Villa At Stamford, The
88 Rockrimmon Road, Stamford, CT 06903 · For profit - Limited Liability company · 128 certified beds · (203) 322-3428 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- 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
- it has an abuse, neglect, or exploitation citation (F0600), cited Jan 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 (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing rating is low (1/5)
- its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
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 | 5 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 3.4% | 18.0% | 15.4% | better |
| Long-stay residents who lose too much weight | 11.5% | 6.5% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.6% | 0.7% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.0% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 71.3% | 22.3% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 2.5% | 3.5% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 3.4% | 16.4% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 12.9% | 17.6% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 93.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 8.3% | 4.0% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 20.9% | 24.7% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 9.1% | 17.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.2% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 90.8% | 69.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 24.1% | 24.3% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 9.4% | 10.7% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.46 | 2.06 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.05 | 1.46 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
59.5% 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 250 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 78.9% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 147 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 0.32 therapist hours per resident per day in 2026Q1 — more than 52% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 43% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 59.5%CMS range 52.9–67.4 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 14.1%CMS range 11.3–16.9 | 10.7% | Oct 2022–Sep 2024 | worse than U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 78.9% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 78.2% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 81.0% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 98.8% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS 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 stay | 0.4% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 3.1% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.9%CMS range 4.6–9.8 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.36 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 128 beds and averages 125.8 residents a day — about 98% occupied, or roughly 2 beds typically open. It runs essentially full — expect a waiting list. 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.
Weekend coverage: total nurse staffing is 3.27 hrs/resident/day on weekends vs 3.67 on weekdays — 11% thinner on weekends. RN hours go from 0.50 to 0.22 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 54% 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
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.
This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
23 citations, most serious first. The 10 most serious are shown; the remaining 13 are one tap away and print in full.
- Potential for harm · Dcited beforedisputed · IDR2026-04-30 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, facility documentation review, and staff interviews for one of three residents (Resident #1) reviewed for quality of care, the facility failed to ensure wound care physician recommendations were transcribed accurately. The findings include: F684Based on record review, facility documentation review, and staff interviews for one of three residents (Resident #1) reviewed for quality of care, the facility failed to ensure wound care physician recommendations were transcribed accurately. The findings include: Resident #1 had a history of Alzheimer's dementia and urinary incontinence. The Resident Care Plan (RCP) dated 4/21/23 identified a toe wound. Interventions directed to observe for signs of infection and to provide treatments and dressing changes as ordered. The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #1 had short- and long-term cognition deficits, and was dependent for ADL care. Nursing note dated 5/23/23 at 3:40 PM identified Resident #1 was seen by MD #1 and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-30 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard 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 review, and staff interviews for one of three residents (Resident #1) reviewed for activities of daily living, the facility failed to ensure the clinical record was complete and accurate to include documentation of personal care. The findings include: Resident #1 had a history of Alzheimer's dementia and urinary incontinence. The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #1 had short- and long-term cognition deficits, and was dependent for ADL care. The Resident Care Plan (RCP) dated 4/21/23 identified a self-care deficit. Interventions directed to provide ADLs and mouth care. Record review of the Personal Hygiene ADL task for May of 2023 identified documentation was missing (blank) on 5/1, 5/5, 5/7, 5/10, 5/11, 5/13, 5/16, 5/17, 5/18, 5/20, 5/22, 5/23, 5/24, 5/25, 5/26 and 5/28/2023 (missing on 16 shifts for the month). Interview and record review with the Director of Nursing (DNS) on 4/30/26 at 10:45 AM identified the ADL Hygiene…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-06-23 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, facility policy review, and interviews for one sampled resident (Resident #1) reviewed for weight loss, the facility failed to ensure the clinical record was complete and accurate to include timely meal intake documentation. The findings include: Resident #1 had diagnoses that included Alzheimer's disease and anxiety. The Annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was unable to complete the Brief Interview for Mental Status (BIMS), indicative of being severely cognitively impaired and required maximum assistance for eating. The Resident Care Plan (RCP) dated 6/23/25 identified Resident #1 had an ADL deficit related to Alzheimer's disease and tardive dyskinesia. Interventions directed to feed resident meals. Review of meal intake documentation for Resident #1 identified from 5/25 through 6/23/2025 the meal intakes identified the following: • Resident #1's breakfast was not documented on: 5/27, 5/31, 6/1, 6/10, 6/13,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-28 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect 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 review of the clinical record, facility documentation, facility policy, and interviews for two (2) of two (2) residents (Resident #1 and Resident #2) reviewed for abuse, the facility failed to ensure that a resident (Resident #1)who had a history of speaking to another resident (Resident #2) in a deragatory manner were free from physical abuse. The findings include: 1. Resident #1 had diagnoses that included impulse disorder, unspecified intellectual disabilities, schizophrenia, and delusional disorder. The annual MDS dated [DATE] identified Resident #1 had short and long-term memory problems, was always incontinent of bowel and bladder, independent with wheeling the wheelchair, and dependent with ADLs. The care plan dated 12/12/24 identified Resident #1 has behavioral problems cries out frequently, diagnoses of developmental delay impulse disorder and delusions, accusatory towards other residents and staff, inappropriate hand gestures and language towards staff and other residents with interventions…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-01 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation, and staff 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 visits provided by social services following an allegation of abuse. The findings include: Resident #1 was admitted on [DATE] with diagnosis of hemiplegia/hemiparesis (weakness of one side of the body) following a cerebral infarction. The nursing admission assessment dated [DATE] identified Resident #1 was alert and oriented. The Resident Care Plan (RCP) dated 9/4/24 identified Resident #1 had a self-care deficit. interventions directed to provide assistance with ADLS (ADL) and use of 1/4 side rails for bed mobility. Facility incident report dated 9/6/2024 identified Resident #1's family reported an allegation that a NA slapped Resident #1 on the back on 9/4/2024 about midnight. An assessment was completed with no injuries noted. The facility summary dated 9/11/2024…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-07-30 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility policy review, and interviews for one sampled resident (Resident #28) reviewed for dental services and for one sampled resident (Resident #45) with a surgical incision, the facility failed to follow dental orders as a prerequisite for a tooth extraction, and failed to administer the prescribed treatment to the left chest in accordance with the physician's order, The findings include: 1. Resident #28 was admitted to the facility on [DATE]. Diagnoses included dysphagia, oropharyngeal phase, cellulitis of face, unspecified protein-calorie nutrition, other psychoactive substance dependence, in remission, and other specified anxiety disorders. The speech screen dated 1/19/2021 identified the resident had a mechanically altered diet related to complaints of difficulty or pain when swallowing and the summary identified the resident had a mechanically altered diet, and a swallowing disorder. A recommendation was made for a swallow evaluation. Review of the Speech Therapy…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-30 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility policy, and interviews for one sampled resident (Resident #23) reviewed for accidents, the facility failed to notify the resident's responsible party when the resident had an incident of smoking in their room. The findings include: Resident #23's diagnoses include chronic obstructive pulmonary disease, dementia, and psychotic disorder with delusions. The quarterly MDS assessment dated [DATE] identified Resident #23 had intact cognition, utilized a walker and wheelchair for mobility, was independent for eating, utilized set up or clean up assistance with oral hygiene and toileting, and required supervision for dressing and personal care. Resident #23's care plan dated 5/20/24 identified an ADL (activities of daily living) self-care performance deficit with interventions that included: limited assistance with a rolling walker on the unit, assistance with bathing/showering, personal hygiene and oral care. The care plan further noted Resident #23 was an elopement…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-30 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility policy, and interviews for one of five sampled residents (Resident #100) reviewed for Preadmission Screening and Resident Review (PASRR), the facility failed to complete a screening for a resident who required one following short-term approval. The findings include: Resident #100's diagnoses include paranoid personality disorder, delusional disorder, post-traumatic stress disorder and major depressive disorder, The quarterly MDS assessment dated [DATE] identified Resident #100 had intact cognition, utilized a wheelchair for mobility, was dependent for all activities of daily living (ADL's.) The assessment further noted the resident's diagnoses were depression, psychotic disorder, and post-traumatic stress disorder. Resident #100's care plan dated [DATE] identified the potential for behavioral problems related to paranoia, delusional, accusatory, towards staff makes fallacious statements. Interventions directed to administer medications as ordered, allow time 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.
- Potential for harm · D2024-07-30 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of clinical records, review of facility policy, and interviews for two of two sampled residents (Resident #23 & #45) reviewed for accidents and splints/medical equipment, the facility failed to develop and implement a comprehensive care plan following an incident of unauthorized smoking in the facility and for the use of an Aspen neck collar (a neck brace that limits movement of the neck) and an implanted loop recorder ( a small device that monitor heart's electrical activity that is inserted under the chest skin). The findings include: 1. Resident #23's diagnoses include chronic obstructive pulmonary disease, dementia, and psychotic disorder with delusions. The quarterly MDS assessment dated [DATE] identified Resident #23 had intact cognition, utilized a walker and wheelchair for mobility, was independent for eating, utilized set up or clean up assistance with oral hygiene and toileting, and required supervision for dressing and personal care. Resident #23's care plan dated 5/20/24…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-30 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the clinical record, review of facility policy and interviews for one sampled resident (Resident #1) or who utilized splints, the facility failed to ensure the resident had splints in place daily as outlined in the physician's orders. The findings include: Resident #1's diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, legal blindness, rheumatoid arthritis, and vascular dementia. The Occupational Therapy Evaluation dated 4/1/2024 identified the upper extremity assessment was not tested due to contracture. The evaluation did not contain a rating that identified the degree/severity of the contracture. The MD/APRN progress note dated 6/19/2024 identified Resident #1 was evaluated by Occupational Therapy and identified physical exam findings of right hand in splint due to spasticity, Left hand with carrot. Strength was documented for bilateral upper extremities. The quarterly MDS assessment dated [DATE] identified 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.
Show the remaining 13 citations
- Potential for harm · D2024-07-30 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility documents, review of facility policy, and interviews for one sampled resident (Resident #23) reviewed for accidents, the facility failed to provide adequate supervision to prevent the resident from smoking in his/her room. The findings include: Resident #23's diagnoses include chronic obstructive pulmonary disease, Dementia without behavioral disturbances and psychotic disorder with delusions. The quarterly MDS assessment dated [DATE] identified Resident #23 had intact cognition, utilized a walker and wheelchair for mobility, was independent for eating, utilized set up or clean up assistance with oral hygiene and toileting, and needed supervision for dressing and personal care. Resident #23's care plan dated 5/20/24 identified the resident had an ADL self-care performance deficit and utilized limited assistance with a rolling walker on the unit, the resident requires assistance by staff for bathing/showering and requires assistance by staff with personal…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-30 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, review of facility documentation, review of facility policies/procedures and interviews for one of three sampled residents (Resident #32), reviewed for transmission-based precaution (TBP) the facility failed to implement the appropriate transmission-based precaution for a resident actively infected with a multi-drug resistant organism (MDRO). The findings include: Resident #32's diagnoses included lymphedema, sepsis, Methicillin Resistant Staphylococcus Aureus (MRSA) infection and schizoaffective disorder. The quarterly MDS assessment dated [DATE] identified Resident #32 had intact cognition, required moderate assistance with transfers and toileting, independent with bed mobility and personal hygiene, ambulatory with the utilization of a walker and a wheelchair. The assessment further identified Resident #32 active diagnoses in the last 7 days included MDRO, and wound infection. The care plan dated 2/20/24 identified Resident #32 had enhanced barrier precaution 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.
- Potential for harm · D2024-01-31 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, observations, facility documentation, facility policy and interviews for one (1) of four (4) residents, (Resident #1 ), who was reviewed for abuse, the facility failed to The findings include: Resident # 1's diagnoses included hemiplegia and hemiparesis (weakness and paralysis) following cerebral infarction (stroke) affecting right dominant side. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 was moderately cognitively intact and required substantial assist with bed mobility and transfers. The Resident Care Plan dated 11/21/23 identified Resident #1 had an activity of daily living (ADL) self-care performance deficit related to disease process and a history of transient ischemic attacks (TIA) or mini stroke with interventions that directed to provide two (2) staff for bed mobility and transfer with mechanical lift and give medications as ordered by the physician and monitor side effects. Physician orders dated 11/30/23 directed aspirin 81 mg and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-02-02 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, review of facility policy, and interviews, for 6 medication carts, the facility failed to maintain medication carts in a clean and sanitary manner. The findings include: 1. Observation of the East 1 - B unit medication cart on 2/1/22 at 8:15 AM with the ADNS and LPN #2 identified a moderate amount of loose pills of assorted sizes and colors and blister pack back covers located at the bottom of the first and second drawer. Interview on 2/1/22 at 8:15 AM with LPN #2 on the East 1 - B unit identified she was not aware of the loose pills and blister pack back covers located at the bottom of the first and second drawer. LPN #2 indicated it is every nurse responsibility to clean the medication cart and after themselves. 2. Observation of the East 1 - A unit medication cart on 2/1/22 at 8:19 AM with the ADNS and LPN #3 identified a moderate amount of loose pills of assorted sizes and colors and blister pack back covers located at the bottom of the first and spilled liquids at bottom of second drawer. Interview on 2/1/22 at 8:19 AM with LPN #3 on the East 1 - A unit…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-02-02 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor 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 interview for 2 of 3 residents (Resident #43 and 94) reviewed for indwelling catheter care, the facility failed to cover the urinary drainage bags. The findings include: 1 Resident #43 was admitted to the facility with diagnoses that included major depressive disorder, prostatic hyperplasia, and chronic kidney disease. A physician's order dated 12/13/21 directed to change privacy bag as needed for soiling. The care plan dated 12/13/21 identified Resident #43 had a Foley catheter related to neurogenic bladder. Interventions included to position the catheter bag and tubing below the level of the bladder and away from the entrance door. Additionally, privacy bag as needed. The quarterly MDS dated [DATE] identified Resident #43 had intact cognition, required extensive assistance for dressing, personal hygiene and toileting. Additionally, Resident #43 had an indwelling catheter. The APRN progress note dated 12/3/21 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-02-02 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect 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 observation, review of the clinical record, facility documentation, facility policy, and interview for 1 of 2 residents (Resident #94) reviewed for abuse, the facility failed to ensure the resident was free from physical abuse. The findings include: Resident #59 was admitted on [DATE] with diagnoses that included vascular dementia, anxiety and major depression. The annual MDS dated [DATE] identified Resident #59 had severely impaired cognition and required assistance with personal care. The care plan dated 9/21/21 identified Resident #59 was dependent on staff for meeting emotional, intellectual, physical, and social needs related to cognitive deficits and physical limitations. Interventions included to introduce the resident to residents with similar background, interests and encourage/facilitate interaction and invite resident to scheduled activities. The care plan also identified Resident #59 had the potential to be verbally aggressive towards staff with interventions that included assess and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-02-02 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide 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, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 5 residents (Resident #20) reviewed for pressure ulcers, the facility failed to implement dietary recommendations to aid in meeting nutritional needs for the resident who had a pressure ulcer. The findings include: Resident #20 was admitted [DATE] with diagnoses that included quadriplegia, diabetes and severe protein-calorie malnutrition. A skin risk assessment dated [DATE] identified Resident #20 was at moderate risk for skin impairment. A nutritional assessment dated [DATE] identified Resident #20 had a sacral wound and a need for further supplementation to aid in meeting nutritional needs. Recommendations included to provide sugar free shakes twice daily. The admission MDS dated [DATE] identified Resident #20 had intact cognition and required extensive assistance with bed mobility, transfers and personal care. Additionally, Resident #20 had a stage 2 unhealed pressure ulcer present 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.
- Potential for harm · D2022-02-02 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 3 residents (Resident #57, 75, and 83) reviewed for respiratory care, the facility failed to ensure the residents oxygen tubing was labeled and changed. The findings include: 1. Resident #57 was admitted to the facility with diagnoses that included respiratory failure, shortness of breath, and pulmonary embolism. The quarterly MDS dated [DATE] identified Resident #57 had intact cognition, required limited assistance for dressing, personal hygiene, and transfers, extensive assistance for toileting and receives oxygen therapy. The care plan dated 1/4/22 identified Resident #57 had congestive heart failure and was on oxygen at 2 - 3 liters per minute as needed to maintain oxygen levels greater than 90%. Interventions included to monitor oxygen saturation as per physician order and as needed. A physician's order dated 1/31/22 directed to administer oxygen at 4 liters per minute via nasal cannula…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-02-02 · tag F0698 — failed to provide proper dialysis care — isolatedProvide 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 observation, review of the clinical record, facility policy and interviews for 1 of 2 residents (Resident #95) reviewed for specialized treatment, the facility failed to provide care according to professional standards for a resident with an arteriovenous fistula (AVF - a connection between an artery and vein used for hemodialysis). The findings include: Resident #95's diagnoses included end stage renal disease, diabetes, hypertension and cerebral infarction. The care plan dated/revised 12/27/21 identified the resident was dependent on hemodialysis related to end stage renal disease and had a left upper arm AVF. Interventions included to check and change dressing daily at access site and document, do not draw blood or take blood pressure in arm with graft, monitor labs and report to doctor as needed. monitor/document/report any signs and symptoms of infection to access site: redness, swelling, warmth or drainage and monitor/document/report for signs and symptoms of bleeding, hemorrhage, bacteremia or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-02-02 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 5 residents (Resident #74) reviewed for unnecessary medications, the facility failed to ensure the pharmacy recommendations were followed up timely. The findings include: Resident #74 was admitted to the facility with diagnoses that included diabetes, migraines, and pain. The significant change MDS dated [DATE] identified Resident #74 had intact cognition, and required extensive assistance for dressing, toileting, personal hygiene, and transfers. Physician's orders for October 2021, dated 10/13/21 directed to apply a Lidoderm patch, 1 patch topically daily, administer Midodrine 2.5mg three times a day, and Insulin Aspart sliding scale twice daily. The care plan dated 10/19/21 identified Resident #74 had a room change related to diabetes. Interventions included to check the residents blood sugar per physician order. Additionally, the care plan identified Resident #73 had orthostatic hypotension and with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-08-13 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor 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 a review of clinical records, review of facility documentation, review of facility policies and procedures, and interviews for one of three residents (R #63) reviewed for abuse, the facility failed to ensure the resident was free from verbal abuse. The finding includes: R #63's diagnoses included dementia, hard of hearing, and depression. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that R #63 had severely impaired cognitive skills, had no verbal behaviors, rejected care four to six days but not daily, and required total assistance of two staff for dressing and personal hygiene. The Resident Care Plan (RCP) dated 7/11/19 identified R #63 resists care. Interventions directed to redirect negative behaviors, and to allow time to de-escalate and re-approach if agitated. Review of a facility incident report dated 6/17/19 at 10:20 AM identified RN #1, NA #3, and NA #4 witnessed NA #2 tell R #63 to keep screaming louder, and when the State comes, the State will hear you. The facility…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-08-13 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide 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 review of the clinical record, facility documentation, facility policy and staff interview for 1 resident (Resident #133) reviewed for death, the facility failed to order medications in a timely manner for a newly admitted resident to ensure availability for administration according to physician's orders. The findings include: Resident #133 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure with hypoxia, acute kidney failure, atrial fibrillation, heart failure, and diabetes mellitus. The nursing admission assessment dated [DATE] at 5:15 PM indicated Resident #133 was alert and oriented, verbally responsive, and had a cough. The admission care plan dated 7/10/19 identified Resident #133 had problems with cardiac output, respiratory, and anticoagulant therapy. Interventions included to administer medications as ordered. Physician's orders dated 7/10/19 directed to administer the following medications; Lipitor (medication to treat high cholesterol) 20 mg via…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · B2024-07-30 · tag F0730 — patternObserve each nurse aide's job performance and give regular training.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on facility documentation review and staff interviews for Three of Three Nurse Aides (NA #2 and NA #3, and NA#4), the facility failed to complete an annual performance evaluations. The findings include: Review of NA #2 personnel file identified a hire date of 7/24/2006 and failed to identify that a yearly performance evaluation was completed for 2023. Review of NA #3 personnel file identified a hire date of 4/29/2002 and failed to identify that a yearly performance evaluation was completed for 2023. Review of NA #4 personnel file identified a hire date of 12/7/2021 and failed to identify that a yearly performance evaluation was completed for 2023. Interview with DNS on 7/30/24 at 9:35 AM identified that each employee should have a performance review completed on their anniversary date and she was responsible for ensuring that the employee annual performance reviews were completed. She further identified that there was no annual performance review completed for NA #2, NA #3, and NA #4 for 2023. Review of facility Annual Employee Evaluations policy identified all employees would…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
“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.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to CENTER MANAGEMENT GROUP — 16 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 3.2 | +0.8 vs chain |
| Health inspection | 4 of 5 | 2.9 | +1.1 vs chain |
| Staffing | 1 of 5 | 1.8 | -0.8 vs chain |
| Quality measures | 5 of 5 | 4.3 | +0.7 vs chain |
The other 15 homes this chain runs (chain average 3.2★, per CMS)
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 / manager | Type | Role | Since |
|---|---|---|---|
| SMITH HOUSE VENTURES LLC | Organization | DIRECT OWNERSHIP INTEREST | since 01/01/2016 |
| BOEHM, SHLOMO | Individual | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 01/01/2016 |
| GROS, CHARLES-EDOUARD | Individual | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 01/01/2016 |
| LEVI, SHLOMO | Individual | INDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2016 |
| DITEODORO, JACK | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/30/2016 |
| LYON, LYNN | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/30/2016 |
| SHOWSTEAD, PETER | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 10/10/2016 |
| ALLEN, DANIEL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2025 |
| KLEIN, BARUCH | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2016 |
| SMITH HOUSE REALTY LLC | Organization | ADP OF THE SNF | since 06/19/2025 |
CMS files one row per role, so the 23 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $2.0M 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
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in CT
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Connecticut Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 075153. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-07-30, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.