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Ark Healthcare & Rehabilitation At Governors House

36 Firetown Rd, Simsbury, CT 06070 · For profit - Limited Liability company · 70 certified beds · (860) 658-1018 Medicare & Medicaid certified

Call the home — (860) 658-1018 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Apr 2024Behavioral-health or dementia-care citation — no harm found (F0758)1 actual-harm citation$16,039 in federal fines
Insights

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

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Apr 2024
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (36) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $16,039 in federal fines (most recent 2024-03-13)

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 4 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 4 of 5

Location & what’s nearby

Hospital
Urgent care / clinic
720 Hopmeadow St · (860) 651-3489 · Call to confirm hours
Pharmacy
714 Hopmeadow St · (800) 746-7287 · Call to confirm hours
Grocery
710 Hopmeadow St · (860) 658-2271 · Call to confirm hours
Park
52 Plank Hill Rd · (860) 658-3836 · Typically dawn to dusk
Place of worship
689 Hopmeadow St · (860) 651-3593

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 4 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 2 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 increased22.4%18.0%15.4%worse
Long-stay residents who lose too much weight7.8%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 infection0.9%1.5%2.0%better
Long-stay residents with depressive symptoms0.5%22.3%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury2.2%3.5%3.3%better
Long-stay residents whose ability to walk worsened20.8%16.4%16.1%worse
Long-stay residents on antianxiety or hypnotic medication21.0%17.6%18.9%worse
Long-stay residents given the seasonal flu vaccine92.7%93.5%95.3%typical
Long-stay residents with pressure ulcers5.2%4.0%4.7%worse
Long-stay residents with worsening bladder/bowel control30.5%24.7%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table14.0%17.8%17.1%better
Short-stay residents who newly got an antipsychotic medication2.3%1.5%1.4%worse
Short-stay residents given the seasonal flu vaccine60.0%69.7%79.4%worse
Short-stay residents rehospitalized after admission21.5%24.3%22.6%typical
Short-stay residents with an outpatient ER visit11.2%10.7%12.0%typical
Long-stay hospitalizations per 1,000 resident days2.022.061.67worse
Long-stay outpatient ER visits per 1,000 resident days1.231.461.80better

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

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

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

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

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

62.0% 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 126 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

62.0%U.S. median 51.5%
Got home and stayed home
10.1%U.S. median 10.7%
Went back to hospital
69.8%U.S. median 56.6%
Met the expected recovery
0.44U.S. median 0.31
Therapy hours / resident / day
0.15hours / resident / day
Physical therapy
0.23hours / resident / day
Occupational therapy
0.06hours / resident / day
Speech therapy

Met the expected recovery: 69.8% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 43 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 0.44 therapist hours per resident per day in 2026Q1 — more than 75% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 27% 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 SNF62.0%CMS range 53.2–71.351.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.1%CMS range 7.2–13.510.7%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 discharge69.8%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 discharge60.5%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 discharge72.1%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 identified98.8%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 discharge95.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened2.4%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 hospitalization7.0%CMS range 4.2–11.07.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.991.02Oct 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

0.59
RN hours/ resident / day
0.87
LPN hours/ resident / day
2.06
Aide hours/ resident / day
3.51
Total nurse hours/ resident / day
0.45
RN hoursweekends
40.7%
Total nursing turnover
60.0%
RN turnover

How full it usually is: this home is certified for 70 beds and averages 66.4 residents a day — about 95% occupied, or roughly 4 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 3.51 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.59 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.06 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 3.62 on weekdays — 10% thinner on weekends. RN hours go from 0.65 to 0.45 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 41% is about the same as the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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

4
deficiencies at the latest standard inspection (2025-12-30)
18
at the previous standard inspection (2024-03-13)

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.

36 citations, most serious first. The 11 most serious are shown; the remaining 25 are one tap away and print in full.

  • Actual harm · Gcited before2024-03-13 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the clinical record, staff interview, and review of facility documentation for 1 of 3 residents (Resident #39) reviewed for pressure ulcers, the facility failed to ensure off-loading of the heels was implemented to prevent a pressure ulcer. The findings include: Resident #39 was admitted to the facility on [DATE] with diagnosis of cerebral vascular infarction (CVA), pleural effusion, and hemiplegia/hemiparesis. A Discharge Summary from the hospital dated 10/20/23 identified Resident #39's skin was without rashes, ulcerations, or petechiae. An admission Braden scale dated 10/20/23 identified Resident #39 was at moderate risk for skin breakdown. A Health Status note dated 10/20/23 identified Resident #39's skin was clean, dry, and intact. The admission Minimum Date Set (MDS) assessment dated [DATE] identified Resident #39 was moderately cognitively impaired and required maximum assistance for eating, was dependent for toileting, transfers, dressing and 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-12-30 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility policy review, and interviews for one sample resident (Resident #70) who experienced a significant change in condition, the facility failed to notify the physician and/or family of the significant change of condition. The findings include:Resident #70 had diagnoses that included protein malnutrition, chronic kidney disease, benign neoplasm of meninges, and dementia.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #70 had moderate cognitive impairment, and required extensive assistance with bed mobility, toileting, hygiene, transfers, and ambulation. The Resident Care Plan (RCP) dated 2/19/25 identified Resident #70 had a nutritional problem or potential nutritional problem related to kidney disease, neoplasm of meninges and dementia. Care plan interventions directed to monitor, record, and report to the physician signs and symptoms of malnutrition, evaluate and make diet changes as recommended, obtain and monitor laboratory or diagnostic…

    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 before2025-12-30 · 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 review of clinical records, review of facility documentation, review of facility policy/procedures and interviews one sampled record (Resident #70) review for significant change, the facility failed to ensure a registered nurse assessed the resident after a significant change of condition and for one sampled resident (Resident #58) reviewed for pain, the facility failed to ensure a medication was administered according to the physician's order, and for one of two residents (Resident #64) reviewed for pain management, the facility failed to ensure physician orders were obtained timely when a medication was unavailable. The findings include: Resident #70 had diagnoses that included protein malnutrition, chronic kidney disease, benign neoplasm of meninges, and dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #70 had moderate cognitive impairment, and required extensive assistance with bed mobility, toileting, hygiene, transfers, and ambulation. The Resident Care…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-12-30 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the clinical record, review of facility documentation, review of facility policy/procedures and interviews for the one sampled resident (Resident #42) reviewed for respiratory care, the facility failed to provide respiratory care and services as ordered by the physician (failed to deliver humidified oxygen as ordered), failed to notify the physician when there was a change in oxygen equipment, failed to ensure oxygen equipment was used according to the manufacturer specifications (application of the non-rebreather without the appropriate oxygen flow rate, or reservoir inflated), and failed to have trained, competent, qualified staff to provide oxygen therapy services. The findings include:Resident #42 was admitted to the facility October 2025 with diagnoses that included systemic Lupus Erythematosus, coronary artery disease, vitamin D deficiency and unstable angina. (No specific respiratory diagnosis)The admission Minimum Data Set (MDS) dated [DATE] identified Resident #42 had…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-05-05 · 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 documentation, facility policy, and interviews for 2 of 3 residents (Resident #2 and 3) reviewed for pressure injuries (ulcers), the facility failed to ensure Braden scale assessments and weekly skin checks were documented and completed per facility policy. The findings include:1. Resident #2 was admitted to the facility on [DATE] with diagnoses that included peripheral vascular disease and dementia.The Braden scale assessment dated [DATE] identified Resident #2 was at moderate risk for developing pressure injuries.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had moderate impairment in cognition (Brief Interview for Mental Status (BIMS) score of 10), had one (1) unstageable pressure injury, and was at risk for developing pressure injuries.A physician's order dated 4/4/25 directed weekly skin checks.The Braden scale assessment dated [DATE] identified Resident #2 was at risk for developing pressure injuries.The care plan 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-27 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, facility policy review, and interviews for two of three residents (Resident #1 and 2) reviewed for abuse, the facility failed to ensure the resident was treated with respect and dignity. The findings include: a. Resident #1 was admitted to the facility with diagnoses that included intellectual disability, autism, and anxiety. An admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 1/12/2025 identified Resident # 1 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderately impaired cognition, and required set-up assistance for eating. The Resident Care Plan (RCP) dated 1/17/2025 identified Resident #1 required assistance for activities of daily living (ADLs) due to intellectual disability and had behaviors such as impulsiveness and screaming at staff. Interventions directed to encourage independence with ADLs and assist as needed. A facility reportable event (RE) form dated 3/11/2025 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 · Dcited before2025-03-27 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for abuse, the facility failed to ensure staff reported an allegation of abuse timely. The findings include: Resident #1 was admitted to the facility with diagnoses that included intellectual disability, autism, and anxiety. An admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 1/12/2025 identified Resident # 1 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderately impaired cognition, and required set-up assistance for eating. The Resident Care Plan (RCP) dated 1/17/2025 identified Resident #1 required assistance for activities of daily living (ADLs) due to intellectual disability and had behaviors such as impulsiveness and screaming at staff. Interventions directed to encourage independence with ADLs and assist as needed. A facility reportable event (RE) form dated 3/11/2025 at 10:00 AM identified an allegation of staff-to-resident abuse without injury. NA #2…

    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 · D2024-04-23 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, facility policy review, and interviews for two of three sampled residents (Resident #1 and Resident #2) who were reviewed for an allegation of resident-to-resident physical abuse, Resident #1 had the right to be free from physical abuse by Resident #2. The findings include: Resident #1's diagnoses included stroke with resultant right sided hemiplegia (paralysis of one side of the body), epilepsy (seizure disorder), post-traumatic stress syndrome, developmental disability, anxiety, and depression. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 rarely or never made decisions regarding tasks of daily living, needed substantial assistance with turning and repositioning while in bed, moderate assistance getting in and out of the bed and chair, and was independent for mobility with a wheelchair. The Resident Care Plan (RCP) dated 1/23/24 identified Resident #1 had impaired balance and was at risk for mood changes.…

    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 · F2024-03-13 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on the staff interviews, facility documentation, and review of the facility policies, the facility failed to ensure that Infection Prevention Control Program standards (IPCP) policies and procedures are reviewed annually by the Administrator, Medical Director, and the Director of Nursing and that the facility maintained an updated list of residents with Multidrug Resistant Organism. (MDRO) The findings included: On 3/1/24 at 11:07 AM, review of the Infection Prevention policies/procedure manual with RN #6 (the Infection Preventionist) and RN #7 (the previous Infection Preventionist) failed to identify the policies had been reviewed and signed by the Administrator, Medical Director, and Director of Nursing annually. Additionally, the signature page was blank, with no signatures present and both RNs stated that they were unaware that the policies needed to be signed on an annual bases. The MDRO (Multidrug Resistant Organisms) list was last updated on 4/14/23 with some of those residents having been discharged or no longer in the same rooms as identified on the MDRO list. RN #7…

    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 · E2024-03-13 · 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 review of the clinical record, facility documentation, facility policy and interviews for 2 of 5 residents (Resident #7 and Resident #43) reviewed for unnecessary medication, the facility failed respond to pharmacy recommendations related to an as needed (PRN) psychotropic medication. The findings include: 1. Resident #7's diagnoses included Alzheimer's disease, anxiety disorder and Type 2 diabetes. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #7 was moderately cognitively impaired, required practical assistance with shower transfer and toileting hygiene and maximal assistance with showering. The Resident Care Plan dated 11/10/23 identified Resident #7 had episodes being resistive to care- refused to shower and refused to change clothes. Interventions included to administer medications as ordered, monitor/document for side effects and effectiveness. A physician's order dated 11/13/23 directed to provide Ativan (Lorazepam) 0.5 milligrams (mg), give 1 tablet by mouth every 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-03-13 · tag F0758 — failed to limit and justify psychotropic drugs — pattern
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    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 residents (Resident # 7 and #43) reviewed for unnecessary medication, the facility failed to order as needed (PRN) psychotropic medications for only 14 days. The findings include: 1. Resident #7's diagnoses included Alzheimer's disease, anxiety disorder and Type 2 diabetes. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #7 was moderately cognitively impaired and required practical assistance with shower transfer and toileting hygiene and maximal assistance with showering. The Resident Care Plan dated 11/10/23 identified Resident #7 had episodes of resistive to care- refused to shower, and refused to change clothes. Interventions included to administer medications as ordered, monitor/document for side effects and effectiveness. A physician's order dated 11/13/23 directed to provide Ativan (Lorazepam) 0.5 milligrams (mg), give 1 tablet by mouth every 24 hours as needed for…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
Show the remaining 25 citations
  • Potential for harm · Dcited before2024-03-13 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility policy, and interviews for 2 of 5 sampled residents (Resident #2 and Resident #58) reviewed for unnecessary medications, the facility failed to initiate a Resident Care Plan related to a diagnosis with corresponding medication use. The findings include: 1. Resident #2's diagnoses included Atrial Fibrillation (A-fib), dementia, and hypothyroidism. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 was moderately cognitively impaired and required assistance with ADL'S, meals, and medications. A physician's order dated 10/2/23 directed to administer Apixaban 2.5 milligram (mg) twice a day for atrial fibrillation (A-fib). Review of the Resident Care Plan (RCP) failed to identify a problem reflecting Resident #2's A-fib or the use of an anticoagulant medication (blood thinner). Interview and review of the clinical record with Registered Nurse (RN) #1 on 3/4/24 at 9:03 AM identified that there was not a RCP for the anticoagulant…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-13 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility policy, facility documentation, and interviews for 1 of 4 sampled residents reviewed for accidents (Resident #15), the facility failed to revise the Resident Care Plan regarding discontinuation of anti-embolism stocking and initiation of interventions following a fall. The findings include: Resident #15's diagnoses included dementia, history of falling, and difficulty walking. a. A physician's order dated 4/7/22 through 3/1/23 directed Resident #15 was independent with bed mobility, wheelchair mobility, transfers, and ambulation with rollator within the facility. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #15 was moderately cognitively impaired, was independent with walking, and required partial/moderate assistance with sit to lying and sit to stand. The Resident Care Plan (RCP) dated 1/17/23 identified Resident #15 was at risk for falls and that Resident #15 had limited physical mobility. Interventions included a…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-13 · 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 review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 sampled residents reviewed for abuse (Resident #15) the facility failed to complete a nurse's note for the refusal of treatment, and for 1 of 4 sampled residents (Resident #33) reviewed for medication administration, the facility failed to check placement of the gastrostomy tube prior administering medication and feeding. The findings include: 1. Resident #15's diagnoses included dementia, depression, and anxiety disorder. The Resident Care Plan (RCP) dated 10/30/23 identified that Resident #15 had episodes of urinary incontinence, the potential for alteration in skin related to incontinence, and had decreased communication skills related to hearing loss. Interventions included to provide incontinent care as needed, to toilet the resident upon waking/prior to meals, to use simple direct communication, to verify verbal communication by repeating back to resident, and to ensure hearing aids were working…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-03-13 · 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 review of clinical records, facility documentation, facility policy, and interviews for 1 of 2 sampled residents reviewed for abuse (Resident #15), the facility failed to complete an assessment by a Registered Nurse after an allegation of mistreatment and for 1 sampled resident (Resident #39) reviewed for splints, the facility failed to ensure a hip abduction splint was applied daily as directed by the physician and for 1 of 3 sampled resident reviewed for hospitalization (Resident #55), the facility failed to obtain physician orders for multiple hospital transfers and for the 1 sampled resident (Resident #64) reviewed for death, the facility failed to transcribe Registered Nurse (RN) pronouncement orders before an RN pronouncement was completed. The findings include: 1. Resident #15's diagnoses included dementia, depression, and anxiety disorder. The Resident Care Plan (RCP) dated [DATE] identified that Resident #15 had episodes of urinary incontinence, the potential for alteration in skin 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 · Dcited before2024-03-13 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the clinical record, facility policy, and interviews for the only sampled resident (Resident #55) reviewed for oxygen therapy, the facility failed to obtain a physician's order for oxygen administration. The findings include: Resident #55's diagnoses included respiratory failure with hypoxia, pneumonia, and Chronic Obstructive Pulmonary Disease (COPD). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #55 was cognitively intact and required moderate assistance for bed mobility and personal hygiene, and required maximum assistance for transfers. Additionally, the MDS identified Resident #55 utilized oxygen therapy. The Resident Care Plan dated 2/28/24 identified Resident #55 had COPD and required supplemental oxygen. Interventions included oxygen administration as ordered by the physician, oxygen saturation as ordered and per policy, monitoring for signs and symptoms of respiratory distress, and encouraging rest periods as needed. Observations 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-13 · tag F0790 — failed to provide dental care — isolated
    Provide routine and 24-hour emergency dental care for each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility policy and interviews for 1 of 1 sampled residents (Resident #19) reviewed for dental, the facility failed to report missing dentures to afford the opportunity for Resident #19 to submit a grievance. Resident 19's diagnosis included unspecified sequelae of cerebral infarction, paroxysmal atrial fibrillation and Type 2 diabetes mellitus. The Annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #19 was independent with eating, required supervision or touching assistance for oral hygiene, substantial/ maximal assistance for toileting hygiene, substantial/ maximal assistance for showering, partial/ moderate assistance for lower body dressing, supervision or touching assistance for upper body dressing. On 3/4/24 at 11:00 AM, interview with Resident #19 identified that his/her upper dentures were missing for about a week and could not recall if he/she told anyone. Interview with Licensed Practical Nurse (LPN) #1 on 3/4/24 at 12:07 PM identified that…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-13 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop 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 staff interviews, facility documentation, and review of the clinical record for 2 of 5 residents (Resident #26 and Resident #39) reviewed for immunizations, the facility failed to ensure that Resident #26 was provided with the Influenza vaccine after receiving consent. Also, the facility failed to ensure that Resident #39 or the resident representative was educated and given the opportunity to consent or decline the Pneumonia vaccination upon admission and subsequent to admission to the facility. The findings include: 1. Resident #26 was admitted to the facility on [DATE] with a diagnosis of heart disease, dementia, and diabetes. Interview and review of the facility immunization tracking with RN #6 (Infection Control Nurse) and RN #7 (the previous Infection Control Nurse) on 3/1/24 at 11:07 AM identified that RN #6 received consent upon admission for Resident #26 to receive the Influenza immunization for the 2023/2024 season. Resident #26 was ill and had Covid-19 on 10/4/23 and that RN #6 never provided…

    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 · D2024-03-13 · tag F0887 — isolated
    Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, facility documentation, and review of the clinical record for 2 of 5 sampled residents (Resident #11 and Resident #59) reviewed for immunizations, the facility failed to ensure upon admission, the residents or resident representative was educated and given the opportunity to consent or decline the Covid-19 vaccine. The findings included: 1. Resident #11 was admitted to the facility on [DATE] with diagnosis of an autoimmune disease, sepsis, and calculus of the kidney. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #11 was moderately cognitively impaired and dependent for toileting and dressing, set up for eating and substantial assist for personal hygiene. 2. Resident #59 was admitted to the facility on [DATE] with diagnosis of chronic obstructive pulmonary disease, sepsis, and congestive heart failure. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #59 moderately cognitively impaired and was dependent for dressing,…

    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 · D2024-03-13 · tag F0940 — failed to train staff — isolated
    Develop, implement, and/or maintain an effective training program for all new and existing staff members.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility documentation, review of facility policy and interviews 3 of 5 employee files reviewed (Licensed Practical Nurse (LPN) #4, LPN #5 and Registered Nurse (RN) #4), the facility failed to ensure that the required employee training's/inservices were completed. The findings include: 1. LPN #4's date of hire was 12/12/23. Review of the facility time-card documentation for LPN #4 identified that she had worked in the facility between 12/12/23 through 2/2/24. 2. LPN #5's date of hire was 11/15/23. Review of facility time-card documentation for LPN #5 identified that she had worked in the facility between 11/15/23 through 2/24/24. 3. RN #4's date of hire was 9/29/23. Review of facility time-card documentation for RN #4 identified that she had worked in the facility between 10/9/23 through 2/18/24. Review of employee files for LPN #4, LPN #5, and RN #4, failed to identify that new employee orientation training/inservices were completed and in the files. Additionally, the employee files failed to identify that documentation of Abuse/Neglect/Exploitation, Dementia,…

    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 · D2024-03-13 · tag F0947 — failed to train nurse aides adequately — isolated
    Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility documentation, employee files, review of facility policy and interviews 1 of 2 Nurse Aide (NA) employee files reviewed (NA #4), the facility failed to ensure that the required employee training/inservices were completed. The findings include: NA #4's date of hire was 9/28/23. Review of the facility time-card documentation for NA #4 identified that she had worked in the facility between 9/28/23 to present. Review of the employee file for NA #4 failed to identify that any inservicing had been provided (Abuse/Neglect/Exploitation, Dementia, Infection Control, Communication and Behavioral Health) and included in the files from the date of hire until present. Interview and record review with the facility Administrator on 3/6/24 at 12:00 PM identified that although the required training/inservices should have been completed upon hire, she was unable to provide documentation that the required inservices had been completed for NA #4. The Administrator further indicated that she did not know the reason the required inservices were not completed and that the person…

    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
  • Potential for harm · Dcited before2024-03-13 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #650) reviewed for a change in condition, the facility failed to ensure the health care representative was notified of new orders for intravenous fluids timely. The findings include: Resident #1 had diagnoses that included congestive heart failure, chronic kidney disease, osteomyelitis of vertebra, dysphagia, diabetes mellitus, and dementia. Review of Resident #650's advance directives dated 11/19/2019 identified Person #3 was the designated health care representative authorized to make any and all health care decisions for Resident #650. The form directed Person #3 was authorized to make decisions including the decision to accept or refuse any treatment, service, or procedure used to diagnose or treat Resident #650's physical or mental conditions and the decision to provide, withhold, or withdraw life support systems. The admission Minimum Data Set (MDS) assessment 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-01-23 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) residents,(Resident #1), reviewed for abuse, the facility failed to ensure the reporting of a suspected crime to local law enforcement following and allegation of staff to resident physical mistreatment. The findings include: Resident #1's diagnoses included atrial fibrillation, type II diabetes and cognitive communication deficit. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 had moderate cognitive impairment, required one person assist with bed mobility and transfer, two person assist with toileting, dressing, and was mobile with the use of a wheelchair. The Resident Care Plan dated 11/28/23 identified Resident #1 had impaired cognitive function and required assistance with activities of daily living related to disease process with interventions directed to communicate with the resident and caregivers regarding resident's capabilities and provide two care givers due…

    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 · D2024-01-23 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) residents, (Resident #1), reviewed for abuse, the facility failed to ensure a complete and thorough investigation was completed following an allegation of staff to resident physical mistreatment. The findings include: Resident #1's diagnoses included atrial fibrillation, type II diabetes and cognitive communication deficit. The hospital Discharge summary dated [DATE] identified abrasions, bruising and excoriation (unspecified location). The admission Minimum Data Set assessment dated [DATE] identified Resident #1 had moderate cognitive impairment, required one person assist with bed mobility and transfer, two person assist with toileting, dressing, and was mobile with the use of a wheelchair. The Resident Care Plan dated 11/28/23 identified Resident #1 had impaired cognitive function and required assistance with activities of daily living related to disease process. Interventions directed to…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2021-12-07 · tag F0684 — failed to provide proper treatment and quality of care — pattern
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, facility policy review, and interviews for three of six residents (Resident #6, #11 and #304) reviewed for a change in condition, the facility failed to ensure physician recommendations were acted upon timely, and the facility failed to ensure treatments provided were indicated, and the facility failed to ensure weights were obtained in accordance with physician's orders. The findings include: a. Resident #6's diagnoses included Alzheimer's disease, difficulty walking and localized edema. The admission MDS dated [DATE] identified Resident #6 had moderate cognitive impairment, was independent with transfers and ambulation, and had no pressure ulcers or other wounds. The care plan dated 9/10/2021 identified Resident #6 had a potential for alteration in skin integrity related to decreased mobility and edema with blisters. Interventions directed to follow skin protocol and document on any skin alterations weekly. Wound physician consultation progress…

    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 · D2021-12-07 · 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 reviews and interviews for two of two residents (Resident# 2, and #31) reviewed for advanced directives, the facility failed to ensure the advance directives were completed timely and were in accordance with resident's wishes. The findings include: a. Resident #2 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease and vascular dementia without behavioral disturbances. The nursing admission assessment dated [DATE] identified Resident #2 was confused and required extensive assistance with ADLs. The Resident Care Plan (RCP) dated [DATE] identified Resident #2 had an established advanced directive of Do Not Resuscitate/Don Not Intubate (DNR/DNI). Interventions directed to adhere to advance directives per resident wishes, and to review the advanced directives with the resident and family quarterly. Clinical record review identified Resident #2 had a family member listed as the responsible party. Additional review identified Advance Directives form signed by…

    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 before2021-12-07 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility's documentation, review of facility's policy, and interviews for one of three residents (Resident #304) reviewed for a change in condition, the facility failed ensure the physician was notified timely when weekly weights were not obtained in accordance with physician's orders. The findings include: Resident #304 was admitted on [DATE] with diagnoses that included metabolic encephalopathy, sepsis, UTI, Marfan's syndrome, urinary retention, muscle weakness, and dementia without behavioral disturbance. A physician's order by Physician's Assistant (PA) #1 dated 11/3/2021 directed to weigh weekly every Friday for four (4) weeks and once a day starting on the first day and ending on the last day of every month. The weight record dated 11/3/2021 identified Resident #304's weight was 98.6 pounds (lbs). The admission Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #304 had severe cognitive impairment, required extensive assistance 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-12-07 · 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, facility documentation review and interviews and for one of two residents reviewed for pressure ulcer, Resident #46, the facility failed to ensure a comprehensive care plan was develped timely related to risk for pressure ulcers and the presence of a pressure ulcer. The findings include: Resident #46 was admitted in August 2021. Resident #46's diagnoses included dementia, diabetes, difficulty walking and a pressure ulcer to the left heel. A Braden Scale for Predicting Pressure Sore Risk dated 8/19/2021 identified the resident was at risk for pressure sores. The admission MDS dated [DATE] identified Resident #46 had severe cognitive impairment, required extensive assistance of one staff for bed mobility and transfers and identified the resident was at risk for developing pressure ulcers and had one unstageable pressure ulcer (due to coverage of wound bed by slough and/or eschar). The Resident Care Plan (RCP) dated 9/9/2021 identified an alteration in personal care related to a…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-12-07 · 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 clinical record review, observations, facility documentation review, and interviews for one of two residents (Resident #46) reviewed for pressure ulcers, the facility failed to ensure consistent use of a skin protection device in accordance with physician orders, and the facility failed to ensure the wound physician's recommendations were acted upon in a timely manner. The findings include: Resident #46 had diagnoses that included diabetes, peripheral vascular disease and a stage 4 pressure ulcer to left heel. The Resident Care Plan (RCP) dated 10/6/2021 identified an ADL self-care deficit. Interventions directed to assist with ADLs. The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #46 had moderate cognitive impairment, required extensive assistance of one staff for bed mobility and transfers, was at risk for developing pressure ulcers and had one stage four pressure ulcer. A physician's order dated 11/11/2021 directed waffle boot to offload heel at all times. Wound physician…

    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 · D2021-12-07 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide 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 clinical record review, observation, interviews, and facility documentation review for one of one resident (Resident #4) reviewed for range of motion, the facility failed to ensure a splint was applied consistently in accordance with physician's orders. The findings include: Resident #4 had diagnoses that included hemiplegia and hemiparesis following cerebrovascular disease affecting his/her right side. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #4 had moderately impaired cognition, required total assistance of one staff for personal hygiene, eating, and had functional limitations in range of motion on one side for both upper extremities. The Resident Care Plan (RCP) dated 9/9/2021 identified Resident #4 had a contracture of the right hand. Interventions directed to the use of a supportive right-hand splint, apply in the AM and off in PM. A physician's order with initial order dated 11/30/2021 directed to apply a right upper extremity (RUE) resting hand splint after AM…

    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 · D2021-12-07 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, facility documentation review, and interviews, for one of twelve bathrooms observed on the secured dementia unit, the facility failed to ensure cleaning products were stored in accordance with accepted practice. The findings include: Intermittent observations on 11/30/2021 from 9:45 AM through 10:53 AM on the secured dementia unit identified residents were ambulating and self-propelling in their wheelchairs independently throughout the unit. Observation of one resident bathroom (room [ROOM NUMBER]) identified the following facility cleaning products were located on the seat of a shower chair: Peroxide Multi Surface Cleaner and Disinfectant. No facility staff/housekeepers were observed within view of the products during the observations, and no residents were observed in the room. Interview and observation with LPN #1 on 11/30/2021 at 11:00 AM identified the cleaning products should not have been left in the bathroom and indicated that housekeeping may have left the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2025-12-30 · tag F0641 — pattern
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, and interviews for one sampled resident (Resident #74) reviewed for resident assessment, the facility failed to ensure the MDS was coded accurately to reflect the current wheelchair mobility status of the resident. The findings include:Resident #74's diagnoses included severe protein calorie malnutrition, Marfan syndrome, osteoarthritis, and Alzheimer's.The physician's order dated 5/16/25 directed to have one person assist with bed mobility, two people assist with transfer, and non-ambulatory.The Occupational Therapy (OT) evaluation and plan of treatment dated from 5/21/25 to 8/11/25 identified Resident #74 required partial to moderate assistance with wheelchair mobility.The quarterly MDS assessment dated [DATE] identified Resident #74 had severe cognitive impairment and was dependent on staff for toileting, personal hygiene, dressing, transfers, and was non-ambulatory. Further review of the assessment identified Resident #74 was coded as independent for…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2024-03-13 · tag F0623 — widespread
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal 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 and interviews for 4 of 4 sampled residents (Resident #18, Resident #19, Resident #43 and Resident #59) reviewed for hospitalization, the facility failed to provide the required notification of transfer/discharge to the state Ombudsman's office. The findings include: 1. Resident #18 diagnoses included Parkinson's disease with dyskinesia, pneumonitis, cognitive communication deficit. An admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #18 was severely cognitively impaired, required extensive assistance of 2 for bed mobility, total dependence for transfers, and total dependence for dressing and toilet use. Nursing notes dated 9/9/23 at 4:26 PM written by Registered Nurse (RN) #8 identified Resident #18 pulled his/her Percutaneous Endoscopic Gastrostomy (PEG) tube out, the on call provider was notified and Resident #18 was transported to the hospital. Advanced Practice Registered Nurse (APRN) #1 progress notes dated 9/13/23 at 10:31 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2024-03-13 · tag F0625 — widespread
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    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 4 of 5 residents (Resident #18, Resident #19, Resident #55, and Resident #59) reviewed for hospitalization, the facility failed to provide documentation that the facility bed hold notice was provided to the resident or resident representative upon hospitalization. The findings include: 1. Resident #18 diagnoses included Parkinson's disease with dyskinesia, pneumonitis, cognitive communication deficit. An admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #18 severely cognitively impaired, required extensive assistance of 2 for bed mobility, total dependence for transfers, and total dependence for dressing and toilet use. Nursing notes dated 9/9/23 at 4:26 PM identified Resident #18 pulled his/her Percutaneous Endoscopic Gastrostomy (PEG) tube out, the on call provider was notified and Resident #18 was transported to the hospital. APRN #1 progress note dated 9/13/23 at 10:31 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2024-03-13 · 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 — the official record, unedited, may be distressing

    Based on staff interview and review of Payroll Based Journal (PBJ) submissions for Quarter 3 in 2023 (April 1, 2023 through June 30, 2023), the facility failed to ensure the data was accurate and did not reflect excessively low weekend staffing. The findings include: PBJ submissions for Quarter 3 of 2023 (April 1, 2023 through June 30, 2023) identified excessively low weekend staffing. On 3/6/24 at 11:12 AM, interview with the Administrator identified the facility provides both payroll hours worked for their employees and agency employees to a contracted company who then submits the data to CMS. She further identified that staffing levels were not low during Quarter 3 in 2023, the long term care facility company identified low staffing pattern submissions, and would review the contracted company reporting procedures.

    Administration Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2024-03-13 · tag F0881 — failed to use antibiotics responsibly — widespread
    Implement a program that monitors antibiotic use.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interviews, facility documentation and review of antibiotic stewardship program, the facility failed to ensure that the policies were reviewed on an annual basis and that data was kept and analyzed according to federal regulations. The findings included: On 3/1/24 at 11:07 AM, review of the facility infection control policy and procedure manual with RN #6 (the Infection Preventionist) and RN #7 (the previous facility Infection Preventionist) failed to identify that facility staff had reviewed the infection control manual on an annual basis. On 3/1/24 at 11:15 AM, review of the antibiotic stewardship program with RN #6 and RN #7 failed to identify that the facility was calculating monthly antibiotic use percentages and failed to identify that percentages were used and reviewed with the Quality Assurance program on a quarterly basis. Further interview with RN #6 and RN #7 on 3/1/24 at 11:15 AM identified that they were unaware that the facility was required to keep percentages of antibiotic use, infections that required antibiotic use, intravenous policies and to have…

    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

“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

$16,039 in federal fines across 1 penalty.

  • $16,039 — penalty dated 2024-03-13

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 / managerTypeRoleShareSince
FRIED, AKIVAIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; W-2 MANAGING EMPLOYEE; CORPORATE OFFICER17%since 10/15/2020
SODDEN, AARONIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; W-2 MANAGING EMPLOYEE; CORPORATE OFFICER17%since 10/15/2020
WIESEL, ALLANIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; W-2 MANAGING EMPLOYEE; CORPORATE OFFICER17%since 10/15/2020
STEIN, ALLENIndividualW-2 MANAGING EMPLOYEE; CORPORATE OFFICERsince 10/15/2020

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

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$10.5M
Net patient revenuemost recent cost report
+6.9%
Operating marginrevenue minus expenses
$359K
Related-party expense4% of expenses
Who pays — share of resident-days
Medicaid 70%Medicare 14%Other / private 16%

This home reported $359K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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

Cost & finances

$405per resident / day
operating cost
$12,313per month
≈ monthly operating cost
$435per 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 075338. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-30, 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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