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Cook Willow Health & Rehabilitation Center, Inc.

81 Hillside Avenue, Plymouth, CT 06782 · For profit - Corporation · 60 certified beds · (860) 283-8208 Medicare & Medicaid certified

Call the home — (860) 283-8208 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Nov 2021Resident-funds citation (F0570)
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 (4/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Nov 2021
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has a citation for mishandling residents’ money or property (F0570)
  • a high number of inspection citations overall (23) — 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) 4 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
130 S Main St · (860) 880-2525 · Call to confirm hours
Pharmacy
130 S Main St · (860) 484-4245 · Call to confirm hours
Grocery
655 Main St · (860) 283-4566 · Call to confirm hours
Park
8 North St · Typically dawn to dusk

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

Quality measures — how residents actually fare

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

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

Trend — is this home getting better or worse?

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

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

Overall rating5★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased14.2%18.0%15.4%typical
Long-stay residents who lose too much weight6.5%6.5%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%0.7%0.9%better
Long-stay residents with a urinary tract infection1.7%1.5%2.0%better
Long-stay residents with depressive symptoms4.8%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 injury2.2%3.5%3.3%better
Long-stay residents whose ability to walk worsened12.6%16.4%16.1%better
Long-stay residents on antianxiety or hypnotic medication22.1%17.6%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%93.5%95.3%typical
Long-stay residents with pressure ulcers0.3%4.0%4.7%better
Long-stay residents with worsening bladder/bowel control20.2%24.7%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table9.3%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 vaccine100.0%69.7%79.4%better
Short-stay residents rehospitalized after admission19.4%24.3%22.6%better
Short-stay residents with an outpatient ER visit3.3%10.7%12.0%better
Long-stay hospitalizations per 1,000 resident days1.882.061.67worse
Long-stay outpatient ER visits per 1,000 resident days0.341.461.80better

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.

61.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 46 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

61.0%U.S. median 51.5%
Got home and stayed home
10.2%U.S. median 10.7%
Went back to hospital
55.6%U.S. median 56.6%
Met the expected recovery
0.22U.S. median 0.31
Therapy hours / resident / day
0.16hours / resident / day
Physical therapy
0.05hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Met the expected recovery: 55.6% 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 27 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 0.22 therapist hours per resident per day in 2026Q1 — more than 27% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 10% 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 SNF61.0%CMS range 48.6–76.751.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.2%CMS range 6.6–14.910.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge55.6%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 discharge51.9%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 discharge29.6%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%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 hospitalization6.3%CMS range 3.1–12.57.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.881.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.94
RN hours/ resident / day
0.73
LPN hours/ resident / day
2.30
Aide hours/ resident / day
3.97
Total nurse hours/ resident / day
0.51
RN hoursweekends
40.8%
Total nursing turnover
37.5%
RN turnover

How full it usually is: this home is certified for 60 beds and averages 50.2 residents a day — about 84% occupied, or roughly 10 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.97 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.94 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.30 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 3.24 hrs/resident/day on weekends vs 4.27 on weekdays — 24% thinner on weekends — a notable drop. RN hours go from 1.12 to 0.51 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 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

7
deficiencies at the latest standard inspection (2025-09-12)
10
at the previous standard inspection (2024-02-06)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

23 citations, most serious first. The 10 most serious are shown; the remaining 13 are one tap away and print in full.

  • Potential for harm · D2026-04-29 · tag F0559 — isolated
    Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of two (2) sampled residents (Resident #1) reviewed for abuse, the facility failed to ensure the victim of a resident-to-resident altercation was afforded the choice to remain in his/her original room before staff initiated a room change following an incident in which Resident #2 threatened Resident #1 with a plastic knife. The facility further failed to ensure the room relocation promoted Resident #1's sense of safety and access within the facility when Resident #1 was moved four (4) rooms away from Resident #2 to a room located at the end of a corridor with no alternate route of exit/access, requiring Resident #1 to routinely pass Resident #2's room to access common areas of the facility. The findings include:1. Resident #1's diagnoses included muscle weakness, type II diabetes mellitus and absolute glaucoma (end stage glaucoma characterized by total irreversible blindness and eye pain).The admission…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-09-12 · 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

    Based on tour of the Dietary Department, review of facility policy and staff interview, the facility failed to ensure perishable food items were dated upon opening and dishwasher temperatures were consistently monitored. The findings include:1. Tour of the Dietary Department on 9/4/25 at 9:40 AM with the Director of Food Services identified the following:a. The dry storage area was observed to contain the following items which were not labeled/dated when opened: a 10 pound (lb.) bag of acini pasta that was 9/10 full, a 10 lb. bag of penne pasta that was 1/3 full, a 10 lb. bag of ziti pasta that was 3/4 full, a 20 lb. bag of split peas that was 1/3 full, and a 2 lb. bag of bread crumbs that was 3/4 full.b. The walk-in cooler was observed to contain the following items which were not labeled/dated when opened: 1/4 of a 6 lb. roll of genoa salami, 1/8 of a 15 lb. section of virginia ham, and 1/8 of a 6 lb. roast beef (cooked rare).c. The walk-in freezer was observed to contain the following items which were not labeled/dated when opened: a 4 lb. bag of corn that was 1/4 full, a 5 lb.…

    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 · D2025-09-12 · 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 clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #56) reviewed for abuse, the facility failed to ensure staff reported an allegation of mistreatment timely, and failed to ensure the State Agency was notified timely of an allegation of mistreatment. The findings include: Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #56) reviewed for abuse, the facility failed to ensure staff reported an allegation of mistreatment timely, and failed to ensure the State Agency was notified timely of an allegation of mistreatment. The findings include: Resident #56's diagnoses included cerebral infarction, dementia, and anxiety disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #56 had a Brief Interview for Mental Status (BIMS) score of fourteen out of fifteen (14/15), indicating alert and oriented, and…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-09-12 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #56) reviewed for abuse, the facility failed to ensure timely investigation of an allegation of mistreatment. The findings include: Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #56) reviewed for abuse, the facility failed to ensure timely investigation of an allegation of mistreatment. The findings include: Resident #56's diagnoses included cerebral infarction, dementia, and anxiety disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #56 had a Brief Interview for Mental Status (BIMS) score of fourteen out of fifteen (14/15), indicating alert and oriented, and required moderate assistance for showers. The Resident Care Plan (RCP) dated 7/9/2025 identified Resident #56 had impaired ADLs (activities of daily living) and mobility related to acute…

    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 · Dcited before2025-09-12 · 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 policy and interviews for 1 of 2 sampled residents (Resident #1) reviewed for accidents, the facility failed to ensure the care plan was revised when Resident #1 was removing the wanderguard bracelet (sensor used to assist in preventing exiting through doorways outside). The findings include:Resident #1 was admitted to the facility in December 2023 with diagnoses that included Alzheimer's dementia, history of viral hepatitis and seizure disorder. Physician's orders dated 6/12/25 directed to check function of wanderguard every night and check placement of wanderguard once a shift. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was moderately cognitively impaired and was independent with activities of daily living (ADLs).The Resident Care Plan dated 6/24/25 identified elopement as an area of concern including having a history of removing the wanderguard bracelet. Interventions included to check wanderguard function daily, check…

    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 · D2025-09-12 · 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 staff interviews, review of the clinical record and facility policy for 1 of 1 sampled resident (Resident #54) reviewed for death, the facility failed to ensure a comprehensive assessment was completed at the time of death. The findings include: Resident #54's diagnoses included hemophagocytic lymph histiocytosis, chronic obstructive pulmonary disease, unspecified atrial fibrillation and, diastolic (congestive) heart failure, and anemia.An admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #54 was cognitively intact and was dependent on staff for all transfers and personal care activities. Additionally, the MDS identified that Resident #54 required set-up assistance for eating.A Resident Care Plan dated 7/1/25 noted Resident #54 had altered respiratory status and difficulty breathing related to a right lower infiltrate from 6/30/25. Interventions included administering medications (specifically bronchodilation inhaled agents) as ordered and monitoring for effectiveness and side…

    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 · D2025-09-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy and staff interviews for 1 of 4 residents reviewed for accidents (Resident #28), the facility failed to provide transfer assistance per the physician's order which resulted in a fall with an injury. The findings include: Resident #28's diagnoses included non-traumatic subarachnoid hemorrhage (bleeding in the brain), muscle weakness, difficulty in walking, unsteadiness on feet and repeated falls. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #28 was cognitively intact and required partial/moderate assistance with transfers, and substantial/maximal assistance with toileting and bed mobility. The MDS indicated Resident #28 had not had any falls since admission/entry, reentry or on the prior assessment.A plan of care progress note (a note written after a resident care plan conference was held) dated 5/15/25 at 12:37 PM identified Resident #28 had a resident care conference held with the interdisciplinary…

    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 · D2025-09-12 · tag F0849 — isolated
    Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy and interviews for the only sampled resident (Resident #7) reviewed for hospice services, the facility failed to ensure hospice provided nursing and social work documentation/communication regarding hospice visits. The findings include:Resident #7 was admitted to the facility in June 2018 with diagnoses that included severe dementia with psychotic disturbances, Type 2 diabetes and was receiving hospice services since October 2024.A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #7 had a short/long term memory problem, had an upper and lower extremity impairment on one side, and was dependent for oral hygiene, toilet use, dressing and personal hygiene. Additionally, the MDS indicated Resident #7 was receiving hospice services.The Resident Care Plan dated 6/4/25 identified hospice care with interventions that included hospice visits, social service as needed for emotional support, and pastoral clergy for…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-09-12 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of clinical records, facility policy and interviews for 1 of 2 sampled residents (Resident #4) reviewed for an indwelling urinary catheter, the facility failed to ensure the drainage bag was not touching the floor. The findings include:Resident #4 was admitted to the facility in January 2024 with diagnoses that included obstructive uropathy and tubulo-interstitial nephritis (inflammation of the tubes and tissue of the kidney).The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #4 was cognitively intact and was totally dependent on staff for assistance with activities of daily living (ADLS). Additionally, the MDS identified Resident #4 had an indwelling urinary catheter. The Resident Care Plan dated 6/19/25 identified a urinary catheter as a concern with interventions that included changing the catheter bag as needed, keep below the level of the bladder, document any pain/discomfort and monitor for signs of infection.A physician's order dated 7/9/25…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-02-06 · 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 the tour of the Dietary Department, staff interview, facility documentation and policy, the facility failed to ensure the Dietary department consistently labeled canned food to reflect their age or shelf life, failed to discard dented cans and failed to ensure proper hair covering for a beard. The findings included: Tour of the Dietary Department on 1/31/24 at 10:37 AM during the initial walk through of the kitchen with the [NAME] Supervisor identified the following: a. The dry storage room had the following food items with no expiration dates: 2 cans of dark red kidney beans (104 oz per can ), 4 cans of white beans (104 oz per can), 2 cans of white beans (14 oz per can), 8 cans of diced tomatoes (104 oz per can ), 15 cans of beets (104 oz per can), 4 cans of baked beans(104 oz per can), 6 cans of corn (104 oz per can), 9 cans of roasted red peppers (22 oz per can), 8 cans of corned beef Hash (104 oz per can), and one opened bag of cornbread stuffing. b. The following cans were dented and were on the shelf within the usable stock: 1 can mandarin oranges(4 oz), 1 can of…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
Show the remaining 13 citations
  • Potential for harm · D2024-02-06 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility policy, and interviews for 1 of 3 sampled residents (Resident #50) reviewed for falls, the facility failed to ensure the Resident Care Plan was comprehensive to include interventions that the facility had implemented for fall prevention. The findings include: Resident #50 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease, dementia, repeated falls and ataxia. A physician's order dated 10/18/23 directed Resident #50 required assistance with transfers and ambulation of 1 and a rolling walker. An admission MDS assessment dated [DATE] identified Resident #50 was moderately cognitively impaired and required supervision touching assistance with bed to chair to bed transfers without limitation in range of motion. Additionally, the MDS identified Resident #50 was frequently incontinent of bladder and occasionally incontinent of bowel. The MDS further identified Resident #50 had a falls prior to admission. The RCP dated 11/6/23 identified a…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-06 · 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 observations, review of the clinical record, staff interviews and facility policy for 1 of 5 residents(Resident #18) reviewed for psychotropic medications, for 1 of 2 residents (Resident #39) reviewed for pressure ulcers and for 1 of 1 sampled resident (Resident #50) reviewed for elopement, the facility failed to revise the resident care plan. The findings include: 1. Resident #18 was admitted to the facility on [DATE] with a diagnosis including dementia, anxiety, and irregular heart rhythm. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #18 was moderately cognitively impaired and required partial or moderate assistance to roll left and right on the bed and substantial or maximal assistance to transfer from the bed to a chair. The MDS also identified Resident #18 did not exhibit physical or verbal behaviors directed towards others or self and that Resident #18 had not received any antianxiety or antidepressant medication. A physicians order dated 3/29/23 directed to…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-06 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide 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 observation and staff interview for 1 of 1 sampled resident (Resident #36) reviewed for Activities of Daily Living (ADLs), the facility failed to provide personal hygiene for nails and removal of facial hair. The findings include: Resident #36's diagnosis included peripheral vascular disease, dementia, and arthritis. The Quarterly Minimum Data Set assessment dated [DATE] identified Resident #36 was severely cognitively impaired, required extensive supervision and assist of 1 for dressing, eating, and personal hygiene, extensive assist of 2 for bed mobility, and toileting, dependent with assist of 2 for transfers. The Resident Care Plan dated 1/27/24 identified Resident #36 required assistance/was dependent for activities of daily living in personal hygiene with interventions that included to supervise ADLs, assist Resident #36 with bathing, hygiene and dressing. Observation on 1/31/24 at 12:00 PM and 2/1/24 at 8:51 AM identified Resident #36's fingernails were long, soiled beneath the nails and had…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-06 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    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 interview for the only sampled resident, (Resident #50), reviewed for bladder and bowel incontinence, the facility failed to correctly code bladder continence and failed to complete a bowel assessment on readmission following a hospitalization. The findings include: Resident #50's diagnoses included a right hip fracture, repeated falls, and dementia. Review of the Nursing admission assessment dated [DATE] identified Resident #50 had multiple daily episodes of urinary incontinence with little to no control, and a bowel evaluation that identified the resident was occasionally incontinent of bowel. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #50 was moderately cognitively impaired, required assistance with activities of daily living, and was frequently incontinent of urine and occasionally incontinent of bowel. The Resident Care Plan dated 10/25/23 identified Resident #50 was at risk for bowel and bladder…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-06 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the clinical record, review of facility documentation, facility policy, and interviews for 3 of 3 residents, (Resident #7, Resident #27, and Resident #253) reviewed for oxygen therapy, the facility failed to appropriately label nasal cannula oxygen tubing (Resident #7), and failed to follow a physician's order related to oxygen administration (Resident #27 and Resident #253). The findings include: 1. Resident #7's diagnoses included respiratory failure with hypoxia, sleep apnea, and Chronic Obstructive Pulmonary Disease (COPD). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #7 was cognitively intact and required moderate assistance for bed mobility and transfers, and required maximum assistance for personal hygiene. Additionally, the MDS identified Resident #7 utilized oxygen therapy. The Resident Care Plan dated 12/26/23 identified Resident #7 had COPD and asthma and required supplemental oxygen. Interventions included oxygen administration as…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-06 · tag F0919 — failed to provide a working call system — isolated
    Make sure that a working call system is available in each resident's bathroom and bathing area.
    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 the only sampled resident reviewed for environment, the facility failed to ensure Resident #20's call bell was within reach. The findings include: Resident #20's diagnoses included dementia, extrapyramidal movement disorder and history of falls. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #20 was moderately cognitively impaired and required a moderate amount of assistance for all transfers, and substantial amount of assistance for toileting and personal hygiene. The Resident Care Plan dated 12/28/23 identified Resident #20 was a fall risk due to unawareness of safety needs. Interventions included ensuring the call bell was within reach and encouraging the resident to use the call bell. Additional interventions included ensuring a working and reachable call light. A physician's order dated 1/6/24 directed to use a rolling walker and assistance of 2 for all transfers.…

    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
  • Potential for harm · D2021-11-22 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, interviews review of facility documentation and review of policy for one of two residents reviewed for Mood or Behavior for (Resident #54), the facility failed to ensure notification to the physician/practitioner following a threat of serious physical harm to Resident # 21. The findings include: 1 a. Resident #21's diagnoses included depressive episodes, anxiety disorder and intellectual disabilities. Resident #21's quarterly MDS assessment dated [DATE] identified the resident had no cognitive impairment, no problems with mood or behaviors and was independent in transfers and ambulation in the room and corridor. Resident #21's care plan dated 6/22/21 identified the resident was at risk to be a victim of abuse or mistreatment, had been aggressive toward others, and had pushed another resident down onto the floor on 6/20/21. Interventions included: Intervene as necessary to ensure my safety, monitor mood and behavior and provide early interventions on any changes, provide…

    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 · D2021-11-22 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, review of facility documentation, policies, and interviews for one resident (Resident # 15) reviewed for abuse, the facility failed to protect the residents from abuse from (Resident # 21). The findings include: 1a. Resident #15 's diagnosis included Alzheimer's disease, dementia with behavioral disturbances, and anxiety disorder. The quarterly MDS assessment dated [DATE] identified Resident #15 was severely cognitively impaired and required limited assistance for ambulation and toileting. The care plan dated 6/7/21 identified Resident #15 was at risk to be a victim of abuse, neglect, or mistreatment and lacks self-protection skills and vulnerable due to cognitive deficits and will not be abused or victimized by others during the review period. The care plan revised on 6/20/21 identified Resident #15 was pushed down by another resident. Interventions included the resident who pushed Resident #15 was moved to another room on a different unit to avoid interaction. b. Resident #21…

    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
  • No harm found · C2025-09-12 · tag F0628 — widespread
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy and interviews for 3 of 3 (Resident #2, Resident #53 and Resident #55) sampled closed records reviewed, the facility failed to ensure the ombudsman was notified of the resident discharges. The findings include 1.Resident #2's diagnoses included urinary tract infection (UTI), myocardial infarction (heart attack), and benign prostatic hyperplasia. An admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 was cognitively intact, had an indwelling catheter, required setup or clean-up assistance with eating, and was dependent for bed mobility and transfers.The Resident Care Plan (RCP) dated 3/10/25 identified Resident #2 had an indwelling catheter upon admission. Interventions included changing the catheter bag as needed, monitor/document pain/discomfort due to the catheter, and monitor/record/report to physician signs/symptoms of UTI (pain, burning, blood tinged urine, urine cloudiness, foul smelling urine). a. A…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2024-02-06 · tag F0570 — pattern
    Assure the security of all personal funds of residents deposited with the facility.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, facility documentation, facility policy and interviews regarding personal funds, the facility failed to ensure adequate coverage through a Surety bond for the Resident Trust Accounts. The findings include: On 2/2/24 at 2:00 PM, interview and review of the Resident Trust Account (RTA) balances with the Business Office Manager indicated that the RTA balance for the period of 9/1/23 to 9/29/23 ranged from 1,288.92 dollars ($) to $20,505.68. Additionally, the RTA balance for the period of 9/30/23 to 10/31/23 identified a balance ranging from $1,288.92 to $36,241.83 throughout that time. The RTA balance for the period of 11/2/23 to 11/30/23 identified a balance ranging from $6,089.80 to $38,789.08 during that time. Furthermore, the RTA balance for the period of 12/1/23 to 12/29/23 indicated a balance ranging from $5,629.92 to $41,901.22. Review of the facility Surety Bond identified the Resident Trust Accounts were insured for $10,000 effective February 28, 2014, with continuous coverage until canceled by either party. Additional interview with the Business Office…

    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
  • No harm found · B2024-02-06 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interviews for 1 observed resident (Resident #13) using the resident television lounge, the facility failed to maintain a homelike environment in 1 of 2 resident areas. The findings include: Resident #13's diagnoses included anxiety, vascular dementia, and tremors. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #13 was cognitively intact and required set up assistance for personal hygiene, showering, and was independent with all other activities of daily living. The Resident Care Plan dated 12/29/23 identified Resident #13 was a fall risk due to deconditioning and tremors. Interventions included ensuring call bell was within reach and educating resident and family about safety reminders. A physician's order dated 1/6/24 directed to allow resident to ambulate and transfer independently with a straight cane as needed. Observation of the [NAME] Wing Television Lounge on 2/2/24 at 9:18 AM identified Resident #13 was using the television room for leisure in…

    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
  • No harm found · B2024-02-06 · tag F0730 — pattern
    Observe each nurse aide's job performance and give regular training.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on review of personnel files and staff interviews for 1 of 3 Nurse Aides (NA) reviewed for annual evaluations (NA #4), the facility failed to complete annual performance evaluations. The findings include: NA #4 was hired on 11/9/97. A performance evaluation was completed on 11/11/21 with no subsequent annual reviews completed. Interview with the DNS on 1/6/24 at 1:30 PM identified that nursing supervisors were given an evaluation to complete with the NA's being evaluated. Once completed, the form is returned to the DNS. The DNS was unable to indicate a reason for the absence of performance evaluations from 11/11/21 for NA #4. Review of the facility employee handbook indicated that employees would receive a performance evaluation at least once a year.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2021-11-22 · tag F0641 — pattern
    Ensure each resident receives an accurate assessment.
    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 and interviews for three of six residents reviewed for Preadmission Screening and Resident Review (PASARR) for (Residents # 18, #19, # 38), the facility failed to ensure the accuracy of the resident's MDS assessment. The findings included: 1.Resident #18's diagnoses included bipolar disorder. The Preadmission Screening and Resident Review (PASARR) Summary of findings dated 11/24/2015 identified the resident was determined to have a serious mental illness, (positive Level 2). The Annual MDS assessment dated [DATE] identified the resident was not considered by the state Level 2 PASARR process to have a serious mental illness and/or intellectual disability or a related condition. Interview and record review with Social Worker #1 on 11/16/21 at 1:50 PM identified the resident had been PASARR level 2 since admission and had a care plan for bipolar disorder. Social Worker #1 further identified that either he/she or the MDS nurse (RN #1) had completed the MDS section related to…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

Owner / managerTypeRoleShareSince
MACDONALD, SUSANIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF100%since 07/01/1975
LE CLAIR, JENNESAIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/30/2004
MACDONALD, WALTERIndividualCORPORATE OFFICERsince 01/15/1990
OH, JONG GILIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/01/2007

CMS files one row per role, so the 11 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted.

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.

$6.9M
Net patient revenuemost recent cost report
-0.4%
Operating marginrevenue minus expenses
$627K
Related-party expense9% of expenses
Who pays — share of resident-days
Medicaid 76%Medicare 8%Other / private 16%

About 76% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $627K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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

$343per resident / day
operating cost
$10,442per month
≈ monthly operating cost
$342per day
avg. revenue, all payers

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

What families pay in CT

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 075349. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-12, 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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