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Sharon Center For Health & Rehabilitation

27 Hospital Hill Road, Sharon, CT 06069 · For profit - Corporation · 88 certified beds · (860) 364-1002 Medicare & Medicaid certified

Call the home — (860) 364-1002 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citations on record (F0600, F0603) — most recent Aug 20251 immediate-jeopardy citation CMS recorded as corrected before the inspection ended (past non-compliance)
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (5/5)
  • lower-than-typical staff turnover (31% vs 45% nationally) — better care continuity
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has abuse, neglect, or exploitation citations (F0600, F0603) — most recent Aug 2025
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (35) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing score sits well above its independent inspection score

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.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 5 of 5
Quality measuresSelf-reported by the facility 3 of 5

Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★★★ 5/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
29 Hospital Hill Rd · (860) 364-7029 · Call to confirm hours
Pharmacy
8 Gay St · (860) 364-5272 · Call to confirm hours
Grocery
10 Gay St · (860) 397-5161 · Call to confirm hours
Park
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 3 of 5
Long-stay residentspeople who live here 3 of 5
Short-stay residentsrehab / post-hospital 4 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 4 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 rating4★
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 increased9.8%18.0%15.4%better
Long-stay residents who lose too much weight7.4%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 symptoms2.3%22.3%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury1.6%3.5%3.3%better
Long-stay residents whose ability to walk worsened11.2%16.4%16.1%better
Long-stay residents on antianxiety or hypnotic medication22.8%17.6%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%93.5%95.3%typical
Long-stay residents with pressure ulcers5.7%4.0%4.7%worse
Long-stay residents with worsening bladder/bowel control20.0%24.7%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table31.6%17.8%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.0%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine82.1%69.7%79.4%typical
Short-stay residents rehospitalized after admission24.5%24.3%22.6%typical
Short-stay residents with an outpatient ER visit22.5%10.7%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.102.061.67worse
Long-stay outpatient ER visits per 1,000 resident days2.871.461.80worse

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.

59.1% 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 130 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

59.1%U.S. median 51.5%
Got home and stayed home
10.3%U.S. median 10.7%
Went back to hospital
61.9%U.S. median 56.6%
Met the expected recovery
0.20U.S. median 0.31
Therapy hours / resident / day
0.08hours / resident / day
Physical therapy
0.12hours / resident / day
Occupational therapy
<0.01hours / resident / day
Speech therapy

Met the expected recovery: 61.9% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 42 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 23% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 29% 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 SNF59.1%CMS range 50.4–65.451.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.3%CMS range 7.5–14.310.7%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 discharge61.9%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge45.2%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 discharge47.6%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 worsened1.1%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.1%CMS range 4.1–11.87.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.001.02Oct 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

0.75
RN hours/ resident / day
0.85
LPN hours/ resident / day
1.95
Aide hours/ resident / day
3.55
Total nurse hours/ resident / day
0.60
RN hoursweekends
31.4%
Total nursing turnover
20.0%
RN turnover

How full it usually is: this home is certified for 88 beds and averages 79.4 residents a day — about 90% occupied, or roughly 9 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 3.55 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.75 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.95 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 3.25 hrs/resident/day on weekends vs 3.67 on weekdays — 11% thinner on weekends. RN hours go from 0.81 to 0.60 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

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

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

Inspection trend

10
deficiencies at the latest standard inspection (2025-08-29)
17
at the previous standard inspection (2023-08-23)

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.

35 citations, most serious first. The 11 most serious are shown; the remaining 24 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2026-04-27 · 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 clinical record review, facility documentation review, facility policy review, and staff interviews for one of three residents (Resident #1) reviewed for accident hazards and supervision, the facility failed to ensure adequate supervision of a resident with moderate cognitive impairment and an unsteady gait requiring walker-assisted ambulation, failed to accurately assess elopement risk despite a BIMS score of 9 indicating moderate cognitive impairment, and failed to ensure staff responded appropriately to an activated exit door alarm by searching for a resident or notifying the supervisor prior to deactivation. On 3/30/2026, Resident #1 exited the facility undetected, walked 0.3 miles on a two-way street without sidewalks or a crosswalk to the hospital emergency department, and remained unaccounted for by staff for one hour and 45 minutes. Resident #1 was on Apixaban (a blood thinner increasing the risk of serious bleeding from falls or trauma), was confirmed by the hospital to be confused 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.

    Quality of Life and Care Deficiencies · Past Non-Compliance
  • Potential for harm · Ecited before2025-08-29 · tag F0756 — failed to review each resident's drug regimen — pattern
    Ensure 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 clinical record review, facility documentation, facility policy and staff interviews for 1 of 5 residents (Resident #1) reviewed for unnecessary medications, the facility failed to review and respond to pharmacy recommendations in a timely manner. The findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses that included dementia, diabetes, and hypertension.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was severely cognitively impaired, dependent on bathing, and personal hygiene. Also, identified Resident #1 required maximal assistance for toileting, dressing and partial moderate assistance for transfers. Further, identifying Resident #1 required set-up assistance for eating.A physician order dated 11/13/24 directed to administer Rexulti (an antipsychotic medication used to treat agitation associated with dementia) 0.5 milligram (mg) tablet every evening.A pharmacy medication review dated 12/6/24 recommended since Resident #1 was started…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-08-29 · tag F0806 — failed to honor food preferences — pattern
    Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
    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 that the correct portion of chicken was served, and corn bread or a similar substitute was provided per facility menu. The findings include: Observation of the lunch menu for 8/25/25 identified 4 oz of chicken and cornbread was to be served.a. Observations in the [NAME] Unit dining room on 8/25/25 at 12:15 PM noted that Resident #13 did not have any protein with his/her lunch meal. Resident #13 was asked if he/she wanted any chicken with lunch by the surveyor. Resident #13 responded that he/she would like chicken. Dietary Aid (DA) #1 responded, we don't have any more chicken. DA #1 did not offer an alternative and/or provide Resident #13 with any protein with his/her meal. Further observation on 8/25/25 at 12:30 PM in the [NAME] Wing dining room noted that 7 small chicken legs were served to residents out of the 11 residents in the [NAME] Wing dining room. Two residents were served an alternative (sandwich) and 2 residents had puree consistency meal. Resident #19 who was 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-08-29 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, review of the clinical record, and facility policy for 3 of 5 residents (Resident #1, Resident #34 and Resident #54) reviewed for infection control, the facility failed to maintain proper infection control techniques regarding social distancing (Resident #1 and Resident #34) and Enhanced Barrier Precautions (EBP) when entering a room of a resident on droplet precautions (Resident #54). The findings include: 1.Resident #1 had diagnoses that included COVID-19, dementia, and diabetes. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was severely cognitively impaired, used a walker, required setup or clean-up assistance with eating, was independent with bed/chair transfers, and required supervision or touching assistance with walking. The Resident Care Plan (RCP) dated 8/23/25 identified Resident #1 was confirmed to have COVID-19 virus. Interventions included to assist Resident #1 with application of face mask as needed and place Resident #1 on…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-29 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    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, interviews and facility policy for 1 of 2 sampled residents observed with medication at the bedside (Resident #50), the facility failed to ensure Resident #50 was assessed and had a physician order to self-administer medication. The findings include: Resident #50's diagnoses included chronic obstructive pulmonary disease (COPD).A physician's order dated 3/25/24 and currently in effect directed ProAir HFA (a bronchodilator used to treat asthma) aerosol solution 108 micrograms (mcg)/act 2 puffs inhaled orally every 6 hours for shortness of breath.The Resident Care Plan (RCP) dated 1/9/25 identified that Resident #50 had an altered respiratory status/difficulty breathing related to COPD. Interventions included administering medications per the physician's order and monitoring for effectiveness/side effects.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #50 was cognitively intact and independent with bed mobility, transfers, and toileting.On 8/26/25 at…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-29 · tag F0603 — failed to not confine residents against their will — isolated
    Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
    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 3 sampled residents reviewed for wounds, the facility failed to ensure Resident #46 was placed on the correct precautions to prevent Resident #46 from being confined to his/her room. The findings include: Resident #46's diagnoses included non-pressure chronic ulcer of right foot with unspecified severity and Type 2 diabetes. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #46 was cognitively intact and required moderate assistance of 1 staff member with activities of daily living.The Resident Care Plan (RCP) dated 7/22/25 identified Resident #46 was on Enhanced Barrier Precautions (EBP) for wounds and indwelling medical devices (intravenous catheter). Interventions included applying personal protective equipment (PPE) when providing high contact care activities.A physician's order dated 8/12/25 directed to apply Mupriocin external ointment (a topical antibiotic used to treat bacterial…

    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 before2025-08-29 · 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 observation, interviews and facility policy for 1 of 2 sampled residents (Resident #48) observed with medication at the bedside, the facility failed to ensure licensed staff followed standards of practice for medication administration and remained with the resident until medication was consumed. The findings include: Resident #48 was admitted to the facility on [DATE] with diagnoses that included congestive heart failure, hypertension, and atrial fibrillation. A physician's order date 8/14/25 directed to administer Metoprolol Tartrate 12.5 mg (milligrams) two times a day for blood pressure, Spironolactone 25 mg once a day for heart failure, Isosorbide Mononitrate ER (extended release) 30 mg one a day for blood pressure, Lorestan Potassium 25 mg two times a day for blood pressure and Aspirin 81 mg in the morning for surgical aftercare.A Resident Care Plan dated 8/17/25 did not reflect that Resident #48 may self-administer medication and/or had been assessed for self-administration of medications.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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-29 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility policy and interviews for 1 of 3 residents (Resident #10) reviewed for pressure ulcer/injury, the facility failed to obtain a timely nutritional evaluation for a resident with a new and worsening wound. The findings include: Resident #10 had diagnoses that included epilepsy (seizure disorder), dementia, and leukoencephalopathy (brain disease that damages the white matter which is responsible for communication between different brain regions).The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #10 was moderately cognitively impaired, at risk for developing pressure ulcer/injury, and was dependent for eating, bed mobility, and transfers.A physician order dated 4/1/25 directed to provide Thrive ice cream (protein rich ice cream) 2 times a day with lunch and dinner for weight loss related to variable oral intake.A Nutritional Evaluation written by Dietician #1 on 4/1/25 at 1:40 PM identified Resident #10 met 51 percent (%) to75% of his/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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-08-29 · 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 Top of FormBased on observations, clinical record review, review of facility documentation, review of facility policy and interviews for the only sampled resident reviewed for respiratory care (Resident #85), the facility failed to follow a physician's order for oxygen administration and failed to ensure oxygen was administered to a resident on continuous oxygen with a diagnoses of chronic obstructive pulmonary disease (COPD). The findings include: Top of FormResident #85's diagnoses included COPD, dependence on supplemental oxygen (O2), and shortness of breath (SOB). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #85 was cognitively intact and required substantial/maximal assistance with bed mobility and full assistance with toileting and transfers. The MDS also indicated Resident #85 had a diagnosis of COPD and was dependent on supplemental O2. A Resident Care Plan (RCP) dated 6/27/25 identified Resident #85 had the potential for alteration in respiratory status 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-07 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for abuse, the facility failed to ensure a resident was treated in a respectful and dignified manner. The findings include: Resident #1 had diagnoses that included anxiety, tobacco use, and moderate dementia with psychotic disturbance. The quarterly MDS dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of fifteen (15) indicative of intact cognition, without the presence of behaviors, continent of bowel and bladder, independent with ADLs and ambulation. The care plan dated 12/10/24 identified Resident #1 is a current smoker with interventions that directed cigarettes and/or lighting material to be given by nursing at the designated times. The physician's orders dated 12/19/24 directed Resident #1 is permitted to smoke during designated smoking times only. Review of the facility's reportable event form dated 1/17/25 at 7:35…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-20 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, facility policy review, and interviews for one of two residents (Resident #2) reviewed for quality of care, the facility failed to honor a resident's advance directives following a change in condition. The findings include: Resident #2's diagnoses included dementia with psychotic disturbances, atrial fibrillation, and malignant neoplasm of prostate. Record review identified Person #1 was Resident #2's court appointed Conservator (COP) for health care decisions. Physician orders dated [DATE] directed Resident #1's code status was a full code. Resident #1 to receive CPR (cardiopulmonary resuscitation). The Resident Care Plan (RCP) dated [DATE] identified Resident #2 had an established advance directive and wished to receive CPR (cardiopulmonary resuscitation). Interventions directed to review advance directives with resident and/or healthcare decision maker quarterly, and support the resident's decision for CPR. The admission Minimum Data Set (MDS)…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 24 citations
  • Potential for harm · Dcited before2024-08-20 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure 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 clinical record review, facility documentation review, facility policy review, and interviews for one of two residents (Resident #1) reviewed for quality of care, the facility failed to monitor the resident's behaviors for a resident receiving antipsychotic medications. The findings include: Resident #1's diagnoses included dementia with behavioral disturbances, major depressive disorder, post-traumatic stress disorder, and anxiety disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 as alert and oriented, and received antipsychotic medications on a routine basis in the prior seven (7) days. The Resident Care Plan (RCP) dated 1/9/2024 identified Resident #1 had the potential to be verbally abusive due to dementia. Interventions directed to monitor behaviors. Physician orders dated 1/23/2024 directed to administer Quetiapine Fumarate (anti-psychotic) 50 milligrams (mg) at 9:00 AM and 100 mg at 8:00 PM, for dementia with behavioral disturbances. Review 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-08-23 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure 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 of the noon meal, clinical record review, review of facility policy and staff interviews, the facility failed to ensure food was served in a manner that contained nutritive value, flavor and was not burned and for (Resident #34), the facility failed to ensure ice cream was not served in a softened form. The findings included: 1. During the noon meal a lunch test tray was ordered from the kitchen on 8/21/23 which consisted of breaded chicken with a side of potatoes and mixed vegetables. The meal served was warm, the chicken and potatoes were flavorful, however the vegetables were overcooked with some of the broccoli and green bean pieces burned. Interview with the Director of Dietary Services (DDS) on 8/22/23 at 11:55 AM indicated the steamer which was used to cook vegetables has been broken for five to six months, forcing staff to cook vegetables in the oven with some water in a pan. The DDS further indicated quality of the food served has diminished due to the alternate cooking method used. A lunch test tray was obtained from the steam table on 8/22/23 at…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-08-23 · 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 observations, facility policy, facility documentation, and interviews, the facility failed to contain food items appropriately in the dry storage room, to discard expired foods, to maintain their three-day emergency supply per menu and to complete daily temperature log sheets. The findings included: 1 a. During a tour of the kitchen with the Dietary Manager on 8/21/23 from 10:00 AM to 11:30 AM identified the following: .The small dry storage room located in the kitchen contained an expired jar of Admiration Maraschino Cherries (8/19/23), a container of Kikkoman Teriyaki Marinade and Sauce and a container of Kikkoman Less Sodium Soy Sauce that were opened and not refrigerated, expired vanilla pudding packets (5/16/23), expired chocolate pudding packets (5/17/23), expired butterscotch pudding and pie filling packets (11/24/21), expired gelatin dessert packets (6/3/21) and expired red assorted gelatin packets (6/3/21), an undated bag of cornflake cereal, an opened, undated, and open bag of croutons, a dented can of Northeast red and green pepper strips, and an opened bag of…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-23 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observations, review of facility policy and procedures and staff interview for 1 out of 3 sampled residents (Residents # 21) who required assistance with care, the facility failed to ensure that signs were not posted in resident's rooms that contained personal and confidential information regarding the resident's plan of care and treatment regimen within eyesight of public view. The findings include: Resident # 21's diagnoses included cerebral infraction with hemiplegia and hemiparesis, dysphagia, heart failure and osteoarthritis. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident # 21 had severe cognitive impairment and required extensive assistance with bed mobility, dressing, eating and personal hygiene. The Resident Care Plan (RCP ) dated 6/22/23 identified Resident #21 with Activity of Daily Living (ADL) deficit. Interventions directed to encourage self-performance, praise all attempts, allow sufficient time for task completion, and assist 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-08-23 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, review of facility documentation, facility policy and staff interviews for 1 of 2 sampled residents (Resident #11) who was reviewed for Accidents/Falls, the facility failed to follow physician's orders and for 1 sampled resident (Resident #473) receiving antiviral medication to treat COVID-19, the facility failed to ensure that verbal medication order was transcribed to a written order in the resident's clinical record per facility policy and to meet professional standards. The findings included: 1. Resident #11's diagnoses included dementia, history of falling, unsteadiness on feet, and muscle weakness. A physician's order dated 4/1/2023 directed to check for placement of pressure alarm and function of bathroom alarm at shift changes every shift. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #11 was severely cognitively impaired and required extensive assistance with bed mobility, transfers, and toilet use. The Resident Care Plan dated 8/16/23…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-23 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility documentation and staff interviews for 1 sampled resident (Resident #473) receiving antiviral medication to treat COVID-19, the facility failed to administer medications as ordered by the physician. The findings include: Resident #473's diagnoses included COVID-19, atrial fibrillation, congestive heart failure, chronic ischemic heart disease, chronic kidney disease, diabetes mellitus, and hypertension. The admission assessment dated [DATE] identified Resident #473 was alert and oriented to person, place, and time, and required assistance with transfer, bed mobility and ambulation. The nurse's note dated 8/16/23 identified Resident #473's COVID-19 swab results were positive. The Resident Care Plan dated 8/16/23 identified Resident #473 had actual COVID-19 infection. Interventions directed to provide transmission-based precautions as ordered and directed a follow up with the Medical Doctor (MD) / Advanced Practice Registered Nurse (APRN) as indicated. 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-08-23 · 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 clinical record reviews, observations, facility documentation, facility policy and interviews for 1 of 7 sampled residents (Resident #624) reviewed for accidents and education regarding water temperature monitoring in resident rooms, and for 1 of 3 residents reviewed for smoking (Resident #37), the facility failed to ensure a portable oxygen delivery device was secured to the adaptive equipment used for ambulation to prevent an accident with a injury, failed to ensure staff was educated regarding acceptable water temperature levels in resident rooms and how to proceed if temperatures were out of normal range, failed ensure a smoking receptacle was within reach and failed to attempt to provide assistance with re-applying a smoking apron during a smoking session. The findings included: 1. Resident #624's diagnoses included malignant neoplasm of the lung, chronic obstructive pulmonary disease, and dementia. The admission Minimum Data Set assessment dated [DATE] identified Resident #624 had some short- 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-08-23 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, and interviews for 1 of 6 sampled residents (Resident #49) reviewed for nutrition, the facility failed to obtain weekly weights as ordered by the physician. The findings include: Resident # 49's diagnosis included unspecified dementia, depressive episodes and feeding difficulties. A review of Resident # 49's weight record identified on 2/1/23 the resident weighed 128 pounds. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #49 as severely cognitively impaired and required extensive assistance of two staff members for transfer. A physician's order dated 3/24/2023 directed to obtain weekly weights every Tuesday until 4/18/2023. The care plan dated 4/6/2023 indicated Resident #49 required a therapeutic diet, had poor oral intake and weight loss. The interventions included in part to monitor the resident's weight as needed. A physician's order dated 4/20/2023 directed to obtain weekly weights every Wednesday until 5/17/2023. Interview and review 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-08-23 · 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 observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #13) reviewed for respiratory therapy, the facility failed to ensure that portable oxygen tanks contained oxygen. The findings include: Resident #13 was admitted to the facility with diagnoses that included dependence on supplemental oxygen, chronic obstructive pulmonary disease, cardiomegaly, and anxiety. A physician's order dated 6/24/20 to present directed supplemental oxygen via nasal cannula at 2 Liters per minute. A physician's order dated 6/24/20 to present directed that pulse oximetry be checked every shift to maintain oxygen saturation greater than or equal to 92%. A physician's order dated 12/8/22 to present directed that the oxygen and tank be checked every shift and to check oxygen saturation one time a day while awake. The annual MDS assessment dated [DATE] identified Resident #13 had moderately impaired cognition and required extensive assistance with dressing 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-23 · tag F0810 — isolated
    Provide special eating equipment and utensils for residents who need them and appropriate assistance.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review and interview for 1 of 5 residents (Resident #32) observed during the dining initial screening, the facility failed to provide the resident with an assistive device for beverage as prescribed. The findings included: Resident #32 diagnoses included dementia, dysphagia, and lack of coordination. A physician's order dated 6/9/22 directed a two handled mug with spout lid. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #32 as severely cognitively impaired and required limited assistance with eating. Resident #32's care plan dated 8/10/22 identified an activity of daily living deficit related to generalized weakness, risk of dehydration related to cognitive deficit, and a potential for impaired nutrition status due to dysphagia/aspiration risk. Interventions included providing a 2 handled mug with spout lid, offering small amounts of fluid frequently, and maintaining aspiration precautions for all solid/beverage intakes. Observation and interview…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-23 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation and staff interview for 1 of 1 sampled resident (Resident #58) reviewed for end of life, the facility failed to ensure the medical record was complete. The findings include: Resident #58's diagnoses included: Chronic Obstructive Pulmonary Disease (COPD), Heart Failure, and Protein Calorie Malnutrition. The Resident Care Plans dated 2/2/23 and 10/4/22 had a terminal prognosis with a potential significant decline in all areas including comfort. Interventions included to assess, assist with coping strategies, respect of wishes, expression of feelings, listening with compassion, calm, quiet environment, monitor closely for signs of pain, goal of maximum comfort, providing privacy during visits, and working cooperatively with special services team. A quarterly MDS assessment dated [DATE], identified Resident #58 as alert and severely cognitively impaired, required extensive assistance of two for bed mobility, dressing, transfers, toilet use, personal hygiene,…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-23 · tag F0865 — failed to run a quality-improvement (QAPI) program — isolated
    Have a plan that describes the process for conducting QAPI and QAA activities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on a review of the facility Quality Assurance and Performance Improvement (QAPI), review of facility documentation, facility policy and interviews, the facility failed to maintain an effective QAPI program that met at least quarterly, develop, and implement appropriate plans of action to correct identified quality deficiencies. The findings include: a. On 8/23/23 at 1:50 PM a review of the facility Quality Assurance and Performance Improvement (QAPI) program and an interview with the Administrator identified although no QAPI signature sheets for meeting attendance could be found for topics of resident appointments mentioned. The agency staff was not reporting off duty in April 2021 in a Medical Staff meeting. July and August 2021 Medical staff meetings addressed topics of vaccines, abuse, and verbal altercations. The Administrator also indicated weight loss and skin issues along with falls were discussed but could not provide an attendance record. The Administrator further indicated that no signature sheets for QAPI attendance or action plans could be found for the year 2021.…

    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 · D2023-08-23 · tag F0867 — failed to act on quality-improvement findings — isolated
    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on a review of the facility Quality Assurance and Performance Improvement (QAPI), review of facility documentation and interviews, the facility failed to maintain an effective QAPI program that met at least quarterly, develop, and implement appropriate plans of action to correct identified quality deficiencies and obtain feedback from staff and residents. The findings include: The Administrator further indicated in an interview on 8/23/23 for the year of 2022 medical staff meeting topics included pressure ulcers, late reporting of assessments, weights and water pitcher were discussed However no signature sheets and no action plans could be found. The Administrator further indicated quality measures should be reviewed monthly, but staffing was an issue, and the Administrator and other staff were working on staffing the facility. The Administrator further indicated the facility had Administrators come and go during this time and that he/she was filling in temporarily and since started on July 17, 2023, and had a medical staff/ QAPI meeting on at time. Although, the Administrator…

    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 · Dcited before2023-08-23 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the facility Infection Control Program, observations, facility policy and interviews, the facility failed to ensure face masks were properly worn during a COVID-19 outbreak. The findings included: 1. An observation on 8/21/23 at 12:20 PM identified Nurse Aide (NA) #7 preparing to serve lunch to a resident in room [ROOM NUMBER]/219 with his/her face mask only covering his/her chin to upper lip area. NA #7 indicated he/she was required to wear a mask during COVID-19 outbreak, policy directed to apply mask to cover the nose to under the chin area. NA # 7 further indicated s/he did not realize his/her nostrils were uncovered. b. Observation on 8/21/23 at 12:21 PM identified Social Worker #1 at the elevator with his/her mask only covering his/her chin to upper lip area. SW #1 indicated a mask is required when there is a COVID-19 outbreak or when a resident was sick, policy directed to apply mask to cover the nose to under the chin area, and the reason her nose was not covered was because his/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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-23 · tag F0909 — failed to maintain a comfortable temperature — isolated
    Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, observations, facility documentation, facility policy and interviews for 2 of 2 sampled residents (Residents #11 and # 28) who were reviewed for accidents, the facility failed to ensure bedrails were securely attached to the resident's bed. The findings included: 1. Resident #11's diagnoses included dementia, history of falling, unsteadiness on feet, and muscle weakness. A physician's order dated 3/30/23 directed a quarter side rail to both sides of bed for mobility and transfers. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #11 was severely cognitively impaired and required extensive assistance with bed mobility, transfers, and toilet use. The Resident Care Plan dated 8/16/23 identified an activities of daily living deficit related to impaired cognition, noncompliance, and decreased mobility, and risk of falls secondary to cognitive impairment, shuffled gait, and noncompliance with safety measures. Interventions directed to provide assistance…

    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 · D2021-07-14 · 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 review, review of facility documentation, facility policy and interviews for 1 of 1 residents (Resident #37) reviewed for mistreatment, the facility failed to ensure Resident #37 was free from abuse. The findings include: Resident #37's diagnoses included dementia without behavioral disturbances, depression, difficulty walking, muscle weakness and osteoarthritis. A Resident Care Plan (RCP) dated 11/24/20 identified a problem with impaired cognition due to dementia with interventions to identify self, speak slowly/clearly and explain all procedures. A Quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #37 was severely cognitively impaired, requiring extensive assistance of 2 staff for bed mobility and toilet use, and assistance of 1 staff for personal hygiene. A RCP dated 12/30/20 identified Resident #37 had behavior and mood patterns of sadness, apathy, anxious and negative statements due to dementia. Interventions included to allow time for expression and to listen…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-07-14 · tag F0637 — isolated
    Assess the resident when there is a significant change in condition
    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 and interviews for one of three residents reviewed for Nutrition (Resident # 40), the facility failed to ensure a significant change Minimum Data Set (MDS) assessment was completed in a timely when the resident had a weight loss.The findings include: Resident # 40's diagnoses included dysphagia, acute kidney failure, muscle weakness and altered mental status. A review of the resident's admission assessment dated [DATE] identified the resident was 5 feet and 1 inch. The admission MDS assessment dated [DATE], completed by RN #3, identified the resident had severe cognitive impairment, required extensive assistance of two staff for bed mobility, required extensive assistance of one staff for eating, noted the resident's height as 61 inches tall [erroneous], weight 196 pounds, had not had weight loss or gain of 5% or more in the past month or 10% or more in the last 6 months and indicated Resident # 40 did not have any pressure ulcers. The nurse's notes dated 6/3/21 identified 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-07-14 · 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 clinical record review, observations, review of facility documentation, facility policy review, and interviews for one of three residents, (Resident #11), reviewed for Accidents, the facility failed to ensure the plan of care was implemented after a skin tear. The findings include: Resident #11's diagnoses included dementia without behavioral disturbances, protein calorie malnutrition, chronic congestive heart failure, anemia, anxiety, depression, dysphasia, psychotic disorders with hallucinations. The annual Minimum Data Set (MDS) quarterly assessment dated [DATE] identified the resident was severely cognitively impaired and indicated the resident required extensive assistance of two people for bed mobility and transfers. The annual Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #11 had a Brief Interview for Mental Status (BIMS) score of 4 out of fifteen, indicative of severe cognitive impairment and indicated the resident required extensive assistance with Activities of Daily…

    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 before2021-07-14 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, review of facility policy and interviews for one of three residents reviewed for Nutrition, (Resident # 40), the facility failed to ensure the resident's weight was monitored per facility policy and failed to ensure dietician recommendations were addressed or communicated in timely to ensure no further weight loss. The findings include: Resident # 40's diagnoses included dysphagia, acute kidney failure, muscle weakness and altered mental status. The admission MDS assessment dated [DATE], completed by RN #3, identified the resident had severe cognitive impairment, required extensive assistance of two staff for bed mobility, required extensive assistance of one staff for eating, noted the resident's height as 61 inches tall [erroneous], weight 196 pounds, had not had weight loss or gain of 5% or more in the past month or 10% or more in the last 6 months, and indicated Resident # 40 did not have any pressure ulcers. The nursing pressure ulcer evaluations dated 6/3/21…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2025-08-29 · tag F0730 — pattern
    Observe each nurse aide's job performance and give regular training.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of personnel files and staff interviews for 3 of 3 employee files reviewed (Nurse Aide (NA) #4, NA #5, and NA #6), the facility failed to ensure the required annual performance evaluations were completed. The findings include:: 1. NA #4's date of hire was 8/27/13. The last performance evaluation identified in the employee's personnel file was dated 10/20/20. Although requested, the facility could not provide an updated annual evaluation for NA #4 for 2021 and 2022. Additional review with human resources identified that no additional evaluations were available. Upon review of NA #4's record with the DNS, she identified that this NA was now a Licensed Practical Nurse (LPN) as of 2022. Additionally, there were no employee yearly evaluations for 2023, 2024, and 2025. Review of the facility time clock documentation for August 2025 for NA #4/LPN identified she currently works in the facility (on 8/6/25, 8/7/25, 8/9/25, 8/10/25, 8/13/25, 8/14/25, 8/15/25, 8/20/25, 8/21/25, 8/23/25, 8/24/25, 8/27/25, and 8/28/25). 2. NA #5's date of hire was 11/30/09. The last yearly…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2025-08-29 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, review of controlled substance (narcotic) records, and facility policy, the facility failed to ensure the completion of the controlled medication count by licensed staff. The findings include: An interview and review of the 1st floor narcotic logbook located on the medication cart with the Nursing Supervisor/Registered Nurse (RN) #2 on 8/27/25 at 9:30 AM, noted 8 out of 78 missing signatures on the Narcotic Change of Shift Audit for August 2025. RN #2 identified signatures should have been completed by two nurses at each shift change for confirmation and reconciliation of the count of narcotics available in the medication cart.An interview and review of the 2nd floor narcotic logbook, located on the medication cart, with the Director of Nursing Services (DNS) on 8/28/25 at 12:20 PM, identified that the narcotic logbook was missing 7 out of 82 expected signatures on the Narcotic Change of Shift Audit for August 2025. The DNS indicated these signatures should be completed by two nurses at each shift change for confirmation and reconciliation 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2023-08-23 · tag F0851 — widespread
    Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interviews and review of Payroll Based Journal (PBJ) submissions for Quarter 4 of 2022, Quarter 1 of 2023, and Quarter 2 of 2023, the facility failed to ensure that PBJ data was complete and accurate. The findings include: PBJ submissions for Quarter 4 of 2022 (July 1 through September 30), Quarter 1 of 2023 (October 1 through December 31), and Quarter 2 of 2023 (January 1 through March 31) identified excessively low weekend staffing. On 8/18/23 at 12:12 PM, an interview with the Administrator indicated that the previous Administrator may not have included contract staff in the data submitted for PBJ for Quarter 4 of 2022, Quarter 1 of 2023, and Quarter 2 of 2023. The Administrator further provided a printed version of the CASPER Report 1702S (Staffing Summary Report) for Quarter 4 of 2022, Quarter 1 of 2023, and Quarter 2 of 2023 and indicated that there was no data submitted for agency Nurse Aides (NAs) utilized when agency NAs were working during those periods. The Administrator then provided a printed version of the CASPER Report 1702S (Staffing Summary Report)…

    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
  • No harm found · B2023-08-23 · tag F0577 — pattern
    Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and staff interview, the facility failed to include state inspection survey results from investigations conducted after the previous re-certification survey. The findings include: Interview with the Resident Council president on 8/22/23 at 10:00 AM identified that he/she was unaware of the location of the state survey inspection results. Observation on 8/22/23 at 10:32 AM identified a glass case located outside the main dining room which included a sign stating the most recent survey results are located in the main lobby entrance. Observation of the state survey inspection book on 8/22/23 at 2:25 PM with the Administrator identified the state survey book/binder was located on a table in the main lobby. Included in the binder was the state survey results from the previous 3 years of re-certification surveys, but failed to include the results from the on-site complaint investigations that had findings identified on 8/26/22, 5/8/23, and 7/11/23. Additionally, the Administrator identified he was not aware of the facility procedure for placing state survey…

    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 · B2023-08-23 · tag F0657 — failed to keep the care plan current — pattern
    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 clinical record reviews, observations, facility documentation, facility policy and interviews for two of four sampled residents (Resident #16 and Resident #39) who were incontinent and utilized incontinent products, the facility failed to revise the comprehensive care plan for the usage of urinary incontinence inserts. The findings include: 1. Resident #16's diagnoses included quadriplegia, contractures to the right hip and right and left ankle and muscle atrophy. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #16 required total assistance with turning and repositioning while in the bed, and toileting. The Resident Care Plan dated 8/10/23 identified Resident #16 had a deficit with activities of daily living and potential for incontinence of bowel and bladder related to quadriplegia. Interventions directed to provide two (2) person assistance with toileting and determine times when resident may be incontinent and assist to the bathroom or commode during these times.…

    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.

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 →

RatingThis homeChain avg
Overall 4 of 53.2+0.8 vs chain
Health inspection 3 of 52.8+0.2 vs chain
Staffing 5 of 53.0+2.0 vs chain
Quality measures 3 of 54.1-1.1 vs chain
The other 41 homes this chain runs (chain average 3.2★, per CMS)
1 of 5Brentwood Center For Health & Rehabilitation, LLCYarmouth, ME 1 of 5The Pines At Utica Center For Nursing And RehabUtica, NY 2 of 5Beacon Brook Center For Health & RehabilitationNaugatuck, CT 2 of 5Bloomfield Center For Nursing & RehabilitationBloomfield, CT 2 of 5Eastside Center For Health & Rehabilitation, LLCBangor, ME 2 of 5Kennebunk Center For Health & Rehabilitation, LLCKennebunk, ME 2 of 5Ludlowe Center For Health & RehabilitationFairfield, CT 2 of 5Mansfield Center For Nursing And RehabilitationStorrs Mansfield, CT 2 of 5Montowese Center For Health & RehabilitationNorth Haven, CT 2 of 5Riverside Health & Rehabilitation CenterEast Hartford, CT 2 of 5Shady Knoll Center For Health & RehabilitationSeymour, CT 2 of 5Summit At Plantsville Center For Health & RehabiliPlantsville, CT 2 of 5The Pines At Catskill Center For Nursing & RehabCatskill, NY 2 of 5The Pines At Glens Falls Ctr For Nursing & RehabGlens Falls, NY 3 of 5Augusta Center For Health & Rehabilitation, LLCAugusta, ME 3 of 5Cambridge Health And Rehabilitation CenterFairfield, CT 3 of 5Evergreen Center For Health & RehabilitationStafford Springs, CT 3 of 5Glastonbury Center For Health & RehabilitationGlastonbury, CT 3 of 5Hebrew Center For Health And RehabilitationWest Hartford, CT 3 of 5Laurel Ridge Center For Health & RehabilitationRidgefield, CT 3 of 5Maefair Center For Health & RehabilitationTrumbull, CT 3 of 5Marlborough Health & Rehabilitation CenterMarlborough, CT 3 of 5Reservoir Center For Health & Rehabilitation, TheMarlborough, MA 3 of 5Water's Edge Center For Health & RehabilitationMiddletown, CT 3 of 5Winship Green Center for Health & Rehab, LLCBath, ME 4 of 5Bethel Health Care CenterBethel, CT 4 of 5Brewer Center For Health & Rehabilitation, LLCBrewer, ME 4 of 5Dover Center For Health & RehabilitationDover, NH 4 of 5Huntington Hills Center for Health and RehabilitatMelville, NY 4 of 5Pines At Bristol For Nursing & Rehabilitation, TheBristol, CT 4 of 5Stone Bridge Center For Health & RehabilitationNewtown, CT 4 of 5The Pines At Poughkeepsie Ctr For Nursing & RehabPoughkeepsie, NY 4 of 5The Pines at Rutland Center for Nursing & RehabiliRutland, VT 4 of 5Village Crest Center For Health & RehabilitationNew Milford, CT 5 of 5Belair Care Center IncBellmore, NY 5 of 5Maple View Health & Rehabilitation CenterRocky Hill, CT 5 of 5Milford Health And Rehabilitation CenterMilford, CT 5 of 5Norway Center For Health & Rehabilitation, LLCNorway, ME 5 of 5Pine Heights at Brattleboro Center for Nursing & RBrattleboro, VT 5 of 5Regency House Nursing And Rehabilitation CenterWallingford, CT

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 / managerTypeRoleShareSince
MYDERT HOLDINGS LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST51%since 06/07/2024
ZADUN HOLDINGS LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST49%since 06/07/2024
CEDAR HILL CAPITAL ASSOCIATES LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 06/07/2024
ILANA OSTREICHER FAMILY TRUSTOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNFNO PERCENTAGE PROVIDEDsince 01/06/2025
JUNIPER CAPITAL ASSOCIATES LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 06/07/2024
MARC EPHRAM OSTREICHER FAMILY TRUSTOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNFNO PERCENTAGE PROVIDEDsince 01/06/2025
OAK MANAGEMENT CAPITAL LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 06/07/2024
YSRO TRUSTOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 06/07/2024
EHRENFELD, MINDYIndividual5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 06/07/2024
GILMARTIN, THOMASIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROLNO PERCENTAGE PROVIDEDsince 06/07/2024
OSTREICHER, MARCIndividualCORPORATE OFFICERsince 06/07/2024
NATIONAL HEALTH CARE ASSOCIATES INCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/07/2024
BAKER TILLY ADVISORY GROUP LPOrganizationADP OF THE SNFsince 06/07/2024
DAVID OSTREICHER FAMILY TRUSTOrganizationADP OF THE SNFsince 01/06/2025
MICHELLE OSTREICHER FAMILY TRUSTOrganizationADP OF THE SNFsince 01/06/2025
PREFERRED THERAPY SOLUTIONS LLCOrganizationADP OF THE SNFsince 06/07/2024
PROCARE LTC HOLDING LLCOrganizationADP OF THE SNFsince 06/07/2024
SHAYNA STEG FAMILY TRUSTOrganizationADP OF THE SNFsince 03/03/2025
YITZCHOK STEG FAMILY TRUSTOrganizationADP OF THE SNFsince 03/03/2025
BAKER, EDWARDIndividualADP OF THE SNFsince 01/06/2025
COHEN, JESSEIndividualADP OF THE SNFsince 01/06/2025
LOPIANSKY, REBECCAIndividualADP OF THE SNFsince 01/06/2025

CMS files one row per role, so the 26 rows in the source record cover these 22 parties — each is shown once here with every role it holds. Nothing is omitted.

16 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.

$10.6M
Net patient revenuemost recent cost report
-10.2%
Operating marginrevenue minus expenses
$1.4M
Related-party expense12% of expenses
Who pays — share of resident-days
Medicaid 72%Medicare 12%Other / private 16%

About 72% 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 $1.4M paid to related parties — landlords or management companies under common ownership — equal to about 12% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$454per resident / day
operating cost
$13,791per month
≈ monthly operating cost
$412per 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 075379. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-29, 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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