Masonicare At Bishop Wicke Health & Rehabilitation
584 Long Hill Ave, Shelton, CT 06484 · Non profit - Corporation · 120 certified beds · (203) 929-5321 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a middle-of-the-pack inspection score (3/5)
- a high payroll-based staffing rating (4/5)
- lower-than-typical staff turnover (36% vs 45% nationally) — better care continuity
- it has 2 actual-harm citations
- a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $8,018 in federal fines (most recent 2024-07-24)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 4 to 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 17.8% | 18.0% | 15.4% | worse |
| Long-stay residents who lose too much weight | 8.2% | 6.5% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 1.2% | 0.7% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 0.6% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.9% | 22.3% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 4.3% | 3.5% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 25.8% | 16.4% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 11.5% | 17.6% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 98.9% | 93.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.9% | 4.0% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 35.8% | 24.7% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 10.8% | 17.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 2.1% | 1.5% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 70.3% | 69.7% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 27.6% | 24.3% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 5.6% | 10.7% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 0.78 | 2.06 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.55 | 1.46 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
63.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 179 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 46.9% 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 98 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 0.29 therapist hours per resident per day in 2026Q1 — more than 45% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 23% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 63.0%CMS range 54.3–69.5 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.7%CMS range 6.8–13.0 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 46.9% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 38.8% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 39.8% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 5.7% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.4%CMS range 4.2–10.5 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.78 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 120 beds and averages 111.8 residents a day — about 93% occupied, or roughly 8 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.47 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.53 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.84 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 4.15 hrs/resident/day on weekends vs 4.59 on weekdays — 10% thinner on weekends. RN hours go from 0.61 to 0.33 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 36% 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
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
25 citations, most serious first. The 12 most serious are shown; the remaining 13 are one tap away and print in full.
- Actual harm · Gcited before2026-04-17 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation, facility policies, and interviews, for one (1) of three (3) sampled residents (Resident #1) reviewed for nutrition, the facility failed to ensure adequate nutritional status and timely identification and response to significant weight loss. This included failure to accurately monitor and evaluate weight changes, obtain a timely re-weight to confirm a significant weight loss, recognize and act upon poor oral intake, notify the physician and Registered Dietitian (RD), implement nutritional interventions, and respond to family concerns. These failures resulted in a significant, unaddressed weight loss and severe malnutrition requiring hospitalization and clinical intervention. The findings include:Resident #1's diagnoses included vascular dementia, history of falls, chronic obstructive pulmonary disease (COPD), gastroesophageal reflux disorder (GERD), and depression.The significant change in condition Minimum Data Set assessment dated [DATE] identified…
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.
- Actual harm · Gcited before2024-07-24 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the clinical record review, facility documentation review, and interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure the resident was properly positioned prior to the provision of care resulting in a fall out of bed. The resident sustained a fractured ankle. The finding includes: Resident #1 was admitted with diagnoses that included Alzheimers disease, osteoarthritis, and abnormalities of mobility. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had moderately impaired cognition, height was 67 inches, weight 181 pounds, and required maximum staff assistance with bed mobility. The Resident Care Plan (RCP) dated 6/28/2024 identified Resident #1 had decreased mobility and was at risk for falls. Interventions included one (1) staff assist for bed mobility. Facility incident report dated 6/28/2024 at 10 PM identified a NA asked the resident to turn onto his/her side so that the NA could provide care. When Resident #1 went…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-17 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation/policies, and interviews, for one (1) of three (3) sampled residents (Resident #1) reviewed for a change in condition, the facility failed to ensure timely notification of the physician, Registered Dietitian (RD) and resident's representative when the resident experienced a significant weight loss and decline in nutritional status, which delayed clinical assessment and intervention for a significant weight loss. The findings include:Resident #1's diagnoses included vascular dementia, history of falls, chronic obstructive pulmonary disease (COPD), gastroesophageal reflux disorder (GERD), and depression.The significant change in condition Minimum Data Set assessment dated [DATE] identified Resident #1 was severely cognitively impaired and unable to make reasonable and consistent decisions regarding tasks of daily living (Brief Interview for Mental Status (BIMS) score of 3) and required supervision when eating.The Resident Care Plan (RCP) dated 10/21/25…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-01-14 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, interviews, and review of facility documents and policies for one (1) of three (3) residents (Resident #2) reviewed for falls, the facility failed to complete an evaluation and assessment following a resident's fall in accordance with facility policy. The findings included:Resident #2 was admitted to the facility in December of 2025 with diagnoses which included Alzheimer's, transient ischemic attack, and depression. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had moderate cognitive impairment (Brief Interview for Mental Status (BIMS) score of 7), required substantial assistance with personal hygiene, toileting, and bathing and was a partial to moderate assist of one (1) with transfers and ambulation with a walker. Review of the Resident Care Plan (RCP) dated 12/18/25 identified Resident #2 had impaired physical mobility due to Parkinson's Disease and was at risk for falls. Interventions directed to assist Resident #2 with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-09-17 · tag F0806 — failed to honor food preferences — patternEnsure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility policy, and interviews for the only sampled resident (Resident #58) reviewed for food choices, the facility failed to provide the correct diet. The findings include:Resident #58's diagnoses included hypertension, gastro-esophageal reflux disease (GERD), and gout.The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #58 had a Brief Interview of Mental Status score of 14 indicating intact cognition, was dependent with personal hygiene, rolling left and right and with chair/bed-to-chair transfers, and required set-up assistance with eating. A signed Physician order dated 2/29/2024 identified Resident #58 had an allergy to garlic. The Resident Care Plan (RCP) dated 5/30/2024 and in effect at the time of survey identified Resident #58 had a nutritional problem or potential nutritional problem related to diagnoses of hypertension, GERD, morbid obesity, constipation, gout, and a food allergy to garlic. Interventions included educating…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-09-17 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and facility policy during a tour of the kitchen, the facility failed to ensure open food items were dated to include opened, expired, and used by dates, and failed to perform hand hygiene prior to placing gloves on during food preparation and food service. The findings include: 1. On 9/10/25 at 9:15 AM, during the initial brief kitchen tour and interview with the Food Service Director, identified in freezer #2, a previously opened and repackaged bag of raspberry turnovers with a handwritten best used by date of 6/7/25 and a previously opened and repackaged bag of apple turnovers, with a handwritten best used by date of 7/11/25. In the refrigerator on the second shelf was a thawed package of ground veal with a handwritten date of 9/2/25, indicating when it was thawed, along with a handwritten note for the veal to be used by 9/4/25. The Food Service Director stated that staff used the best used by date as the food's expiration date. Subsequent to the surveyor's inquiry, the Food Service Director noted she would dispose of the expired raspberry and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-09-17 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of clinical record, facility policy, and interviews for 1 of 3 sampled residents (Resident #87) reviewed for pressure ulcers, the facility failed to perform hand washing/sanitization during wound care. The findings include:Resident #87's diagnoses included peripheral vascular disease, dementia, and traumatic brain injury.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #87 had a Brief Interview of Mental Status (BIMS) score of 3 indicating severe cognitive impairment, was dependent for personal hygiene, rolling left and right, and chair/bed-to-chair transfers, and had an unstageable pressure ulcer presenting as a deep tissue injury (DTI).The Resident Care Plan (RCP) dated 9/10/2025 identified Resident #87 had a DTI on his/her left inner heel related to immobility and peripheral vascular disease. Interventions included administer treatments as ordered and monitor for effectiveness, initiate Enhanced Barrier Precautions (EBP) per orders, and follow…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-17 · tag F0657 — failed to keep the care plan current — isolatedDevelop 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 interviews, review of the clinical record, facility documentation, and policy for 1 of 8 sampled residents (Resident #93), reviewed for accidents, the facility failed to revise the Resident Care Plan (RCP) following a fall. The findings include:Resident #93's diagnoses included osteoarthritis, gout, and adjustment disorder.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #93 had a Brief Interview of Mental Status (BIMS) score of 13 indicating intact cognition and required partial/moderate assistance for lower body dressing, and transfers. Additionally, the MDS identified Resident #93 had a fall in the month prior to admission.The Resident Care Plan dated 8/30/25 identified Resident #93 was at risk for falls related to weakness. Interventions included anticipating and meeting resident needs, appropriate footwear when ambulating, maintain a safe environment free of spills, clutter, adequate lighting, call light and personal items in reach, and keep the bed in low…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-09-17 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interview for 2 of 2 sampled residents (Resident #49 and Resident #109) reviewed for skin issues, the facility failed to ensure neurological assessments were completed after falls. The findings include: 1. Resident #49 had diagnoses that included Alzheimer's disease, hypertension, and anxiety. A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #49 was severely cognitively impaired, used a wheelchair, required setup or clean-up assistance with eating, substantial/maximal assistance with bed mobility, and was dependent for transfers. The Resident Care Plan (RCP) dated 11/7/24 identified Resident #49 was at risk for falls related to poor safety awareness and medical conditions. Interventions included to ensure Resident #49's call light was within reach, ensure prompt, and review information on past falls and attempt to determine possible root causes of falls, and alter or remove any potential causes if…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-09-17 · tag F0676 — failed to keep up residents' daily-living abilities — isolatedEnsure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
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, review of the clinical record, and facility policy for the only sampled resident (Resident #43) reviewed for communication difficulties, the facility failed to identify a change in communication ability had occurred and failed to provide appropriate services related to the change in status. The findings include:Resident #43's diagnoses included cerebral infarction, acquired deformity of head, left sided hemiplegia, and adjustment disorder with depressed mood.The annual Minimum Data Set assessment dated [DATE] identified Resident #43 had a Brief Interview of Mental Status (BIMS) score of 12 indicating moderate cognitive impairment, was independent with eating, required moderate assistance with oral hygiene, was dependent on chair/bed-to-chair transfers, and had obvious or likely cavities or broken natural teeth and clear speech with distinct intelligible words.The Resident Care Plan (RCP) dated 7/11/2024 identified he/she had oral/dental health problems related to some broken…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-17 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, clinical record review, and facility policy for 1 of 3 sampled residents (Resident #7) reviewed for pressure ulcers, the facility failed to set an alternating pressure mattress at the correct setting, per the physician order. The findings include: Resident #7's diagnoses included Alzheimer's disease, vascular dementia, and unspecified systolic (congestive) heart failure. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #7 had a short-term and long-term memory problem and was dependent on staff for toileting hygiene, rolling left and right in bed, lying to sitting on side of bed, and transfers. Additionally, the assessment identified 1 stage 3 pressure ulcer that was not present upon admission/entry or reentry into the facility and that there was a pressure reducing device for the bed. The Resident Care Plan (RCP) dated 8/12/2025 identified Resident #7 had a pressure ulcer to the coccyx related to immobility and bowel/bladder incontinence. Interventions…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-09-17 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility documentation, facility policy and interviews for 2 of 8 sampled residents (Resident #16 and Resident #49) reviewed for accidents, for Resident #16, the facility failed to transfer a resident according to the plan of care resulting in a fall, and for Resident #49, the facility failed to implement new Resident Care Plan (RCP) interventions following falls, and failed to utilize wheelchair equipment according to the Resident Care Plan. The findings include: 1. Resident #16's diagnoses included pain in left hip, abnormalities of gait and mobility, Parkinson's disease, psychotic disturbance, and anxiety. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #16 had a Brief Interview for Mental Status score of 14, indicating no cognitive impairment and required a wheelchair/walker for mobility and needed partial/moderate assistance for bed mobility, toileting, and bathing transfers. A Facility Reported Incident (FRI) form dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 13 citations
- Potential for harm · D2025-09-17 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, facility policy, and interviews, for the only sampled resident (Resident #68) reviewed for respiratory issues, the facility failed to change the resident's nebulizer mask and tubing per the facility policy. The findings include:Resident #68's diagnosis included: anemia, heart failure and chronic obstructive pulmonary disease.The quarterly Minimum Data Set assessment dated [DATE] identified Resident #68 had a Brief Interview of Mental Status score of 13 indicating intact cognition and required substantial/maximal assistance with upper and lower body dressing, and transfers and partial/moderate assistance with bed mobility. A physician's order dated 8/25/25 directed to provide Ipratropium-Albuterol Inhalation Solution (0.5-2.5 MG/3ML) to be used with the resident's nebulizer as needed every 6 hours for complaints/feelings of shortness of breath while awakeObservations of Resident #68's nebulizer equipment identified that the tubing was dated 7/18/25 (indicating when first put into use) and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-17 · tag F0881 — failed to use antibiotics responsibly — isolatedImplement a program that monitors antibiotic use.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of facility documentation, facility policy and interviews during a review of the infection control program, the facility failed to ensure documentation of a 48-to-72-hour review of antibiotic use and failed to ensure practitioners were documenting the rationale for continued antibiotic use when the antibiotic failed to meet the criteria. The findings include:Interview and review of the Antibiotic Stewardship Program on 9/14/25 from 11:00 AM through 12:30 PM with the Infection Control Nurse (ICN), Registered Nurse (RN) #1 and Assistant Director of Nursing Services (ADNS) identified that the facility used McGeer's criteria in determining if antibiotic use was appropriate for a suspected or diagnosed infection. Although the information was reviewed as a guide, the facility practice did not include documentation of the review. Additionally, it was identified that practitioners (physician/Advanced Practice Registered Nurse, APRN) were not consistently documenting the rationale for continuing the use of antibiotics when McGeer's criteria had not been met.A. RN #1 indicated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-17 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy and interviews for 2 of 5 sampled residents (Resident #86 and #88) for vaccinations, the facility failed to ensure the pneumococcal vaccine was offered. The findings included:1.Resident #86's was admitted to the facility in January 2020. Resident #86's diagnoses included heart disease and hypertension.The quarterly Minimum Data Set assessment dated [DATE] identified that Resident #86 had a Brief Interview for Mental Status score of 15 indicating intact cognition and required moderate assistance with Activities of Daily Living (ADL).The Resident Care Plan dated 9/12/25 failed to address Resident #86's vaccination status. A review of Resident #86's clinical record for the pneumococcal conjugate vaccination (PCV) status identified that he/she received the PCV 13 in July of 2021. The Center for Disease Control (CDC) pneumococcal vaccination recommendation indicated that Resident #86 was to receive 1 dose of either the PVC20 or PCV21 one…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-02-21 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation of the Dietary Department, staff interview, and facility policy, the facility failed to ensure food items were dated and labeled, the kitchen was in clean and sanitary condition, and adequately store a chemical solution. The findings include: Tour of the Dietary Department on 2/14/24 at 11:00 AM and 2/20/24 at 9:55 AM with the Operations Manager identified the following: a. The kitchen floor was observed throughout the entirety of the kitchen with debris and food on the floor (including under the storage racks). b. Dust and debris was observed on the ice machine vents with dried stains going down the side of the ice machine. Additionally, black grime was observed on a metal bar, located beneath the ice machine lid, adjacent to the front panel. c. The reach-in refrigerator was noted with stains running down the outside of the doors. d. The milk and orange juice cooler had stains and marks on the doors. e. The racks used for clean dishes to drip dry were dirty with debris and grime. One rack was observed to have clean dishes stored on it. f. The grease trap…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-21 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility policy and interviews for 1 of 5 residents (Resident #60) reviewed for unnecessary medications, the facility failed to initiate a care plan for an anticoagulant (blood thinning) medication. The findings include: Resident #60's diagnoses included heart failure, atrial fibrillation, and edema. A physician's order dated 2/2/24 directed to administer Eliquis (an anticoagulation medication) 2.5 milligrams (mg) by mouth twice daily (BID). The Medication Administration Record dated 2/2/24 to 2/21/24 identified Resident #60 received Eliquis 2.5 mg by mouth BID at 8:30 AM and 8:30 PM. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #60 was without cognitive impairment and required total assistance with transfers and substantial/maximal assistance with bathing. Additionally, the MDS had anticoagulation coded for consideration for care planning. Interview and review of the Resident Care Plan (RCP) with RN #3 on 2/21/24 at 9:56 AM identified…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-02-21 · tag F0676 — failed to keep up residents' daily-living abilities — isolatedEnsure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the clinical records, facility policy, and interviews for 2 of 3 residents (Resident #5 and #57) reviewed for Activities of Daily Living (ADL's), the facility failed to ensure personal hygiene services were provided to dependent residents. The findings include: 1. Resident #5's diagnoses included vascular dementia, Cerebral Vascular Accident (CVA) affecting the dominant side, and osteoporosis. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #5 was severely cognitively impaired and required setup assistance for transfers, dressing, and personal hygiene. The Resident Care Plan dated 1/11/24 identified that Resident #5 was unable to perform ADL's independently due to impaired cognition, mixed dementia, and osteoporosis. Interventions included providing the assistance of 1 staff for transferring, toileting, and personal hygiene. An observation on 2/14/24 at 11:47 AM, identified Resident #5 in his/her room with long facial hair. Observation on 2/16/24…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-21 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the clinical record, facility policy, and interviews for the only sampled resident (Resident #5) reviewed for positioning/mobility, the facility failed to ensure an AFO (Ankle Foot Orthotic) brace/splint was in place. The findings include: Resident #5's diagnoses included right footdrop, Cerebral Vascular Accident (CVA) affecting the right dominant side, and osteoporosis. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #5 was severely cognitively impaired, had a right sided physical impairment requiring set-up assistance for lower body dressing and putting on and taking off footwear, and was independent for transfers. The Resident Care Plan dated 1/11/24 identified a history of a CVA with hemiparesis (partial paralysis on one side of the body) and foot drop. Interventions included Resident #5 to independently apply and remove right lower extremity AFO. Observations on 2/14/24 at 11:08 AM and 2/15/24 at 1:16 PM, identified an AFO on a bedside chair 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.
- Potential for harm · D2024-02-21 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy and interviews for the only sampled resident (Resident #39) reviewed for bowel and bladder incontinence, the facility failed to assess a decline in continence status and failed to implement a plan to restore continence. The findings include: Resident #39 was admitted to the facility for short term rehabilitation on 12/28/23 with diagnoses that included a fall with bilateral shoulder dislocations, hilar mass with metastasis to the brain, and intracranial bleed. Inter-agency Patient Referral Report (W-10) from the hospital dated 12/28/23 identified Resident #39 was continent of bowel and bladder. An Interdisciplinary admission assessment dated [DATE] identified Resident #39 was not incontinent of bladder with no history of incontinence and continent of bowel. The Resident Care Plan (RCP) dated 12/28/23 identified a potential for skin impairment secondary to decreased mobility, incontinence, pain, and compromised medical condition.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-02-21 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility policy, and interviews for 1 of 4 residents, (Resident #77) reviewed for nutritional status, the facility failed to obtain weights per the facility policy. The findings include: Resident #77 was admitted to the facility on [DATE] with diagnoses that included a fractured hip with repair, dementia, and irritable bowel syndrome. (Resident #77 was discharged on 12/7/23 and readmitted on [DATE].) A Nursing admission assessment dated [DATE] identified Resident #77 was alert forgetful and confused and required limited assistance with eating and extensive assistance with transfers. Review of Resident #77's weight record identified a readmission weight on 12/12/23 of 99 pounds, and Resident #77's was reweighed on 12/15/23 and noted to be 88.6 pounds (a 10.4lb/10.5% loss in 3 days). Resident #77's next weight occurred on 12/18/23 (3 days later) which identified a weight of 94 lbs. (a 5.74 pound weight gain from 12/15/23). Resident #77 was noted with a total overall weight…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-21 · tag F0770 — failed to provide lab services — isolatedProvide timely, quality laboratory services/tests to meet the needs of residents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical record, review of facility policy, facility documentation, and staff interview for 1 of 5 sampled residents, (Resident #57) reviewed for unnecessary medications, the facility failed to follow a physician order to obtain laboratory work (labs). The findings include: Resident # 57's diagnoses included diabetes, congestive heart failure (CHF), and dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #57 was severely cognitively impaired and required set up or clean-up assistance with eating, partial to moderate assistance with oral hygiene and chair to bed transfers. The Resident Care Plan (RCP) dated 11/2/23 identified that resident was at risk of altered blood glucose levels. Interventions included monitoring blood sugars as ordered and calling the doctor according to parameters. A physician's order in effect from 04/28/23 through 2/12/24 directed to monitor lab values for HbA1c, (blood sugar average) every 6 months in May and November. Review of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-21 · tag F0810 — isolatedProvide 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, review of the clinical record, facility policy, and interviews for 1 of 4 sampled residents, (Resident #19) reviewed for nutrition, the facility failed to provide the proper adaptive equipment. The findings include: Resident # 19's diagnoses included cerebral aneurysm infarction, right sided craniotomy, left sided hemiparesis (paralysis), diabetes, and mood disorder. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #19 was moderately cognitively impaired, required set up and clean up assistance with eating, and was dependent on staff for transfers and movement about the facility. The Resident Care Plan dated 2/14/24 identified Resident #19 required assistance with Activities of Daily Living. Interventions directed to provide small meal portions and assist with meals as needed. An observation on 2/14/24 at 12:14 PM identified Resident # 19 seated in the dining room with his/her lunch in front of him/her. Resident #19 was noted to be having difficulty grasping 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.
- No harm found · B2024-02-21 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, facility policy, and interviews for 1 of 3 nursing units reviewed for the environment, the facility failed to ensure a homelike environment in the Pavilion 3 dining room. The findings included: During the initial dining observation on 2/14/24 at 12:29 PM a chair scale was noted in the Pavilion 3 dining room during the lunch meal with Resident's #8, 26, 31, 35, 42, 50, and 60 present. Observation on 2/15/24 at 11:02 AM, identified the chair scale in the Pavilion 3 dining room. Observation on 2/16/24 at 9:32 AM, identified the chair scale in the Pavilion 3 dining room. Interview with LPN #1 on 2/16/24 at 2:42 PM identified that the chair scale had been located under the television of the Pavilion 3 dining room for as long as she could remember, and she thought it was bolted to the floor. She indicated that she was unaware it had back wheels and could be moved. Additionally, she was unaware that the chair scale could not be stored in a resident area. Subsequent to surveyor inquiry, LPN #1 called maintenance on 2/16/24 at 2:43 PM to move the chair scale. 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.
- No harm found · B2024-02-21 · tag F0639 — patternMaintain 15 months of resident assessments in the resident's active clinical record.
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 4 sampled residents (Resident #57) reviewed for nutrition, the facility failed to have 15 months of Minimum Data Set (MDS) assessments readily available. The findings include: Resident #57's diagnoses included vascular dementia, type II diabetes mellitus, and heart failure. During a review of Resident #57's nutritional needs on 2/15/24 at 10:17 AM, the resident's quarterly MDS dated [DATE] was not available in the clinical record and was not noted to be filed on the nursing unit. In an interview and review of Resident #57's Minimum Data Set (MDS) records with LPN #1 on 2/15/24 at 10:17 AM, LPN #1 failed to identify that Resident #57 had an MDS that was readily available following the quarterly MDS dated [DATE]. Further, LPN #1 indicated that she did not have access to the electronic record and that she would have to contact the MDS Coordinator to print the MDS dated [DATE], so it would be located and accessible on the nursing unit.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$8,018 in federal fines across 1 penalty.
- $8,018 — penalty dated 2024-07-24
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| UNITED METHODIST HOMES, INC. | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 05/23/1970 |
| MASONICARE INC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 100% | since 12/31/2024 |
| JUKIC, ZVONIMIR | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 07/05/2015 |
| LAWLOR, DAVID | Individual | CORPORATE OFFICER | — | since 01/01/2012 |
| VENOIT, JON-PAUL | Individual | CORPORATE OFFICER | — | since 12/31/2024 |
CMS files one row per role, so the 8 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted.
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $392K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in CT
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Connecticut Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 075163. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-17, 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.