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Ark Healthcare & Rehabilitation At St. Camillus

494 Elm St, Stamford, CT 06902 · For profit - Limited Liability company · 124 certified beds · (203) 325-0200 Medicare & Medicaid certified

Call the home — (203) 325-0200 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citations on record (F0600, F0602, F0605) — most recent Jun 20261 actual-harm citation1 immediate-jeopardy citation CMS recorded as corrected before the inspection ended (past non-compliance)$8,018 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)
  • lower-than-typical staff turnover (35% vs 45% nationally) — better care continuity
Worth asking about
  • it has abuse, neglect, or exploitation citations (F0600, F0602, F0605) — most recent Jun 2026
  • it has 1 actual-harm citation
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $8,018 in federal fines (most recent 2024-07-11)
  • its facility-reported quality-measure rating is low (2/5)

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 2 of 5

Location & what’s nearby

Hospital
★★★★★ 5/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
37 Glenbrook Rd Ste 3 · (203) 674-0774 · Call to confirm hours
Pharmacy
200 Shippan Avenue · (203) 323-3491 · Call to confirm hours
Grocery
ShopRite0.2 mi
200 Shippan Ave · (203) 964-9500 · Call to confirm hours
Park
464 Shippan Ave · (203) 977-4140 · 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 2 of 5
Long-stay residentspeople who live here 2 of 5
Short-stay residentsrehab / post-hospital 2 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 3 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating3★
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 increased18.8%18.0%15.4%worse
Long-stay residents who lose too much weight6.5%6.5%5.4%worse
Long-stay residents with a catheter left in their bladder0.7%0.7%0.9%better
Long-stay residents with a urinary tract infection2.2%1.5%2.0%worse
Long-stay residents with depressive symptoms29.7%22.3%6.5%worse 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 injury2.3%3.5%3.3%better
Long-stay residents whose ability to walk worsened21.3%16.4%16.1%worse
Long-stay residents on antianxiety or hypnotic medication13.1%17.6%18.9%better
Long-stay residents given the seasonal flu vaccine94.2%93.5%95.3%typical
Long-stay residents with pressure ulcers2.9%4.0%4.7%better
Long-stay residents with worsening bladder/bowel control22.4%24.7%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table39.5%17.8%17.1%worse
Short-stay residents who newly got an antipsychotic medication4.5%1.5%1.4%worse
Short-stay residents given the seasonal flu vaccine42.9%69.7%79.4%worse
Short-stay residents rehospitalized after admission25.0%24.3%22.6%worse
Short-stay residents with an outpatient ER visit18.3%10.7%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.272.061.67worse
Long-stay outpatient ER visits per 1,000 resident days2.731.461.80worse

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

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

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

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

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

55.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 87 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

55.9%U.S. median 51.5%
Got home and stayed home
12.0%U.S. median 10.7%
Went back to hospital
52.6%U.S. median 56.6%
Met the expected recovery
0.30U.S. median 0.31
Therapy hours / resident / day
0.08hours / resident / day
Physical therapy
0.16hours / resident / day
Occupational therapy
0.06hours / resident / day
Speech therapy

Met the expected recovery: 52.6% 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 57 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 0.30 therapist hours per resident per day in 2026Q1 — more than 49% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 9% 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 SNF55.9%CMS range 45.5–66.851.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF12.0%CMS range 9.0–16.610.7%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 discharge52.6%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge45.6%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 discharge45.6%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened1.1%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.3%CMS range 4.2–10.87.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.161.02Oct 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

0.45
RN hours/ resident / day
0.81
LPN hours/ resident / day
2.23
Aide hours/ resident / day
3.48
Total nurse hours/ resident / day
0.29
RN hoursweekends
34.7%
Total nursing turnover
36.4%
RN turnover

How full it usually is: this home is certified for 124 beds and averages 117.2 residents a day — about 95% occupied, or roughly 7 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 3.481 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.45 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.23 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 3.16 hrs/resident/day on weekends vs 3.61 on weekdays — 12% thinner on weekends. RN hours go from 0.51 to 0.29 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 35% is below the national median of 45%.

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

Inspection trend

8
deficiencies at the latest standard inspection (2026-04-27)
8
at the previous standard inspection (2024-07-11)

Deficiencies are unchanged from the previous inspection. 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.

24 citations, most serious first. The 12 most serious are shown; the remaining 12 are one tap away and print in full.

  • Immediate jeopardy · Jdisputed · IDR2026-06-23 · tag F0605 — failed to not use drugs as a restraint — isolated
    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
    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 review, observation of facility video, and staff interviews for one of three residents (Resident #1), reviewed for accidents, the facility failed to ensure a resident with dementia that was dependent for personal care and mobility and had no physician orders for opioids was free from exposure to opioids. The resident was identified unresponsive to verbal or tactile stimulation with pinpoint pupils, and was transferred to the hospital where he/she was diagnosed with suspected opioid intoxication, received Narcan, and had two (2) laboratory tests that were positive for opioids, resulting in a finding of Jeopardy. The findings include: Resident #1 had a diagnosis of vascular dementia and history of a stroke (CVA) with hemiparesis and hemiplegia (one sided weakness/paralysis). The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview Mental Status (BIMS) score of 6 indicating severely impaired cognition, and was dependent…

    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
  • Actual harm · Gcited before2024-10-18 · 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 a review of clinical records, facility documentation, and interviews for one (1) of three (3) residents (Resident #1) reviewed for accidents, the facility failed to ensure that staff provided the resident with the required assistance with bed mobility and as a result, Resident #1 fell out of bed and sustained a left femur (thigh bone) fracture. The finding includes: Resident #1 had diagnoses of Parkinson's, dementia, abnormalities of gait and mobility and generalized muscle weakness. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1's Brief Mental Interview (BIMS) score of six (6) indicative of severely impaired cognition, was always incontinent of bowel and bladder, and was dependent with bed mobility and Activities of Daily Living (ADLs). A physician's order dated 8/29/24 directed to provide extensive assistance of 2 with bed mobility and 1/4 bed rails as an enabler, to assist with turning and repositioning. The care plan dated 9/10/24 identified Resident #1 at risk for ADL…

    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 · Ddisputed · IDR2026-06-23 · tag F0602 — failed to protect residents from theft of their belongings — isolated
    Protect each resident from the wrongful use of the resident's belongings or money.
    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, record review, and facility documentation review for one of three residents (Resident #2) reviewed for abuse, the facility failed to ensure the resident was free from misappropriation of resident property. The findings include: Resident #1 had a diagnosis of vascular dementia. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview Mental Status (BIMS) score of 6 indicating severely impaired cognition. The Resident Care Plan (RCP) dated 4/20/26 identified a self-care deficit. Interventions directed Resident #1 was non-ambulatory and dependent for wheelchair mobility, transfer with two (2) assist via mechanical lift, and provide personal care. Record review identified Resident #1 had no physician orders that directed administration of Risperdal (non-opioid medication used to treat bipolar), Trazadone (used to treat depression/not an opioid), Morphine (opioid medication used to treat pain or shortness of breath), or any opioids. Resident #2 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ddisputed · IDR2026-06-23 · tag F0755 — failed to provide safe pharmacy services — isolated
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and facility documentation review for one of three residents (Resident #2) reviewed for abuse, the facility failed to ensure staff followed accepted medication administration practices administration practices. The findings include: Review of facility surveillance video identified on [DATE] at approximately 2:30 AM (3 hours and 30 minutes after her shift started), LPN #1 was observed to exit Resident #1's room, walk down the hallway toward the nursing station with her medication cart keys in her right hand and a black item the size of a cell phone in her left hand. LPN #1 went to the medication cart, placed the cell phone sized item on top of the left side of the med card and she unlocked the cart and placed her keys on top of the right side of the medication cart. Without unlocking or referring to the laptop on the medication cart (med cart) or the Medication Administration Record (MAR), LPN #1 then opened a large non-narcotic drawer and removed an item that appeared to be…

    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 · Ecited before2026-04-27 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on a tour of the Dietary Department, observations, review of facility documentation, facility policy, and interviews the facility failed to ensure food temperatures were consistently obtained and logged prior to serving meals, refrigerator and freezer temperatures were consistently monitored and documented, dishwasher temperatures were consistently monitored and documented prior to washing dishes, sanitizer solution was consistently tested and logged prior to use to disinfect pots and pans and kitchen surfaces per manufacturer recommendations, and dietary staff wore a beard guard when preparing and serving food. The findings include: A tour of the Dietary Department on 4/20/26 at 8:00 AM with the Food Service Director (FSD) identified the following:1. Food temperature for breakfast, lunch, and dinner meal log sheets for 2025 were not completed. 2. Refrigerator and freezer log sheets for 2025 were not completed. 3. Dishwasher temperature log sheets for 2025 were not completed.4. Sanitizer parts per million (PPM) log sheets for 2025 were not completed.Interview with the FSD 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-04-27 · tag F0887 — pattern
    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

    Based on clinical record reviews, review of the facility Infection Control Program, facility documents facility policy and interviews, the facility failed to provide education regarding the Covid Vaccine to staff members offering to provide the vaccine or inform where staff could obtain a Covid vaccination, and the facility failed to ensure documentation of screening residents for the eligibility to receive the Covid vaccine was completed, and residents and responsible parties received copies of Covid Vaccination educational materials prior to deciding to vaccinate or decline vaccination. The findings include: An interview and facility document review with the Assistant Director of Nursing Services (ADNS/Infection Preventionist(IP) on 4/23/2026 at 10:15 AM identified she/he was unable to locate specific staff education regarding the Covid Vaccine and offering the vaccine or indicate where they could receive the vaccine. The Staff Development Nurse, RN#2 identified she/he provided staff training on the Covid infection and staff members roles within the facility as it pertains to 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
  • Potential for harm · D2026-04-27 · 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 observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 6 residents (Resident #3) reviewed for dining, the facility failed to ensure a dignified dining experience. The findings include:Resident #3 had diagnoses that included dementia and end-stage renal disease. The physician's order dated 3/1/26 directed a regular renal diet and thin liquids. The annual Minimum Data Set (MDS) dated [DATE] identified Resident #3 had severely impaired cognition and required setup or cleanup assistance for eating.The Resident Care Plan (RCP) dated 3/19/26 identified Resident #3 was at risk for further decline in ADL self-care related to increased weakness, fatigue, and continuous deconditioning. Interventions included the use of adaptive equipment, built-up utensils, scoop plate, double- handled sippy cup, and assistance of one with eating.Observation on 4/22/26 at 8:50 AM noted Resident #3 seated in a wheelchair at a round table in the lounge while Nurse Aide (NA) #1…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-27 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation, review of facility policy and staff interviews for 1 of 4 residents (Resident #6) reviewed for abuse, the facility failed to keep the resident safe from physical and verbal abuse. The findings include:Resident #6 a conserved resident was admitted with diagnoses of bipolar disorder and anxiety disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #6 had moderately impaired cognition and exhibited verbal behaviors directed towards others. Resident #6 required substantial/maximal assistance for toileting, was independent in standing from a sitting position, and used a wheelchair for mobility. The MDS assessment further identified Resident #6 did not have any skin problems or wounds.The Resident Care Plan (RCP) dated 1/21/2025 identified Resident #6 was at risk for alteration in mood and behaviors as evidenced by yelling at staff. Interventions included leaving the resident alone and returning later if the resident was…

    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 · D2026-04-27 · 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 review of the clinical records, facility documentation, facility policy, and interviews for 2 of 3 residents (Resident #21 and Resident# 117) reviewed for Preadmission Screening and Resident Review (PASRR), the facility failed to ensure the state agency was updated subsequent to the residents' new psychiatric diagnoses. The findings include:1. Resident #21 had diagnoses that included anxiety and dementia. a. A PASRR Level 1 screen dated 11/27/24 identified Resident #21 had a diagnosis of dementia with no mental health diagnosis and received a dementia exemption. The outcome identified Resident #21's approval remained valid unless changes occur or additional information suggests a primary mental health illness then rescreening should occur to reassess need for PASRR evaluation.A psychiatric Advanced Practice Registered Nurse (APRN) note dated 12/2/24 identified Resident #21 had diagnoses of anxiety and depression (new diagnoses for Resident #21).A physician's order dated 12/2/24 directed to administer…

    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 before2026-04-27 · 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 clinical record review, observations, review of facility policy and interviews for 1 of 4 residents (Resident #1) reviewed for pressure ulcers, the facility failed to revise the resident plan of care regarding pressure ulcer interventions to prevent skin breakdown. The findings include: Resident #1 was admitted on [DATE] diagnosis includes pneumonia. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 was cognitively intact, was at risk for pressure ulcers, and had an unstageable deep tissue injury. The care plan (not dated) indicated Resident #1 had a pressure ulcer classified as a deep tissue injury (DTI) on the right buttock which was present on admission to the facility. Interventions included checking skin at least weekly, providing good nutrition and providing incontinent care. A Health Status Note dated 3/26/2026 at 12:17 PM identified during an observation of Resident # 1's left heel the heel was noted to be boggy with skin intact; no complaints of discomfort 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-27 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    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, facility policy, and interviews for 1 of 2 residents (Resident #23) reviewed for Activities of Daily Living (ADLs), the facility failed to ensure a resident was provided and or offered showers. The findings include: Resident #23 was admitted on [DATE] with diagnoses that included depression and schizophrenia.The admission MDS assessment dated [DATE] identified Resident #23 had moderately impaired cognition, had not exhibited refusal of care, and required moderate assistance with bathing. The MDS assessment further identified it was very important for the resident to choose her/his preferred bathing method including a shower, tub bath, bed bath, or sponge bath.The RCP dated 3/4/2026 identified Resident #23 required assistance with activities of daily living (ADLs). Interventions included providing supervision for bathing and dressing. An undated nurse aide care card also indicated the resident required supervision for bathing 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 · D2026-04-27 · tag F0808 — failed to follow doctor-ordered diets — isolated
    Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
    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, facility policy and interviews for 1 of 4 Residents (Resident #52) reviewed for nutrition, the facility failed to ensure a resident with a therapeutic diet was provided with food items to meet the needs of the resident. The findings include: Resident #52's diagnoses included ulcerative colitis and diverticulitis.The physician's order dated 10/16/2025 directed a regular diet with regular texture, thin consistency, low fiber, and double portions/double protein with all meals.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #52 had intact cognition and was not on a therapeutic diet (despite the physician's order for a low fiber diet).The Resident Care Plan dated 4/28/2026 identified Resident #52 was at risk for malnutrition related to multiple chronic diseases and exacerbation of ulcerative colitis. Interventions included providing supplements as ordered, offering preferred foods, and serving the prescribed low fiber diet with double…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
Show the remaining 12 citations
  • Potential for harm · E2024-07-11 · tag F0585 — failed to handle grievances — pattern
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation of Resident Information, review of policy and interviews, the facility failed to inform residents of how to complete a grievance and ensure forms were accessible and available to residents and visitors. The findings include. On 7/8/2024 at 12:57 PM a meeting with 8 residents identified they were unaware of how to complete a grievance or where the forms were located. An interview with Social Worker #1 on 7/9/2024 at 10:00AM indicated the grievance forms were located in the nursing office behind the nursing station on both floors. During an observation and interview with Social Worker #1 on 7/9/2024 at 10:15 AM identified the grievance policy was noted to be posted on a bulletin board to the right when exiting the elevator on the 3rd floor prior to needing to use a code to enter the 3rd units. Further observations and interview with SW#1 identified s/he was unable to locate the grievance forms on the paper wall file in the nursing office behind the nurse's station. SW #1 could not provide any other location for forms but indicated the forms had been provided 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 Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-07-11 · tag F0657 — failed to keep the care plan current — pattern
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility policy and interviews for 2 of 7 sampled residents for (Resident #13) who were reviewed for range of motion, the facility failed to ensure the comprehensive care plan was revised for a resident with identified with physical limitations of the hands and for (Resident # 98), the facility failed to develop a care plan to address the residents skin integrity to prevent further skin break down and for 1 of 2 residents reviewed for accidents for (Resident # 54), the facility failed to revise the resident's care plan timely post fall. The findings included: 1. Resident #13 was admitted with diagnoses that included mild cognitive impairment, protein calorie malnutrition and anxiety disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #13 was moderately cognitively impaired, had no functional limitations in the upper/ lower extremities, required partial to moderate assist in bed mobility and oral care and total assist in all other activities…

    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 · Ecited before2024-07-11 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — pattern
    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, observations, and interview for 1 of 2 residents reviewed for pressure ulcers (Resident # 98), the facility failed to ensure staff consistently provided evidence of turning and repositioning the resident prior to the development of a pressure ulcer and the facility failed to ensure physician's orders were obtained for recommendations made by a consulting wound physician contributing to the pressure ulcer's further decline. The findings included. Resident #98's diagnoses included Stage 3 pressure ulcer of the left heel, paraplegia, and diabetes mellitus. A physician's order dated 1/16/2024 directed to provide a pressure redistribution mattress every shift. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #98 was cognitively intact, at risk for pressure ulcers, had no unhealed pressure ulcers and required extensive assistance of two persons for bed mobility. A physician's order dated 3/6/2024 directed to assist Resident #98 out of bed to an…

    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 · E2024-07-11 · tag F0688 — failed to keep residents mobile / prevent decline — pattern
    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 reviews, observations, facility documentation, facility policy and interviews for 2 of 7 sampled residents (Resident #13 and Resident #97) reviewed for position and mobility, the facility failed to ensure further evaluation and timely treatment were implemented for resident(s) with newly identified limited mobility to maintain, improve or prevent further decline in range of motion and mobility over time and for 1 of 7 residents reviewed for contractures ( Resident # 86) the facility failed to ensure the application of braces and/or splints as per physician's orders.The findings included: 1.Resident #13 was admitted with diagnoses that included mild cognitive impairment, protein calorie malnutrition and anxiety disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #13 as moderately cognitively impaired, had no functional limitations in the upper/ lower extremities, required partial to moderate assist in bed mobility, oral care, and total assist in all…

    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 · Ecited before2024-07-11 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the tour of the Dietary Department, observations, policy review, and staff interviews, the facility failed to ensure the kitchen was maintained in a clean, sanitary manner and failed to ensure staff applied proper beard guards and failed to consistently labeled and stored food to reflect their age or shelf life. The findings included: Tour of the dietary department on 7/1/24 at 10:40AM, during the initial walk through of the kitchen with the Dietary Manager (DM) identified the following: a. The kitchen was observed to have ceiling tiles with a brown substance noted on them. b. The dishwasher wash station identified that a piece of a cover was broken and discolored in the clean area. c. The dishwasher had black substance noted around the edges. d. The tiles in the kitchen and dishwasher room were observed with a black substance. e. The floor throughout the kitchen was noted to have dirt, debris, and food. f. The second-floor nourishment refrigerator was noted to have a red substance covering the bottom…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-11 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, facility policy and interviews for 1 of 2 sampled residents (Resident #72) reviewed for missing property, the facility failed to ensure a report of a missing item was thoroughly investigated to conclude loss or theft and Observations of the facility environment, the facility failed to ensure a sanitary environment by ensuring a rusted medicine cabinet without doors was replaced and for 1 of 3 sampled residents (Resident #88) who was reviewed for environment, the facility failed to provide a clean, home like environment related to cleaning of a small appliance which was provided by the facility and based on observations and interviews for 3 of 4 shower rooms, the facility failed to provide a homelike, sanitary, and safe environment for the 3 of 4 showers. The findings included: 1. Resident #72 had diagnoses included morbid obesity, heart failure and absence of a right leg above the knee. The annual Minimum Data Set (MDS) assessment dated [DATE] identified…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-11 · 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

    Based on observation, facility policy and interviews for 1 of 3 Residents (Resident #45), observed during medication administration, the facility failed to meet professional standards when staff borrowed(Resident # 202 's Lactulose medication to administer to Resident # 45 when the resident's medication was not available. The findings include. Resident #45's diagnosis included Type 2 diabetes mellitus and incontinence. A physician's order dated 9/30/2023 directed to administer Lactulose Oral Solution 10grams/15ml and to provide 15 ml's orally, once daily for constipation and to hold for loose stool or diarrhea. The 6/9/2024 quarterly Minimum Data Set (MDS) assessment indicated moderate cognitive loss. The care plan dated 6/25/2024 indicated Resident #45 was at risk for complications related to constipation. Intervention included: monitoring medications for side effects and to follow facility bowel protocol for bowel management while increasing fiber and fluid intake and to update the physician with any concerns. On 7/8/2024 at 8:02 AM an observation and interview with LPN #1 during…

    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 · D2024-07-11 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    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, staff interviews for 1 of 1 resident reviewed for specialized treatment (Resident #48), the facility failed to consistently maintain the resident's communication log regarding the resident's status with the specialized treatment center. The findings include: Resident #48's diagnosis of end-stage kidney disease, dementia, and Parkinson's disease. The quarterly MDS assessment dated [DATE] identified Resident #48 was cognitively intact and required set-up assistance with eating, personal hygiene, and transferring to and from the bed. A care plan dated 7/3/2024 indicated the resident was at risk for dehydration, or fluid deficit related to end stage kidney disease and receiving specialized treatment. Interventions included: monitoring intake and output, and monitoring vital signs as ordered/per protocol. The care plan also indicated that Resident #48 required specialized treatment three times per week on Tuesdays, Thursdays, and Saturdays. On 7/8/2024, a review of…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-22 · 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 the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for accidents, the facility failed to ensure a resident had an elopement risk evaluation when the resident expressed intentions on leaving the facility. The findings include: Resident #1 had diagnoses that included altered mental status, adjustment disorder with anxiety, generalized muscle weakness, and anorexia. A review of Resident #1's admission elopement risk assessment dated [DATE] identified Resident #1 was not at risk for elopement. The care plan dated 2/16/2024 identified Resident #1 was at an increased risk for falls and injury related to adjustment issues to the new environment, anxiety, agitation, deconditioning due to alcohol abuse, sepsis, and pyelonephritis. Interventions directed to anticipate and meet the resident's needs and encourage resident to participate in activities that promote exercise, physical activity for strengthening and improved…

    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 before2021-12-20 · 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 observation, clinical record review, review of facility policy and interviews for 2 of 3 residents (Resident #28 and Resident #71) reviewed for pressure ulcers, the facility failed to follow physician orders for every 1 hour re-positioning for Resident #28 and failed to ensure a thorough assessment was completed when a pressure area was identified and failed to ensure a wound consultant's recommendations were reviewed and implemented in a timely manner for Resident #71. The findings include: 1. Resident #28 diagnoses included a severe nerve, brain and spinal cord disease, diabetes, pressure ulcers and dementia. Physician's orders dated 9/10/21 directed a strict turn and position every 1 hour for Resident #28 related to wound care. A significant change Minimum Data Set assessment dated [DATE] identified Resident #28 had intact cognition and was totally dependent on staff for bed mobility and transfers. A Resident Care Plan (RCP) dated 10/19/21 identified Resident #28 had a pressure ulcer 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 before2021-12-20 · 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

    Based on observation, clinical record review and staff interview for 1 of 12 residents reviewed for medication administration (Resident #92), the facility failed to ensure the medication cart and resident medications were secured. The findings include: Observation on 12/16/21 at 5:59 AM in the hallway of the second floor identified an unlocked and unattended medication cart located in front of a resident's room. Additionally, eight medication cups containing pills were located on top of the medication cart, none of the medications were identified with a room number and a resident name. A total of fourteen medications were noted in the eight medication cups. Further observation noted LPN #1 returned to the medication cart after leaving a resident room. Interview with LPN #1 on 12/16/21 at 5:59 AM indicated that he was leaving the cart unattended and unlocked for a brief amount of time and that although it was his regular practice to pre-pour resident medications, he usually would keep them in the top drawer of the medication cart. LPN #1 further indicated that the reason he did 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
  • Potential for harm · D2021-12-20 · 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

    Based on observation, clinical record review and interview for 1 of 12 residents observed during medication administration (Resident #92) the facility failed to administer medication appropriately therefore causing the medication error rate to be above 5%. The findings include: Observation of LPN #1 during medication preparation and administration for Resident #92 on 12/16/21 at 6:36 AM identified LPN #1 poured Pantoprazole 40 mg (a medication for the treatment of gastro-esophageal reflux disease) into a medication cup. The medication package for Pantoprazole identified do not crush. LPN #1 also poured Nifedipine Extended Release 30 mg (a medication for the treatment of hypertension) and then proceeded to crush both medications and mix them with apple sauce. LPN #1 was then observed proceeding to Resident #92's bedside, checked the identification bracelet and began to administer the applesauce containing the crushed medication until surveyor intervention. Interview with LPN #1 on 12/16/21 at 6:47 AM indicated that he always crushed Pantoprazole and Nifedipine Extended Release…

    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

“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.

“Disputed” is CMS’s own flag, not our reading: the CMS deficiency file records whether the home has formally contested a citation, and we reproduce that. IDR is Informal Dispute Resolution, run by the state survey agency that wrote the citation; IIDR is Independent Informal Dispute Resolution, a separate process before an outside entity, available when CMS has proposed a civil money penalty. They are different processes and we mark them differently. Two things to hold at once. A disputed citation is still a citation — it was written by a surveyor, it stands on the record unless and until it is changed, and we neither hide it nor discount it. And we cannot tell you how the dispute came out: CMS publishes that a citation is under dispute, not the outcome, so a tag marked here may since have been upheld, reduced, or deleted, and an unmarked tag may have been disputed and resolved before this file was cut. Ask the home what it disputed and why — it is entitled to tell you, and the answer is often the most informative thing on this page.

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

$8,018 in federal fines across 1 penalty.

  • $8,018 — penalty dated 2024-07-11

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.

$16.0M
Net patient revenuemost recent cost report
+2.3%
Operating marginrevenue minus expenses
$1.6M
Related-party expense10% of expenses
Who pays — share of resident-days
Medicaid 83%Medicare 10%Other / private 6%

About 83% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.6M paid to related parties — landlords or management companies under common ownership — equal to about 10% 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

$396per resident / day
operating cost
$12,050per month
≈ monthly operating cost
$406per 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 075320. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-27, 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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