Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Harmony Care At Stamford during CMS and state inspections, most recent first.
The facility failed to maintain a QAA/QAPI committee with the required members for four quarterly meetings. Record review showed the Medical Director was not present at any of the reviewed QAPI meetings, and the ADMN stated the MD either could not or would not attend while making rounds, giving orders, and signing orders during the meetings. The facility’s QAA committee list identified the required members as the Administrator, MD, DON, and ADON.
MDS assessments incorrectly coded current tobacco use as no for four residents whose records and observations showed they were smoking. Residents with COPD, dementia, depression, anxiety, and HTN were observed smoking on the enclosed patio, and staff provided and lit cigarettes for some of them. The DON said tobacco status should be correct on the MDS, while the MDS Coordinator and ADON gave explanations for why the coding may not match the resident’s smoking status.
Physician Face-to-Face Visit Documentation Not Maintained: The facility failed to ensure three residents were seen by the attending physician at least every 60 days. Records for residents with diagnoses including fracture, cirrhosis, anxiety, seizures, and severe intellectual disabilities showed no physician progress note documentation for extended periods, and residents stated they had not seen a physician in months. The ADMN and DON reported the MD made rounds and gave orders, but progress notes were not being sent and there was no written evidence of physician rounds.
Failure to obtain consent for psychotropic medications: A resident with depression, anxiety, and dementia, who had a BIMS score indicating cognitive intactness, received trazodone and sertraline without documented written consent from herself or her representative before the meds were started. The resident stated she did not know what medications she took and did not remember being educated or signing any papers, while the DON and Administrator confirmed written consent was required before psychotropic meds were administered.
A resident with bipolar disorder, major depressive disorder, and a PASRR Level I screening positive for Mental Illness did not have a PASRR Level II evaluation completed. The resident’s MDS also identified PASRR Serious Mental Illness, and the DON and MDS Coordinator stated the Level II review should have been completed, but it was not. The facility did not have a PASRR policy when requested.
A resident admitted with depression, anxiety, and dementia did not have a baseline care plan developed within 48 hours of admission. The DON stated the baseline care plan should be started within 48 hours, and the ADMN said the charge nurse and ADON were responsible for ensuring it was completed, but record review showed no evidence of a baseline care plan in the chart.
Smoking Status Not Addressed in Care Plans Two residents with intact cognition and diagnoses including COPD were observed smoking in the enclosed patio area, with staff supervising, providing cigarettes, and lighting them. Their comprehensive care plans did not address smoking status, despite facility policy requiring smoking-related privileges, restrictions, and concerns to be noted on the care plan and communicated to all personnel caring for the resident. The DON stated the omission was due to lack of staff education, and the ADON and nursing staff acknowledged smoking status should be included.
Missing CPAP Physician Order and Parameters: A resident with chronic respiratory failure, morbid obesity, CHF, and a pacemaker had CPAP equipment at the bedside and reported using CPAP at night, but the chart contained no physician order with settings or parameters for CPAP. The DON stated residents requiring CPAP should have a written order and parameters, and that the order was not entered after readmission.
Incomplete Smoking Assessments in Resident Records: The facility failed to keep complete and accurately documented records for two residents who smoked. One resident with bipolar disorder, DM2, HTN, and MDD had only one smoking assessment on file, and another resident with COPD, HTN, depression, and coordination issues had an admission smoking assessment but no documented quarterly reassessment. The DON stated smoking assessments were to be completed at admission and quarterly, and that the Activity Director had recently been assigned to complete them.
Several residents did not have their MDS assessments completed within the federally required 14-day window after the ARD, with delays attributed to staff transitions, change of ownership, and instructions from corporate to delay transmissions. The affected residents had various complex medical conditions, and the facility's policy and federal guidelines for timely assessment completion were not followed.
Two residents did not have comprehensive care plans developed or implemented for hospice services and oxygen use, despite physician orders and direct observations indicating these services were being provided. The required documentation, including measurable objectives and timeframes, was missing from their care plans, and staff interviews revealed a lack of awareness regarding these omissions.
Two residents receiving continuous supplemental oxygen did not have physician orders documented for their oxygen therapy, and one resident's room lacked required 'oxygen in use' signage. Both residents were observed on oxygen, but their records did not include necessary orders or care plan documentation, and facility policy requiring these steps was not followed.
Two residents with severe cognitive impairment did not receive blood pressure medications according to physician-ordered parameters. Nursing staff administered antihypertensive and vasopressor medications outside of specified blood pressure thresholds, and failed to provide PRN Clonidine for multiple episodes of hypertension. Leadership interviews confirmed expectations for staff to follow medication parameters, but lapses were attributed to inattention, and no relevant policy was found.
A resident admitted with pneumonia, chronic pulmonary disease, and emphysema, and requiring continuous oxygen, did not have a baseline care plan developed within 48 hours of admission as required by facility policy. The DON confirmed the omission and attributed it to transition in leadership and unclear follow-through by the admitting nurse.
The facility did not repair damaged drywall in water heater closets, which allowed rodents to enter the building. Multiple residents and staff reported seeing mice in halls and rooms, and rodent droppings were observed in several locations. The pest control vendor identified the damaged drywall as an entry point for rodents and had notified maintenance, but the issue remained unaddressed.
The facility did not maintain an effective pest control program, as evidenced by ongoing reports and observations of mice and rodent droppings in resident rooms, hallways, and utility areas. A resident reported repeated sightings and droppings in her room, and staff and other residents also noted mouse activity. The pest control vendor identified unrepaired damaged drywall in water heater closets as a key entry point for rodents, which had not been addressed despite recommendations, resulting in continued pest presence.
The facility failed to maintain safe room temperatures, resulting in two residents experiencing room temperatures of 86 F. Despite complaints, the facility was waiting for parts to repair the air conditioning system and did not implement temporary solutions.
The facility failed to electronically submit complete and accurate direct care staffing information to CMS for FY Quarter 1 2024. The Administrator stated that the former accountant responsible for the submission did not complete the task, and the facility's nurse consultant is now in the process of submitting the data for the current quarter. Record review indicated a total of 27 residents and 47 staff, and the facility's policy requires staffing information to be reported electronically to CMS through the PBJ system.
The facility failed to develop and implement person-centered, comprehensive care plans with measurable objectives for five residents, making it difficult to evaluate the effectiveness of the care provided. The DON and an LVN acknowledged the deficiencies, attributing them to recent turnover in nursing leadership.
The facility failed to review and revise comprehensive care plans within 7 days of assessments for four residents, including not updating a resident's care plan to reflect the discontinuation of bed and chair alarms. Interviews revealed that the DON and MDS coordinator were new and had overlooked the updates.
QAPI Committee Lacked Required Medical Director Participation
Penalty
Summary
The facility failed to maintain a quality assessment and assurance committee with the required members for four quarterly QAPI meetings reviewed. Record review of the Quality Assurance Performance Improvement attendance sign-in forms showed that the Medical Director was not present for the 3rd Quarter 2025 meeting, the 4th Quarter 2025 meeting, the January 2026 meeting, or the 03/10/2026 meeting. The facility’s QAA committee document listed the required members as Administrator, MD, DON, and ADON. During an interview on 06/17/2026 at 12:10 PM, the ADMN stated that no Medical Director was present for QAPI during the last four quarters. He stated the MD either could not or would not attend, and that the MD was making rounds, giving orders, and signing orders during QAPI meetings. The facility policy titled Quality Assurance and Performance Improvement stated that the facility shall develop, implement, and maintain an ongoing facility-wide QAPI program that builds on the Quality Assessment and Assurance Program to actively pursue quality of care and quality of life goals.
MDS Assessments Incorrectly Coded Tobacco Use
Penalty
Summary
The facility failed to ensure that the MDS assessments accurately reflected tobacco use status for 4 of 5 residents reviewed for assessment accuracy: Resident #1, Resident #2, Resident #18, and Resident #30. Resident #1 had diagnoses including COPD, dementia, major depressive disorder, anxiety, and high blood pressure, and his annual MDS dated 02/16/2026 coded current tobacco use as no despite an observation on 06/16/2026 showing him smoking outside in the enclosed patio area. Resident #2 had COPD, major depressive disorder, anxiety, high blood pressure, and emphysema, and her annual MDS dated 11/18/2025 also coded current tobacco use as no despite being observed smoking on the patio. Resident #18 had COPD, dementia, and high blood pressure, and her admission MDS dated 04/30/2026 coded current tobacco use as no despite being observed smoking on the enclosed patio area. Resident #30 had COPD, dementia, depression, anxiety, and high blood pressure, and her admission MDS dated 02/26/2026 coded current tobacco use as no despite being observed smoking on the enclosed patio area and later stating she had smoked since age 18 or 19 and that the facility was aware of her tobacco use status when she was admitted. On 06/17/2026, Resident #2, Resident #18, and Resident #30 were assisted to the enclosed patio area to smoke, and staff provided and lit cigarettes for each resident. During interviews, the DON stated the MDS Coordinator was responsible for entering MDS data and expected tobacco use status to be correct, while the MDS Coordinator stated the tobacco use section may have been coded differently because a resident may have started using tobacco after admission or after the annual assessment. The ADON stated a resident may not admit to smoking when admitted, and the RAI Manual states that if the resident states they used tobacco during the 7-day look-back period, code yes.
Physician Face-to-Face Visit Documentation Not Maintained
Penalty
Summary
The facility failed to ensure that Resident #2, Resident #4, and Resident #16 were seen face-to-face by a physician at least once every 60 days. Record review for Resident #2 showed diagnoses including a right leg fracture, anxiety, and major depression, with a BIMS of 15 indicating no cognitive impairment, but physician progress notes from 10/22/2025 through 06/08/2026 contained no documentation from the primary physician. During observation and interview, Resident #2 stated she had not seen a physician for as long as she could remember. Resident #4’s record showed diagnoses including cirrhosis of the liver and anxiety, with a BIMS of 15 indicating no cognitive impairment, but physician progress notes from 10/22/2025 through 05/06/2026 contained no documentation from the primary physician. During interview, Resident #4 stated he saw the new physician in May but had not seen a physician in months before that. Resident #16’s record showed diagnoses including seizures and severe intellectual disabilities, with a BIMS of 03 indicating severe cognitive impairment, but physician progress notes from 10/29/2025 through 06/08/2026 contained no documentation from the primary physician. The ADMN stated the new Medical Director started in May 2026 and that the MD was making rounds, giving orders, and signing orders, but was not sending documentation and progress notes. The DON stated the MD left at the end of April 2026, made visits, but did not send progress notes, and there was no written evidence of the MD making rounds on residents.
Failure to Obtain Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure Resident #25 was informed of and participated in her treatment, including advance information about the risks, benefits, and alternatives of proposed care, and failed to obtain consent before administering psychotropic medications. Resident #25 was an [AGE]-year-old female admitted with diagnoses of depression, anxiety, and dementia. Her admission MDS reflected a BIMS score of 12, indicating she was cognitively intact, and the care plan identified use of antidepressant medication with interventions to educate the resident, family, and caregivers about risks, benefits, and side effects. Her physician orders included trazodone 50 mg in the evening for insomnia and sertraline 50 mg in the morning for depression, both ordered on 05/29/2026. Record review showed Resident #25 received sertraline each morning and trazodone each evening throughout June 2026, but there was no evidence in the electronic medical chart that she or her representative signed consent for either medication before administration began. During interview, Resident #25 stated she did not really know what medications she took, that she just took what staff brought her, and that she did not remember being educated or signing any papers for her antidepressants. The DON stated consent must be obtained prior to administering psychotropic medications and that it was the ADON's and admitting nurse's responsibility to ensure consent was received. The Administrator stated all psychotropic medications must have written consent prior to administration and that the issue had been missed.
Failure to Complete PASRR Level II Review for a Resident with Mental Illness
Penalty
Summary
The facility failed to refer a resident for a PASRR Level II resident review after the resident’s PASRR Level I screening was positive for Mental Illness. Resident #28 was admitted with diagnoses including bipolar disorder, Type II diabetes mellitus, hypertension, and major depressive disorder. The resident’s annual MDS assessment identified PASRR Serious Mental Illness, and the care plan addressed a mood problem related to bipolar disorder. The record review also showed the resident’s PASRR Level I screening coded “yes” for Mental Illness, but there was no evidence that a Level II PASRR evaluation had been completed. During interviews, the DON stated that any resident with a positive PASRR Level I should have a Level II PASRR evaluation and plan, and that the MDS Coordinator was responsible for ensuring PASRRs were completed and accurate. The MDS Coordinator stated the resident’s primary diagnosis was dementia for billing purposes and that the Level II PASRR evaluation was not done, adding that she was responsible for ensuring PASRR Level IIs were completed. The facility also did not have a PASRR policy when requested by the ADM.
Failure to Initiate Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to develop and implement a baseline care plan for Resident #25 within 48 hours of admission. Resident #25 was an [AGE] year-old female admitted with diagnoses of depression, anxiety, and dementia, and her admission MDS assessment reflected a BIMS score of 12, indicating she was cognitively intact. Record review of her electronic medical chart on 06/16/2026 showed no evidence of a baseline care plan. During interviews, the DON stated that a baseline care plan should be initiated within 48 hours of admission and said she had been out on leave when Resident #25 was admitted. She stated it was the ADON and admitting nurse’s responsibility to ensure the baseline care plan was initiated. The ADMN also stated that all new admissions should have a baseline care plan initiated within 48 hours, said the DON was on leave, and stated the responsibility began with the charge nurse and then the ADON. Facility policy titled, Care Plans-Baseline, dated March 2022, stated that a baseline plan of care to meet the resident’s immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission.
Smoking Status Not Included in Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that included measurable objectives and time frames for two residents who were identified as current smokers. Resident #1 was an older male admitted with diagnoses including COPD, dementia, major depressive disorder, anxiety, and hypertension. His annual MDS showed a BIMS score of 14 out of 15, indicating intact cognition, and his care plan, which had been reviewed and revised multiple times, did not address his smoking status. Resident #30 was an older female admitted with diagnoses including COPD, dementia, depression, anxiety, and hypertension. Her admission MDS showed a BIMS score of 15 out of 15, indicating intact cognition, and her comprehensive care plan, which had also been reviewed and revised, did not address her smoking status. Both residents were observed smoking in the enclosed patio area, with dietary staff supervising them during one observation and staff assisting them to the patio, providing cigarettes, and lighting them during another observation. During interviews, the DON stated the smoking status was not included on the care plans because proper education with staff had not been done and said she, the ADON, and the MDS Coordinator were responsible for the care plans. The ADON and nursing staff stated a resident's smoking status should be included on the care plan, and the facility policy stated smoking-related privileges, restrictions, and concerns are to be noted on the care plan and all personnel caring for the resident shall be alerted to these issues.
Missing CPAP Physician Order and Parameters
Penalty
Summary
The facility failed to maintain complete and accurately documented medical records for one resident by not obtaining a physician order with settings and parameters for CPAP use. The resident had diagnoses including chronic respiratory failure with hypercapnia, morbid obesity, congestive heart failure, and a cardiac pacemaker. The resident’s physician orders reviewed on 06.01.2026 showed no order for CPAP, while the annual MDS dated 05.01.2026 listed active diagnoses of heart failure, respiratory failure, morbid obesity, and cardiac pacemaker. The care plan dated 04.05.2026 documented oxygen therapy related to sleep apnea, with oxygen used when sleeping and room air while awake. During interview and observation on 06.15.2026, the resident stated he used a CPAP machine at night and was usually able to apply it himself. The CPAP machine and mask were observed at the bedside. During interview on 06.17.2026, the DON stated residents who required CPAP should have a written physician order and parameters for use, and stated the issue occurred because the resident was readmitted and the orders were not entered into the system. The facility policy titled CPAP/BiPAP Support stated the physician’s order should be reviewed to determine oxygen concentration, flow, and PEEP pressure settings for the machine.
Incomplete Smoking Assessments in Resident Records
Penalty
Summary
The facility failed to maintain complete and accurately documented medical records for 2 of 13 residents reviewed, involving safe smoking assessments for two residents who smoked. Resident #28 was an older female admitted with diagnoses including bipolar disorder, type II diabetes mellitus, hypertension, and major depressive disorder. Her record showed she was cognitively intact with a BIMS score of 15, had an active bipolar diagnosis, and was identified in the care plan as a tobacco smoker at risk for injury. A smoking assessment dated 11.28.2025 found her to be a safe smoker with supervision, but no additional smoking assessments were found in the EMR. Resident #30 was an older female admitted with diagnoses including COPD, hypertension, depression, and lack of coordination. Her admission MDS showed a BIMS score of 15, indicating she was cognitively intact, with COPD listed as an active diagnosis and oxygen therapy documented under special treatments. Her EMR contained a safe smoking assessment dated 2.18.2026 stating she required supervision when smoking, but there was no evidence that the quarterly smoking assessment due in May 2026 was completed. During interview, the DON stated smoking assessments should have been completed at admission and quarterly, and that the Activity Director had recently been made responsible for completing them, while she remained responsible for ensuring they were completed.
Failure to Complete and Update MDS Assessments Within Required Timeframes
Penalty
Summary
The facility failed to complete and update the Minimum Data Set (MDS) assessments for multiple residents within the required timeframes. Specifically, seven residents did not have their quarterly or annual MDS assessments completed within 14 calendar days of the Assessment Reference Date (ARD), as mandated by federal regulations. The residents affected had a range of medical diagnoses, including intellectual disabilities, anxiety disorder, high blood pressure, diabetes, heart disease, dementia, and other chronic conditions. The MDS assessments for these residents were completed significantly later than required, with completion dates well beyond the 14-day window after the ARD. Interviews with facility staff revealed that the MDS nurse was responsible for completing and updating the MDS assessments, but there was a lack of clarity and oversight regarding the timely completion of these assessments. The Director of Nursing (DON) acknowledged her ultimate responsibility for ensuring assessments were completed but cited her recent start in the position and the need to catch up as contributing factors. The Administrator attributed the delays to a transition period during a change of ownership, which involved transferring residents to new identification numbers and the MDS Coordinator covering multiple buildings. The MDS Coordinator also indicated that corporate instructions to delay transmission of MDS assessments until the new provider numbers were assigned contributed to the late completion. Facility policy required that MDS assessments be conducted and submitted in accordance with federal and state timeframes, specifically referencing the Resident Assessment Instrument (RAI) Manual. The manual stipulates that quarterly assessments must be completed at least every 92 days, with the MDS completion date no later than 14 days after the ARD. Despite these requirements, the facility did not adhere to the mandated timelines for the affected residents, resulting in a deficiency related to timely resident assessment updates.
Failure to Develop and Implement Comprehensive Care Plans for Hospice and Oxygen Use
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes for two residents. One resident, with diagnoses including COPD, dementia, hypertension, and seizures, was receiving hospice care as indicated by physician orders and MDS documentation, but there was no documented focus, goal, or interventions for hospice care in the resident's care plan. Another resident, diagnosed with secondary malignant neoplasm of bone, hypertension, dementia, and chronic pain, was observed receiving oxygen therapy via nasal cannula, but there was no physician order or care plan documentation for oxygen use, nor was there an oxygen in use sign posted in the room. Interviews with the MDS Coordinator and DON revealed a lack of awareness regarding how these omissions occurred, despite their stated responsibilities for care plan development and review. The facility's policy requires comprehensive care plans to be developed and implemented for each resident, including measurable objectives and timeframes, but this was not followed for the residents in question. Record reviews and direct observations confirmed that the required care planning for hospice services and oxygen use was not completed or documented as required.
Failure to Obtain Physician Orders and Post Oxygen Signage for Residents on Supplemental Oxygen
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents who required continuous supplemental oxygen. For both residents, there was no evidence of a physician's order for the administration of oxygen, despite both being observed on continuous oxygen therapy via nasal cannula. One resident, a female with diagnoses including pneumonia, chronic pulmonary disease, and emphysema, was admitted for therapy and was cognitively intact. She was observed using oxygen at 4LPM, but her records lacked both a physician's order and a comprehensive or baseline care plan. The other resident, a male with diagnoses including secondary malignant neoplasm of bone, hypertension, unspecified dementia, and chronic pain, was also observed on oxygen at 5LPM without a physician's order or care plan documentation for oxygen use. Additionally, the facility failed to post required 'oxygen in use' signage for one of the residents receiving oxygen therapy. Observations confirmed the absence of this signage on two separate occasions. The facility's own policy requires verification of a physician's order and the posting of 'oxygen in use' signs as part of safe oxygen administration. The DON acknowledged that orders and signage should have been in place and was unable to explain how the oversight occurred.
Failure to Administer Blood Pressure Medications per Physician Parameters
Penalty
Summary
The facility failed to ensure that residents' drug regimens were free from significant medication errors, as evidenced by the administration of antihypertensive and vasopressor medications outside of physician-ordered parameters for two residents. For one male resident with severe cognitive impairment and a history of hypertension, respiratory failure, and kidney failure, nursing staff administered Carvedilol and Lisinopril despite blood pressure readings below the physician-ordered threshold for holding these medications. Additionally, the same resident received Midodrine, a medication to increase blood pressure, when his systolic blood pressure was above the hold parameter specified in the physician's order. These errors occurred multiple times throughout the month, with specific blood pressure readings and staff members documented for each incident. For a female resident with severe cognitive impairment, anxiety, dementia, and hypertension, staff failed to administer Clonidine as ordered for systolic blood pressure readings over 160. Despite numerous documented episodes of elevated blood pressure that met the criteria for as-needed Clonidine administration, the medication was not given according to the physician's order. The medication administration record confirmed that Clonidine was omitted during each qualifying episode. Interviews with the DON, Medical Director, and Administrator revealed that the expectation was for nurses to follow physician orders and medication parameters, and to check for standing PRN orders when blood pressure readings were abnormal. The DON and Administrator attributed the failures to nurses not paying attention, while the Medical Director expressed concern about the concurrent use of medications with opposing effects and emphasized the importance of adhering to medication parameters. The facility was unable to provide a policy regarding medication administration or following physician orders.
Failure to Develop Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for one resident. Specifically, a female resident admitted with diagnoses including pneumonia, chronic pulmonary disease, and emphysema, and who was on continuous oxygen, did not have a baseline care plan documented in her facility records. The Admission MDS assessment indicated no cognitive impairment. During an interview, the DON acknowledged that a baseline care plan should have been completed upon the resident's readmission and stated that the admitting nurse was responsible for this task. However, the DON was unable to explain why the care plan was not completed, noting she was new to her position and still acclimating. Facility policy requires a baseline plan of care to be developed within 48 hours of admission.
Failure to Repair Damaged Drywall and Control Rodent Entry
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public by not repairing damaged drywall in hot water closets located outside several halls. Observations revealed that the water heater closets for multiple halls had damaged drywall at the bottom, creating holes that allowed rodent access into the inside walls of the facility. Rodent droppings were observed in five out of six closets, and a mouse was seen in a bird cage and running under a wall. The administrator acknowledged ongoing issues with mice in the facility, including sightings in halls and resident rooms, and attributed the problem in part to the facility's location near fields and an abandoned building. Multiple residents reported seeing mice in the halls and, in one case, in a resident's room, where rodent droppings were also observed. Staff interviews confirmed that residents had reported mouse sightings, and maintenance staff stated they were aware of the rodent problem but were not aware of the damaged drywall as a potential entry point. The pest control vendor confirmed that the facility had a rodent problem for the past three months, had placed traps, and had informed maintenance that the damaged drywall in the water heater rooms was an entryway for rodents, but the damage had not been repaired.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in an environment that was not free of pests and rodents. Review of the grievance log revealed a complaint regarding pest control, and pest control logs indicated that mice were being targeted during monthly visits by the pest control vendor. The administrator acknowledged ongoing issues with mice, attributing the problem to the facility's proximity to fields and an abandoned building. Multiple residents reported sightings of mice and rodent droppings in their rooms and hallways, with one resident specifically noting repeated sightings and droppings in her room, which she reported to the administrator. Staff interviews confirmed that residents had reported mouse sightings, and staff had relayed these reports to maintenance. Observations by the investigator included rodent droppings in a resident's room and in water heater closets, as well as a mouse eating bird feed in a bird cage before escaping into the wall. The maintenance staff, who had only recently started working at the facility, was aware of the rodent problem but was not informed about damaged drywall in water heater closets that could serve as entry points for rodents. The pest control vendor confirmed the ongoing rodent issue and stated that damaged drywall in water heater rooms, which had not been repaired despite recommendations, was making pest control efforts ineffective. Observations revealed that five out of six water heater closets had damaged drywall and rodent droppings, providing access for rodents into the facility.
Failure to Maintain Safe Room Temperatures
Penalty
Summary
The facility failed to maintain a safe and comfortable environment for residents by not preventing the temperature from reaching 86 F in two residents' rooms. Resident #1, a male with a history of cerebral infarction, diabetes, depression, and hypertension, reported that his room felt warm and that he had to use fans to circulate the warm air. Resident #2, a male with congestive heart failure, open wounds, and skin conditions, also reported that his room was hot and that he had informed the staff multiple times about the issue. Observations confirmed the high temperatures in both rooms. Interviews with the facility's maintenance staff and administrator revealed that the air conditioning system on Hall 1 was not functioning properly, and the facility was waiting for parts to repair it. The maintenance staff admitted to not checking room temperatures regularly and stated that they were busy with other repairs. The administrator acknowledged that no complaints had been voiced by the residents and that the facility was waiting for corporate approval for the repairs. The corporate owner mentioned difficulties in obtaining parts due to the rural location and stated that temporary solutions like window units or moving residents to other halls were not implemented. The facility's policy required maintaining temperatures between 71 and 81 F for resident comfort and safety, which was not adhered to in this case.
Failure to Submit Direct Care Staffing Information to CMS
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS for FY Quarter 1 2024 (October 1-December 31). This failure was identified during an interview with the Administrator, who stated that the former accountant responsible for the submission did not complete the task. The Administrator mentioned that the management office verified with IQIES and attempted to pull a report, but it was blank. The facility's nurse consultant is now in the process of submitting the data for the current quarter. Record review of the facility's Civil Rights form dated 03/11/2024 indicated a total of 27 residents and 47 staff, including 5 Registered Nurses, 6 Licensed Vocational Nurses, 12 Direct Care Staff, 6 Dietary Staff, 4 Housekeeping and Laundry staff, and 14 others. The facility's policy on Reporting Direct-Care Staffing Information (Payroll-Based Journal) states that staffing and census information should be reported electronically to CMS through the PBJ system in compliance with the Affordable Care Act. The policy also specifies that staffing information should be collected daily and reported for each fiscal quarter no later than 45 days after the end of the reporting quarter. However, the facility failed to adhere to this policy for FY Quarter 1 2024.
Failure to Develop Measurable Care Plan Objectives
Penalty
Summary
The facility failed to develop and implement person-centered, comprehensive care plans for five residents, which included measurable objectives and timeframes to meet their medical, nursing, mental, and psychosocial needs. The care plans for these residents contained objectives that were not measurable, making it difficult to evaluate or quantify the effectiveness of the care provided. This deficiency was identified through interviews and record reviews of the residents' care plans and medical histories. Resident #1, a female with severe cognitive impairment and multiple medical diagnoses, had care plan objectives that were vague and not measurable. For example, objectives such as 'The resident will maintain current level of cognitive function' and 'The resident will demonstrate effective coping skills' did not provide specific, measurable criteria. Similar issues were found in the care plans of Resident #4, Resident #8, Resident #14, and Resident #24, who also had various medical conditions and cognitive impairments. Their care plans included objectives like 'Resident will continue to attend activities daily' and 'Resident's nutritional status will remain stable,' which lacked measurable outcomes. During interviews, the DON and an LVN acknowledged the deficiencies in the care plans. The DON, who started working at the facility in November 2023, admitted that the objectives needed to be measurable to determine the effectiveness of the interventions. The LVN stated that she did not look at the care plans and was unaware of their contents. The facility's policy on care plans emphasized the need for measurable objectives and timetables, but this was not reflected in the care plans reviewed. The DON attributed the oversight to recent turnover in nursing leadership and acknowledged that the care plans needed to be individualized and updated to reflect the residents' current needs.
Failure to Update Comprehensive Care Plans
Penalty
Summary
The facility failed to review and revise resident-centered comprehensive care plans within 7 days of a comprehensive assessment for four residents. Specifically, the care plans for Resident #1, Resident #4, Resident #8, and Resident #14 were not updated within the required timeframe. This failure was identified through observation, interviews, and record reviews, which revealed discrepancies between the dates of comprehensive assessments and the subsequent care plan reviews. For instance, Resident #1's care plan was last reviewed several months before the comprehensive assessment date, and similar issues were found for the other residents mentioned. Additionally, the facility did not update Resident #8's care plan to reflect a change in condition regarding the discontinuation of bed and chair alarms. Despite the comprehensive assessment indicating that these alarms were no longer necessary, the care plan still listed them as required interventions. Observations confirmed that no alarms were in place, and interviews with the DON revealed that the oversight was due to care plans not being revised as needed. Interviews with the DON and the MDS coordinator highlighted that both were relatively new to their positions and acknowledged the oversight in updating the care plans. The facility's policy mandates that comprehensive care plans be developed within seven days of the assessment and revised as residents' conditions change. However, the DON mistakenly believed the timeframe for updating care plans was 14 days, contributing to the delay in revisions. The facility's failure to adhere to its policies and federal regulations could potentially compromise the care and services provided to the residents.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 25 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Stamford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At Haskell | 15.6 mi | ★★★★★ | 0 | 0 |
| Homeplace Manor Healthcare Center | 20.4 mi | ★★★★★ | 25 | 0 |
| Stonewall Living Center | 29.8 mi | ★★★★★ | 2 | 0 |
| Northern Oaks Living & Rehabilitation Center | 31.3 mi | ★★★★★ | 18 | 0 |
| Silver Spring | 31.9 mi | ★★★★★ | 8 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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