Mansfield Center For Nursing And Rehabilitation

Location & what’s nearby

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

Quality measures — how residents actually fare

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.

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.

60.2% 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 146 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 61.1% 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 54 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 0.35 therapist hours per resident per day in 2026Q1 — more than 58% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 17% 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.

Staffing

How full it usually is: this home is certified for 98 beds and averages 84.3 residents a day — about 86% occupied, or roughly 14 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 3.86 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.72 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.34 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 3.61 hrs/resident/day on weekends vs 3.97 on weekdays — 9% thinner on weekends. RN hours go from 0.82 to 0.47 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

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

Inspection deficiencies

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

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.

33 citations, most serious first. The 13 most serious are shown; the remaining 20 are one tap away and print in full.

• Actual harm · Gcited before2025-12-04 · 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 clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) who was dependent on staff for transfers, the facility failed to ensure two (2) staff members were present during a mechanical lift transfer resulting in the resident tipping in the lift, hitting his/her head and sustaining an injury. The findings include:Resident #1's diagnoses included severe dementia with agitation, hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following a subarachnoid hemorrhage (bleeding in the space between the brain and the membrane that covers it) affecting the left non-dominant side, muscle weakness and need for assistance with personal care. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of five (5) out of fifteen (15) indicative of severely impaired cognition, required substantial assistance with bed…

  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 · Past Non-Compliance
• Actual harm · Gcited before2025-04-10 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, review of facility documentation, review of facility policy, and interviews, for two of six sampled residents (Residents #13 and #47) reviewed for accidents, the facility failed to ensure the required staff assistance was utilized during the use of the mechanical lift, and for one of six sampled residents (Resident #33) the facility failed to ensure the required staff assistance was in place during a mechanical lift transfer and failed to ensure the resident was attached to the lift correctly, which resulted in an accident and injury. The findings include: 1. Resident #13 was admitted to the facility in January 2025 with diagnoses that included metabolic encephalopathy, dementia, and renal failure. The admission MDS assessment dated [DATE] identified Resident #13 had intact cognition, functional limitation in range of motion of the bilateral upper extremities, utilized a wheelchair for mobility, was dependent on staff for toileting hygiene, toileting and transfers from the…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2023-04-11 · 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 clinical record reviews, facility documentation, facility policy, and interviews for one (2) of six (6) residents reviewed for (Resident #204), the facility failed to ensure a resident had appropriate supervision while in the bathroom, and that leg rests were removed from the wheelchair prior to a transfer, resulting in an injury and for accidents for (Resident # 31), the facility failed to ensure staff remove the plastic covering from a hot beverage within accordance to facility practice to prevent a burn and . The findings included : 1. Resident #204 had diagnoses that included Alzheimer's disease, and weakness of right dominant side following a stroke. The admission nursing assessment dated [DATE] at 5:30 PM identified Resident #204 was alert only to person, had problems with his/her memory, and had fallen within the last month. The fall risk assessment dated [DATE] identified Resident #204 had a fall within the previous six (6) months and was identified as a fall risk. The baseline care plan dated…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited beforedisputed · IDR2026-05-07 · tag F0761 — failed to label and store drugs safely — isolated
  Ensure 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

  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) sampled residents (Resident #1) reviewed for controlled substances, the facility failed to ensure controlled substances were securely stored in separately locked, permanently affixed compartments accessible only to authorized personnel, and failed to maintain accountability and chain of custody for controlled substances during reconciliation and disposal processes, resulting in one (1) bottle of Lorazepam becoming unaccounted for. The findings include:Resident #1 was admitted to the facility with diagnoses that included cerebral atherosclerosis, dementia and a cardiac pacemaker.The Change in Condition Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severely impaired cognition (Brief Interview for Mental Status (BIMS) score of one (1), was receiving hospital care while a resident and was taking antidepressant and antianxiety medications.The Resident Care Plan (RCP)…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-04-21 · tag F0580 — failed to tell family and doctor about changes — isolated
  Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of two (2) residents (Resident #1) reviewed for medication administration, the facility failed to ensure medications that were not administered per physician orders were reported to the physician. The findings include:Resident #1 was admitted to the facility with diagnoses that included anxiety, dermatitis and hypothyroidism. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had intact cognition (Brief Mental Interview for Mental Status (BIMS) score of fifteen (15) and was taking antianxiety medication. The Resident Care Plan (RCP) dated 2/17/26 identified Resident #1 had hypothyroidism. Interventions included to give thyroid replacement therapy as ordered, monitor/document/report signs of hypothyroidism, and stress the importance of taking the medication everyday. The RCP further identified Resident #1 had psychotropic medication use related to antianxiety. 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited beforedisputed · IDR2026-04-21 · 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 review of the clinical record, facility documentation, facility policy, and interviews for one (1) of two (2) residents (Resident #1) reviewed for medication administration, the facility failed to ensure medications were administered as ordered. The findings include:Resident #1 was admitted to the facility with diagnoses that included anxiety, dermatitis and hypothyroidism. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had intact cognition (Brief Mental Interview for Mental Status (BIMS) score of fifteen (15) and was taking antianxiety medication. The Resident Care Plan (RCP) dated 2/17/26 identified Resident #1 had hypothyroidism. Interventions included to give thyroid replacement therapy as ordered, monitor/document/report signs of hypothyroidism, and stress the importance of taking the medication everyday. The RCP further identified Resident #1 had psychotropic medication use related to antianxiety. Interventions included medication as ordered 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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-12-04 · tag F0656 — failed to write and follow a full care plan — isolated
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) who was dependent on staff for transfers and exhibited behavioral symptoms, the facility failed to follow the resident's plan of care when the resident exhibited behaviors during a mechanical lift transfer which resulted with the resident sustaining an injury. The findings include: Resident #1's diagnoses included severe dementia with agitation, hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following a subarachnoid hemorrhage (bleeding in the space between the brain and the membrane that covers it) affecting the left non-dominant side, muscle weakness and need for assistance with personal care. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of five (5) out of fifteen (15) indicative of severely impaired cognition, required substantial…

  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 · Fcited before2025-04-10 · tag F0812 — failed to store, cook, and serve food safely — widespread
  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 observation, review of facility policy/procedures and interviews, the facility failed to ensure that food stored in the refrigerator and freezer was labeled with an expiration and open date, and the staff failed to wear beard restraints. The findings include: During the initial brief tour of the kitchen on 4/2/25 at 9:41 AM with the Dietary Manager identified cooler #2 contained eight waffles in an open package stored with no expiration date and no open date as well as a Starbucks mocha drink that was 2/3 full. Interview on 4/2/25 at 9:42 AM with the Dietary Manager identified the waffles should be labeled with the open date and the expiration date. Observation on 4/2/25 at 9:46 AM identified the walk-in refrigerator contained shredded cabbage that was opened with no open date label and no expiration date and Parmesan cheese wrapped with saran wrap with no open date and no expiration date. Interview on 4/2/25 at 9:48 AM with the Dietary Manager identified the cabbage was recently opened to make coleslaw and that it should have been labeled with the date opened and date it…

  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 · F2025-04-10 · tag F0880 — failed to prevent and control infections — widespread
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, review of facility policy/procedures and interviews for 1 of 3 residents (Resident #57) reviewed for pressure injuries, the facility failed to ensure facility staff used appropriate PPE when providing care to a resident on Enhanced Barrier Precautions (EBP) and failed to ensure infection control surveillance data collection reports were complete and compiled on a monthly basis. The findings include: 1. Review of the infection control program for the period of April 2023 to January 2024 with the Regional Director of Clinical Operations (RN #7) and the Infection Preventionist (IP) Nurse (RN #4) on 4/7/25 at 12:57 PM failed to identify that monthly surveillance infection reports and analysis of infection trends were completed from April of 2023 through January 2024 within the monthly Antibiotic Report as well as the quarterly reports provided for April 2023, July 2023, and October 2023. The Antibiotic Report was provided by RN #7, which indicated that this 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.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-04-10 · tag F0881 — failed to use antibiotics responsibly — widespread
  Implement a program that monitors antibiotic use.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility documentation, facility policy and interviews, during a review of the facility antibiotic stewardship program, the facility failed to ensure that the facility's antibiotic surveillance tracking report of antibiotic use, patterns and resistant trends was completed and reviewed at the quarterly medical staff meetings and for one of five sampled residents (Resident #13) reviewed for unnecessary medications, the facility failed to ensure that the antibiotic stewardship was followed for a resident receiving antibiotics. The findings include: 1. Review of the antibiotic stewardship program for the period of April 2023 to January 2024 with the Regional Director of Clinical Operations (RN #7) and the Infection Preventionist (IP) Nurse (RN #4) on 4/7/25 at 12:57 PM failed to identify any completed documentation presented quarterly at the Medical Staff meeting that included rates of antibiotic usage, patterns and resistance trends, and infections which meet McGeer for…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-04-10 · tag F0755 — failed to provide safe pharmacy services — pattern
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 755 Based on review of facility documentation, review of facility policy/procedures and interviews, the facility failed to establish a complete system of records of receipt and disposition of all controlled medications in sufficient detail to enable an accurate reconciliation. The findings include: Review of the bi-monthly narcotic drug audit form dated [DATE] identified the facility was auditing to ensure that medication carts were locked, all controlled drugs have a proof of use sheet, the narcotic count was correct, all change of shift narcotic count sheets were signed, all narcotic medications were labeled correctly, and no expired narcotic medication was stored in the medication cart. Review of the narcotic reconciliation with the ADNS on [DATE] at 1:40 PM identified that there were four binders in the ADNS office that contained the yellow Controlled Substance Disposition Records (CSDR), the CSDR sheets were organized by nursing unit and arranged in alphabetical order. Additionally, the oldest yellow CSDR…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-04-10 · tag F0658 — failed to meet professional standards of care — isolated
  Ensure services provided by the nursing facility meet professional standards of quality.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility documentation, review of facility policy, and interviews, for one of six sampled residents (Resident #33) reviewed for accidents and required a mechanical lift for transfers, the facility failed to ensure the resident was assessed by a registered nurse following an incident that occurred during a transfer with the mechanical lift. The findings include: Resident #33's diagnoses included Alzheimer's disease, aphasia, muscle weakness and chronic kidney disease. The annual MDS assessment dated [DATE] identified Resident #33 had intact cognition, did not display behaviors, required maximal assistance with bed mobility, upper body dressing and was dependent on care for lower body dressing and toileting hygiene. The assessment further identified the resident did not ambulate, utilized a wheelchair and was dependent on staff for mobility. The care plan dated 8/21/24 identified Resident #33 had an activities of daily living (ADL) self-care performance deficit due to…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-01-13 · 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 clinical record reviews, review of facility documentation and interviews for one (1) of three (3) sampled residents (Resident #1) who were reviewed for the misappropriation of personal property, the facility failed to ensure a controlled medication prescribed for Resident #1, Ativan, was not removed from the facility. The findings include: Resident #1's diagnoses included cerebral infarction, anxiety, and depressive disorder. A physician's order dated 10/20/24 directed to administer Ativan 1 milligram (mg) every eight (8) hours as needed for anxiety. The Resident Care Plan dated 10/22/24 identified Resident had a history of depression and anxiety. Interventions directed to administer medications as ordered, monitor for effect, and psych consultation as needed. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 was alert and oriented to person, place, and time, experienced delusions, exhibited no behavioral symptoms, and received an antidepressant medication. The nurse's note…

  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

“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.

Fines & penalties

$24,460 in federal fines across 2 penalties.

• $11,190 — penalty dated 2025-12-04
• $13,270 — penalty dated 2025-04-10

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.

Part of a chain

This home belongs to NATIONAL HEALTH CARE ASSOCIATES — 42 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 →

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

CMS files one row per role, so the 53 rows in the source record cover these 25 parties — each is shown once here with every role it holds. Nothing is omitted.

14 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 $198K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in CT