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Masonicare Health Center

22 Masonic Avenue, Wallingford, CT 06492 · Non profit - Corporation · 260 certified beds · (203) 679-5900 Medicare & Medicaid certified

Call the home — (203) 679-5900 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0603) — cited Dec 2024Resident-funds citations (F0565, F0568)Behavioral-health or dementia-care citations — no harm found (F0744, F0758)1 actual-harm citation$13,085 in federal fines
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0603), cited Dec 2024
  • it has citations for mishandling residents’ money or property (F0565, F0568)
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $13,085 in federal fines (most recent 2024-11-13)
  • its payroll-based staffing rating is low (1/5)
  • nursing-staff turnover (70%) runs well above the national median (45%)

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.

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 4 of 5

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
67 Masonic Ave · (203) 265-0355 · Call to confirm hours
Pharmacy
284 S Colony Rd · (203) 265-6336 · Call to confirm hours
Grocery
35 N Colony St · (203) 269-1943 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 4 of 5
Short-stay residentsrehab / post-hospital 5 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 3 stars. From monthly CMS archive snapshots.

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

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased19.4%18.0%15.4%worse
Long-stay residents who lose too much weight6.5%6.5%5.4%worse
Long-stay residents with a catheter left in their bladder0.3%0.7%0.9%better
Long-stay residents with a urinary tract infection1.3%1.5%2.0%better
Long-stay residents with depressive symptoms3.2%22.3%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury6.2%3.5%3.3%worse
Long-stay residents whose ability to walk worsened22.4%16.4%16.1%worse
Long-stay residents on antianxiety or hypnotic medication8.3%17.6%18.9%better
Long-stay residents given the seasonal flu vaccine96.3%93.5%95.3%typical
Long-stay residents with pressure ulcers1.7%4.0%4.7%better
Long-stay residents with worsening bladder/bowel control31.1%24.7%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table14.8%17.8%17.1%better
Short-stay residents who newly got an antipsychotic medication0.6%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine76.6%69.7%79.4%typical
Short-stay residents rehospitalized after admission24.7%24.3%22.6%typical
Short-stay residents with an outpatient ER visit5.9%10.7%12.0%better
Long-stay hospitalizations per 1,000 resident days1.352.061.67better
Long-stay outpatient ER visits per 1,000 resident days1.101.461.80better

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

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

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

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

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

66.0% 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 335 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

66.0%U.S. median 51.5%
Got home and stayed home
9.2%U.S. median 10.7%
Went back to hospital
52.3%U.S. median 56.6%
Met the expected recovery
0.24U.S. median 0.31
Therapy hours / resident / day
0.10hours / resident / day
Physical therapy
0.12hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 52.3% 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 128 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 0.24 therapist hours per resident per day in 2026Q1 — more than 33% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 42% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF66.0%CMS range 61.6–71.851.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.2%CMS range 7.2–11.810.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge52.3%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge43.8%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge42.2%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified98.3%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting99.1%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.6%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization5.9%CMS range 3.7–7.97.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.801.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.00
RN hours/ resident / day
0.11
LPN hours/ resident / day
0.25
Aide hours/ resident / day
0.36
Total nurse hours/ resident / day
0.00
RN hoursweekends
69.6%
Total nursing turnover
69.4%
RN turnover

How full it usually is: this home is certified for 260 beds and averages 232.3 residents a day — about 89% occupied, or roughly 28 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 0.36 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.00 is below the 0.55-hour RN benchmark and nurse-aide staffing of 0.25 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 0.47 hrs/resident/day on weekends vs 0.32 on weekdays — about the same on weekends as weekdays. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 70% is well above the national median of 45%.

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

Inspection trend

9
deficiencies at the latest standard inspection (2024-12-09)
6
at the previous standard inspection (2022-03-18)

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

Inspection deficiencies

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

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

28 citations, most serious first. The 11 most serious are shown; the remaining 17 are one tap away and print in full.

  • Actual harm · Gcited before2024-11-13 · 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 policies and interviews for one (1) of three (3) sampled residents (Resident #1) who were dependent on staff for transfers, the facility failed to properly transfer a resident which ultimately resulted in a fall with a laceration to the head and subdural hematoma. The findings include: Resident #1's diagnoses included dementia, difficulty walking, and generalized muscle weakness. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had a BIMS score of two (2) indicating short and long-term memory recall deficits and was dependent on staff for turning and repositioning when in bed and transfers getting in and out of the bed and chair. The Resident Care Plan dated 8/3/24 identified Resident #1 had a self-care deficit and was at risk for falls due to impaired balance, dementia, and poor safety awareness. Interventions directed assistance of two (2) with bed mobility and mechanical lift transfers. The nurse's note 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 · F2024-12-09 · 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 observations, review of facility policy and interviews, the facility failed to ensure food items were dated when stored, were removed once out of date for use and failed to ensure kitchen staff with facial hair were supplied and wore beard guards. The findings included: Observations during the initial tour of the kitchen on 12/2/24 at 9:50 AM identified the following: Several staff with facial hair, to include the Executive Chef and [NAME] #5 hair did not have beard guards and [NAME] #5 was actively preparing foods. Interview on 12/2/24 at 10:00 AM with the Executive Chef and the Sous Chef identified that several staff who have facial hair do not have beard guards in place. The Executive Chef identified the facility does not have any and indicated they were ordered but had not been received. Observation on 12/2/24 at 10:30 AM of the walk-in prep refrigerator Identified the following prepared foods that had exceeded the amount of days to be used: • Cheese Blitzes, full tray not covered, not dated with fruit that was turning brown • Stuffed peppers with beef stuffing full…

    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 · Ecited before2024-12-09 · tag F0578 — failed to honor advance directives / code status — pattern
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, review of facility policy/procedures and interviews for three of six sampled residents (Resident #18) reviewed for advance directives, the facility failed to ensure consents were obtained regarding the resident's wishes regarding advance directives and decisions related to cardiopulmonary code status from the resident/responsible party. The findings include: 1. Resident #18 was admitted to the facility in July/2024. The resident was sent out to the hospital on [DATE], and readmitted to the facility in September of 2024 with diagnoses that included metabolic encephalopathy, altered mental status, and cerebral infarction. The admission MDS assessment dated [DATE] identified Resident #18 had severely impaired cognitive function, did not display behaviors, required substantial/maximal assistance with bed mobility, dressing and personal hygiene and was dependent for transfers. The care plan dated [DATE] identified Resident #18 was at risk for impaired cognitive function related to…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-12-09 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interviews for the facility and 1 of 6 sampled residents (Resident #80) reviewed for Abuse, and for the facility reviewed for a safe, clean, comfortable and homelike environment, the facility failed to ensure residents resided in a safe, clean, comfortable environment. The findings included: Observation on 12/2/24 at 12:00 PM of the 3 Ramage unit North side identified a hole in the wall on the left side of the nurses' station with facility maintenance staff standing by it. The maintenance staff identified there had been a water leak and staff was standing by awaiting additional staff to replace the sheet rock. At that time this was the only active work being done. However, the base molding on the entire unit was not present. Observation on 12/4/24 at 11:05 AM of 3 Ramage North and South identified the walls in all the hallways were patched with spackle and sanded. The drywall residue/dust was clumped on the floor under the areas of sanding, spread across the floor of the hallway, across some resident room doorways, behind the barrier doors in the hallway, 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-12-09 · tag F0603 — failed to not confine residents against their will — pattern
    Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of clinical records, review of facility policy and interviews for three of six sampled residents (Residents #13, #38, #82) who resided on a secured unit, the facility failed to ensure there was documentation of the clinical criteria met for placement in the unit and that the secured unit was the least restrictive setting for the residents. The findings include: 1. Resident #13's diagnoses included dementia, bipolar disorder and liver cancer. An Elopement Risk Evaluation dated 10/3/24 indicated Resident #13 was disoriented, and forgetful with intermittent confusion, had a diagnosis of a cognitive impairment (dementia) and was not appropriate for a wander guard device. The quarterly MDS assessment dated [DATE] identified Resident #13 had severe cognitive impairment, exhibited no behavioral symptoms, was totally dependent for transfers, grooming and toileting, was non-ambulatory, and utilized a manual wheelchair for mobility. Review of psychiatric progress notes from 6/1/24 through…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-12-09 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility documentation, review of facility policy/procedures, and interviews, the facility failed to ensure the water management plan was followed and failed to ensure positive legionella water sampling testing result was reported to the State Agency. The findings include: Review of the facility annual Water Management Plan meeting identified that legionella testing to be done monthly. A request was made to the Administrator and the Director of Maintenance on 12/6/24 at 3:15 PM for all Legionella testing completed from April 2022 to November 2024 and the Water Management Plan binder provided by the contracted company. On 12/9/24 the facility provided at 8:30 AM testing few testing results for the years 2023 and 2024 and annual water management plan meeting minutes. Another request was made to the Director of Maintenance on 12/9/24 at 9:15 AM for Legionella testing results for the year 2022 and the missing testing results for 2023 and 2024 the facility was unable to provide testing results of April 2022 through December 2022, December of 2023, January, February 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-09 · tag F0730 — isolated
    Observe each nurse aide's job performance and give regular training.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on review of employee files and staff interviews for one of three nurse aides (NA #4), the facility failed to complete an annual performance evaluation. The findings include: Review of NA #4 personnel file identified a hire date of 1/18/2010 and failed to identify that a yearly performance evaluation was completed for 2022, 2023, or 2024. Interview with administrator on 12/3/24 at 2:30 PM identified that each employee should have a performance review completed on an annual basis on the anniversary of their hire date. She identified that the unit manager on the floor was responsible for ensuring the performance evaluation were completed yearly and could not find documentation to identify that the performance evaluation was completed for NA #4. Although requested, policy for performance evaluation was not available.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-09 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, review of facility documentation, review of facility policy/procedures and interviews for two of five sampled residents (Resident #120, and Resident #135) reviewed for unnecessary medications, the facility failed to ensure documentation of the provider's decisions and actions were noted on the pharmacist consultant's recommendation form and that the form was maintained as part of the clinical record. 1. Resident #120's diagnoses included unspecified dementia, anxiety disorder, and heart failure. The quarterly MDS assessment dated [DATE] identified Resident #120 was severely cognitively impaired, required substantial/maximal assistance with bed mobility and dressing, was dependent on staff for transfers and personal hygiene, and utilized a wheelchair for mobility. The care plan dated 3/7/24 identified Resident #120 was at risk for behavioral changes related to psychotropic medications with interventions that included administer psychotropic medications 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 · D2024-12-09 · 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

    Based on observations, review of facility policy, and interviews, the facility failed to ensure the medication adminstraion cart was secure. The findings include: Interview on 12/2/24 at 11:30 AM with NA#5 identified the unit as the locked down dementia unit. Observation on 12/2/24 at 11:37 AM identified LPN#4 had finished prepping medication and walked into the dining room to administer to a resident. The cart was located to the right side of the entrance to the dining room. As LPN#4 walked away from the cart, he failed to secure the cart and all drawers could be opened and medications accessed. LPN#4 then came back into the hallway where the cart was located and intercepted a confused resident who needed redirection. LPN#4 escorted the resident down the hallway to the resident's room which was approximately 50 feet down the hallway. LPN#4 entered the resident room and the medication cart was not within his line of sight. Observation on 12/2/24 at 11:46 AM identified LPN#4 returned to the medication cart. Interview on 12/2/24 at 11:47 AM with LPN#4 identified that the medication…

    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 · D2024-12-09 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, review of facility documentation, review of facility policy/procedures, and interviews for two of five sampled residents (Resident #25 and Resident #144), reviewed for immunizations, the facility failed to administer the pneumococcal vaccine as requested by the resident upon admission and failed to offer the appropriate pneumococcal vaccine to the resident. The findings include: 1. Resident #25 was admitted to the facility in the month of January 2024 with diagnoses that included type 2 diabetes mellitus, major depressive disorder, and Wernicke's encephalopathy. The quarterly MDS assessment dated [DATE] identified Resident #25 was cognitively intact. The assessment further identified that the resident did not receive the pneumococcal vaccine as it was not offered. Review of the Informed Consent for Pneumococcal Vaccine Vaccination consent form identified Resident #25 gave the facility permission to administer the pneumococcal/Prevnar as recommended by current Centers 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 · D2024-12-09 · tag F0568 — isolated
    Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
    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/procedures, and interviews for one sampled resident (Resident #25), reviewed for personal funds, the facility failed to ensure funds were deposited into the resident fund account in a timely manner. The findings include: Resident #25 was admitted to the facility in January 2024 with diagnoses that included type 2 diabetes mellitus, major depressive disorder, and Wernicke's encephalopathy. The quarterly MDS assessment dated [DATE] identified Resident #25 was cognitively intact, dependent on care with toileting hygiene, lower body dressing, personal hygiene and transfers. The assessment further identified the resident was non-ambulatory and utilized a wheelchair for mobility. Interview with Person #10 (Resident #25's responsible party) on 12/4/24 at 11:15 AM identified that Resident #25 was owed money from Social Security, which the Business Manager identified the facility had not received the funds and was advised…

    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
Show the remaining 17 citations
  • Potential for harm · Dcited before2024-12-09 · 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 review, review of facility documentation, and interviews for one of three sampled residents (Resident #169) reviewed for accidents, the facility failed to provide a safe transfer for the resident to prevent a skin injury. The findings include: Resident #169 had diagnoses that included dementia, muscle wasting and atrophy, atrial fibrillation, and anxiety. The quarterly MDS assessment dated [DATE] identified Resident #169 had moderate cognitive impairment, was dependent on staff for transfers, and utilized a wheelchair for mobility. The nurse's notes dated 7/16/24 at 8:51 PM written by RN #2 identified he was called into Resident #169's room related to an open area to the lower right lateral leg. Resident #169 was not able to determine the cause of the injury to the lower right leg. He also identified Resident #169 was sitting in his/her wheelchair and NA #3 was assisting Resident #169 back to bed when the injury was noted. A steri-strip (wound closure tape) was applied, and responsible…

    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 before2024-07-08 · 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 three (3) residents (Resident #1) reviewed for behaviors, the facility failed to notify a physician when a resident who was exhibiting behaviors was administered an as needed medication for behaviors that was ineffective. The findings include: Resident #1's diagnoses included dementia with anxiety. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was severely cognitively impaired, required extensive assistance with bed mobility, transfers, and toileting. The Resident Care Plan dated 4/1/24 identified that Resident #1 was at risk for alterations in mood and behaviors related to a diagnosis of dementia with interventions that directed to administer medications as ordered, psychiatric consults as needed and to report and document restlessness, agitation and wandering. A physician's order dated 5/9/24 directed to administer Trazodone 50 mg (a sedative) by mouth every 8…

    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 before2024-07-08 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation, and interview, for one (1) of three (3) residents reviewed for incontinence, (Resident #1), the facility failed to ensure that the resident was had a comprehensive care plan in place for urinary incontinence. The findings include: Resident # 1 had a diagnosis of urinary retention and benign prostatic hyperplasia (prostate gland enlargement). An admission Minimum Data Set (MDS) assessment dated [DATE] identified that the resident had severe cognitive impairment, required extensive assistance with Activities of Daily Living (ADL's) and had an indwelling urinary catheter within the assessment period. Review of physician's orders dated 12/17/23 directed to discontinue the indwelling urinary catheter. Review of a quarterly MDS assessment dated [DATE] identified that the resident was frequently incontinent of urine. Review of ADL flow sheets for March, April, and May 2024 identified that the resident was incontinent of urine. Review of the clinical record failed…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-08 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation, and interview, for one (1) of three (3) residents reviewed for incontinence, (Resident #1), the facility failed to ensure an assessment was completed to assess for continence after an indwelling catheter was discontinued. The findings include: Resident # 1 had a diagnosis of urine retention and benign prostatic hyperplasia (prostate gland enlargement). An admission Minimum Data Set (MDS) assessment dated [DATE] identified that the resident had severe cognitive impairment, required extensive assistance with activities of daily living and had an indwelling urinary catheter within the assessment period. Review of physician's orders dated 12/17/23 directed to discontinue the indwelling urinary catheter. Review of the clinical record failed to identify a bladder assessment was completed to assess continence status once the indwelling urinary catheter was discontinued. Review of a quarterly MDS assessment dated [DATE] identified that the resident was frequently…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-08 · tag F0744 — failed to care for residents with dementia — isolated
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #1) reviewed for behaviors, the facility failed to ensure that a resident's behaviors were addressed and failed to code behaviors on the behavior flow sheets. The findings include: 1) Resident #1's diagnoses included dementia with anxiety, atrial fibrillation (irregular heartbeat), difficulty in walking, and muscle weakness. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was severely cognitively impaired, required extensive assistance with bed mobility, transfers, and toileting. The Resident Care Plan dated 4/1/24 identified that Resident #1 was at risk for alterations in mood and behaviors related to a diagnosis of dementia with interventions that directed to administer medications as ordered, psychiatric consults as needed and to report and document restlessness, agitation and wandering. A physician's order dated 5/9/24 directed to…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-12-11 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, facility policy review and interviews for one of three residents, (Resident #1), reviewed for accidents, the facility failed to ensure care was provided in accordance with the plan of care. The findings included: Resident #1 was admitted to the facility with diagnoses that included dementia, heart failure, diabetes mellitus, morbid obesity, and osteoarthritis of both knees. The Resident Care Plan (RCP) dated 8/16/2023 identified Resident #1 was a fall risk. Interventions directed transfer status to use sit to stand lift ([NAME]) lift for all functional transfer including toileting and to ensure wearing appropriate footwear. A quarterly MDS dated [DATE] identified Resident #1 was alert and oriented, and requiring extensive assistance with 2 staff for transfers. The nurse aid care card directed Resident #1 required use of a sit to stand lift ([NAME]) with assist of two (2) for transfers and to use a grab bar for a standing brief changes. A facility…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-03-18 · tag F0565 — failed to support the resident council — pattern
    Honor the resident's right to organize and participate in resident/family groups in the facility.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on facility documentation review, facility policy review, and interviews for facility Resident Council review, the facility failed ensure the Resident Council met on a regular basis and the facility failed to ensure a staff responded to Resident Council concerns timely. The findings include: 1. A review of Resident Council minutes from January 2020 through March 16, 2022 identified no Resident Council meetings occurred from January 2020 through July 7, 2021, and from January 2022 through March 16, 2022. An interview on 3/16/2022 at 8:35 AM with the Recreation Director identified she had taken over the role of overseeing Resident Council concerns beginning in July 2021. The Recreation Director indicated meetings did not occur during January 2020 through July 7, 2021, and from January 2022 through March 16, 2022 due to COVID-19 outbreaks in the facility. The Recreation Director indicated she did not meet with resident council members in an alternate format (remotely or individually) to allow opportunities to discuss resident concerns during the time when meetings were not held…

    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 before2022-03-18 · 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 clinical record review, facility policy review, and interviews for one resident (Resident #129) reviewed for nutrition, the facility failed to ensure the MD/APRN was notified of a significant weight loss in a timely manner. The findings included: Resident #129 was admitted on [DATE] with diagnoses that included severe protein-calorie malnutrition, vitamin D deficiency. The admission assessment note dated 1/19/2022 identified Resident #129 was alert and required extensive assistance with personal care. The Resident Care Plan (RCP) dated 1/20/2022 identified severe protein calorie malnutrition. Interventions directed to monitor and report significant weight loss of three (3) pounds in one (1) week, and greater than 5% loss in 1 month, 7.5% loss in 3 months, and 10% loss in 6 months to MD as needed. Review of the weight record identified the following weights: 1/19/2022, 118.2 pounds (lbs); 2/1, 115.4 lbs; 2/8 115.5 lbs; 2/9/2022, 107 lbs, a significant weight loss (loss of 11.2 lbs). Additional review…

    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 · D2022-03-18 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for one of three residents (Resident # 49) reviewed for abuse, the facility failed to ensure the care plan was revised timely after an incident with another resident. The findings include: Resident #49 was admitted with diagnoses that included dementia and essential hypertension. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #49 was severely cognitively impaired and independent with ambulation and toileting. The Resident Care Plan (RCP) 12/29/2020 identified Resident #49 had impaired cognitive function and a self-care deficit. Interventions directed to supervise as needed. A Reportable Event dated 12/31/2020 identified NA #1 heard arguing in Resident #49's room. Upon entry, she observed Resident #32 and #49 were in the bathroom arguing, and Resident #32 was pulling on Resident #49's thumb. The residents were separated and assessed for injuries with none noted. Resident #32 was placed…

    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 · D2022-03-18 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide 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 clinical record review, facility documentation review, facility policy review, and interviews for one resident (Resident #129) reviewed for nutrition, the facility failed to ensure the dietician was notified timely of a significant weight loss. The findings include: Resident #129 was admitted on [DATE] with diagnoses that included severe protein-calorie malnutrition, vitamin D deficiency. The admission assessment note dated 1/19/2022 identified Resident #129 was alert and required extensive assistance with personal care. The Resident Care Plan (RCP) dated 1/20/2022 identified severe protein calorie malnutrition. Interventions directed to monitor and report significant weight loss of three (3) pounds in one (1) week, and greater than 5% loss in 1 month, 7.5% loss in 3 months, and 10% loss in 6 months to MD as needed. Review of the weight record identified the following weights: 1/19/2022, 118.2 pounds (lbs); 2/1, 115.4 lbs; 2/8 115.5 lbs; 2/9/2022, 107 lbs, a significant weight loss (loss of 11.2 lbs).…

    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 before2022-03-18 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, facility documentation review, facility policy review, and interviews for one of two residents (Resident #439) reviewed for infection control, the facility failed to ensure appropriate infection control practices were followed for residents on precautions. The findings include: Resident #439 was admitted on [DATE] with a diagnosis of pneumonia. The RCP dated 3/12/2022 identified Resident #438 was at risk for COVID-19 infection related to a recent hospitalization. Interventions directed to place Resident #439 on a 14-day quarantine to monitor for signs and symptoms of COVID-19. Observation on 3/14/2022 at 11:06 AM identified Recreation Therapist #1 in Resident #439's room sitting across from Resident #439, separated by a tray table. Recreation Therapist #1 was observed wearing a face mask, gown, and gloves and was observed without the benefit of wearing a face shield. Interview at the time of the observation with Recreation Therapist #1 identified although she should…

    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 · D2019-01-29 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a clinical record review, staff interviews, and a review of facility documentation for one of two resident's reviewed for dignity (Resident # 163), the facility failed to ensure care and services were provided in a dignified manner. The findings include: Resident # 163 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, hypertension, and peripheral vascular disease. An annual Minimum Data Set (MDS) dated [DATE] indicated Resident #163 had moderate cognitive impairment, no behaviors, and required extensive assistance with bed mobility, transfer, and walking. A resident care plan dated 3/29/18 identified a problem with communication related to impaired hearing and shortness of breath with interventions that included to maintain the resident's dignity by enabling effective communication and maintain paper at the bedside for communication. Review of a nurse's note dated 5/25/18 indicated Resident #163 was alert and oriented with signs of anxiety as…

    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 before2019-01-29 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, interviews, and review of facility policy for one sampled Resident (Resident # 215) reviewed for Advance Directives the facility failed to review advance directives with the Resident and/or the Resident's responsible party after a readmission from the hospital. The findings include: Resident # 215 was admitted to the facility on [DATE] with diagnoses that included a history of a myocardial infarction, congestive heart failure, coronary artery disease, depression, atrial fibrillation, and dementia. An APRN progress note dated 10/5/18 at 1:32 PM identified Resident #215 suffered a cardiac arrest at the facility on 10/5/18. The progress note further identified cardiopulmonary resuscitation was initiated, and Resident # 215 was transferred to an acute care setting. Upon return to the facility the hospital Discharge summary dated [DATE] identified Resident #215's code status was Do Not Resuscitate (DNR). A Physician order dated 10/11/18 directed Do Not Resuscitate. An APRN…

    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 · D2019-01-29 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management 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 a review of the clinical record, a review of facility documentation, staff interviews, and a review of the facility policy, for one sampled resident reviewed for pain (Resident # 692), the facility failed to implement interventions for pain relief per the plan of care in a timely manner. The findings include: Resident # 692 was admitted on [DATE] with diagnoses that included open reduction and internal rotation of a right ankle fracture (ORIF), schizoaffective disorder, intramedullary and extramedullary lesions of the spine and bilateral cerebellar pontine angle lesions of the brain. The Discharge summary dated [DATE] identified Resident #692 had a previous history of extensive brain and spinal lesions and a recent history of a mechanical fall resulting in a right ankle fracture requiring an open reduction and internal rotation of the fracture (ORIF). Resident #692 was discharged to the facility with recommendations for acetaminophen every six hours as needed for discomfort, elevation of the right…

    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 · D2019-01-29 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and staff interviews for 1 of 5 residents (Resident #300), reviewed for unnecessary medications, the facility failed to ensure that as needed (prn) orders for psychotropic medications were limited to 14 days. The findings include: Resident #300 was admitted to the facility with diagnoses that included psychosis due to Parkinson's disease, confusion, and dementia. A physician's order dated 12/9/17 directed to administer quetiapine (Seroquel) (an antipsychotic medication) 25mg every 6 hours as needed for psychosis. A physician's order dated 9/5/18 directed to administer clonazepam (Klonopin) (a controlled medication that can treat seizures or anxiety) 0.5mg every 4 hours as needed for agitation. The care plan dated 9/11/18 identified Resident #300 had problems related to dementia, with behaviors such as restlessness, crying and wandering. Interventions included to administer medications as ordered, assess effectiveness and follow up…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • No harm found · Bcited before2023-08-04 · tag F0656 — failed to write and follow a full care plan — pattern
    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 review, facility policy review, and interviews for one of three sampled residents (Resident #1) who were at risk for the development of pressure ulcers, the facility failed to develop a care plan on admission to address the prevention of the development of a pressure ulcer. The findings include: Resident #1's diagnoses included local infection of the skin and subcutaneous tissue, cognitive communication deficit, muscle wasting and atrophy, weakness, cellulitis of left upper limb, muscle weakness and polyosteoarthritis. A physician's order dated 4/1/23 directed for skin checks weekly. The admission Resident Care Plan dated 4/7/23 identified a self-care deficit. Interventions directed to assist of one (1) for bathing, bed mobility, dressing, toileting, and transfers, set up for personal hygiene and eating, provide resident with increased processing time when giving verbal instructions, simple instructions work best, and requires setup assistance for use of…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2022-03-18 · tag F0623 — widespread
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, and interviews for two sampled residents (Resident #116 and #237), the facility failed to ensure the Ombudsman was notified timely of resident discharges from the facility. The findings include: 1. Resident #116 had diagnoses that included chronic respiratory failure with hypoxia, chronic respiratory failure with hypercapnia, severe morbid obesity with alveolar hypoventilation, congestive heart failure. a. A nurse's note dated 12/16/2021 at 9:13 PM identified Resident #116 had a change in condition and mental status. Resident #116 was unable to open his/her eyes and verbally unresponsive. The APRN was notified and directed to send Resident #116 to the hospital for evaluation, and Resident #116 was transferred. A nurse's note dated 12/22/2021 at 2:37 PM identified Resident #116 was readmitted to the facility at 1:52 PM with a diagnosis of toxic metabolic encephalopathy. b. Nurse's note dated 1/8/2022 at 9:59 PM identified Resident #116 was lethargic,…

    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

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

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

Fines & penalties

$13,085 in federal fines across 1 penalty.

  • $13,085 — penalty dated 2024-11-13

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Who owns this facility

Owner / managerTypeRoleSince
BEAULIEU, STEVENIndividualW-2 MANAGING EMPLOYEE; CORPORATE OFFICERsince 10/12/2020
VENOIT, JON-PAULIndividualW-2 MANAGING EMPLOYEE; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROLsince 01/01/2014
WOOD, COURTNEYIndividualW-2 MANAGING EMPLOYEEsince 09/01/2020
BUCKNER, NEWTONIndividualCORPORATE DIRECTORsince 11/06/2018
BIRNEY, PATRICKIndividualCORPORATE OFFICERsince 01/05/2022
EARLE, CHRISTOPHERIndividualCORPORATE OFFICERsince 01/05/2022
POLITO, ROBERTIndividualCORPORATE OFFICERsince 01/05/2022
MASONICARE INCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 10/01/1995

CMS files one row per role, so the 11 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

1 organizational owner 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.

$9.9M
Net patient revenuemost recent cost report
-20.4%
Operating marginrevenue minus expenses
$892K
Related-party expense8% of expenses
Who pays — share of resident-days
Medicaid 52%Medicare 4%Other / private 44%

This home reported $892K 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

$498per resident / day
operating cost
$15,144per month
≈ monthly operating cost
$414per day
avg. revenue, all payers

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

What families pay in CT

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Connecticut Medicaid page.

Typical monthly cost in Connecticut
$15,208/mo
Nursing home (semi-private)
$16,729/mo
Nursing home (private)
$9,118/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 075135. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-12-09, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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