Saint Josephs Living Center INC
14 Club Rd, Windham, CT 06280 · Non profit - Corporation · 120 certified beds · (860) 456-1107 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- a high payroll-based staffing rating (4/5)
- lower-than-typical staff turnover (32% vs 45% nationally) — better care continuity
- it has an abuse, neglect, or exploitation citation (F0602), cited Jul 2024
- it has 1 actual-harm citation
- a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $13,065 in federal fines (most recent 2026-04-01)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 4 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 4 to 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 12.8% | 18.0% | 15.4% | better |
| Long-stay residents who lose too much weight | 8.6% | 6.5% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.7% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.5% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 24.1% | 22.3% | 6.5% | typical for the state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 3.4% | 3.5% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 13.2% | 16.4% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 19.8% | 17.6% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 93.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.4% | 4.0% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 25.0% | 24.7% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 17.7% | 17.8% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 0.4% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 81.6% | 69.7% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 26.2% | 24.3% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 15.7% | 10.7% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.23 | 2.06 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.26 | 1.46 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
61.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 67 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 65.1% 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 43 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 0.25 therapist hours per resident per day in 2026Q1 — more than 35% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 28% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 61.8%CMS range 47.3–70.9 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.3%CMS range 7.7–15.8 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 65.1% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 65.1% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 53.5% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not 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 stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 1.8% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 8.1%CMS range 4.2–13.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.77 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 120 beds and averages 108.7 residents a day — about 91% occupied, or roughly 11 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.91 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.72 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.51 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.61 hrs/resident/day on weekends vs 4.03 on weekdays — 10% thinner on weekends. RN hours go from 0.84 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 32% 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
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.
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.
22 citations, most serious first. The 11 most serious are shown; the remaining 11 are one tap away and print in full.
- Actual harm · G2026-04-01 · tag F0697 — failed to manage pain — isolatedProvide 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 record review, interviews, and facility policy review, the facility failed to recognize, assess, and manage acute pain for two of three sampled residents reviewed for accidents (Residents #1 and #5), resulting in actual harm when both residents experienced prolonged unrelieved pain after emergent injuries. Resident #1 sustained a second degree burn on 3/4/26 with documented discomfort. Yet, staff did not complete a comprehensive pain assessment or administer available PRN analgesia. The ordered burn dressing was no applied until the next shift, leaving the resident to report throbbing pain for many hours without follow up from nursing. Similarly, on 3/15/26, Resident #5 experienced a witnessed fall with visible left arm deformity and severe pain, but staff failed to administer any PRN pain medication before the resident was transported to the emergency department approximately 35 minutes later, despite active orders for both acetaminophen and morphine; the resident did not receive pain relief until more…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-01 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy and interviews for two (2) of three (3) sampled residents (Residents #1 and #5) reviewed for accidents, the facility failed to maintain complete and accurate clinical records by failing to ensure physician orders obtained following an incident were transcribed into the medical record and failing to ensure all licensed nurses involved in the incidents documented the care and services provided. The findings include:1. Resident #1's diagnoses included dementia without behavioral disturbances, type II diabetes mellitus, muscular dystrophy (progressive muscle weakness and degeneration), lymphedema (chronic swelling of the body's tissues caused by lymphatic fluid buildup) and anxiety disorder.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had intact cognition (Brief Interview for Mental Status (BIMS) score of 15), and was independent for eating, bed mobility, transfers and ambulation.The Resident 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.
- Potential for harm · Ecited before2024-12-10 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the clinical record, facility documentation, facility policy and interviews for 6 of 13 residents (Resident #22, Resident #36, Resident #44, Resident #64, Resident #71 and Resident #89) reviewed for Enhanced Barrier Precautions (EBP) and 1 of 2 residents (Resident #211) reviewed for Transmission Based Precautions (TBP), the facility failed to initiate Enhanced Barrier Precautions (EBP) per Center of Disease Control (CDC) guidelines for residents with a history of Multiple Drug Resistant Organisms (MDROs) and failed to perform hand hygiene after exiting a resident room and before entering another resident room and failed to maintain Transmission Based Precautions (TBP) while assisting a resident with a positive COVID-19 diagnosis. The findings include: 1. Resident #22, Resident #36 and Resident #44 had diagnoses that included a history of Methicillin Resistant Staphylococcus Aureus (MRSA) Resident #64 had diagnoses that included a history of Clostridium Difficile (C. Diff.).…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-10 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the clinical record, facility documentation, facility policy and interviews for 1 of 6 residents (Resident #208) reviewed for Nutrition, the facility failed to identify preferences for meals and provide choices for food items. The findings include: Resident #208 was admitted to the facility in November of 2024 and had diagnoses that included fracture of upper end of the right humerus and diabetes. A Physician's order dated 11/21/24 at 4:36 PM directed to provide a regular diet, regular thin consistency. A Dietary admission assessment dated [DATE] at 2:11 PM identified Resident #208 wanted a diet change to a diabetic diet with limited carbohydrate portions, increased vegetables and protein. assessment indicated the Food Service Director would updated. On 11/25/24 at 2:21 PM a Physician's order directed to provide a consistent carbohydrate diet, regular texture, regular thin consistency per resident request. The admission Minimum Data Set assessment dated [DATE] identified Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-10 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor 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 observations, review of the clinical record, facility documentation, facility policy and interviews for 1 of 2 residents (Resident #12) reviewed for the environment, the facility failed to ensure resident room temperatures were comfortable. The findings included: Resident #12 was admitted to the facility in April of 2023 with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD), Muscle Weakness, and Congestive Heart Failure. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #12 was cognitively intact (Brief Interview for Mental Status (BIMS) score of 14). Observations on 12/4/24 at 11:30 AM, identified Resident #12 lying in bed, closest to the window, wearing a red jacket (fleece material), and covered in two thick plush blankets. The room temperature was observed to be cool. Interview with Resident #12 on 12/4/24 at 11:30 AM, identified the room temperature had been cold for a couple of weeks and when Resident #12 communicated feeling cold to the staff, a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-12-10 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility documentation, facility policy and interviews for 1 of 2 residents (Resident #81) reviewed for pressure injuries, the facility failed to ensure a dietician assessment was completed in a timely manner for a resident with a new facility acquired pressure injury and failed to perform preventative weekly skin assessments per provider order and facility policy and failed to perform weekly wound assessments per provider order. The findings include: Resident #81 was admitted to the facility in November of 2023 and had diagnoses that included Parkinson ' s disease, diabetes, and aphasia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #81 was severely cognitively impaired (Brief Interview for Mental Status (BIMS) score of 6), required partial/moderate assistance with bed mobility and transfers and was at risk for developing pressure injuries. The Resident Care Plan (RCP) dated 7/31/2024 identified Resident #81 had potential…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-10 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 5 residents (Resident #210) reviewed for accidents, the facility failed to follow the plan of care to prevent an accident for a resident who was at risk of falls. The findings include: Resident #210 was admitted to the facility in October of 2022 with diagnoses that included acute and chronic respiratory failure, heart failure, long term (current) use of anticoagulants and difficulty in walking. Physician ' s order dated [DATE] directed to administer oxygen at 3 liters (L) per minute via nasal cannula. Physician's order dated [DATE] directed to place a sensor alarm to Resident #210's bed and chair every shift for safety. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #210 was moderately cognitively impaired (Brief Interview for Mental Status (BIMS) score of 12) and was dependent for toileting hygiene, required moderate assistance with positioning from lying to sitting on the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-12-10 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the clinical record, facility documentation, facility policy and interviews for 1 of 6 residents (Resident #203) reviewed for nutrition and hydration, the facility failed to obtain accurate weights and failed to notify the provider of weight increases according to provider order. The findings include: Resident #203 was admitted to the facility in December of 2024 and had diagnoses that included periprosthetic fracture around the internal prosthetic right hip, diabetes, congestive heart failure (CHF) and hypertension. The admission assessment dated [DATE] identified Resident #203 was alert and oriented to person, place and time. The Resident Care Plan dated 12/2/24 identified CHF and a risk for complications due to CHF. Interventions included to administer medications as ordered, check labs as ordered, chest x-ray as needed, daily weights for CHF, report weight gain of 3 pounds (lbs.) or more in a day to physician, diet as ordered, notify Physician of signs or symptoms of CHF…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-10 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of facility documentation, facility policy, and interviews, the facility failed to ensure shift to shift controlled drug reconciliation was consistently completed and failed to maintain documentation of bi-monthly controlled drug audits. The findings include: 1. Observations on 12/9/24 at 1:50 PM of the St. [NAME]'s A medication cart with the Assistant Director of Nursing (ADNS) identified the December Change of Shift Inventory Record for Required Drugs sheet (the controlled drug reconciliation form that the on-coming and off-going nurses complete to ensure controlled drugs are counted) were missing signatures on the following dates: A. 12/3/24: 7:30 AM to 3:00 PM off-going, 3:30 PM to 11:00 PM off-going B. 12/4/24: 7:30 AM to 3:00 PM off-going, 3:30 PM to 11:00 PM off-going C. 12/6/24: 7:30 AM to 3:00 PM on-coming and off-going, 11:30 PM to 7:00 AM off-going D. 12/8/24: 7:30 AM to 3:00 PM off-going, 3:30 PM to 11:00 PM on-coming and 11:30 PM to 7:00 AM off-going Interview with LPN…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-10 · tag F0806 — failed to honor food preferences — isolatedEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
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 interviews, review of the clinical record, and facility policy for 1 of 9 residents (Resident #57) reviewed for food and nutrition, the facility failed to assist a dependent resident with menu selection. The findings include: Resident #57 was admitted to the facility in July of 2023 and had diagnoses that included legal blindness, gastro-esophageal reflux disease, and feeding difficulties A provider order dated 12/12/23 directed a regular diet, regular texture with an allergy to eggs and egg derivates. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #57 was cognitively intact (Brief Interview for Mental Status (BIMS) score of 13), required set up assistance for eating, and was dependent for toileting, bathing, and transfers. The Resident Care Plan (RCP) dated 10/30/24 identified Resident #57 had impaired visual function related to legal blindness. Interventions included reviewing medications for side effects which affect vision and telling the resident where their items…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-10 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the clinical record, facility documentation, facility policy and interviews for 2 of 8 residents (Resident #85 and Resident #98) reviewed for infection control, the facility failed to identify and document vaccination status and offer vaccinations for resdients newly admitted to the facility. The findings include: 1. Resident #85 was admitted to the facility in October of 2024, with diagnoses that included Alzheimer's Disease, Atrial Fibrillation, Asthma and Osteoporosis. The admission Minimum Data Set assessment dated [DATE] identified Resident #85 was severely cognitively impaired (Brief Interview for Metal status (BIMS) score of 3). Review of the Electronic Health Record (EHR) immunization record identified that a Moderna Covid-19 vaccine was administered on 11/18/24 and an Influenza vaccine was administered on 12/9/24 but failed to identify if a Pneumovax vaccine was offered, refused or administered. The facility failed to identify any documentation of a Vaccine…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 11 citations
- Potential for harm · D2024-07-24 · tag F0602 — failed to protect residents from theft of their belongings — isolatedProtect each resident from the wrongful use of the resident's belongings or money.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #2) reviewed for abuse, the facility failed to ensure a resident was free from mistreatment. The findings include: Resident #2's diagnoses included Parkinsonism, schizophrenia, and depression. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 was alert and oriented (no cognitive impairment). The Resident Care Plan (RCP) dated 5/17/2024 identified Resident #2 had a history of socially inappropriate behavioral symptoms. Interventions directed to provide education on what is not acceptable behavior. Review of facility Reportable Event Form dated 7/9/2024 at 10:30 AM identified Resident #2 reported to a NA that he/she did not want a certain NA to provide care because that NA asks for money. Resident #2 stated he/she gave NA #1 $80.00 and he/she wanted it back. An investigation was initiated, and NA #1 was removed from the schedule. The report…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-05-28 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, and interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure a physician order for STAT (immediate) x-rays were ordered as STAT. The findings include: Resident #1's diagnoses included dementia and syncope. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severely impaired cognition, required supervision or touch assistance with ambulation and toilet transfers, and had no falls since the prior assessment. The Resident Care Plan (RCP) dated 4/22/2024 identified Resident #1 had a history of falls related to poor safety awareness and cognitive deficits. Interventions directed ambulation assist of one (1) with gait belt and four-wheel walker and to keep call light in reach at all times. Physician order dated 3/20/2024 directed a hospice evaluation. Physician order dated 3/26/2024 directed CMO (comfort measures only), Do Not Resuscitate (DNR), Do Not Intubate (DNI),…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-05-28 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, and interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure the clinical record was complete and accurate to include an RN assessment was completed after a resident fall. The findings include: Resident #1's diagnoses included dementia and syncope. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severely impaired cognition, required supervision or touch assistance with ambulation and toilet transfers, and had no falls since the prior assessment. The Resident Care Plan (RCP) dated 4/22/2024 identified Resident #1 had a history of falls related to poor safety awareness and cognitive deficits. Interventions directed ambulation assist of one (1) with gait belt and four-wheel walker and to keep call light in reach at all times. Review of facility incident report dated 4/29/2024 at 4:30 PM identified Resident #1 fell on the floor on his/her left side in the bathroom…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-08-31 · tag F0800 — patternProvide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interviews, and review of facility policy during the initial tour of the kitchen, the facility failed to ensure the proper concentration of sanitizing solution for one of three sanitization buckets reviewed. The findings include: Interview and observation with the Food Service Supervisor on 8/24/22 at 10:15 AM identified three buckets of sanitizing solution for cleansing kitchen surfaces, one in a sink, one on a mobile cart, and one on a shelf below a food preparation surface. The Food Service Supervisor indicated that the sanitizing solutions had been mixed on 8/24/22 between 9:30 and 10:00 AM and that the proper level of sanitization for food contact surfaces is 150-200 parts per million (PPM) for quaternary ammonia compound (QAC). Upon testing, the sanitization bucket that was in use and stored on the mobile cart indicated a level of 0 parts PPM of QAC which failed to reach the appropriate level of sanitization. The Food Service Supervisor re-tested the sanitization solution using a new package of dip sticks, but the sanitization level again indicated a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-08-31 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
FACILITY Kitchen Based on observations, interviews, and review of facility policy during the initial tour of the kitchen, the facility failed to ensure essential kitchen equipment was free of debris and maintained in a clean and sanitary manner, that food items were appropriately labeled, that expired food was discarded prior to the expiration date and that during meal distribution food items were appropriately covered. The findings include: 1. Observations during the initial kitchen tour on 8/24/22 at 10:00 AM identified the following: A. Observation of the ice machine identified a black substance on the interior back of the machine above the current supply of ice for kitchen use. Interview and review of facility policy with the Food Service Supervisor at 10:40 AM identified that the kitchen ice machine was scheduled to be cleaned every three months by maintenance. The Food Service Supervisor indicated that the interior of the ice bin currently required cleaning, that the black substance above the ice was easily removed with a paper towel and could have been mold, the current…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-08-31 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Resident #36 Accidents Based on review of the clinical record, facility documentation, facility policy and interviews for the only sampled resident (Resident #36) who was reviewed for falls, the facility failed to revise the care plan. The findings include: Resident #36 's diagnoses included repeated falls, difficulty walking, and dementia. The most recent Physical Therapy Discharge summary dated [DATE] recommended supervision during all functional transfers and ambulation due to decreased safety and history of fall, The quarterly MDS assessment dated [DATE] identified Resident #36 was cognitively intact and required the limited assistance of one staff for transfers and walking, and the extensive assistance of one staff for toilet use. The care plan dated 4/1/22 identified Resident #36 was at risk for falls. Interventions directed to provide two staff assist for transfers, a sensor alarm to the chair, to check the sensor alarm every shift, and to assist with transfers and ambulation as indicated. The physician's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-08-31 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Resident #66 Nutrition Based on observation, clinical record review, review of facility policy and interview for 1 of 2 residents (Resident#66) reviewed for nutrition, the facility failed to ensure a reweight was obtained timely for verification, after a significant weight loss was identified. The findings include: Resident #66's diagnoses included Alzheimer's disease, moderate protein-calorie malnutrition, hypertension, anxiety and depression. The Annual MDS dated [DATE] identified Resident #66 was severely cognitively impaired and was independent with eating after set up. Resident was 60 inches tall and weighed 123 pounds (lbs). The Care Plan dated 5/7/22 identified resident had an increased risk for alteration in nutrition. Interventions directed to provide diet as ordered, document the percent consumed at each meal, weight resident weekly and document and obtain nutritional consult as needed to ensure resident is meeting nutritional needs. The Physician ' s orders dated 6/2/22 directed to provide a regular…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-08-31 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Resident #20 Urinary Catheter or UTI Based on clinical record review, observations, facility policy review, and interviews for the only sampled Resident, (Resident #20) reviewed for urinary catheter use, the facility failed to position the urinary collection bag in a clean manner. The findings include: Resident #20's diagnoses included Benign Prostatic Hypertrophy (BPH) with urinary retention. The admission Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #20 was severely cognitively impaired and required limited assistance of one staff with transfers and required extensive assistance with locomotion and dressing and required a urinary catheter. The Resident Care Plan (RCP) dated 6/9/22 identified an indwelling catheter and failed voiding trial on 6/2/22, retention of urine. Interventions directed to position the urinary catheter bag and tubing below the level of the bladder to gravity, secure Foley catheter to avoid dislodgement, and use a privacy bag for collection bag. A physician's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-11-07 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy and interview for one resident (Resident # 100) reviewed for Advanced Directives, the facility failed to ensure a RN May Pronounce order was in place prior to the expiration of the resident. The findings include: Resident #100 was admitted to the facility on [DATE]. Resident # 100's diagnoses included CHF, chronic kidney disease, atherosclerotic heart disease, and unstable angina. The admission MDS assessment dated [DATE] identified Resident # 100 had severely impaired cognition, required extensive assistance with Activities of Daily Living (ADL), transfers and with mobility; noted a walker and indicated the resident utilized a wheelchair for mobility. The care plan dated [DATE] identified poor prognosis due to severe cardiac disease and the implementation of palliative care. Interventions directed to honor the resident's Advanced Directives and noted Comfort Measures. The physician's orders for Advanced Directives for [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.
- Potential for harm · Dcited before2019-11-07 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the clinical record, interviews and review of facility policy for one of three residents reviewed for pressure ulcer, (Resident # 201), the facility failed to consistently offload the resident's heels per physician's orders and to ensure the application of green boots in accordance to the plan of care. The findings include: Resident # 201 was admitted on [DATE]. Resident # 201's diagnoses included Congestive Heart Failure (CHF) and muscle weakness, The admission MDS assessment dated [DATE] identified Resident #201 had severe cognitive impairment, required extensive assistance of two staff for bed mobility, one stage 1 pressure ulcer and had two Suspected Deep Tissue Injuries (DTI). The admission MDS assessment directed staff to apply a pressure reducing device to the resident's bed and chair, to apply pressure ulcer/injury care and did not note any turning /repositioning program. The care plan dated 10/9/19 identified a problem with skin integrity but did not reflect heel DTI or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-11-07 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility documentation and interviews for one of four residents (Resident # 22) reviewed for medication administration, the facility failed to follow facility policy when administering a resident's medication and failed to ensure infection prevention techniques during administration of a medication were performed to prevent the spread of infection. The findings include: Resident # 22 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus, chronic kidney disease and muscle weakness. The quarterly MDS assessment dated [DATE] identified Resident # 22 had intact cognition, required supervision with eating and received a diuretic 7 days a week. The care plan dated 8/14/19 identified an alteration in nutritional status. Interventions included: to monitor laboratory blood work values as directed and to report abnormal laboratory blood work values to the physician. A physician's order dated 11/2/19 directed to administration…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$13,065 in federal fines across 1 penalty.
- $13,065 — penalty dated 2026-04-01
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 / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| LEGACY LIFECARE, INC. | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 100% | since 04/09/2025 |
| CHELSEA JEWISH LIFECARE INC | Organization | 5% OR GREATER MORTGAGE INTEREST; 5% OR GREATER SECURITY INTEREST; OPERATIONAL/MANAGERIAL CONTROL | — | since 10/02/2023 |
| BERMAN, ADAM | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 04/09/2025 |
| FIEBELKORN, DOUGLAS | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | — | since 01/21/2026 |
| GALLUP, LORRAINE | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | — | since 06/12/2012 |
| GOLDSMITH, SUSAN | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | — | since 01/21/2026 |
| LAPOINTE, LAURENCE | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | — | since 06/25/2008 |
| MILEWSKA, NANCY | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 04/09/2025 |
| MULLEN, ELIZABETH | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/09/2025 |
| REIDY, RICHARD | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | — | since 04/09/2025 |
| SANTERRE, JENNIFER | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/09/2025 |
| SPIEKER, A. GARY | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | — | since 04/09/2025 |
| WHITTEN, ROBERT | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 04/09/2025 |
| ALESSANDRO, JOSEPH | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2023 |
| ANFANG, STUART | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 10/02/2023 |
| BERMAN, BARRY | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 10/02/2023 |
| BIRLE, HANS | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 10/02/2023 |
| BRUDNICK, JEFFREY | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 10/02/2023 |
| COE, LISA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 12/23/2024 |
| CRESCENZO, DONNA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 12/13/2010 |
| FORMAN, SHARON | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 10/02/2023 |
| GREENSPAN, HOWARD | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 10/02/2023 |
| KOWAL, MARISSA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/30/2024 |
| MACLELLAN, GENEVIEVE | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 10/02/2023 |
| O'BRIEN, TERRENCE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/11/2021 |
| RICHMAN, GILDA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 10/02/2023 |
| WEISS, JUDY | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 10/02/2023 |
CMS files one row per role, so the 52 rows in the source record cover these 27 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.
This home reported $1.1M paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in CT
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Connecticut Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 075321. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-12-10, 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.