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Saint Mary Home

2021 Albany Ave, West Hartford, CT 06117 · Non profit - Corporation · 256 certified beds · (860) 570-8200 Medicare & Medicaid certified

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Flagged for abuse1 actual-harm citation
Insights

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

In its favor
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
  • lower-than-typical staff turnover (24% vs 45% nationally) — better care continuity
Worth asking about
  • CMS has flagged it for abuse
  • it has abuse, neglect, or exploitation citations (F0602, F0603) — most recent Nov 2024
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
  • its independent health-inspection rating is low (2/5)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

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

Worth a closer look. This home's staffing and quality-measure ratings run 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
Urgent care / clinic
200 Bloomfield Ave · (860) 768-6601 · Call to confirm hours
Pharmacy
324 N Main St · (860) 236-1988 · Call to confirm hours
Grocery
55 Sunny Reach Dr · (929) 805-6402 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship
1855 Albany Ave · (860) 236-1245

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

Quality measures — how residents actually fare

Overall quality measures 5 of 5
Long-stay residentspeople who live here 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 fell from 3 to 2 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 rating2★
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 increased17.3%18.0%15.4%worse
Long-stay residents who lose too much weight3.5%6.5%5.4%better
Long-stay residents with a catheter left in their bladder0.5%0.7%0.9%better
Long-stay residents with a urinary tract infection1.7%1.5%2.0%better
Long-stay residents with depressive symptoms0.0%22.3%6.5%check this — see note marked star 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 injury4.2%3.5%3.3%worse
Long-stay residents whose ability to walk worsened17.8%16.4%16.1%worse
Long-stay residents on antianxiety or hypnotic medication10.3%17.6%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%93.5%95.3%typical
Long-stay residents with pressure ulcers2.7%4.0%4.7%better
Long-stay residents with worsening bladder/bowel control27.1%24.7%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table10.7%17.8%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine99.4%69.7%79.4%better
Short-stay residents rehospitalized after admission20.8%24.3%22.6%typical
Short-stay residents with an outpatient ER visit9.0%10.7%12.0%better
Long-stay hospitalizations per 1,000 resident days0.812.061.67better
Long-stay outpatient ER visits per 1,000 resident days1.991.461.80worse

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

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.

56.6% 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 302 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

56.6%U.S. median 51.5%
Got home and stayed home
12.3%U.S. median 10.7%
Went back to hospital
58.1%U.S. median 56.6%
Met the expected recovery
0.31U.S. median 0.31
Therapy hours / resident / day
0.15hours / resident / day
Physical therapy
0.13hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 58.1% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 136 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 0.31 therapist hours per resident per day in 2026Q1 — more than 50% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 20% 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 SNF56.6%CMS range 51.1–61.551.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF12.3%CMS range 9.8–15.010.7%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 discharge58.1%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 discharge55.1%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 discharge44.9%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge100.0%98.7%Oct 2024–Sep 2025CMS 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 stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened1.3%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 hospitalization6.0%CMS range 3.7–9.17.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.841.02Oct 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

0.70
RN hours/ resident / day
0.83
LPN hours/ resident / day
2.28
Aide hours/ resident / day
3.80
Total nurse hours/ resident / day
0.42
RN hoursweekends
23.8%
Total nursing turnover
30.0%
RN turnover

How full it usually is: this home is certified for 256 beds and averages 199.0 residents a day — about 78% occupied, or roughly 57 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 3.80 hrs/resident/day is at or above 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 2.28 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.51 hrs/resident/day on weekends vs 3.92 on weekdays — 11% thinner on weekends. RN hours go from 0.82 to 0.42 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 24% is below the national median of 45%.

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

Inspection trend

7
deficiencies at the latest standard inspection (2024-11-12)
7
at the previous standard inspection (2022-02-16)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

26 citations, most serious first. The 11 most serious are shown; the remaining 15 are one tap away and print in full.

  • Actual harm · G2022-02-16 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    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 interview for 1 resident (Resident #60) reviewed for hospitalization, the facility failed to ensure medications were accurately reconciled after the resident returned from the hospital resulting in the omission of a medication for 9 days which resulted in a significant change in the residents mental status and a subsequent 12 day hospitalization. The findings include: Resident #60's diagnoses included schizophrenia, cerebral palsy, congenital hydrocephalus and seizure disorder. A progress note, written by MD #3 (resident's primary care physician) dated 10/13/20 identified Resident #60 had a history of schizophrenia and seizure disorder and was currently on Clozapine 400mg daily. The quarterly MDS dated [DATE] identified Resident #60 had moderately impaired cognition, required total 1-person assistance with bathing, extensive 2-person assistance with bed mobility, transfers, toilet use and locomotion on unit, extensive 1 person…

    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 · D2026-03-03 · 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 clinical record review, interviews, and facility documentation/policies for one (1) of three (3) residents (Resident #5) reviewed for Advanced Directives, the facility failed to honor a resident's Advanced Directive which specified Do Not Resuscitate and Do Not Intubate (DNR/DNI) when the resident was found unresponsive and without a pulse. The findings included:Resident #5 was admitted to the facility in November of 2025 with diagnoses that included peripheral vascular disease, cellulitis of left lower limb, and unspecified open wound of left lower limb.The Nursing admission assessment by RN #6 dated [DATE] at 4:51 PM identified Resident #5 arrived to the facility by stretcher, had reduced strength of the lower extremities, could ambulate with assistance, and utilized a four (4) wheel walker.The Current Consent for Life Sustaining Procedure dated [DATE] (located in the resident's paper chart and signed by both the resident and Medical Director) identified Resident #5 refused cardiopulmonary…

    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 · Past Non-Compliance
  • Potential for harm · D2026-02-04 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, and staff interviews, for one (1) of two (2) residents (Resident #1) reviewed for an injury of known origin, the facility failed to ensure the resident received necessary care and services when a physician-ordered x-ray was not obtained following complaints of left lower extremity pain, resulting in an eight (8) day delay in diagnosis of acute displaced fractures of the distal tibia and fibula. The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included childhood polio, osteoporosis and Alzheimer's dementia. The Nursing admission assessment dated [DATE] identified Resident #1 was oriented to person, place, time and event. The Resident Care Plan dated 10/9/25 identified Resident #1 was at risk for bilateral leg pain with interventions that included pain medications as ordered, complete pain assessment/evaluations, and observe for non-verbal indicators of pain (facial grimacing, guarding, furrowed brow,…

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

    Quality of Life and Care Deficiencies · Past Non-Compliance
  • Potential for harm · Dcited before2025-11-19 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard 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 clinical records, facility documentation and policy, interviews for one (1) of three (3) residents (Resident #1) reviewed for wounds, the facility failed to ensure the clinical record was complete and accurate to include documentation of a physician order for wound care. The findings included:Resident #1 had diagnoses which included an unspecified wound, and local infection of the skin, subcutaneous tissue. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Mental Interview for Mental Status (BIMS) of fifteen (15) indicative of intact cognition. Review of the RCP dated 8/20/2025 identified Resident #1 had an open wound/impaired skin integrity to the left lower extremity. Interventions directed to apply treatment: wound vac on Mondays/Wednesdays/Fridays. A physician's order dated 8/31/2025 directed to apply a wound vac at a low, continuous suction of 125 millimeters. Review of a nurse's note dated 9/1/2025 at 12:34 AM identified Resident…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-11-12 · tag F0887 — widespread
    Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical records, review of facility documentation, facility policy/procedures, and interviews for 5 of 5 residents (Resident #83, Resident #97, Resident #120, Resident #160 and Resident #187), reviewed for immunizations, the facility failed to ensure that the COVID-19 vaccination were offered and/or assessed to residents. The findings include: 1. Resident #83 was admitted to the facility in the month of June 2024 with diagnoses that included pneumonia, multiple rib fracture, and Alzheimer's disease. The quarterly MDS assessment dated [DATE] identified Resident #83 had severely impaired cognition. The assessment further identified that Resident #83 COVID-19 vaccination was not up to date. Review of Resident #83's immunization consents and/records, along with the new admission vaccine audit documentation for June 2024 with the Infection Preventionist (RN #2) on 11/7/24 at 9:45 AM failed to identify that the COVID-19 booster vaccine was offered to the resident. 2. Resident #97 was admitted…

    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 · E2024-11-12 · tag F0572 — pattern
    Give residents a notice of rights, rules, services and charges.
    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 that resident rights were reviewed on an ongoing basis. The findings include: A review of the resident council's monthly meeting minutes for the period of May 2024 through October 2024 failed to identify that resident rights were reviewed at the resident council meetings and/or that resident rights information was disseminated to the resident council as a group or to the residents in general. Interview on 11/04/24 at 2:07 PM with the resident council identified that the facility did not review resident rights during the resident council meetings and did not disseminate resident rights information to the residents on a routine basis. Interview on 11/7/24 at 9:29 AM with the Therapeutic Recreation Director identified the residents received a Resident's [NAME] of Rights when admitted to the facility. She further noted that she is the designated person that assists the residents with the resident council meetings and noted that the meetings did not have 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-11-12 · 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 the facility assessment and interviews for six sampled residents (Residents #29, #55, #60, #142, #167, and #184) residing on the secured unit (West 1), the facility failed to assess, care plan, demonstrate the secured unit was the least restrictive setting, and obtain consents for residents who were selected to reside on the secured unit. The findings included: Observations during all days of the survey October 31st, November 4, 5, 6, 7, and 8, 2024 identified the [NAME] 1 unit located on the first floor had entrance doors that were closed and secured. There was a key code pad adjacent to the doors that required a number code to be entered in order to gain access to the unit. All exterior doors and stairwell doors on the unit also required a key code to access the door. The staff was noted to input the code for visitors to exit the unit or enter the unit. Review of the Facility Assessment on 11/4/24 identified the facility's capability of managing…

    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 before2024-11-12 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and review of facility policy for 3 of 4 medication rooms, the facility failed to ensure medication rooms had sanitary refrigerators, maintained at appropriate temperatures and expired medications were removed from the cabinets. Additionally, for 3 of 5 medication carts, the facility failed to ensure the carts were clean. The findings include: Observation of the [NAME] Crossing medication storage room with LPN #4 on 10/31/24 at 10:30 AM noted expired medication contained in the overstock cabinet consisting of 1 full bottle of 325 milligrams(mg) of Aspirin (100 tablets) with an expiration date of 9/24, and the freezer had a heavy accumulation of frost/ice. Interview with LPN #4 on 10/31/24 at 10:35 AM identified that she was unsure of who was responsible for cleaning out and restocking medication in the medication storage room. LPN #4 identified that the freezer needed to be defrosted and that the 11:00 PM to 7:00 AM shift was responsible for picking up discontinued medications.…

    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 · E2024-11-12 · tag F0883 — failed to offer flu and pneumonia vaccines — pattern
    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 #83 and Resident #160), reviewed for immunizations, the facility failed to administer the pneumococcal vaccine as requested by the resident upon admission. The findings include: 1. Resident #83 was admitted to the facility in the month of June 2024 with diagnoses that included pneumonia, multiple rib fracture, and Alzheimer's disease. The quarterly MDS assessment dated [DATE] identified Resident #83 had severely impaired cognition. Review of the Vaccination Consent form for pneumovax identified Resident #83 gave the facility permission to administer the pneumovax vaccine on 6/26/2024. Review of Resident #83 clinical records failed to identify that he/she had received the vaccination at the facility or had change his/her decision. 2. Resident #160 was admitted to the facility in the month of June 2024 with diagnoses that included schizoaffective…

    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 · Dcited before2024-11-12 · 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, review of facility documentation, review of facility policy/procedures and interviews for one of six sampled residents (Resident #60) residing on the secured unit, the facility failed to ensure the resident's care plan was comprehensive in regards to behaviors of wandering, elopement risk and placement on a secured unit. The findings included: Resident #60 was admitted to the facility in October of 2023 with diagnoses that included dementia, personal history of disease of the nervous system and sensory organs, and unsteadiness on feet and repeated falls. The annual MDS assessment dated [DATE] identified Resident #60 had severely impaired cognition, required partial/moderate assistance with chair to bed, toilet, and tub transfers, required supervision or touching assistance with walking 10 feet and wheeling 150 feet in the wheelchair. Additionally, the MDS indicated the resident did not exhibit wandering, rejection of care, or physical or verbal behaviors. The care plan…

    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 · D2024-11-12 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, review of facility documentation, review of facility policy and interviews for one sampled resident (Resident #58) reviewed for Activities of Daily Living (ADL's), the facility failed to ensure the resident was provided nail care. The findings include: Resident #58's diagnoses include dementia, disorientation and difficulty swallowing. The quarterly MDS assessment dated [DATE] identified Resident #58 was severely cognitively impaired, was moderately visually impaired, required moderate assistance for personal hygiene and was dependent for toileting, showering, and transfers. The Social Worker note dated 9/5/24 at 12:55 PM identified Resident #58 was very hard of hearing and had poor eyesight. The care plan dated 9/24/24 identified Resident #58 was at risk for a self-care deficit, required assistance with activities of daily living related to a visual impairment with interventions that included providing assistance in completing ADL tasks, and assistance with…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 15 citations
  • Potential for harm · Dcited before2024-09-10 · 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 #2) reviewed for accidents, the facility failed to ensure care was provided in accordance with the plan of care. The findings include: Resident #2's diagnoses included cerebral infarction, and hemiplegia (weakness) of left nondominant side. The admission MDS assessment dated [DATE] identified Resident #2 required extensive two (2) persons physical assist for bed mobility/support. Review of Physical Therapy evaluation note dated 5/4/2024 indicated that Resident #2 was instructed on rolling side to side with max assist of two (2), noted Resident #2 listed towards the right side with noted left hemiplegia neglect, attempted to sit at edge of bed with assist of two (2), and unable to sit fully upright at edge of bed. The Resident Care Plan (RCP) dated 5/6/2024 identified Resident #2 required assistance with ADLS. Interventions directed assist of two (2) with ADLs as needed.…

    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 · D2024-09-10 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #2) reviewed for accidents, the facility failed to ensure resident care was provided in accordance with the plan of care to prevent a fall. The findings include: Resident #2's diagnoses included cerebral infarction, and hemiplegia (weakness) of left nondominant side. The admission MDS assessment dated [DATE] identified Resident #2 required extensive two (2) persons physical assist for bed mobility/support. Review of Physical Therapy evaluation note dated 5/4/2024 indicated that Resident #2 was instructed on rolling side to side with max assist of two (2), noted Resident #2 listed towards the right side with noted left hemiplegia neglect, attempted to sit at edge of bed with assist of two (2), and unable to sit fully upright at edge of bed. The Resident Care Plan (RCP) dated 5/6/2024 identified Resident #2 required assistance with ADLS. Interventions directed assist of two…

    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 · D2024-08-08 · 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 clinical record reviews, facility documentation, facility policies and interviews for one of three sampled residents (Resident #1) who was having episodes of diarrhea and required staff assistance to unplug an intravenous (IV) pump prior to toileting, the facility failed to respond to the resident's call bell timely which led to the resident utilizing the bed side wash basin to relieve him/herself of a bowel movement. The findings include: Resident #1's diagnoses included acute gastroenteropathy, diarrhea, Methicillin susceptible staph infection, unsteadiness on feet, weakness, and depression. The admission Resident Care Plan dated 5/12/24 identified Resident #1 had a self-care deficit, was at risk for falls, was receiving IV antibiotics for an infection, was on contact precautions due to diarrhea and Norovirus, and was at risk for skin breakdown. Interventions directed to allow the resident to complete as much as possible with activities of daily living tasks and then assist as necessary, provide…

    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 before2024-06-11 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard 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, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for notification, the facility failed to ensure the clinical record was complete and accurate to reflect the conservator of person was notified when a new medication was ordered and administered. The findings include: Resident #1 with diagnoses that included dementia, weakness, and depression. The comprehensive nursing admission assessment dated [DATE] identified Resident #1 had severely impaired cognition, was always incontinent of bowel and occasionally incontinent of bladder and required assistance of one with bed mobility, personal hygiene, transfers, and eating. The care plan dated 5/15/24 identified Resident #1 had mood and behavior concerns as evidenced by a depression diagnosis with interventions that directed to administer medications as ordered, monitor for adverse reactions, provide a calm, quiet environment, and monitor for triggers of mood and…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-01-26 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation, facility policy, and interviews for one (1) of three (3) residents, (Resident #1), reviewed for behaviors, the facility failed to review and revise the care plan to include interventions for chewing behaviors at all times. The findings include: Resident # 1 had diagnoses that included Alzheimer's disease, dementia with behavioral disturbance, anxiety, dysthymic disorder, and major depressive disorder. The care plan dated 11/1/2023 identified Resident #1 had impaired thought process related to Alzheimer's and dementia and chewing behaviors with interventions directed to provide a chewing device that will be given to the resident when out of bed in the wheelchair. An undated care card identified that the resident was to be provided with the chewing device while out of bed and in the wheelchair. The care plan and care card failed to identify interventions for the chewing behavior while the resident was in bed. A significant change in status MDS dated [DATE]…

    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 · E2022-02-16 · 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

    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 6 of 7 units, the facility failed to ensure comfortable and safe temperature levels in the resident rooms and maintain a temperature range of 71 degrees to 81 degrees per CMS guidelines. The findings include: Observation of resident units and resident rooms on 1/18/22 at 1:35 PM - 4:00 PM with Maintenance Person #1 identified the resident rooms temperatures ranged between 55 degrees Fahrenheit and 78 degrees Fahrenheit. West 1 unit resident room temperatures ranged between 66 degrees and 74 degrees F. Observation identified multiple residents with extra bath blankets covering them in the rooms. East 1 unit resident room temperatures ranged between 66 degrees and 72 degrees. Observation identified multiple residents with sweaters and extra bath blankets covering them. East 2 unit resident room temperatures ranged was between 55 degrees and 75 degrees. Observation identified multiple residents with…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-02-16 · tag F0807 — failed to offer suitable drinks — pattern
    Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
    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 docuentation, facility policy, and interviews for 6 of 7 units reviewed for hydration, the facility failed to ensure fresh drinking water was provided for hydration. The findings include: Tour on 1/18/22 at 1:35 PM through 3:30 PM with Maintenance #1 on [NAME] 1, East 1, East 2, [NAME] 2, [NAME] and [NAME] identified no water pitchers on the units or in resident rooms. Interview with NA #4 on 1/18/22 at 1:44 PM on the [NAME] 1 unit identified she has been employed at the facility for 10 ½ years. NA #4 identified she was aware the residents did not have water pitchers. She indicated she was not assigned to pass out the water pitchers. NA #4 indicated the kitchen did not deliver water pitchers to the unit today. Interview with NA #5 on 1/8/22 at 1:47 PM on the [NAME] 1 unit identified she has been employed at the facility for 6 years. NA #5 identified she was aware the residents did not have water pitchers. She indicated her assignment was 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-02-16 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, review of facility documentation, facility policy, and interviews, the facility failed to maintain an accurate record of the dishwasher temperatures and failed to ensure repair or replacement of equipment parts was completed in a timely manner. The findings include: 1. Observation on 1/10/22 at 9:40 AM with Sous Chef #1 identified he was not aware that the dishwashing machine temperature log had been completed, in advance, for the date of 1/10/22 for lunch and dinner. Interview on 1/10/22 at 10:55 AM with the Director of Dining Services identified she was not aware that the dishwasher machine temperature log had been completed for the date of 1/10/22 for lunch and dinner. The Director of Dining Services indicated the dietary aide should not have filled the form out prior to lunch and dinner. Interview on 1/10/22 at 11:00 AM with Sous Chef #1 identified he educated the dietary aide on the importance of filling out the dish machine temperature log accurately. Subsequent to surveyor inquiry a training/in-service participant log dated 1/10/22 was provided 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-02-16 · tag F0602 — failed to protect residents from theft of their belongings — isolated
    Protect each resident from the wrongful use of the resident's belongings or money.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of banking statements, facility's documentation and interviews for 1 of 4 residents, (Resident #66) who was reviewed for misappropriation, the facility failed to prevent misappropriation of the resident's personal funds. The findings include: Resident #66 was admitted to facility in 2017. Interview on 1/13/22 at 11:48 AM with Person #1 (Resident #66's representative) identified that the resident received quarterly financial statements from facility. Following detailed review of the quarterly statements, Person #1 noted that Resident #66 had been billed for multiple hairdresser visits in one day and/or week. Person #1 notified the Regional Ombudsman who organized a meeting with the Administrator and 2 representatives from the business office. A review of Resident #66's personal funds records by the facility identified that a total of $268.75 was withdrawn from the account without permission. Person #1 indicated the facility failed to provide any information regarding what happened to the $268.75 and reported that he/she was told by the facility that Resident #66'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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-02-16 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard 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, facility documentation, facility policy and interviews for 1 resident (Resident #700), reviewed for skin integrity, the facility failed to maintain an accurate clinical record according to the resident's experience. The findings included: Resident #700's diagnoses included severe intellectual disabilities, anxiety disorder and osteoarthritis. The admission MDS dated [DATE] identified Resident #700 had moderately impaired cognition and no pressure ulcers. Review of the wound physician's progress notes dated 9/7, 9/14, and 9/21/21 identified that Resident #700 was admitted to the facility on [DATE] for rehabilitation and long-term care after a three-month hospitalization. The note indicated the resident is evaluated at this time by wound care for an area of pressure ulceration on the right buttock which was present on admission. Interview with RN #7 on 2/15/22 at 3:08 PM and review of the wound note dated 9/7/21 indicated that the Resident #700's pressure ulcer was…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-02-16 · tag F0919 — failed to provide a working call system — isolated
    Make sure that a working call system is available in each resident's bathroom and bathing area.
    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 resident (Resident #47) reviewed for environment, the facility failed to ensure a nonfunctioning call light was reported and replaced immediately, per facility policy. The findings include: Resident #47 was admitted to the facility with diagnoses that included hemiplegia. The quarterly MDS dated [DATE] identified Resident #47 had intact cognition, was frequently incontinent of bowel and occasionally incontinent of bladder and required extensive assistance with bed mobility, toilet use and hygiene. Resident #47 required total assistance with transfers. The care plan dated 11/16/21 identified functional urinary incontinence related to neurological dysfunction, history of BPH. Interventions included to check for incontinence, change if wet/soiled, clean skin with mild soap and water, apply moisture barrier, three times daily, evaluate incontinence pattern to determine voiding schedule, use pads/briefs…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-07-25 · 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 review of the clinical record, review of facility documentation, review of facility policy and/or procedures, and interviews, for one resident reviewed for an injury of unknown origin (Resident #214), the facility failed to facility failed to review and/or revise the plan of care to address the resident's transfer status and/or needs. The findings include: Resident #214's diagnoses included Alzheimer's disease, dementia without behavioral disturbance, abnormalities with gait and mobility, osteoporosis, and status/post closed hip fracture of the right femoral neck. A quarterly assessment dated [DATE] identified Resident #214 as severely cognitively impaired, without behaviors, requiring limited assistance of one staff for transfers, with unsteady balance when transitioning from a seated to standing position, and as only able to stabilize with human assistance. The Resident Care Plan (RCP) and/or nurse aide care assignment (updated on 5/1/19) identified a problem with Activities of Daily Living (ADL) Care…

    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 · D2019-07-25 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, review of facility documentation, review of facility policy, and interviews, for one of four residents (Resident #1) reviewed for medication administration, the facility failed to ensure the medication administration and/or controlled substance record was accurately documented in a timely manner. The findings include: Observation of med cart B on [NAME] Crossing unit with Licensed Practical Nurse (LPN) #3, on 7/22/19 at 10:59 AM identified that the amount of Oxycodone 5mg tablets on Resident #1's controlled substance disposition record was not consistent with the amount of tablets in the blister pack. (Controlled substance record indicated one more than was found in Oxycodone blister card). Observation of the Medication Administration Record at that time with LPN #3 identified that Oxycodone 5 mg had not been documented as given on 7/22/19 AM. An interview with LPN #3 on 7/22/19 at 11:07 AM indicated that he/she usually signs off a narcotic when he/she removes…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-07-25 · 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 observation and interview, for one of four medication carts reviewed, the facility failed to ensure medication carts were free from several loose pills in the bottom of the medication cart. The findings include: Observation of the dementia unit medication cart with Licensed Practical Nurse (LPN) #1 on 7/24/19 at 2:28 PM identified the medication cart had many loose pills in the bottom of the cart. Interview with the Director of Nurses (DNS) on 7/24/19 at 2:51 PM identified the medication carts should be cleaned on Sundays on the 11:00PM to 7:00AM shift and the DNS would not be able to know if these medication were all from since Sunday. The DNS further identified that there is no policy for cleaning medication carts, it is the facility procedure to clean the carts on 11:00PM to 7:00AM shift on Sundays. Observation and interview with Licensed Practical Nurse (LPN) #1, with LPN #1 removing loose pills from the bottom of the medication cart on 7/24/19 at 2:56 PM identified 80 loose pills removed from the blister pack drawer of the medication cart, with more loose pills…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-07-25 · tag F0812 — failed to store, cook, and serve food safely — isolated
    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 — the official record, unedited, may be distressing

    Based on observation, interviews, and review of facility documentation, the facility failed to ensure food temperatures were monitored consistently. The findings include: Review of facility food temperature logs for July 2019 with the Head Chef on 7/22/19 at 10:40 AM identified that the majority of supper temperatures were blank, (all were blank except for July 5th, 10th, 11th, 15th, and 21st). Breakfast and lunch temperatures were not recorded on 7/10/19, 7/11/19, and 7/12/19, and breakfast temperatures were also not recorded on the 7/14/19. The Head Chef further identified that all meal temperatures should have been documented and the cooks were responsible for this. The facility failed to ensure that temperatures were consistently documented.

    Nutrition and Dietary 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

No federal fines in the current CMS record.

Part of a chain

This home belongs to TRINITY HEALTH — 19 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 →

RatingThis homeChain avg
Overall 3 of 53.3-0.3 vs chain
Health inspection 2 of 53.0-1.0 vs chain
Staffing 4 of 54.0≈ chain avg
Quality measures 5 of 53.7+1.3 vs chain
The other 18 homes this chain runs (chain average 3.3★, 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 / managerTypeRoleShareSince
MERCY COMMUNITY HEALTH INC.Organization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 01/01/1997
TRINITY CONTINUING CARE SERVICESOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST100%since 07/01/2016
DEMAIDA, RACHAELIndividualW-2 MANAGING EMPLOYEEsince 01/01/2022
LATOVICK, PAMELAIndividualW-2 MANAGING EMPLOYEE; CORPORATE DIRECTORsince 07/01/2016
HAMILTON-CRAWFORD, JANICEIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 01/01/2022
JOHNSON, PATRICKIndividualCORPORATE DIRECTORsince 12/31/2011
KANE, ANNIndividualCORPORATE DIRECTORsince 01/01/2022
MCKEON, PATRICIAIndividualCORPORATE DIRECTORsince 01/01/2022
MURPHY, PETERIndividualCORPORATE DIRECTORsince 05/31/2013
RAMAN, SHYAMALAIndividualCORPORATE DIRECTORsince 01/01/2022
SINGH, GAGANDEEPIndividualCORPORATE DIRECTORsince 01/01/2022
WALKER, MARKIndividualCORPORATE DIRECTORsince 05/31/2011
BOWENS, MARCUSIndividualCORPORATE OFFICERsince 03/01/2022

CMS files one row per role, so the 15 rows in the source record cover these 13 parties — each is shown once here with every role it holds. Nothing is omitted.

2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$31.9M
Net patient revenuemost recent cost report
+1.3%
Operating marginrevenue minus expenses
$2.8M
Related-party expense9% of expenses
Who pays — share of resident-days
Medicaid 42%Medicare 4%Other / private 55%

This home reported $2.8M paid to related parties (affiliated landlords or management companies) in its most recent cost report.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. 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

$315per resident / day
operating cost
$9,567per month
≈ monthly operating cost
$319per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2024). 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 075085. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-11-12, 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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