI),…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 15 citations
  • Potential for harm · D2023-09-29 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, review of facility documentation, staff interviews, and facility policy, the facility failed to ensure the environment was maintained in good repair and a homelike manner. The findings include: Tour of the facility 9/25/23 at 11:50 AM identified the following: Room A 209 was observed with a black substance noted in the vents of the window unit air conditioner. Observation with Manager of Facilities on 9/25/23 at 12:00 PM identified the air conditioner in room A 209 had a black substance noted in the vents of the window unit air conditioner. Subsequent to surveyor's inquiry, the window unit air conditioner in room A 209 was replaced with a brand-new window unit air conditioner. Interview with the Manager of Facilities on 9/28/23 at 1:10 PM indicated that window unit air conditioners are cleaned, and filters changed in April when window unit air conditioners are put in and cleaned again in October when window unit air conditioners are removed and stored. Additionally, the Manager of Facilities indicated there was no documentation of cleaning of window air…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-29 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    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 interviews for resident 1 of 1 (Resident #72) reviewed for care planning, the facility failed to ensure that the resident's had an admission baseline care plan. The findings include: Resident #72's diagnoses included chronic heart failure, myocardial infarction, atrial fibrillation, and pleural effusion. Resident was admitted to facility on 9/1/2023. An admission MDS assessment dated [DATE] identified the resident was alert and cognitively intact and required extensive assistance of two with bed mobility, transfers, toilet use, and extensive assistance of one for dressing, personal hygiene, and supervision with assistance of one for eating. On 9/29/23, review of Resident #72's clinical record identified the resident's RCP dated 9/3/23 contained several care plan entries from a previous admission in 2021. However, the resident had not been at the facility since discharge in 2021. The facility had not discontinued care plan items from a 2021 admission these items which…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-29 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review and interview for 1 of 3 residents with dentures (Resident #57), the facility failed to revise the plan of care to meet the resident's dental needs. The findings include: Resident #57's diagnoses included heart disease, gastro-esophageal reflux, anemia, anxiety, depression, and adjustment disorder. Review of Comprehensive Nutritional assessment dated [DATE] identified Resident #57 had no oral/dental problem and had dentures. The Observation Report dated 8/22/23 identified Resident #57's oral cavity with no ulcers, lesions, halitosis, dry membranes, or bleeding gums. The quarterly Minimum Data Set assessment dated [DATE] identified Resident # 57 had moderate cognitive impairment, had no broken or loosely fitting full or partial denture and required extensive assistance with bed mobility and eating. An undated Dental Request for Service form identified no for dental services and signed by Resident #57's Representative. A physician's order dated 8/28/23 directed regular…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-29 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for 2 of 2 residents (Resident #31 and Resident #87) reviewed for care planning, the facility failed to revise and update the resident's care plan according to timely. The findings include: 1. Resident #31 was admitted to the facility on [DATE]. The resident's diagnoses. included atrial fibrillation, knee amputation and dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #31 had intact cognition, required extensive assistance of 2 for bed mobility, was totally dependent on 2 for transferring, dressing and toilet use, and dependent on 1 for personal hygiene. The resident care plan (RCP) for Resident #31 was last reviewed and revised on 3/8/23 by LPN #1. The social worker care conference note dated 8/31/23 indicated there was a resident care conference for Resident #31 with the social worker, dietician, a nurse, and two of the resident's family members present regarding Resident…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-09-29 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review and staff interviews for 2 of 3 residents reviewed during dining (Residents #8 and #29), the facility failed to ensure supervision during group dining to prevent a potential accident. The finding include: An observation and interview on 9/25/2023 at 1:11 PM interview with RN#4 identified s/he was brought to the dining area to observe 2 residents still eating and unattended by staff. RN#4 stayed in the dining area until 1:13 PM when another staff member was able to take over supervision of the residents still in dining room. 1. Resident #8's diagnosis included cerebral infarction, and dementia. The significant change Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #8 was severely cognitively impaired and required extensive assistance of one person for eating. The care plan dated 8/10/23 indicated Resident#8 had a decreased ability to perform self-care activities and to assist with eating. 2. Resident #29's diagnosis included chronic congestive heart…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-09-29 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, clinical record review, facility policy review, and interviews for 1 of 4 medication carts on the first floor, the facility failed to ensure medications were stored in a secure manner. The findings include: Observation on 9/25/23 at 11:35 AM of the first-floor unit identified the medication cart parked by a resident's room in the hallway with clear plastic medicine cup containing one pink, round tablet left on top of the cart. Further observation identified RN #2 was inside the resident's room, wearing personal protective equipment and providing care while facing the resident inside the room at which time leaving the medication cart placed in the hallway not within eyesight of RN#2 from the room. Further observation identified staff members, visitors and residents walking by the medication cart with medication visible on top of the cart. Interview with RN #2 on 9/25/23 at 11:54 AM identified she could not see the medicine cup with the medication left on top of the cart from inside the resident's room. RN #2 further identified the medication should be disposed…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2021-07-06 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, facility documentation review, facility policy review, and interviews for kitchen review, the facility failed to ensure the walk-in refrigerator was maintained at the appropriate temperature, and the facility failed to ensure high refrigerator temperatures were rechecked for accuracy and recorded any repeat temperature checks. The findings include: Observations and interview on 7/6/2021 at 8:48 AM with the Administrator and Food Services Manager (FSM) identified that the refrigerator temperature should be below 41 degrees Fahrenheit (F). The walk-in refrigerator temperature near the door was 46, and near the back of the walk-in refrigerator was 39 F. The Administrator identified the refrigerator door did not shut properly and they were waiting to have it repaired. Random temperature checks of two milk containers stored at the back of the refrigerator at the time of the interview, identified the milk temperatures were both 43 F, and they should have been 41 F or less. Review of the temperature logs identified temperature recordings were over 41 F on 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-07-06 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review and interviews for one sampled resident reviewed for abuse (Resident #43), the facility failed to ensure the resident received assistance in a dignified manner. The findings include: Resident #43's diagnoses included Spastic Hemiplegic Cerebral Palsy and Dysphagia (difficulty swallowing). The quarterly (MDS) assessment dated [DATE] identified Resident #43 was alert and oriented, and had no mood or behavior problems. The assessment further identified that Resident #43 was totally dependent on staff for activities of daily living (ADL) including bed mobility, required extensive assistance with eating and did not have any broken or loosely fitting full or partial dentures. The Resident Care Plan (RCP) dated 5/21/2021 identified a problem with decreased ability to perform self-care (i.e. self-feeding, wash, dress), and anxiety. Interventions directed to provide one staff assist for all meals and to provide oral care with power toothbrush twice a day.…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-07-06 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, facility policy review, and interviews for one of three residents reviewed for abuse, (Resident #4), the facility failed to ensure staff consistently implemented the facility policy for abuse and the facility failed to ensure staff reported an allegation of mistreatment timely. The findings include: Resident #4's diagnoses included dementia, osteoarthritis, and anxiety disorder. The quarterly MDS dated [DATE] identified Resident #4 had severe cognitive impairment, no mood problems, no hallucinations or delusions, no behaviors, and required extensive assistance of one staff for dressing. The care plan dated 12/10/20 identified a problem of accusatory behavior and visual hallucinations. Interventions directed to maintain a calm environment and approach in a slow, gentle manner. Physician order dated 10/8/20 directed add diagnosis of primary osteoarthritis of left shoulder. A Reportable Event Form dated 1/5/21 identified Resident #4 stated a nurse's aide pushed him/her…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-07-06 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, facility documentation review, and interviews for one of four residents, (Resident #17), reviewed for pressure ulcers, the facility failed to ensure a dressing order was in place prior to use, and failed to ensure appropriate monitoring of skin covered by a dressing, and failed to ensure a dressing was changed regularly. The findings include: Resident #17's diagnoses included congestive heart failure, kidney disease, dysphagia, cognitive impairment, and difficulty walking. The significant change MDS dated [DATE] identified Resident #17 had moderately impaired cognition, was dependent for bed mobility, transfers, toileting and personal hygiene, was at risk for pressure ulcers and did not have any pressure ulcers. The care plan dated 4/8/21 identified Resident #17 was at risk for pressure ulcers due to decreased mobility, chair bound and moisture from incontinence. Interventions directed to conduct skin assessments, off load heels when in bed, avoid sheering skin when…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-07-06 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, facility documentation review, and interviews for one of two residents (Resident #17) reviewed for accidents, the facility failed to implement the plan of care related to fall prevention. The findings include: Resident #17's diagnoses included congestive heart failure, kidney disease, dysphagia, cognitive impairment, and difficulty walking. A fall risk assessment dated [DATE] identified Resident #17 was at high risk for falls. The quarterly MDS dated [DATE] identified the resident had moderate cognitive impairment, required extensive assistance of one staff for bed mobility, transfers, ambulation and toilet use, and had one fall with no injury since the prior assessment. The care plan dated 2/7/21, identified the resident had a fall on 2/7/21, was observed lying on the floor, interventions included chair alarm applied. Physician orders dated 2/7/21 directed to use a chair alarm, check alarm for proper functioning, do not leave unattended without alarm, and the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2025-01-28 · tag F0638 — pattern
    Assure that each resident’s assessment is updated at least once every 3 months.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical record reviews, review of the Resident Assessment Instrument (RAI) Manual, facility policy, and interviews for 2 of 4 sampled residents (Resident #49 and Resident #89) reviewed for resident assessment, the facility failed to complete a Quarterly Minimum Data Set (MDS) assessment in a timely manner. The findings include: 1. Resident #49's diagnoses included dementia and spinal stenosis. On 1/27/25 at 10:43 AM review of MDS submissions with MDS Coordinator #2 (LPN #1) identified a quarterly MDS assessment was completed on 8/16/24, but failed to complete further MDS assessments. Additionally, MDS Coordinator #2 identified a quarterly MDS assessment should have been completed in November 2024 (72 days past due). 2. Resident #89's diagnoses included chronic systolic heart failure and type 2 diabetes mellitus. On 1/27/25 at 10:43 AM review of MDS submissions with MDS Coordinator #2 (LPN #1) identified a quarterly MDS assessment was completed on 8/28/24, but failed to complete further MDS assessments. Additionally, MDS Coordinator #2 identified a quarterly MDS assessment…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2025-01-28 · tag F0640 — pattern
    Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, staff interview and Resident Assessment Instrument (RAI) policy for 4 of 4 sampled residents (Resident's #49, #52, #89, and #96) reviewed for late Minimum Data Set (MDS) transmittals, the facility failed to ensure MDS' were transmitted timely. The findings include: Interview and transmittal review of MDS' on 1/27/25 at 10:23 AM with MDS Coordinator #1 (RN #5) identified the following: 1. Resident #49 was admitted to the facility in February 2023. a. An annual MDS assessment was completed on 2/20/24, but not transmitted until 3/11/24 (5 days past due). b. A quarterly MDS assessment was completed on 8/16/24, but not transmitted until 9/19/24 (19 days past due). 2. Resident #52 was admitted to the facility in October 2021. a. A quarterly MDS assessment was completed on 6/20/24, but not transmitted until 8/15/24 (42 days past due). b. A quarterly MDS assessment was completed on 12/17/24, but not transmitted until 1/23/25 (23 days past due). 3. Resident #89 was admitted to the facility in September 2023. a. A quarterly MDS assessment was completed on 5/30/24, but…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2025-01-28 · tag F0921 — failed to keep a safe, functional, sanitary building — pattern
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on tour of the nourishment rooms and interviews, the facility failed to ensure that 3 sinks in 4 nourishment rooms were maintained in a clean and sanitary manner. The findings included: Observations and interviews on 1/23/25 at 10:35 AM with Director of Environmental Services and Administrator revealed the following: a. The first floor [NAME] nourishment room cabinet under the sink was locked with a zip tie and a green substance was noted on the bottom of the cabinet. Interview with the Director of Environmental Services at that time indicated that it should not have a green substance on the bottom and the green substance must be coming from the pipes. b. The first floor [NAME] North nourishment room door was unlocked, the sink was noted with a container under the pipe that was collecting water with small black particles on the bottom of the cabinet. The Director of Environmental Services turned on the faucet which revealed a slow leak coming from the pipe under the cabinet. He indicated that the particles…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • No harm found · Bcited before2021-07-06 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interview and review of facility policy, for medication storage review, the facility failed to ensure that all Intravenous (IV) solutions and supplies were removed from the emergency supply timely when expired. The findings include: Interview and observation with RN #4 (Infection Control Nurse) on 6/15/21 at 12:50 PM identified the facility emergency medication box (e-box) contained thirty-seven (37) heparin solution 5 cubic centimeter (cc) syringes with an expiration date of 3/31/21. Additionally, there were five (5) intravenous solution (IV) 1000 milliliter (ml) bags of Dextrose 5% one-half normal saline and two (2) Dextrose 5% IV solution 1000 ml bags that did not have their original outer protective bag cover and had no documentation of the date they were received from the pharmacy. RN #4 indicated that she or the supervisors were responsible to check the e-box for expired medications, and would check expiration dates prior to using the medication. RN #4 indicated that the e-box should be checked weekly for any expired meds and the expired heparin solution…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

Owner / managerTypeRoleSince
ROBBINS, JEFFREYIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/08/2025
AGBA, CHIBUEZEIndividualCORPORATE DIRECTORsince 12/09/2021
KOSTURKO, MARYELLENIndividualCORPORATE DIRECTORsince 04/10/2024
PATEL, BIMALIndividualCORPORATE DIRECTORsince 12/01/2024
SMULLEN, ERICIndividualCORPORATE DIRECTORsince 12/09/2021
BARANIK, DAVIDIndividualCORPORATE OFFICERsince 10/31/2016
BOISVERT, GERALDIndividualCORPORATE OFFICERsince 11/11/2013
VINAL, SUSANIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/14/2025

CMS files one row per role, so the 11 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

What families pay in CT

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 075293. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-01-28, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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