Wolcott Hall Nursing Center, INC
215 Forest St, Torrington, CT 06790 · For profit - Corporation · 60 certified beds · (860) 482-8554 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a middle-of-the-pack inspection score (3/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- a high number of inspection citations overall (33) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $11,190 in federal fines (most recent 2025-02-08)
- its payroll-based staffing rating is low (2/5)
- its facility-reported quality-measure rating is low (1/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 1 of 5 |
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
| Overall quality measures | 1 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 1 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
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 | 19.1% | 18.0% | 15.4% | worse |
| Long-stay residents who lose too much weight | 5.2% | 6.5% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 0.8% | 0.7% | 0.9% | typical |
| Long-stay residents with a urinary tract infection | 2.9% | 1.5% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 22.6% | 22.3% | 6.5% | typical for the 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 | 6.4% | 3.5% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 15.6% | 16.4% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 19.7% | 17.6% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 92.3% | 93.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.8% | 4.0% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 22.0% | 24.7% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 21.4% | 17.8% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.4% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 21.8% | 69.7% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 26.8% | 24.3% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 16.9% | 10.7% | 12.0% | worse |
‡ 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.
48.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 90 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 51.8% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 56 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 0.55 therapist hours per resident per day in 2026Q1 — more than 85% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 33% 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 | 48.0%CMS range 40.1–57.8 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 12.4%CMS range 8.4–17.4 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 51.8% | 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 | 39.3% | 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 | 42.9% | 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 | 100.0% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 | 0.0% | 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 | 2.8% | 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 3.8–13.1 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.14 | 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 60 beds and averages 48.9 residents a day — about 82% occupied, or roughly 11 beds typically open. It usually has some room. 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 3.29 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.70 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.85 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 2.87 hrs/resident/day on weekends vs 3.47 on weekdays — 17% thinner on weekends. RN hours go from 0.76 to 0.53 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 46% is about the same as the national median of 45%. 1 administrator has left in the past year.
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 11 most serious are shown; the remaining 22 are one tap away and print in full.
- Actual harm · Gcited before2025-02-08 · 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 record review and interviews for one of three sampled residents (Resident #42) reviewed for accidents, the facility failed to ensure the resident was free from injury resulting from an instant hot pack. The findings include: Resident #42's diagnoses included dementia, ulcerative colitis, liver cancer, brain cancer, and colon cancer. The quarterly MDS assessment dated [DATE] identified Resident #42 had intact cognition (BIMS of 15), was totally dependent on staff for transfers, toileting, hygiene, and dressing, and utilized a manual wheelchair for mobility. The Resident Care Plan (RCP) dated 11/15/24 identified Resident #42 had a recall, memory impairment and impaired decision making related to dementia. Care plan interventions directed to use short and simple sentences, allow time to respond when speaking to the resident, when confused or forgetful offer gentle reminders, and if the resident does not understand, please state in simple terms. The physician's orders for the month of November 2024 directed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-01-07 · 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 reviews, review of facility documentation, facility policies, and interviews for one (1) of three (3) sampled residents (Resident #1) who were reviewed for accidents, the facility failed to ensure facility staff provided adequate supervision to prevent Resident #1 from exiting the facility unattended. The findings include:Resident #1's diagnoses included depression, anxiety, congestive heart failure, pressure ulcer to the heel and a history of falls. The significant change in status Minimum Data Set assessment dated [DATE] identified Resident #1 had some memory recall deficits, required substantial assistance with toileting hygiene, was dependent for bathing, dressing and personal hygiene, and utilized a walker and/or wheelchair for mobility. The Nursing Evaluations dated 11/10/25 identified Resident #1 was not at risk for elopement. A December monthly physician's order identified Resident #1 may go out on a leave of absence with a responsible party. The nurse's note dated 12/28/25…
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 before2025-03-05 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, interviews, and review of facility documentation and policies for one (1) of three (3) residents reviewed for fluid status, the facility failed to complete dehydration evaluations in accordance with facility policy and failed to notify the provider with the results of a dehydration evaluation timely. The findings included: Resident #1 had diagnoses that included adjustment disorder with depressed mood, peripheral vascular disease, and unspecified congestive heart failure. Review of the Nursing admission assessment dated [DATE] identified Resident #1 had a very poor food intake pattern, Resident #1 never ate a complete meal, rarely ate more than one-third of any food offered, ate two (2) servings or less of protein (meat or dairy products) per day, and took fluids poorly. Review of the Comprehensive Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Mental Interview for Mental Status (BIMS) of five (5) indicative of severely impaired cognition.…
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 · E2025-02-08 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of facility documentation, review of facility policy/procedures and interviews, the facility failed to establish a system of records of receipt and disposition of all controlled medications in sufficient detail to enable an accurate reconciliation and failed to have a system in place to keep an accurate accounting of controlled medications. The findings include: Observation on [DATE] at 11:35 AM identified the DNS office contained a binder that held the yellow Controlled Substance Disposition Records (CSDR), the CSDR sheets were organized alphabetically. Additionally, some of the yellow CSDR sheets were from 2023 and had not yet been reconciled with the white CSDR nor were the medications identified as having been destructed. The book did not contain audit sheets for 2024 and the last signed off narcotic audit was [DATE] Interview on [DATE] at 11:45 AM with the DNS and RN#8 identified that the DNS is responsible for narcotic reconciliation in the facility and completed an audit 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 · D2025-02-08 · 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 observations, review of the clinical record, review of facility policy/procedures and interviews for one of two sampled residents (Resident #252) reviewed for respiratory care, the facility failed to ensure a physician order was in place for a resident who required oxygen therapy. The findings included: Resident #252 was admitted to the facility on [DATE] with diagnoses included dementia, without behavioral disturbance, psychotic disturbance, mood disturbance anxiety, and dyspnea. The hospital Discharge summary dated [DATE] identified Resident #252 was administered oxygen via nasal cannula at 2 lpm (liters per minute) while in the hospital. The nursing admission assessment dated [DATE] at 11:05 AM identified Resident #252 was admitted to the facility with diminished lung sounds, exhibited shortness of breath (SOB) with exertion, utilized oxygen, and had diagnoses of asthma, and chronic obstructive pulmonary disease (COPD) The baseline care plan dated 1/29/25 identified Resident #252 received respiratory…
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 before2025-02-08 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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/procedures and interviews, the facility failed to ensure the medication administration cart was appropriately secured during the medication administration pass while not within the line of sight of the nurse. The findings include: Observations of medication administration on 2/6/25 at 9:31 AM identified LPN #2 was able to access the medications without using a key to unlock the medication cart. She used her fingers to pull the lock out and was able to open the drawers containing the medications. LPN #2 prepared Resident #45's medications and then pushed the lock in on the cart and entered the resident's room and pulled the privacy curtain. The medication cart was not within LPN #2's line of sight. LPN #2 returned to the cart and was able to pull the locking mechanism out and without using a key, was able to access medications. At 9:52 AM, LPN #2 prepared medications for Resident #250, LPN#2 pushed the locking mechanism on the med cart, entered the room, and pulled the privacy curtain closed. The medication cart was not within LPN #2's…
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 before2025-02-08 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, review of facility policy, review of facility documentation, and interviews for two of five sampled residents (Resident #4 and Resident #5), reviewed for immunizations, the facility failed to ensure that the pneumococcal vaccine was administered as requested by the resident upon admission. The findings include: 1. Resident #4 was admitted to the facility in September of 2024 with diagnoses that included dementia, type 2 diabetes mellitus, anemia, and atrial fibrillation. The admission MDS assessment dated [DATE] identified Resident #4 had moderately impaired cognition. Review of the Pneumococcal Vaccine Consent form identified Resident #4 responsible party gave the facility permission to administer the pneumococcal based on the guidance provided on current pneumococcal vaccine schedule per the Centers for Disease Control and Prevention (CDC) in collaboration with the provider oversight on 10/9/24. Review of Resident #4 clinical records on 2/6/25 failed to identify that he/she…
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 · D2024-07-03 · tag F0585 — failed to handle grievances — isolatedHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for grievances, the facility failed to initiate a grievance concern for a missing item. The findings include: Resident #1 had diagnoses that included dementia, anxiety, agitation, and depression. A progress note dated 1/10/2023 at 12:07 P.M. written by the Administrator identified she was notified of Resident #1's misplaced wedding ring. The Administrator identified a concern form would be initiated, she spoke with Resident #1's family member regarding Resident #1's misplaced wedding ring and will initiate a search. A progress note dated 1/11/2023 at 8:25 P.M. written by the Administrator identified she followed up with Resident #1's family member in person today regarding Resident #1's misplaced ring and a search was still in progress. Review of the facility's Grievance Log from 1/1/2023 to 12/31/2023 failed to provide documentation to reflect a grievance concern form was completed on 1/10/2023 for Resident #1's missing wedding…
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 before2024-05-24 · 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 clinical record review, facility documentation review, and interviews for one of three residents (Resident #2) reviewed for medication errors, the facility failed to ensure medication was administered in accordance with physician orders and failed to ensure the resident received the correct dose of a cancer treatment medication. The findings include: Resident #2's diagnoses included malignant neoplasm of the prostate and malignant neoplasm of the bone. A physician order dated 10/3/2022 directed to administer Abiraterone Acetate (used to treat cancer) 250 milligrams (mg), four (4) tablets once a day for a total dose of 1000 mg for prostate cancer. The admission Minimum Data Set assessment dated [DATE] identified Resident #2 had moderately impaired cognition, had a diagnosis of cancer, benign prostatic hyperplasia (BPH) and obstructive uropathy. The facility medication error report dated 11/2/2022 identified after counting the Abiraterone Acetate for planned discharge, the facility staff identified a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-10-04 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of facility documentation and interviews, the facility failed to ensure the environment was maintained in a clean, sanitary, and homelike manner. The findings included: Review of the infection control surveillance and safety rounds dated 8/22 completed by LPN #3 (who collected data) identified all areas has been met. Recommendations of Infection Control Nurse identified the facility needed painting. Observations during tour on 9/28/22 from 10:30 AM through 11:30 AM and again on 10/4/22 at 8:38 AM with the Administrator, DNS, and the Maintenance/Housekeeping/Laundry Director identified the following: a. Damaged, chipped, marred bedroom walls, bathroom walls, hallways walls, and/or bathroom doors in rooms on the [NAME] Court unit #204, 207, 210, and 211. The Migeon Lane unit #101, 103, 105, hallway, 110, 114, 116, and rehabilitation department. b. Damaged and cracked floor tiles in bedroom in rooms on the [NAME] Court unit 200, nurse's station, hallway, and in 206. The Migeon Lane 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 · Ecited before2022-10-04 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — patternProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident # 30) reviewed for pressure ulcers, the facility failed to ensure consistent conduct weekly wound monitoring for a resident with a pressure ulcer. The findings include: Resident #30 was admitted with diagnoses that included type II diabetes mellitus, hemiplegia and hemiparesis following other cerebrovascular disease affecting left non-dominant side. A quarterly minimum data set (MDS) assessment dated [DATE] identified Resident #30 was without cognitive impairment, required extensive 2 person assist with bed mobility and personal care, total assist with transfers, was at risk for the development of pressure ulcers and did not have any unhealed pressure ulcers, The care plan dated 9/2/21 identified Resident #30 was at risk for skin breakdown due to decreased mobility, incontinence, and poor circulation. Interventions included consultation with wound care specialist as ordered/needed, follow all…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 22 citations
- Potential for harm · E2022-10-04 · tag F0725 — failed to have enough nursing staff — patternProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, review of facility documentation, facility assessment, and interviews, the facility failed to ensure that staffing levels were adequate for (44) residents on 2 units in accordance with the plan of care. The findings include: a. A review of the daily staffing breakdown schedule from 6/1/22 through 10/4/22 identified insufficient staff on all shifts. Further review of the staffing identified the facility had been scheduling the Temp Student Nurse Aides and the Hospitality Aides on the daily staffing schedule. The facility has been utilizing the Student Nurse Aides and the Hospitality Aides as a Certified Nurse Aide and counting the Hospitality Aides and Temp Student Nurse Aides as part of the staffing count on all shifts. A review of the staffing allocation sheet dated 10/3/22 identified the day shift had one (1) Registered Nurse, two (2) Licensed Practical Nurse, four (4) Nurse Aides. The allocation sheet failed to reflect documentation that one of the Nurse Aide was Temp Student Nurse Aide, and only three Nurse Aides was scheduled. A review of the census report…
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 · E2022-10-04 · tag F0726 — failed to have competent, trained nursing staff — patternEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of facility documentation, facility assessment, and interviews, the facility failed to ensure nursing staff possess the competencies and skill sets necessary to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental, and psychosocial well-being. The findings include: A review of the daily staffing breakdown schedule from 6/1/22 through 10/4/22 identified insufficient staff on all shifts. The facility had been scheduling the Temp Student Nurse Aides and the Hospitality Aides on the daily staffing schedule. The facility has been utilizing the Hospitality Aides as a Certified Nurse Aide and counting the Hospitality Aides as part of the staffing count on all shifts. Review of the daily staffing breakdown schedule from 6/1/22 through 9/30/22 identified on numerous days and shifts the Temp Student Nurse Aide and the Hospitality Aide had been left alone on the unit for one to four hours alone on the units. Review of the daily staffing breakdown schedule from 6/1/22 through 9/30/22…
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 before2022-10-04 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of facility policy, and interviews for 1 of 2 medication storage room, the facility failed to maintain the medication storage room in a clean manner and for 1 of 2 narcotic refrigerator, the facility failed to ensure the narcotic refrigerator freezer was free from build-up ice, and for 1 of 2 medications carts, the facility failed to maintain the medication cart in a clean and sanitary manner, and the facility failed to secure a medication following a specialized services appointment. The findings included: 1. Observation of the medication storage room on [NAME] Court unit on 9/29/22 at 10:38 AM with the DNS identified the window curtains with multiple brown stains, and dirt. 2. Observation of the medication storage room on [NAME] Court unit on 9/29/22 at 10:38 AM with the DNS identified the narcotic refrigerator freezer with accumulation of build-up ice. Interview with the DNS on 9/29/22 at 10:38 AM identified she was not aware of the above issues. The DNS indicated the licensed…
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 · E2022-10-04 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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 observations of the kitchen, review facility documentation, facility policy, and interviews, the facility failed to ensure a clean and sanitary kitchen. The findings included: An observation on 9/28/22 at 9:50AM of the kitchen identified the following: 1. A large amount of brown congealed buildup along the back of the sink, stoves, and all counter against the wall where the floor meets the wall. 2. Multiple smears and smudges on door of the stove with large amount of brown buildup on the front and sides of the stove and a moderate amount of brown buildup on the sides of the handle on the stove. 3. The Convection oven with a large amount of brown congealed buildup on the control knobs, along the sides and behind the stove on the floor. 4. A large amount of brown congealed buildup on the steam table face and around control knobs. 5. Ice holder with a small amount of blackened buildup at the bottom of the holder and small amount of caked gray buildup on the top closure. 6. The face of the ice machine was observed with a large amount of scaled white buildup along the front 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 · Ecited before2022-10-04 · tag F0880 — failed to prevent and control infections — patternProvide 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 observations, facility policy review and interviews for infection control, the facility failed to follow infection control guideline regarding discarding soiled gloves and failed to ensure isolation gowns were readily available for adherence to proper Personal Protective Equipment (PPE) use. The finding included: 1. Observation on [DATE] at 10:50 AM identified Hospitality Aide (HA) #1 exited room [ROOM NUMBER] with gloves on. Hospitality Aide (HA) #1 walked down the hallway with 1 plastic bag of soiled and dirty linen (touched bedroom doorknob with glove hand). HA #1 observed surveyor watching her then she removed glove off one hand. Interview with HA #1 on [DATE] at 10:55 AM identified she has been employed by the facility for 6 months. HA #1 indicated she forgot to take her gloves off before coming out of the room. HA #1 indicated she is aware she is not supposed to come out of a room and touched the doorknob with gloved hands. Interview with the DNS on [DATE] at 10:16 AM identified she was not aware…
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 · D2022-10-04 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
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 sampled resident reviewed for misappropriation (Resident #15), the facility failed to implement the written policies and procedures for abuse to thoroughly investigate an allegation of misappropriation. The findings include: Resident #15 was admitted with diagnoses that included multiple sclerosis, bladder cancer and depression. A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #15 was cognitively intact requiring limited assistance with 1 staff member for bed mobility, transfer, and personal hygiene. The social services note dated 9/21/22 at 12:35 PM identified a concern report form was filled out regarding NA care. The report noted the social worker, DNS and Administrator will follow up. A facility Reportable Event form dated 8/4/22 identified that Resident # 15 reported that s/he had given $20.00 to NA #8 to purchase personal items at the store and that NA #8 never…
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 · D2022-10-04 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for sampled resident reviewed for misappropriation (Resident #15), the facility failed to implement the written policies and procedures for abuse to thoroughly investigate an allegation of misappropriation to prevent further abuse. The findings include : Resident #15 was admitted with diagnoses that included multiple sclerosis, bladder cancer and depression. A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #15 was cognitively intact requiring limited assistance with 1 staff member for bed mobility, transfer, and personal hygiene. The social services note dated 9/21/22 at 12:35 PM identified a concern report form was filled out regarding NA care. The report noted the social worker, DNS and Administrator will follow up. A facility Reportable Event form dated 8/4/22 identified that Resident # 15 reported that s/he had given $20.00 to NA #8 to purchase personal items at the store…
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 · D2022-10-04 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility documentation, review of policy and staff interview for one sampled resident (Resident # 20) reviewed for falls, the facility failed to revise the care plan timely to provide further falls and for. The findings include: Resident #20 was admitted with diagnoses that included personal history of cerebral infarction, muscle weakness with difficulty walking and dementia. The quarterly MDS assessment dated [DATE] identified Resident #20 had severe cognitive impairment, required extensive two person assist with bed mobility, transfers, ambulated with assist of a walker, and had a history of previous falls. The care plan dated 5/13/22 identified Resident #20 required assist with Activities of Daily Living (ADL). Intervention includes to provide the assistance of two with a rolling walker. The care plan also identified the resident was at risk for falls and had a history of falls. Interventions included: the provision of a flat call bell on the left side of the 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.
- Potential for harm · D2022-10-04 · tag F0658 — failed to meet professional standards of care — isolatedEnsure 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, facility documentation, facility policy, and interviews for 1 resident (Resident # 20) reviewed for medication administration, the facility failed to ensure medications were administered according to professional standards and within facility policy. The findings include: Resident #20 was admitted with diagnoses that included personal history of cerebral infarction, muscle weakness with difficulty walking and dementia. The quarterly MDS assessment dated [DATE] identified Resident #20 had severe cognitive impairment and required assist with personal care. The care plan dated 5/13/22 identified Resident #20 was confused and forgetful due to dementia and required assist with ADL. Interventions included to allow time to respond when speaking, offer gentle reminders and if confused directed to restate in simpler terms. The nursing progress note dated 7/19/2022 at 11:56AM identified during morning medication pass, GPN (Graduate Practical Nurse identified as LPN #4) accidentally gave…
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 before2022-10-04 · 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 clinical record reviews, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #20) reviewed for falls, the failed to ensure neurological testing was completed for a resident who sustained an unwitnessed fall and for one resident (Resident #30) reviewed for skin condition(s), the facility failed to ensure consistent weekly wound monitoring for a resident with non-pressure related wounds and failed to follow recommendations from a specialty service or hospital for a resident with a non-pressure related wound and for 1 sample resident (Resident # 41) reviewed for death, the facility failed to ensure that there was a written physician's order of RN May Pronounce Death when a resident death was anticipated. The findings included: 1. Resident #20 was admitted with diagnoses that included personal history of cerebral infarction, muscle weakness with difficulty walking and dementia. A quarterly MDS assessment dated [DATE] identified Resident #20 had severe cognitive impairment,…
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 before2022-10-04 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Base clinical record reviews, facility policy review and interviews for 1 sample resident (Resident # 241) reviewed for hydration, the facility failed to monitor and record Intake and Output (I&O) according to the facility policy and for 1 sample resident (Resident # 9) reviewed for edema, the facility failed to monitor the resident weight according to the physician order. The findings included: 1. Resident #241 diagnoses included acute ischemic heart disease, anxiety, depression, hypertension and type 2 diabetes mellitus and dehydration. The admission MDS assessment dated [DATE] identified Resident #241 had intact cognition and required extensive assistance of 1 to 2 person with toileting, dressing, transfer, and non-ambulatory The physician's order dated 9/13/22 directed to push fluid every shift for 7 days. Review of Electronic Medication Administration Record (e-MAR) from 9/13/22 through 9/19/22 identified nursing staff was signing off the administered push fluid every shift without recording the actual…
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 · D2022-10-04 · 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 documentation, facility policy, and interviews for 1 sampled resident (Resident#26) reviewed for specialized treatment, the facility failed to ensure the resident's communication form to the specialized center was complete and the facility failed to ensure the licensed staff consistently reviewed the communication form after the resident received specialized services and the facility failed to ensure consistent monitoring and documentation of Intake and Output for a resident on fluid restriction who received specialized treatment and the facility failed to ensure a medication receive during specialized treatment was secure in the medication storage room or medication cart and the facility failed to obtain a physician's order for a resident receiving specialized treatment. The findings included: 1. Resident #26 was admitted to the facility on [DATE]. The resident's diagnoses included end stage renal disease, dependence on specialized treatment, type 2…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-10-04 · tag F0730 — isolatedObserve 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 review of facility documentation, facility policy and interview, the facility failed to ensure mandatory annual training for all staff was completed for 2 Nurse Aides (NA #2 and NA #3). The findings include: Review of NA #2's employee file on 10/3/22 and 10/4/22 identified that NA #2 had not completed the mandatory annual competency training required for a NA. Review of NA #3 employee file on 10/3/22 and 10/4/22 identified NA #3 had not completed the mandatory annual competency training required for a NA. Interview with the DNS on 10/4/22 at 12:35 PM identified she was responsible of ensuring all staffs attended and completed their mandatory annual training. She also indicated that she started the annual mandatory training model for all the staffs this year rather than using a rolling monthly education for all the staffs. The DNS further indicated NA #2 and NA #3 were per diem nurse aides who are required to attend and complete the mandatory annual training including that same as the regular staff. The facility failed to ensure that all staff members completed the annual…
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 · D2022-10-04 · 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 clinical record review and interview for two of five residents reviewed for Unnecessary Medication for (Resident # 20), the facility failed to consistently monitor the resident's blood pressure according to facility policy and procedure and for (Resident # 241), the facility failed to address the pharmacy recommendation in a timely manner in accordance to facility practice. The findings included: 1. Resident # 20's diagnoses included dementia with behavior disturbances, Transient Ischemic Attack (TIA), Acute Kidney Failure, hypertension, arteriosclerotic heart disease, hyperlipidemia, and major depression. An annual MDS assessment dated [DATE] identified the resident was severely cognitively impaired and required extensive assistance with most ADL. A pharmacy report dated April 2022 noted Metoprolol for hypertension and directed to please monitor blood pressure at least weekly as directed by prescriber per facility policy and procedure. The quarterly MDS 5/3/22 and a significant change MDS assessment…
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 before2022-10-04 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 2 of 5 residents (Resident # 6 and Resident #29) reviewed for Pneumococcal immunization, the facility failed to develop a method to track and / or monitor immunization status, screen for eligibility and provide for Pneumococcal vaccination as ordered. The findings include: 1. Resident #6 was admitted to the facility with diagnoses that included dementia, epilepsy, and depression. An admission MDS assessment dated [DATE] identified Resident # 6 had mildly impaired cognition and required limited assistance with 2 staff for bed mobility and limited assistance with 1 staff for personal hygiene. A Pneumococcal conjugate consent form was signed by Resident #6 ' s responsible party on 4/20/22 authorizing Resident #6 to receive the pneumococcal conjugate (PCV 13) vaccine. A physician's order dated 4/21/22 directs to provide Resident #6 pnuemovax 0.5 ml in on admission if not received. Interview and review of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-12-12 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
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 procedures and interviews for one of three residents reviewed for skin integrity (Resident #15), the facility failed to develop skin interventions on the Baseline Resident Care Plan. The findings included: Resident #15 was admitted to the facility on [DATE] with diagnoses that included, altered mental status, non-healing comminuted intra-articular fracture of the left distal femur, left ischial wound and osteomyelitis. A hospital discharge summary and the inter-agency patient referral form (W-10) dated 9/6/19 identified Resident #15 was status post Stage 2 pressure ulcers to the left ischial tuberosity and coccyx. The W-10 further directed pressure ulcer prevention interventions per protocol, low air loss bed or mattress, frequent repositioning every 2 hours, waffle cushion when out of bed to chair, limit sitting times to 1-2 hour intervals, and frequent weight shifts for the coccyx and left ischium, continue wound care to the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-12-12 · 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 review of the clinical record, facility documentation, facility policy and interviews for one of three sampled residents reviewed for skin integrity (Resident #15), the facility failed to implement preventative skin recommendations and failed to complete a weekly body audit. The findings included: Resident #15 was admitted to the facility on [DATE] with diagnoses that included, altered mental status, non-healing comminuted intra-articular fracture of the left distal femur, left ischial wound and osteomyelitis. A hospital discharge summary and the Inter-Agency Patient Referral form (W-10) dated 9/6/19 identified Resident #15 was status post Stage 2 pressure ulcers to the left ischial tuberosity and coccyx. The W-10 further directed pressure ulcer prevention interventions per protocol, low air loss bed or mattress, frequent repositioning every 2 hours, waffle cushion when out of bed to chair, limit sitting times to 1-2 hour intervals, and frequent weight shifts for the coccyx and left ischium, continue…
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 before2019-12-12 · 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 observation, interviews and review of facility policy, for one of one resident observed for wound care (Resident #23), the facility failed to follow infection control practices during a wound treatment and for one of fifteen bathrooms observed, the facility failed to ensure personal care items were stored in a safe and sanitary manner. The findings include: 1. Resident #23's diagnoses included peripheral vascular disease, hypertension and cognitive deficit. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #23 had a short and long term memory problem, required extensive assistance of two for bed mobility, extensive assistance of one for dressing, eating, toilet use, and required total assistance of one for personal hygiene. The Resident Care Plan dated 8/7/19 identified Resident #23 had an alteration in skin integrity/multiple areas to the right foot related to cognitive impairment, immobility, incontinence, and a nutritional deficit. Interventions included to turn 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.
- No harm found · B2025-02-08 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard 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 review of the clinical record, review of facility policy/procedures and interviews for 1 of 5 sampled residents (Resident #18) reviewed for unnecessary medication, the facility failed to ensure monthly pharmacy medication regimen review recommendations were part of the clinical record. The findings include: Resident #1's diagnoses included anxiety disorder, bipolar disorder, and dementia. The annual MDS assessment dated [DATE] identified Resident #18 was severely cognitively impaired, had no behaviors, was independent with bed mobility, transfers, dressings and personal hygiene. The care plan dated 10/28/23 identified Resident #18 utilized antipsychotic medication and antidepressant medication for management of bipolar disorder and dementia w/behavioral disturbance with interventions that included be aware of movements of the mouth, trunk or extremities, and be aware of medication changes. The consultant pharmacist's monthly regiment review dated 12/14/23 identified there were recommendations made.…
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 · B2019-12-12 · tag F0641 — patternEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, interviews and review of the Resident Assessment Instrument (RAI) Manual for 1 of 2 sampled residents (Resident #11) reviewed for Preadmission Screening and Resident Review (PASRR) and for 1 of 1 sampled residents reviewed for smoking (Resident #20), the facility failed to ensure the Minimum Data Set (MDS) was coded accurately. The findings include: 1. Resident # 11 was admitted to the facility on [DATE] with diagnoses that included anxiety, unspecified psychosis and major depressive disorder. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #11 was not considered by the state Level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. The Resident Care Plan dated 12/5/19 identified Resident #11 had a positive Level II psychiatric diagnosis with interventions that included an annual psychiatric evaluation, individual psychotherapy with a trained psychotherapist, and mental health counseling. An…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · Bcited before2019-12-12 · 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 review of facility documentation and interviews for one of three employee files reviewed (Nurse Aide #2), the facility failed to ensure a Nurse Aide (NA) performance evaluation was completed annually. The findings include: Review of NA #2's employee file identified the date of hire was 7/28/87, and NA #2 was terminated on 7/28/19. Additionally, NA #2 had not had a performance appraisal completed in 2017, 2018 or 2019. Interview on 12/11/19 at 12:42 PM with the Administrator identified that it was his/her responsibility to ensure that yearly employee appraisals were completed. The Administrator identified that he/she began employment at the facility in June 2019, and has initiated tracking and evaluations as of October 2019. The Administrator further identified that the facility expectation was for performance appraisals to be done after the introductory period and annually thereafter. Facility policy for Employee Performance and Review identified the employee will be provided a formal and documented performance review at the end of the employee's introductory period 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.
- No harm found · B2019-12-12 · tag F0943 — patternGive their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of facility documentation and interviews, for one of three sampled Nurse Aides (NA) reviewed for abuse prohibition inservicing (NA #2), the facility failed to ensure annual training for abuse prohibition was completed. The findings include: Interview and review of facility documentation with the Administrator on 12/11/19 at 12:37 PM identified that NA #2's date of hire was 7/28/87 and termination date was 7/28/19. NA #2 had abuse training in March 2018 with no evidence of further annual training. Interview with the Administrator at that time identified NA #2 should have had abuse prohibition training in March 2019. Additionally, the Administrator identified that the Staff Development nurse was responsible for tracking inservice training, but was asked to do additional nursing tasks and then went out on leave. The Administrator further identified that when the facility identified they were behind on abuse training, the facility retrained all staff in September 2019. The Administrator also identified that the facility does not have a policy regarding staff development,…
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.
- 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
$11,190 in federal fines across 1 penalty.
- $11,190 — penalty dated 2025-02-08
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 APPLE REHAB — 20 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 | 2 of 5 | 2.3 | -0.3 vs chain |
| Health inspection | 3 of 5 | 2.5 | +0.5 vs chain |
| Staffing | 2 of 5 | 2.7 | -0.7 vs chain |
| Quality measures | 1 of 5 | 2.5 | -1.5 vs chain |
The other 19 homes this chain runs (chain average 2.3★, 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 | Share | Since |
|---|---|---|---|---|
| FOLEY, BRIAN | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR | 100% | since 03/12/1986 |
| SINGH, DEVIKA | Individual | W-2 MANAGING EMPLOYEE | — | since 09/10/2018 |
| VESS, RYAN | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 03/15/2013 |
CMS files one row per role, so the 6 rows in the source record cover these 3 parties — each is shown once here with every role it holds. Nothing is omitted.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $510K 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
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 075111. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-02-08, 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.