15 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
19 fire-safety deficiencies
Top issue: Egress (5 deficiencies)
Windsor, CT
1-star overall rating with 2-star inspections with $29,202 in total fines with 15 recent health deficiencies with 19 fire-safety deficiencies in the latest cycle
581 Poquonock Ave, Windsor, CT
(860) 688-7211
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Beds
108
Certified beds
Average residents
92
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1971-09-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
RN hours / resident day
0.41
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.72
Licensed practical nurse staffing · state 0.84 · national 0.87
Aide hours / resident day
1.88
Nurse aide staffing · state 2.28 · national 2.35
Total nurse hours
3.01
All reported nurse hours · state 3.83 · national 3.89
Licensed hours
1.12
RN + LPN hours · state 1.54 · national 1.54
Weekend hours
2.87
Weekend nurse staffing · state 3.41 · national 3.43
Weekend RN hours
0.31
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.47
CMS adjusted RN staffing hours
Adjusted total hours
3.43
CMS adjusted total nurse staffing hours
Case-mix index
1.20
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
48%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Program rank
4,801
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
38.52
Composite VBP score used to determine payment impact.
Payment multiplier
0.9916
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
4.30
Baseline 19.56% · Performance 19.44% · Measure score 4.30 · Achievement 4.30 · Improvement 0
Healthcare-associated infections
4.80
Baseline 6.25% · Performance 6.40% · Measure score 4.80 · Achievement 4.80 · Improvement 0
Total nurse turnover
3.21
Performance 50.56% · Measure score 3.21 · Achievement 3.21 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
3.09
Baseline 3.40 hours · Performance 3.96 hours · Measure score 3.09 · Achievement 3.09 · Improvement 1.84
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.99% |
10.72%
1.7 pts better
|
No Different than the National Rate · Eligible stays 62 · Observed rate 3.23% · Lower 95% interval 5.94% |
| Discharge to community | 46.75% |
50.57%
3.8 pts worse
|
No Different than the National Rate · Eligible stays 56 · Observed rate 35.71% · Lower 95% interval 34.51% |
| Medicare spending per beneficiary | 0.98 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 85.71% |
95.27%
9.6 pts worse
|
Numerator 30 · Denominator 35 |
| Falls with major injury | 2.86% |
0.77%
2.1 pts worse
|
Numerator 1 · Denominator 35 |
| Discharge self-care score | 35% |
53.69%
18.7 pts worse
|
Numerator 7 · Denominator 20 |
| Discharge mobility score | 25% |
50.94%
25.9 pts worse
|
Numerator 5 · Denominator 20 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 35 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.4% |
7.12%
0.7 pts better
|
No Different than the National Rate · Eligible stays 35 · Observed rate 2.86% · Lower 95% interval 3.4% |
| Staff COVID-19 vaccination coverage | 6.03% |
8.2%
2.2 pts worse
|
Numerator 7 · Denominator 116 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 25% |
56.45%
31.5 pts worse
|
Numerator 5 · Denominator 20 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
2.1
0.1 pts worse
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.2 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
1.5
0.6 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.9 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.9% |
87.5%
10.4 pts better
|
93.4%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.9% · Q2 100.0% · Q3 100.0% · Q4 92.4% · 4Q avg 97.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
93.5%
6.5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.9% |
3.4%
2.5 pts better
|
3.3%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 1.2% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.3% |
17.1%
16.8 pts better
|
11.4%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% |
| Percentage of long-stay residents who lose too much weight | 7.9% |
6.4%
1.5 pts worse
|
5.4%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 11.4% · Q3 4.2% · Q4 7.2% · 4Q avg 7.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.3% |
17.3%
7 pts better
|
19.6%
9.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 10.4% · Q3 12.2% · Q4 9.3% · 4Q avg 10.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.6% |
19.4%
9.8 pts better
|
16.7%
7.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 12.8% · Q3 9.5% · Q4 9.8% · 4Q avg 9.6% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 11.2% |
18.1%
6.9 pts better
|
16.3%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.3% · Q2 11.0% · Q3 4.2% · Q4 23.2% · 4Q avg 11.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.6% |
18.4%
1.8 pts better
|
14.9%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.2% · Q2 16.0% · Q3 15.3% · Q4 24.3% · 4Q avg 16.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.9%
0.9 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.7%
1.7 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.4% |
24.8%
6.4 pts better
|
19.8%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.3% · Q2 28.3% · Q3 14.4% · Q4 15.7% · 4Q avg 18.4% |
| Percentage of long-stay residents with pressure ulcers | 4.1% |
4.4%
0.3 pts better
|
5.1%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 5.7% · Q3 4.0% · Q4 2.1% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.8% |
70.5%
27.3 pts better
|
81.7%
16.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.3% · Q2 100.0% · Q3 100.0% · Q4 92.6% · 4Q avg 97.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.7% |
11.1%
3.6 pts worse
|
12.0%
2.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.7% · Observed 14.7% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 5.4% |
1.5%
3.9 pts worse
|
1.6%
3.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 4.2% · Q3 6.4% · Q4 8.3% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.8% |
69.7%
26.1 pts better
|
79.7%
16.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.5% |
25.0%
2.5 pts worse
|
23.9%
3.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.5% · Observed 26.5% · Expected 23.0% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (5 deficiencies)
19 fire-safety deficiencies
Top issue: Egress (5 deficiencies)
Top issue: Quality of Life and Care (2 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Top issue: Quality of Life and Care (4 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Fire safety
Fire Safety
Establish emergency prep training and testing.
Corrected 2024-02-27
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-02-27
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-02-27
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-02-27
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-02-27
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-02-28
Fire Safety
Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors.
Corrected 2024-02-27
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-02-27
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-02-27
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-14
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-02-27
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-02-27
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-02-27
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2024-03-07
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-02-27
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-02-27
Fire Safety
Meet other general requirements that are deficient.
Corrected 2024-02-27
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-02-27
Fire Safety
Ensure proper storage of liquid oxygen.
Corrected 2024-02-27
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2022-01-28
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2022-01-28
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-01-28
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-01-28
Fire Safety
Meet other general requirements that are deficient.
Corrected 2022-01-28
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-01-28
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2019-08-22
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2019-08-22
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2019-08-22
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2019-08-22
Inspection history
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-06-02
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-03-15
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-03-15
Health
Hire a qualified full-time social worker in a facility with more than 120 beds.
Corrected 2024-03-15
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-07
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-03-15
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2024-05-07
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-03-15
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-03-15
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-05-07
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-03-15
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2024-03-15
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2024-03-15
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-03-15
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-03-15
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-04-08
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2022-02-17
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-02-17
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-02-17
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-02-17
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-02-17
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2019-08-20
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2019-08-20
Health
Dispose of garbage and refuse properly.
Corrected 2019-08-20
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2019-08-20
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2019-08-20
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2019-08-20
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2019-08-20
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2019-08-20
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2019-08-20
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2019-08-20
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2019-08-20
Penalties and ownership
Fine · fine $19,432
Fine
Fine · fine $9,770
Fine
5% Or Greater Direct Ownership Interest · Individual
W-2 Managing Employee · Individual
5% Or Greater Direct Ownership Interest · Organization
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