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River Glen Health Care Center

162 South Britain Rd, Southbury, CT 06488 · For profit - Limited Liability company · 120 certified beds · (203) 264-9600 Medicare & Medicaid certified

Call the home — (203) 264-9600 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citations on record (F0600, F0603) — most recent Jul 2025Behavioral-health or dementia-care citation — no harm found (F0741)
Insights

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

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • it has abuse, neglect, or exploitation citations (F0600, F0603) — most recent Jul 2025
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • about 17% of its spending goes to commonly-owned related companies

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

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

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
900 Main St S #100 · (203) 262-1911 · Call to confirm hours
Pharmacy
370 Main St S · (203) 267-6718 · Call to confirm hours
Grocery
ShopRite0.5 mi
775 Main St S · (203) 262-1477 · Call to confirm hours
Park
(203) 264-5858 · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 5 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 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 held steady at 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 increased13.0%18.0%15.4%better
Long-stay residents who lose too much weight4.0%6.5%5.4%better
Long-stay residents with a catheter left in their bladder3.0%0.7%0.9%worse
Long-stay residents with a urinary tract infection3.3%1.5%2.0%worse
Long-stay residents with depressive symptoms1.5%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 worsened19.4%16.4%16.1%worse
Long-stay residents on antianxiety or hypnotic medication13.3%17.6%18.9%better
Long-stay residents given the seasonal flu vaccine97.4%93.5%95.3%typical
Long-stay residents with pressure ulcers3.7%4.0%4.7%better
Long-stay residents with worsening bladder/bowel control29.4%24.7%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table18.2%17.8%17.1%typical
Short-stay residents who newly got an antipsychotic medication0.8%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine57.5%69.7%79.4%worse
Short-stay residents rehospitalized after admission23.5%24.3%22.6%typical
Short-stay residents with an outpatient ER visit10.8%10.7%12.0%better
Long-stay hospitalizations per 1,000 resident days0.732.061.67better
Long-stay outpatient ER visits per 1,000 resident days0.261.461.80better

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.

63.5% 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 517 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

63.5%U.S. median 51.5%
Got home and stayed home
10.7%U.S. median 10.7%
Went back to hospital
56.0%U.S. median 56.6%
Met the expected recovery
0.57U.S. median 0.31
Therapy hours / resident / day
0.26hours / resident / day
Physical therapy
0.26hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 56.0% 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 241 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 0.57 therapist hours per resident per day in 2026Q1 — more than 86% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 22% 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 SNF63.5%CMS range 59.0–67.551.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.7%CMS range 8.3–12.810.7%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 discharge56.0%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 discharge39.8%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 discharge52.3%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 identified96.8%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 setting98.4%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 discharge98.9%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 worsened0.9%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.5%CMS range 4.4–8.67.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.911.02Oct 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

0.79
RN hours/ resident / day
0.83
LPN hours/ resident / day
2.08
Aide hours/ resident / day
3.71
Total nurse hours/ resident / day
0.48
RN hoursweekends
39.6%
Total nursing turnover
33.3%
RN turnover

How full it usually is: this home is certified for 120 beds and averages 110.6 residents a day — about 92% occupied, or roughly 9 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.71 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.79 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.08 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 3.28 hrs/resident/day on weekends vs 3.88 on weekdays — 15% thinner on weekends. RN hours go from 0.92 to 0.48 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 40% is about the same as the national median of 45%.

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

Inspection trend

10
deficiencies at the latest standard inspection (2025-08-15)
4
at the previous standard inspection (2023-12-22)

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

Inspection deficiencies

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

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.

27 citations, most serious first. The 10 most serious are shown; the remaining 17 are one tap away and print in full.

  • Potential for harm · D2025-08-15 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation(s), review of the clinical record, facility policy and interviews for 1 of 4 residents (Resident #118) reviewed for respiratory care, the facility failed to properly store medication and obtain a physician order with completion of a self administration assessment for a resident with chronic obstructive pulmonary disease (COPD). The findings include:Resident #118's diagnoses included COPD, chronic respiratory failure with hypoxia, emphysema, and pneumonia. A physician's order dated 7/16/25 directed Ventolin HFA (a bronchodilator used to treat asthma) aerosol solution 108mcg/act (Albuterol Sulfate HFA) 2 puffs inhaled orally every 4 hours as needed for shortness of breath.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #118 was cognitively intact and required partial/moderate assistance with bed mobility, transfers, and toileting. The MDS indicated Resident #118 was on continuous oxygen therapy.The Resident Care Plan (RCP) dated 7/29/25 identified Resident #118…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-15 · 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 review of the clinical record, facility policy and interviews for the 1 of 32 sampled residents (Resident #2) reviewed for advanced directives, the facility failed to ensure advanced directives were consistent. The findings include:Resident #2's was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease, acute respiratory failure with hypercapnia (retention of carbon dioxide) and chronic kidney disease. A State of Connecticut Department of Public Health transfer of Do Not Resuscitate (DNR) order form signed by the physician on [DATE] indicated Resident #2 had a valid DNR order which was written on [DATE] and was retained in the resident's medical record. A hospital discharge summary for Resident #2 dated [DATE] at 11:59 PM identified the discharge code status as do not resuscitate/do not intubate (DNR/DNI). An admission physician's order dated [DATE] indicated Resident #2 was a DNR. An Advanced Practice Registered Nurse (APRN) order written by APRN #2 dated [DATE] directed…

    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 before2025-08-15 · 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 observations, review of the clinical record, interviews and facility policy for the only resident reviewed for communication/sensory (Resident #8), for 1 of 3 sampled resident (Resident #32) reviewed for pressure ulcers, for the only sampled resident reviewed for positioning (Resident #90), the facility failed to ensure a comprehensive care plan was in place for hearing (Resident #8), for refusals of care (Resident #32) and for functional limitation in range of motion (Resident #90). The findings include: 1.Resident #8 diagnoses included failure to thrive, heart failure, and osteoarthritis. A facility contracted audiology consult form dated 9/17/24 identified that Resident #8 had a right and left hearing aid from another company. The aids were cleaned for wax and debris and were functioning. Resident #8 declined to receive new hearing aids at that time. No follow up audiology consults were in the clinical record. The Resident Care Plan (RCP) dated of 5/22/25 identified Resident #8 was hard of hearing…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-15 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility policy and interviews for 1 of 3 residents (Resident #15) reviewed for advance directives, the facility failed to update the resident care plan (RCP) for a resident with comfort measures only (CMO) and no intravenous hydration (IVs). The findings include:Resident #15 had diagnoses that included dementia, anemia, and hypertension.A Do Not Resuscitate Consent Form dated [DATE] identified do not resuscitate (DNR) was discussed with Resident #15's responsible party by the Advanced Practice Registered Nurse (APRN) #4 and Resident #15's responsible party signed the form in agreement with changing Resident #15 to DNR.An APRN #4's progress note dated [DATE] at 11:53 AM identified Resident #15's code status/advance directives was changed by probate court on [DATE] from full code to DNR. The note further identified an order was in place for DNR and registered nurse may pronounce (RNP)(the RN may officially declare a resident deceased ).An APRN advance directives order dated…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-15 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, review of the clinical record and policy for 1 of 1 sampled resident (Resident #131) reviewed for death, the facility failed to ensure the Registered Nurse Pronouncement was comprehensive to include a full assessment. The findings include:Resident #131's diagnoses included congestive heart failure, cerebral infarction, and hypertension.A Resident Care Plan dated 4/17/25 identified Resident #131 had a self-care deficit related to impaired mobility and incontinence. Interventions included to aid in bathing resident as needed and provide assistance with eating, dressing, grooming and oral care as needed.The quarterly Minimum Data Set assessment dated [DATE] identified Resident #131 was cognitively intact, required substantial maximal assistance for toileting, bathing, and transfers. Also, identifying Resident #131 required set up assistance for eating.A physician's order dated 6/22/25 directed Do Not Resuscitate (DNR), Register Nurse Pronouncement (RNP), and comfort measures only.Nursing…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-15 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 3 residents (Resident #87) reviewed for falls, the facility failed to provide supervision for a resident who required assistance of 1 with toileting and supervision with ambulation, resulting in a fall. The findings include: Resident #87 had diagnoses that included Alzheimer's disease, macular degeneration, and hypertension.A Fall Risk Evaluation assessment dated [DATE] at 10:10 AM and completed by Registered Nurse (RN) #1 identified Resident #87 was at a high risk for falls related to poor recall, judgement, and safety awareness. Additionally, the Fall Risk Evaluation identified Resident #87 had 1-2 falls in the past 3 months. The Resident Care Plan (RCP) dated 7/2/24 identified Resident #87 was at risk for falls related to medication side effects, history of falls, and deconditioning. Interventions included to transfer Resident #87 with contact guard assistance/ hand hold assistance and a rolling walker,…

    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 · D2025-08-15 · 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, clinical record review, interviews, and facility policy for 1 of 4 residents (Resident #2) reviewed for respiratory care, the facility failed to obtain a physician's order for a resident utilizing a continuous positive airway pressure (CPAP) machine nightly. The findings include: Resident #2's diagnoses included obstructive sleep apnea (OSA), acute respiratory failure with hypercapnia (retention of carbon dioxide) and asthma. A respiratory care evaluation form dated 7/17/25 identified Resident #2 had his/her own CPAP machine with a nasal mask at the bedside which the resident indicated he/she had worn on the prior night and to continue to observe and educate the resident with CPAP use. An Advanced Practice Registered Nurse (APRN) progress note dated 7/21/25 at 9:45 AM and written by APRN #2 identified Resident #2 had a history of obstructive sleep apnea, should be encouraged to use the CPAP machine during his/her skilled nursing facility (SNF) stay and the resident should be educated 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 · D2025-08-15 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility policy and interviews for 1 of 3 residents (Resident #15) reviewed for pressure ulcer/injury, the facility failed to ensure Resident #15 was placed on Enhanced Barrier Precautions (EBP) for a Stage 3 pressure ulcer. The findings include:Resident #15 had diagnoses that included dementia, anemia, and hypertension.The Resident Care Plan (RCP) dated 6/28/25 identified Resident #15 was at risk for alteration in skin integrity related to impaired mobility, incontinence, shearing, friction, and cognition. Interventions included to observed skin condition with care daily and report abnormalities, and provide preventative skin care routinely and as needed. The RCP further identified Resident #15 had actual skin breakdown related to a stage 2 pressure injury on the right buttock. Interventions included administer treatment per physician orders, encourage and assist to turn and position as needed, and obtain wound consult as needed. The quarterly Minimum Data…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-07 · 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 record review, facility documentation, and staff interviews for one of three residents (Resident #1) reviewed for abuse, the facility failed to ensure the resident was free from verbal mistreatment. The findings include: Resident #1 was admitted to the facility during 6/2025 with diagnoses that included metabolic encephalopathy and a history of falls. The admission Minimum Data Set (MDS) dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of six (6), indicating severely impaired cognition, had no behaviors and required maximal assistance with transfers. The Resident Care Plan (RCP) dated 6/13/2025 identified cognitive loss related to metabolic encephalopathy, and a risk for falls. Interventions directed to use simple words, reinforce the need to call for assistance, and to assist the resident with ADLs. Facility reportable event dated 6/16/2025 at 2 AM identified Resident #1 was confused, trying to get out of bed, and yelling out for his/her spouse, and the roommate…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-07 · tag F0603 — failed to not confine residents against their will — isolated
    Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, facility documentation, and staff interviews for one of three residents (Resident #1) reviewed for abuse, the facility failed to ensure the resident was free from involuntary seclusion. The findings include: Resident #1 was admitted to the facility during 6/2025 with diagnoses that included metabolic encephalopathy and a history of falls. The admission Minimum Data Set (MDS) dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of six (6), indicating severely impaired cognition, had no behaviors and required maximal assistance with transfers. The Resident Care Plan (RCP) dated 6/13/2025 identified cognitive loss related to metabolic encephalopathy, and a risk for falls. Interventions directed to use simple words, reinforce the need to call for assistance, and to assist the resident with ADLs. Facility reportable event dated 6/16/2025 at 2 AM identified Resident #1 was confused, trying to get out of bed, and yelling out for his/her spouse, and 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
Show the remaining 17 citations
  • Potential for harm · D2025-07-07 · 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 record review, facility documentation, and staff interviews for 1 of 3 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 during 6/2025 with diagnoses that included metabolic encephalopathy and a history of falls. The admission Minimum Data Set (MDS) dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of six (6), indicating severely impaired cognition, had no behaviors and required maximal assistance with transfers. The Resident Care Plan (RCP) dated 6/13/2025 identified cognitive loss related to metabolic encephalopathy, and a risk for falls. Interventions directed to use simple words, reinforce the need to call for assistance, and to assist the resident with ADLs. Facility reportable event dated 6/16/2025 at 2 AM identified Resident #1 was confused, trying to get out of bed, and yelling out for his/her spouse, and the roommate reported…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-07-07 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, facility documentation, and staff interviews for one of three residents (Resident #1) reviewed for abuse, the facility failed to ensure the medical record was complete and accurate to include documentation of an allegation of abuse timely. The findings include: Resident #1 was admitted to the facility during 6/2025 with diagnoses that included metabolic encephalopathy and a history of falls. The admission Minimum Data Set (MDS) dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of six (6), indicating severely impaired cognition, had no behaviors and required maximal assistance with transfers. The Resident Care Plan (RCP) dated 6/13/2025 identified cognitive loss related to metabolic encephalopathy, and a risk for falls. Interventions directed to use simple words, reinforce the need to call for assistance, and to assist the resident with ADLs. Facility reportable event dated 6/16/2025 at 2 AM identified Resident #1 was confused, trying to get out of…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-31 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of two (2) residents (Resident #1) reviewed for abuse, the facility failed to ensure the resident was treated in a respectful and dignified manner. The findings include: Resident #1 had diagnoses that included moisture associated skin damage (MASD), anxiety, dysthymic disorder, muscle weakness, difficulty walking, lymphedema, and type 2 diabetes mellitus. The Resident Evaluation dated 3/7/2025 at 7:35 P.M. by Licensed Practical Nurse (LPN) #4 indicated Resident #1 was admitted to the facility with a superficial 3 centimeter slit to the coccyx, sacral-coccyx, and buttocks with excoriation. A physician's order dated 3/7/2025 directed to apply triad cream to buttocks and coccyx every shift for excoriation. The 5-day [NAME] Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of fourteen (14) indicative of intact cognition, was always incontinent of…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-12-22 · 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, observations, review of facility policy and interviews for two sampled residents (Residents #28 and #47) reviewed for dining, the facility failed to ensure a dignified experience. The findings include: 1. Resident #28's diagnoses included other abnormalities of gait and mobility, bicipital tendinitis right shoulder, and abnormal posture. The quarterly MDS assessment dated [DATE] identified Resident #28 had intact cognition and required set up assistance with eating and oral hygiene. Resident #28's care plan dated 11/28/23 identified an ADL (activities of daily living) self-care deficit related to muscle weakness with interventions that included: assist with daily hygiene, grooming, dressing, oral care and eating as needed. Observations on 12/18/2023 at 8:05 AM 12/18/2023 at 12:42 PM identified Resident # 28 was served breakfast and lunch in a Styrofoam container with plastic utensils and a plastic cup. Interview with Resident #28 on 12/18/2023 at 8:00 AM identified residents are…

    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 · D2023-12-22 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    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 four sampled residents (Resident #72 and Resident #86) reviewed for Preadmission Screening and Resident Review (PASRR), the facility failed to request a PASRR level 2 assessment for a resident with a new psychiatric diagnosis and failed to obtain and complete a PASRR level II screen in timely manner when the resident's approved stay had expired. The findings include: 1. Resident #72's diagnoses included delusional disorder. The quarterly MDS assessment dated [DATE] identified Resident #72 had moderately impaired cognition, required set-up assistance with eating and supervision or touching assistance with oral hygiene, and substantial/maximal assistance with toileting hygiene. Resident #72's care plan dated [DATE] identified the problem of increased agitation, and yelling out, with interventions that included: observe for mental status/behavioral changes when new medication is started or with 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-12-22 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    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 clinical record, facility policy review, and interviews for one of three sampled residents (Resident #91) reviewed for medication administration, the facility failed to ensure medication error rate of less than five percent. The findings include: Resident #91's diagnoses included cervical spinal cord injury, quadriplegia, spinal stenosis, and neuromuscular dysfunction of bladder. The physician's orders dated 11/5/23 directed to administer Aripiprazole (anti-psychotic medication) 5 milligrams (mg) by mouth every day and to administer Duloxetine (anti-depressant medication) 60 mg capsules 2 capsules (a total of 120 mg) by mouth daily. The admission MDS assessment dated [DATE] identified Resident #91 had intact cognition and required extensive assistance with bed mobility, transfers, toileting, and hygiene. Observation of medication administration for Resident #91 on 12/18/23 at 8:35 AM, with LPN #1 identified that he placed 4 capsules of Duloxetine 60 mg (total of 240mg), 2 tablets…

    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 · Dcited before2021-08-31 · 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, facility policy and interviews for one of two residents reviewed for allegation of abuse (Resident #69), the facility failed to provide care and assistance in a dignified manner. The findings include: Resident #69's diagnoses included generalized anxiety disorder, muscle weakness and urinary incontinence. A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that the resident had no cognitive impairment, had no mood or behavioral indicators or symptoms and noted no rejection of care. The assessment further identified Resident #69 required extensive assistance with all Activities of Daily Living (except eating) including bed mobility and toilet use. Resident care plan dated 11/16/20 identified a problem with behavior symptoms related to being away from home /daily routine and medical condition. Interventions included to use consistent approaches when giving care and to provide care and assistance with two (2) staff. The facility Reportable…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-08-31 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, interviews, review of facility policy for two of five residents (Residents # 27 and # 28) reviewed for skin non-pressure or pressure ulcer, the facility failed to ensure timely notification to the resident's representative when a change in condition related to skin integrity was identified. The findings included: 1. Resident #27's diagnoses included dementia, dysphagia, muscle weakness and difficulty walking. The care plan dated 3/8/21 identified the resident was at risk for alterations in skin integrity related to impairment in mobility and incontinence. Interventions included to observe skin condition daily with ADL care and report abnormalities. The quarterly MDS assessment dated [DATE] identified the resident had severe cognitive impairment, required extensive assistance of two staff for bed mobility and extensive assistance of one staff for transfers, toilet use and personal hygiene; the resident was at risk for developing pressure ulcers, had no unhealed pressure ulcers…

    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 before2021-08-31 · 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 and interviews for one of two residents reviewed for allegation of abuse for (Resident #69), the facility failed to implement the resident's plan of care related to staff provision of care. The finding include: Resident #69's diagnoses included generalized anxiety disorder, muscle weakness and urinary incontinence. A quarterly MDS assessment dated [DATE] identified the resident had no cognitive impairments, had no mood or behavioral indicators or symptoms and no rejection of care. The assessment further identified that Resident #69 required extensive assistance with all activities of daily living (except eating) including bed mobility and toilet use. Resident Care Plan (RCP) dated 11/16/21 identified a problem with behavior symptoms related to being away from home /daily routine and medical condition. Interventions included to use consistent approaches when giving care and to provide care and assistance with two (2) staff. The facility Reportable Event (RE)…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-08-31 · 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 observations, review of clinical records, interviews and review of facility policy for one of two residents reviewed for skin non-pressure for (Resident #28), the facility failed to conduct and RN assessment, failed to obtain a practitioner's order prior to writing and implementing a treatment order and failed to follow facility policy for Care of Skin Tears-Abrasions and Minor Breaks and for one sampled resident (Resident #89) reviewed for Quality of Care, the facility failed to ensure the resident's ted stocking was applied daily in accordance to physician's orders. The findings included: 1. Resident # 28's diagnoses included metabolic encephalitis, dementia and acute kidney failure. The admission MDS dated [DATE] identified the resident had severe dementia, no mood or behavior problems, required total assistance for transfers, required extensive assistance of two staff for bed mobility and toileting, and required extensive assistance of one staff for dressing, eating and personal hygiene. The…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-08-31 · 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, interviews and review of facility documentation for one of four residents reviewed for Pressure Ulcer for (Resident # 27), the facility failed to ensure a timely RN assessment when the resident had a skin change to the coccyx. The findings include: Resident #27's diagnoses included dementia, dysphagia, muscle weakness and difficulty walking. The care plan dated 3/8/21 identified the resident was at risk for alterations in skin integrity related to impairment in mobility and incontinence. Interventions included to observe skin condition daily with ADL care and report abnormalities. The quarterly MDS assessment dated [DATE] identified the resident had severe cognitive impairment, required extensive assistance of two staff for bed mobility and extensive assistance of one staff for transfers, toilet use and personal hygiene; the resident was at risk for developing pressure ulcers, had no unhealed pressure ulcers and noted pressure reducing devices for the resident's bed and…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-08-31 · tag F0711 — isolated
    Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
    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 and interviews for one resident (Resident #298) reviewed for Physician Services, the physician failed to conduct the admission History and Physical timely and sign admission physician's orders timely. The findings include: 1 a. Resident #298 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy, abscess of abdominal wall, and hypertension. The care plan dated 8/13/21 identified a cardiac disease. Interventions directed to administer medications and treatments per physicians' orders. The admission orders dated 8/13/21 did not have a signature from a physician or the APRN. The admission MDS assessment dated [DATE] identified Resident #298 had intact impaired cognition and required extensive assistance for hygiene, dressing, and toileting. The History and Physical dated 8/25/21 at 11:41 A.M. by the physician identified that Resident #298 was admitted with abdominal abscess in surgical wound. The History and…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-08-31 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of clinical records, interviews and review of facility policy for three of five residents reviewed ( Residents #27, #28, and # 89), the facility failed to ensure an accurate record. The findings included: 1. Resident #27's diagnoses included dementia, dysphagia, muscle weakness and difficulty walking. The care plan dated 3/8/21 identified the resident was at risk for alterations in skin integrity related to impairment in mobility and incontinence. Interventions included observe skin condition daily with ADL care and report abnormalities. The quarterly MDS assessment dated [DATE] identified the resident had severe cognitive impairment, required extensive assistance of two staff for bed mobility and extensive assistance of one staff for transfers, toilet use and personal hygiene; was at risk for developing pressure ulcers, had no unhealed pressure ulcers and had pressure reducing devices for bed and chair. A nurse's note written by LPN #2, dated 6/25/21, identified: Open area to…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-08-31 · 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 review of the clinical record reviews, facility documentation, facility policy, and interviews for four of five Residents (Resident #1, #8 and #27,) reviewed for Pneumococcal Vaccines, the facility failed to educate and offer residents and/or representative vaccines timely. The findings included: Interview and clinical record review with Infection Control Nurse on 8/30/21 at 10:50 A.M. identified on the resident's admission information provided to surveyor noted the admission coordinator will ask resident vaccination status on admission. The next day the Infection Control nurse will be responsible for following up to see if the resident was vaccinated or not vaccinated. The policy directed to offer and have the resident sign on admission accepting or refusing vaccines unless the resident can't sign for themselves then the admission nurse will call the family. The family will be asked if the resident had vaccines. The facility will ensure all signatures on necessary paperwork. The policy also notes 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2025-08-15 · 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 clinical record review, staff interview and the Resident Assessment Instrument (RAI) manual policy for the only resident reviewed for communication/sensory (Resident #8), for 1 of 3 reviewed for pressure ulcers (Resident #15), for the only sampled resident reviewed for position/mobility (Resident #90) and for 1 of 3 reviewed for accidents (Resident #117), the facility failed to ensure that the Minimum Data Set (MDS) assessment was coded correctly for the use of hearing aids (Resident #8), limited range of motion (Resident #15), position/mobility (Resident #90) and falls (Resident #117). The findings include: 1.Resident #8 diagnoses included failure to thrive, heart failure, and osteoarthritis. The Resident Care Plan (RCP) dated 5/22/25 identified Resident #8 was hard of hearing with interventions that included to attempt to minimize noise, refer to audiology as needed and when talking to Resident #8, use simple sentences, maintain eye contact and use gestures. The RCP lacked documentation that Resident…

    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 · B2025-08-15 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility documentation, facility policy and interviews related to facility bi-monthly narcotic audits, the facility failed to ensure that bimonthly narcotic audits were completed to monitor for possible drug diversion in the facility. The findings include: An interview with the interim DNS on 8/12/25 at 12:30 PM identified that she was unable to locate any facility documentation of bi-monthly narcotic audits conducted by the facility since the previous re-certification survey dated 12/22/23. The DNS indicated that she had only been employed by the facility since March 2025 as the ADNS and had been the interim DNS since July 2025. She stated that she had not completed any bi-monthly narcotic audits and that audits would have been conducted by the previous DNS at the facility. The interim DNS was able to provide a facility binder that contained all the current yellow narcotic reconciliation sheets for the residents in the facility receiving narcotics but there were no complete narcotic audit forms. The DNS presented 3 yellow narcotic reconciliation sheets with 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2023-12-22 · tag F0741 — failed to have staff trained for behavioral health — pattern
    Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
    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, the facility failed to have NA staff complete the annual competency course for dementia care. The findings include: Review of NA #9's personnel file identified she has been employed at the facility since 3/30/22 on the 11pm to 7 am shift at 37.5 hours weekly. The file further identified a letter dated 7/6/23 that noted that NA #9 had not completed her yearly in-service trainings and that she would be removed from the schedule if the trainings were not completed. A review of the staffing schedule dated 12/10/23 and 12/15/23 identified NA #9 worked one eight-hour shift. Interview on 12/21/23 at 10:53 AM with the ADNS identified that when staff do not complete the annual training requirements, we try to give them time to complete the training at the facility or to complete it at home to make it easier for them. We provide reminders and time to complete the training, for example, if the training is due in October, we would give them until the end of December to complete it. When the training is not…

    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

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to CAREONE — 37 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 5 of 53.4+1.6 vs chain
Health inspection 4 of 52.9+1.1 vs chain
Staffing 4 of 53.2+0.8 vs chain
Quality measures 5 of 54.4+0.6 vs chain
The other 36 homes this chain runs (chain average 3.4★, per CMS)
1 of 5Care One At MillburyMillbury, MA 1 of 5Care One At RandolphRandolph, MA 1 of 5Careone At OradellOradell, NJ 2 of 5Care One At BrooklineBrookline, MA 2 of 5Care One At NewtonNewton, MA 2 of 5Care One At RedstoneEast Longmeadow, MA 2 of 5Care One At WeymouthWeymouth, MA 2 of 5CareOne At Hanover TownshipWhippany, NJ 2 of 5Careone At MiddletownAtlantic Highlands, NJ 2 of 5Rehab & Nursing Ctr Greater PittsburghGreensburg, PA 3 of 5Care One At LexingtonLexington, MA 3 of 5Care One At LowellLowell, MA 3 of 5Care One At New BedfordNew Bedford, MA 3 of 5CareOne At Madison AvenueMorristown, NJ 3 of 5CareOne At MoorestownMoorestown, NJ 3 of 5CareOne at New MilfordNew Milford, NJ 3 of 5Careone At East BrunswickEast Brunswick, NJ 3 of 5Careone At Ridgewood AvenueParamus, NJ 3 of 5Careone At WellingtonHackensack, NJ 4 of 5Care One At ConcordW Concord, MA 4 of 5Care One At Essex ParkBeverly, MA 4 of 5Care One At NorthamptonNorthampton, MA 4 of 5CareOne At TeaneckTeaneck, NJ 4 of 5CareOne at The HighlandsEdison, NJ 4 of 5Careone At CresskillCresskill, NJ 4 of 5Careone At EveshamMarlton, NJ 4 of 5Careone At LivingstonLivingston, NJ 4 of 5Careone At ParsippanyParsippany Troy Hill, NJ 4 of 5Careone At Somerset ValleyBound Brook, NJ 5 of 5Care One At HolyokeHolyoke, MA 5 of 5Care One At PeabodyPeabody, MA 5 of 5Care One At WilmingtonWilmington, MA 5 of 5CareOne At WallWall, NJ 5 of 5Careone At HolmdelHolmdel, NJ 5 of 5Careone At ValleyWestwood, NJ 5 of 5Careone At WayneWayne, NJ

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
THCI COMPANY, LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 04/30/2002
CARE HOLDINGS, LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 04/30/2002
CARE REALTY, LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 04/30/2002
DES-C 2009 GRATOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 06/30/2017
THCI HOLDING COMPANY, LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 04/30/2002
STRAUS, DANIELIndividual5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 04/30/2002
BARUCH, DAVIDIndividualW-2 MANAGING EMPLOYEE; CORPORATE OFFICERsince 12/01/2021
HEALTHBRIDGE MANAGEMENT LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 07/28/2003

CMS files one row per role, so the 9 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted.

6 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

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

$17.9M
Net patient revenuemost recent cost report
+2.3%
Operating marginrevenue minus expenses
$2.9M
Related-party expense17% of expenses
Who pays — share of resident-days
Medicaid 42%Medicare 21%Other / private 37%

This home reported $2.9M paid to related parties — landlords or management companies under common ownership — equal to about 17% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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

Cost & finances

$449per resident / day
operating cost
$13,658per month
≈ monthly operating cost
$460per 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 075241. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-15, 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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