Laurel Ridge Center For Health & Rehabilitation
642 Danbury Road, Ridgefield, CT 06877 · For profit - Limited Liability company · 126 certified beds · (203) 438-8226 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- CMS has flagged it for abuse
- it has an abuse, neglect, or exploitation citation (F0600), cited Apr 2025
- 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 1 actual-harm citation
- a high number of inspection citations overall (31) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- about 18% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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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 1 to 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 6.5% | 18.0% | 15.4% | better |
| Long-stay residents who lose too much weight | 6.9% | 6.5% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.7% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.5% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 14.0% | 22.3% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 4.7% | 3.5% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 5.6% | 16.4% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 13.9% | 17.6% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 86.1% | 93.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.7% | 4.0% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 24.2% | 24.7% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 22.8% | 17.8% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 1.0% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 40.7% | 69.7% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 11.1% | 24.3% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 11.8% | 10.7% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 1.50 | 2.06 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.86 | 1.46 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
53.0% 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 143 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 67.8% 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 59 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 0.20 therapist hours per resident per day in 2026Q1 — more than 22% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 17% 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 53.0%CMS range 43.7–63.1 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.5%CMS range 7.3–14.1 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 67.8% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 59.3% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 67.8% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 97.6% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not 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 stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 3.7% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.6%CMS range 3.7–9.7 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.96 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 126 beds and averages 114.0 residents a day — about 90% occupied, or roughly 12 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 4.06 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.61 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.53 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 3.66 hrs/resident/day on weekends vs 4.23 on weekdays — 14% thinner on weekends. RN hours go from 0.70 to 0.36 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 38% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are 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.
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.
31 citations, most serious first. The 11 most serious are shown; the remaining 20 are one tap away and print in full.
- Actual harm · Gcited before2022-08-11 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for 5 of 5 residents (Resident #6, Resident #40, Resident #55, Resident #161, and Resident #262) reviewed for resident to resident altercations, the facility failed to ensure a resident was free from physical mistreatment. The findings include: 1. Resident #6's diagnoses included dementia, hypertension and type II diabetes mellitus. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #6 was moderately cognitively impaired and required limited 1 person assistance with transfers and ambulation. The Resident Care Plan (RCP) dated 2/17/22 identified Resident #6 had impaired cognition related to dementia. Interventions directed to use simple, direct communication, verbal cues and task segmentation. The RCP also identified Resident #6 required 1 person assistance for transfers related to decreased strength, coordination, balance and impaired safety awareness, and Resident #6 not always wait for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-05-06 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, interviews, and review of facility documentation and policy for one (1) of three (3) residents (Resident #1) reviewed for accidents, the facility failed to ensure a change of condition was reported to the provider on two occasions in accordance with facility policy. The findings included: Resident #1 was admitted to the facility in December of 2024 with diagnoses that included unspecified dementia, Type 2 diabetes mellitus, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severe cognitive impairment and was dependent with eating, oral and personal hygiene, and independent with ambulation. Review of the Resident Care Plan (RCP) dated 2/26/25 identified Resident #1 wandered related to dementia with behaviors and had the potential for falls due to poor safety awareness. Interventions directed to ensure Resident #1's room and the surrounding environment were safe and free from hazards that could cause harm and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-04-08 · tag F0725 — failed to have enough nursing staff — widespreadProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — the official record, unedited, may be distressing
Based on staff interview and review of Payroll Based Journal (PBJ) the facility failed provide appropriate number of staff for Quarter 2 (January 1, 2024 through March 31, 2024 ). The findings include: PBJ submissions for Quarter 2, 2024 (January 1, 2024 to March 31, 2024) indicated excessively low weekend staffing. An interview on 4/8/25 at 11:41 AM with the Administrator identified for Quarter 2 in 2024 (January 1, 2024 to March 31, 2024), the previous owner would not allow the facility to use agency staff or to have licensed staff work as Nursing Assistants, which would assist with having adequate nursing staff. Further identifying that the facility did have low weekend staffing during Quarter 2 of 2024. Review of the Mandatory submission of staffing information based on payroll data in a uniform format. The facility must electronically submit to CMS complete and accurate direct care staffing information.
- Potential for harm · F2025-04-08 · tag F0851 — widespreadElectronically 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, 2025 (October 1, 2024 through December 31, 2024) the facility failed to ensure the PBJ data was submitted accurately. Also, it was identified through the PBJ report that the facility failed provide appropriate number of staff for Quarter 2 (January 1, 2024 through March 31, 2024 ). The findings include: PBJ submissions for Quarter 1 of 2025 identified the facility was had 1-star rating, Registered Nurse (RN) Hours and Licensed Nursing Coverage for 24 hours/day for 10/1/24, 10/2/24, 10/3/24, 10/4/24, 10/5/24, 10/6/24, 10/7/24, 10/8/24, and 10/9/24 identified no RN hours and failed to have licensed nursing coverage 24 hours/day. Also, identified on the PBJ report for Quarter 2, 2024 (January 1, 2024 to March 31, 2024) indicated excessively low weekend staffing. An interview on 4/8/25 at 11:41 AM with the Administrator identified that the No Registered Nurse hours along and a licensed nursing coverage for 24 hours in a day was triggered (coded) incorrectly by the previous owner of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-04-08 · tag F0609 — failed to report abuse allegations — patternTimely 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 record review, facility documentation, and staff interviews for 1 of 1 residents (Resident #9) reviewed for an injury of unknown origin, for 2 of 4 residents involved in resident to resident altercations (Resident #59 and Resident #81), and for four of eight residents (Resident #27, #40, #62 and #99) reviewed for abuse, the facility failed to report the injury of unknown origin (Resident #9) and the resident to resident altercations to the Stage Agency. Additionally, for Resident #27, #40, #62 and #99, the facility failed to ensure staff reported an allegation of abuse immediately. The findings include: 1. Resident #9 was admitted to the facility in October of 2024 with diagnoses that included hemiplegia (one sided muscle paralysis) affecting the right dominant side, hypertension, and diabetes. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #9 was cognitively intact, was dependent on staff for toileting and required maximum assistance for personal hygiene and bed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-04-08 · tag F0679 — failed to provide activities — patternProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility documentation, facility policy and interviews for 1 of 2 residents (Resident #104) reviewed for recreational activities, the facility failed to provide activities that met Resident #104's interests and preferences. The findings include: Resident #104 was admitted to the facility in October 2024 with diagnoses that included chronic kidney disease, diabetes, combined forms of age-related bilateral cataracts, and hypertension. An activities admission assessment dated [DATE] indicated Resident #104's past interests included drawing/painting, fishing, traveling, sports, movies, concerts, cooking, and listening to music. An admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #104 had a severe cognitive impairment, highly impaired vision, adequate hearing, and supervision or touching assistance with activities of daily living. The MDS (daily preferences) further identified that Resident #104 indicated that it was very important for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-04-08 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, facility documentation, facility policy and interviews, the facility failed to ensure food temperatures were palatable. The findings include: A Resident council meeting was completed on 4/2/25 at 1:44 PM and residents verbalized concerns regarding food palatability, specifically cold food. The residents identified that they had raised the issue with the Food Service Director (FSD) during Monthly Food Committee meetings but food continued to be cold. Review of Food Committee Meeting minutes from 4/10/24 through 3/12/25 identified residents' concerns about cold food. On 4/10/24 residents expressed concerns about cold coffee, cold soup and cold dinner. On 8/14/24 a resident raised concern about cold soup. On 2/12/25 the FSD informed residents that if they get cold food, they could call the kitchen or ask the Nurse Aides (NA's) to warm the food since thermometers were available at the nursing stations to measure food temperatures. On 3/13/25 the issue about cold soup and cold meals was mentioned once again and the FSD encouraged residents to ask staff for food 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.
- Potential for harm · E2025-04-08 · tag F0809 — failed to serve meals on a reasonable schedule — patternEnsure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
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 resident and staff interviews, initial tours and review of the facility policy, the facility failed to ensure snacks were passed out after dinner/before bed. The findings include: 1. Resident #14 's diagnosis included cerebral palsy, chronic kidney disease, and bipolar disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #14 was cognitively intact, and dependent assist for showering, dressing, personal hygiene, and repositioning. The MDS further identified Resident #14 required a set up for eating. The Resident Care Plan (RCP) dated 1/6/25 identified Resident #14 had an activities of daily living risk related to paralysis and cerebral palsy with intervention that included to provide a mechanical lift for transfers with assistance of 2, Resident #14 was non ambulatory and was to be provided set up assistance for meals. On 4/1/25 at 10:22 AM during initial tour Resident #14 identified that she/he was not always offered a snack and at times Resident #14 would want 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.
- Potential for harm · Dcited before2025-04-08 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, facility documentation, facility policy and interviews for four sampled residents (Resident #59, Resident #81, Resident #90 and Resident #100) reviewed for mistreatment, the facility failed to prevent resident to resident altercations between Resident #59 and Resident #81, and between Resident #90 and Resident #100. Additionally, for four of eight residents (Residents #27, #40, #62 and #99) reviewed for abuse, the facility failed to ensure the residents were free from neglect and that care was provided in a timely manner on 3/8/2025 during the 7 AM to 3 PM shift. The findings include: 1a. Resident #59 was admitted to the facility in September of 2022 with diagnoses that included dementia, anxiety, and dysphagia. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #59 was severely cognitively impaired, had verbal behavioral symptoms directed towards others, had the behavior of wandering, and was independent with eating, bed mobility and transfers. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-08 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 4 residents (Resident #9) reviewed for accidents, the facility failed to conduct a complete investigation for a resident with an injury of unknown origin. The findings include: Resident #9 was admitted to the facility in October of 2024 with diagnoses that included hemiplegia (one sided muscle paralysis) affecting the right dominant side, hypertension, and diabetes. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #9 was cognitively intact, was dependent on staff for toileting and required maximum assistance for personal hygiene and bed mobility and transfers. The MDS further identified Resident #9 with an impairment on one side of his/her upper extremity and lower extremities and used a walker and wheelchair for ambulation. The Resident Care Plan (RCP) dated 10/24/24, identified Resident #9 required extensive assistance of 1 staff member for self-care tasks due to weakness,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-08 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the clinical record, facility documentation, facility policy and interviews for 1 of 2 residents (Resident #104) reviewed for recreational activities, the facility failed to develop a comprehensive care plan regarding Resident #104's activity needs and preferences. The findings include: Resident #104 was admitted to the facility in October 2024 with diagnoses that included chronic kidney disease, diabetes, combined forms of age-related bilateral cataracts, and hypertension. An activities admission assessment dated [DATE] indicated Resident #104's past interests included drawing/painting, fishing, traveling, sports, movies, concerts, cooking, and listening to music. The Resident Care Plan dated 11/24/24 identified Resident #104 had impaired visual function related to visual loss in left eye from previous stroke and bilateral cataracts. Interventions included one-on-one visits from staff. An admission Minimum Data Set assessment dated [DATE] identified Resident #104 with a severe…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 20 citations
- Potential for harm · Dcited before2025-04-08 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the clinical record, facility documentation, facility policy and interviews for 1 of 3 residents (Resident #40) reviewed for pressure ulcers, for 1 of 2 residents (Resident #45) reviewed for positioning and for 1 of 3 residents (Resident #102) reviewed for nutrition, the facility failed to ensure an air mattress was set at the appropriate setting. Additionally, for 1 of 1 resident (Resident #65) reviewed for a non-pressure skin condition, the facility failed to initiate timely treatments. The findings include: 1. Resident #40's diagnosis included cerebrovascular disease, pressure ulcer, and epilepsy. The annual Minimum Date Set (MDS) assessment dated [DATE] identified Resident #40 was severely cognitively impaired, was dependent on bathing, dressings, personal hygiene, and transfer. Also, identified that Resident #40 was a set up for eating and had an unhealed stage 3 pressure ulcer. The Resident Care Plan dated 2/3/25 identified Resident #40 had a facility acquired stage 3…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-04-08 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, facility documentation, and staff interviews for one of six residents (Resident #40) reviewed for abuse, the facility failed to ensure the medical record was complete and accurate to include timely documentation of an APRN visit. The findings include: Resident #40 had a diagnosis of hemiplegia/ hemiparesis (weakness/paralysis) of the right dominant side, and aphasia. The annual MDS dated [DATE] identified severely impaired cognitive skills, required assistance with ADLs, and was always incontinent of bladder and bowel. The Resident Care Plan (RCP) dated 2/3/2025 identified alteration in ADLs, and incontinence. Interviews directed to assist with ADLs and provide incontinent care. A facility incident report dated 3/10/2025 at 12 noon identified on 3/8/2025 at approximately 1:30 PM, LPN #1 identified when LPN #1 was providing treatments when he identified Resident #40 had not received timely incontinent care. Interview and record review with the DNS on 3/28/2025 at 9:32 AM identified care…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-08 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, facility documentation, facility policy and staff interviews for 1 of 8 residents (Resident #9) reviewed for accidents, for 1 of 4 residents reviewed for resident to resident altercations (Resident #59 and Resident #81) and for four of eight residents (Residents #27, #40, #62 and #99) reviewed for abuse, the facility failed to ensure Registered Nurse (RN) assessments were completed timely. The findings include: 1. Resident #9 was admitted to the facility in October of 2024 with diagnoses that included hemiplegia (one sided muscle paralysis) affecting the right dominant side, hypertension, and diabetes. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #9 was cognitively intact, was dependent on staff for toileting and required maximum assistance for personal hygiene and bed mobility and transfers. The MDS further identified Resident #9 with an impairment on one side of his/her upper extremity and lower extremities and used a walker and wheelchair for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-01 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, facility policies, and interviews for one (1) of two (2) sampled residents (Resident #2) who was reviewed for an allegation of resident-to-resident abuse, the facility failed to ensure the resident was free from physical abuse. The findings include: Resident #1's diagnoses included dementia with psychosis, craniotomy for temporal lobe tumor, anxiety disorder, and depression. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 was alert and oriented and was independent for mobility with an assistive device. The Resident Care Plan dated 9/4/24 identified Resident #1 was currently taking antidepressants, antipsychotic, and psychotropic medications. Interventions directed to monitor and record occurrences for target behavior symptoms of hallucinations and document per facility protocol, administer medications as ordered by the physician and monitor for any adverse reactions, and psychiatric evaluations as needed. Resident #2's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-08-11 · tag F0687 — failed to care for feet properly — patternProvide appropriate foot care.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record review, facility documentation, facility policy, and interviews for one sampled resident (Resident #10) reviewed for foot care, the facility failed to provide podiatry care to a diabetic resident in a timely manner. The findings included: Resident #10 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, non-insulin dependent diabetes, and atrial fibrillation. Physician's order dated 7/19/22 directed Resident #10 should have podiatry consult/care as needed, and that body audits were to be completed weekly on shower days (Tuesdays). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #10 was cognitively intact and required one-person physical assist with dressing and personal hygiene. The Resident Care Plan (RCP) dated 8/4/22 identified Resident #10 had a diagnoses of diabetes with interventions that included podiatry consults as ordered and skin audits per facility protocol. The Treatment…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2022-08-11 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure 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 observation, review of the clinical record, facility documentation, facility policy, and interviews for 2 of 3 Residents (Resident #19 and Resident #96) reviewed for accidents, the facility failed to follow manufacturer recommendations for the use of a Wanderguard and complete accurate wandering/elopement assessments. The findings include: 1. Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #19), the facility failed to ensure a physician ' s order was clarified for the use of a wandering device when checking function according to physician orders and failed to ensure a resident was assessed for elopement risk according to scope of practice. The findings include: Resident #19 was admitted with diagnoses that included bipolar disorder, psychotic disorder with delusions and hemiplegia. An Elopement Risk Screen dated [DATE] identified a score of 3 indicating Resident #19 was at risk for elopement. A quarterly Minimum Data Set…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-08-11 · tag F0756 — failed to review each resident's drug regimen — patternEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
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 record review and staff interview for 1 of 5 sampled residents reviewed (Resident #21) for unnecessary medication, the facility failed to ensure the MD/APRN responded to pharmacy recommendations in a timely manner and failed to ensure an Abnormal Involuntary Movement Scale (AIMS) was completed every 6 months for a resident receiving an antipsychotic medication. The findings include: Resident #21's diagnoses included dementia with behavioral disturbances, anxiety, depressive episodes, diabetes, and insomnia. Physician's order dated 1/22/21 directed Atorvastatin Calcium (a medication to treat abnormal lipid levels) 80 mg once a day and Quetiapine Fumarate (Seroquel) 25 mg (an antipsychotic medication). Physician's order dated 3/3/21 directed Gabapentin (a medication to treat nerve pain) 300 mg three times a day and Magnesium Oxide (a dietary supplement) 400 mg once in the morning. Physician's order dated 3/11/21 directed Niferex (Iron Combinations) 150 mg twice daily for anemia. Physician's order dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-08-11 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, review of facility documentation, and interviews, the facility failed to ensure Dietary staff wore a beard restraint when working in the kitchen and the facility failed to maintain the kitchen in a clean and sanitary manner. The findings include: 1. Observation on 8/8/22 at 10:22 AM with the FSD (Food Service Director) identified Dietary Aide (DA) #1 had full facial beard while working in the kitchen without the benefit of a beard restraint covering the beard. Interview with DA #1 on 8/8/22 at 10:23 AM identified he had been employed by the facility for 19 years and was not aware that he had to wear a beard restraint when working in the kitchen. Interview with the FSD on 8/8/22 at 10:35 AM identified the previous Dietary Regional Manager for said the male staff did not have to wear beard guards. Review of the facility uniform policy directed to minimize risk of contamination from street clothes, and to maintain a professional appearance about the department. The uniform will be the responsibility of the employee. [NAME] guards will be worn at the discretion 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.
- Potential for harm · E2022-08-11 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of facility documentation, facility policy, and interviews, the facility failed to perform hand hygiene and implement facial masking practices according to infection control standards. The findings include: a. Observation on 8/9/22 at 8:19 AM identified LPN #1 exiting room [ROOM NUMBER] with one gloved hand carrying a needle. LPN #1 discarded the needle in the hazardous waste container, removed the glove and proceeded to handle the computer mouse with the same previously gloved hand without first performing hand hygiene. An interview on 8/9/22 at 8:19 AM with LPN #1 identified she should have performed hand hygiene after discarding her glove. The facility policy for Hand Hygiene directs to perform alcohol-based hand sanitizer after removing gloves. b. An observation on 8/10/22 at 5:50 AM identified LPN #3 was standing at the medication cart without the benefit of a surgical mask or face shield. An interview on 8/10/22 at 5:50 AM with LPN #3 identified her surgical mask was in 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.
- Potential for harm · D2022-08-11 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 8 residents (Resident #78) reviewed for code status (the level of medical intervention a person wishes to have started if their heart or breathing were to stop), the facility failed to obtain and verify Resident #78's code status with the responsible party on admission. The findings include: Resident #78 was admitted to the facility on [DATE] with diagnoses that included hemiplegia, tracheostomy, and encephalopathy. A Hospital Discharge summary dated [DATE] did not address the code status for Resident #78. The baseline Resident Care Plan (RCP) dated [DATE] identified Resident #78 wished to receive CPR with interventions that included to review advanced directives with the resident and/or health care decision maker quarterly and to support Resident #78's decision for CPR (but failed to identify any discussions were conducted with Resident #78's responsible party to verify code status). A physician's order…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-08-11 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, review of facility documentation, policy and interview for 1 sampled resident (Resident #56) reviewed for an injury of unknown origin, the facility failed to ensure an injury of unknown origin was reported to the State Agency. The findings include: Resident #56's diagnoses included vascular dementia with behavioral disturbance, osteoarthritis and adult failure to thrive. The Quarterly Minimum Data Set assessment dated [DATE] identified Resident #56 was severely cognitively impaired and required total 1 to 2 person assistance with all activities of daily living (ADL's). The Resident Care Plan dated 6/23/22 identified Resident #56 was at risk for alteration in skin integrity due to decreased mobility, incontinence, and age-related skin fragility. Interventions included to inspect skin for redness, irritation or breakdown during care and to complete weekly skin inspections. Physician's orders dated 7/7/22 directed activity level as bed mobility with extensive 1…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-08-11 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for 2 of 2 residents (Resident #40 and Resident #262) reviewed for resident to resident altercations, the facility failed to implement the plan of care to ensure a resident with a previous history of physical mistreatment by another resident (Resident #262) was kept separated from that resident, which resulted in a second incident of a resident to resident altercation. The findings include: 1. Resident #40 was admitted with diagnoses that included traumatic brain injury, hemiplegia, and dementia. A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #40 was severely cognitively impaired, required extensive one person assistance with bed mobility, transfers, and locomotion on the unit with the use of a walker or wheelchair. A Resident Care Plan (RCP) dated 12/23/21 identified Resident #40 had an activities of daily living (ADL) deficit related to having a traumatic brain injury and hemiplegia…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-08-11 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, review of facility documentation, policy and interview for 1 sampled resident (Resident #56) reviewed for an injury of unknown origin, the facility failed to ensure Registered Nurse (RN) #2 documented an assessment of a bruise after the area was assessed per standards of practice. The findings include: Resident #56's diagnoses included vascular dementia with behavioral disturbance, osteoarthritis and adult failure to thrive. The Quarterly Minimum Data Set assessment dated [DATE] identified Resident #56 was severely cognitively impaired and required total 1 to 2 person assistance with all activities of daily living (ADL's). The Resident Care Plan dated 6/23/22 identified Resident #56 was at risk for alteration in skin integrity due to decreased mobility, incontinence, and age-related skin fragility. Interventions included to inspect skin for redness, irritation or breakdown during care and to complete weekly skin inspections. Physician's orders dated 7/7/22…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-08-11 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #1) reviewed for nutrition and for 1 resident (Resident #22) reviewed for dialysis, the facility failed to ensure weights were obtained timely for a resident with a newly placed gastrostomy feeding tube (Resident #1) and failed to ensure the intake records were accurate and totaled each day for a resident on a fluid restriction (Resident #22). The findings include: 1. Resident # 1's diagnoses included cerebral infarction (stroke), dysphagia, lack of coordination, weakness, and required a gastrostomy feeding tube placement during hospitalization from 4/5/22 to 4/28/22. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was moderately cognitively impaired and required assistance of 2 with mobility, transfers, dressing and transfers. The MDS further identified Resident #1 required assistance of 1 for toilet use and received 51% or more of total calories…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-08-11 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #44) reviewed for respiratory care, the facility failed to ensure oxygen tubing was labeled and dated when changed per policy. The findings include: Resident #44's diagnoses included chronic obstructive pulmonary disease (COPD) and chronic respiratory failure. The quarterly MDS assessment dated [DATE] identified Resident #44 had moderately impaired cognition and required limited assistance for dressing, toilet use, and transferred with 1-person physical assist. Additionally, the MDS identified Resident #44 required oxygen therapy. The Resident Care Plan dated 6/9/22 identified Resident #44 had a diagnosis of Chronic Obstructive Pulmonary Disease (COPD). Interventions included to administer oxygen and monitor effectiveness by checking saturation if indicated. A physician's order dated 6/6/22 directed supplemental oxygen via nasal cannula at 1 to 2 liters per minute to keep…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-10-30 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each 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 observation, review of the clinical record, review of facility policy, and interviews for one sampled resident (Resident #100) reviewed for accommodation of needs, the facility failed to ensure a call light was accessible to a resident with paraparesis. The findings include: Resident #100 was admitted to the facility on [DATE] with diagnoses that included paraplegia, thoracic spinal cord injury, neuralgia, neuritis, and diabetes. The care plan dated 10/6/19 identified Resident #100 required assistance with activities of daily living due to bilateral upper extremity weakness, coordination deficits, and lower extremity weakness. Interventions directed to maintain autonomy to the highest possible level. A physician's order dated 10/6/19 directed to provide assistance with activities of daily living and the use of assistive devices with meals. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #100 was without impaired cognition and required extensive assistance with 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.
- Potential for harm · Dcited before2019-10-30 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, review of facility documentation, review of facility policy, and interviews, for one of seven sampled residents (Resident #32) reviewed for accidents, the facility failed to administer oxygen when the saturation level was low. The findings include: Resident #32 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, unspecified asthma, repeated falls, and weakness. A physician's order dated 7/1/19 directed to ambulate with rolling walker and limited assist of one. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #32 had impaired short and long term memory and required extensive assistance with toilet use and dressing. The Resident Care Plan (RCP) dated 7/13/19 identified Resident #32 was at risk for falls with interventions that directed to not leave the resident alone in the bathroom, leave walker at bedside, and place call light within reach. A review of the facility's reportable…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-10-30 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 b. Resident #19 was admitted to the facility on [DATE] with diagnoses that included ataxia, stiffness of the right and left hand, and contracture of the muscle in the right lower leg. A fall risk assessment dated [DATE] identified Resident #19 was at a risk for falls. The Nurse Aide Care Card dated 6/7/19 identified Resident #19 required total assistance with bathing and in addition if the resident was resistive to bathing, tell nurse and try again later. A physician's order dated 8/2/19 directed for dressing and bathing Resident #19 required assistance of two. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #19 had short and long term memory problems and required extensive assistance with dressing, transfers, and personal hygiene. The Resident Care Plan (RCP) dated 8/10/19 identified Resident #19 required assistance with functional care. Interventions directed to provide extensive assistance of two with dressing and bathing. The nurse's note dated 8/22/19 identified Resident #19…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-10-30 · tag F0791 — failed to provide routine dental services — isolatedProvide or obtain dental services for each 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 observation, review of the clinical record, review of facility documentation, and interviews, for one of two residents reviewed for dental services (Resident #11), the facility failed to ensure timely follow up when the resident's upper dentures were lost at the facility. The findings include: Resident #11 was admitted on [DATE] with diagnoses that included dementia. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #11 had severely impaired cognition, required supervision for personal hygiene, and had no dental problems. The care plan dated 8/13/19 identified Resident #11 had an Activities of Daily Living (ADL's) deficit related to dementia with interventions that included to assist with ADL's. Physician's orders dated 9/1/19 directed Consult: Dental care as needed. A report of missing property form completed by Licensed Practical Nurse (LPN) #3, dated 9/20/19, identified that Resident #11 was missing his/her partial bridge and a search of room and pockets was done.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · B2025-04-08 · tag F0644 — patternCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 2 residents (Resident #83) reviewed for Preadmission Screening and Resident Review (PASRR), the facility failed to refer Resident #83 for a Level II PASRR evaluation after identifying a new mental disorder. The findings include: Resident #83 was admitted to the facility in January 2023 with diagnoses that included a cerebral infarction affecting right dominant side and Parkinson's disease. Upon admission to the facility, there was no mental disorder diagnoses identified. A PASRR Level I screen dated 1/11/23 identified that a Level II PASRR screening was not required because there was no evidence of a PASRR condition of an intellectual/developmental disability or a serious behavior health condition. Additionally, it identified if changes were to occur or new information refuted those findings, a new screening must be submitted. An Advanced Practice Registered Nurse (APRN) note dated 5/26/23 identified Resident #83 with a new diagnosis of psychotic disorder with delusions due 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.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to NATIONAL HEALTH CARE ASSOCIATES — 42 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 3.2 | -0.2 vs chain |
| Health inspection | 2 of 5 | 2.8 | -0.8 vs chain |
| Staffing | 4 of 5 | 3.0 | +1.0 vs chain |
| Quality measures | 5 of 5 | 4.1 | +0.9 vs chain |
The other 41 homes this chain runs (chain average 3.2★, per CMS)
Showing 40 of 41; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| BG II OPCO ML LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 10/10/2024 |
| CEDAR HILL CAPITAL ASSOCIATES LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; 5% OR GREATER SECURITY INTEREST; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 10/10/2024 |
| DYMER HOLDINGS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 10/10/2024 |
| ILANA OSTREICHER FAMILY TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; 5% OR GREATER SECURITY INTEREST; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 10/10/2024 |
| JUNIPER CAPITAL ASSOCIATES LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; 5% OR GREATER SECURITY INTEREST; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 10/10/2024 |
| MARC EPHRAM OSTREICHER FAMILY TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; 5% OR GREATER SECURITY INTEREST; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 10/10/2024 |
| OAK MANAGEMENT CAPITAL LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; 5% OR GREATER SECURITY INTEREST | NO PERCENTAGE PROVIDED | since 10/10/2024 |
| YSRO TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; 5% OR GREATER SECURITY INTEREST | NO PERCENTAGE PROVIDED | since 10/10/2024 |
| ZADUN II HOLDINGS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 10/10/2024 |
| EHRENFELD, MINDY | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 10/10/2024 |
| MASTER TENANT HOLDCO CT5 II LLC | Organization | 5% OR GREATER SECURITY INTEREST; ADP OF THE SNF | — | since 10/10/2024 |
| OSTREICHER, MARC | Individual | 5% OR GREATER SECURITY INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/10/2024 |
| NATIONAL HEALTH CARE ASSOCIATES INC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 12/10/2024 |
| CANNAVARO, CAITLIN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 12/31/2024 |
| GILMARTIN, THOMAS | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 12/04/2024 |
| BAKER TILLY ADVISORY GROUP LP | Organization | ADP OF THE SNF | — | since 12/10/2024 |
| PREFERRED THERAPY SOLUTIONS LLC | Organization | ADP OF THE SNF | — | since 12/10/2024 |
| PROCARE LTC HOLDING LLC | Organization | ADP OF THE SNF | — | since 12/10/2024 |
| BERMAN, EDWARD | Individual | ADP OF THE SNF | — | since 12/31/2024 |
| OSTREICHER, ILANA | Individual | ADP OF THE SNF | — | since 12/04/2024 |
CMS files one row per role, so the 36 rows in the source record cover these 20 parties — each is shown once here with every role it holds. Nothing is omitted.
14 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 78% 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 $2.7M paid to related parties — landlords or management companies under common ownership — equal to about 18% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in CT
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Connecticut Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 075395. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-08, 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.