Cycle 1
Health 2023-09-25 · Fire 2023-09-25
11 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Middlebury, CT
Complete Care At Middlebury
4-star overall rating with 3-star inspections with 11 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
778 Middlebury Rd, Middlebury, CT
(203) 758-2471
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
58
Certified beds
Average residents
54
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Complete Care
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
85 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
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
Hours and turnover
RN hours / resident day
0.76
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.83
Licensed practical nurse staffing · state 0.84 · national 0.87
Aide hours / resident day
2.33
Nurse aide staffing · state 2.28 · national 2.35
Total nurse hours
3.92
All reported nurse hours · state 3.83 · national 3.89
Licensed hours
1.59
RN + LPN hours · state 1.54 · national 1.54
Weekend hours
3.51
Weekend nurse staffing · state 3.41 · national 3.43
Weekend RN hours
0.48
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.14
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.69
CMS adjusted RN staffing hours
Adjusted total hours
3.55
CMS adjusted total nurse staffing hours
Case-mix index
1.51
Higher values indicate more complex resident acuity
RN turnover
55%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
49%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,441
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
23.64
Composite VBP score used to determine payment impact.
Payment multiplier
0.9832
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.35
Performance 20.81% · Measure score 1.35 · Achievement 1.35 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
3.62
Baseline 6.52% · Performance 6.75% · Measure score 3.62 · Achievement 3.62 · Improvement 0
Total nurse turnover
1.65
Baseline 38.60% · Performance 56.94% · Measure score 1.65 · Achievement 1.65 · Improvement 0
Adjusted total nurse staffing
2.84
Baseline 4.49 hours · Performance 3.89 hours · Measure score 2.84 · Achievement 2.84 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.94% |
10.72%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 74 · Observed rate 9.46% · Lower 95% interval 7.63% |
| Discharge to community | 58.69% |
50.57%
8.1 pts better
|
Better than the National Rate · Eligible stays 73 · Observed rate 57.53% · Lower 95% interval 51.29% |
| Medicare spending per beneficiary | 0.96 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 98.77% |
95.27%
3.5 pts better
|
Numerator 80 · Denominator 81 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 81 |
| Discharge self-care score | 75.93% |
53.69%
22.2 pts better
|
Numerator 41 · Denominator 54 |
| Discharge mobility score | 77.78% |
50.94%
26.8 pts better
|
Numerator 42 · Denominator 54 |
| Pressure ulcers or injuries, new or worsened | 2.47% |
2.29%
0.2 pts worse
|
Numerator 2 · Denominator 81 · Adjusted rate 2.36% |
| Healthcare-associated infections requiring hospitalization | 6.75% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 52 · Observed rate 5.77% · Lower 95% interval 3.69% |
| Staff COVID-19 vaccination coverage | 44.44% |
8.2%
36.2 pts better
|
Numerator 48 · Denominator 108 |
| Staff flu vaccination coverage | 28.07% |
42%
13.9 pts worse
|
Numerator 32 · Denominator 114 |
| Discharge function score | 70.37% |
56.45%
13.9 pts better
|
Numerator 38 · Denominator 54 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 52 · Denominator 52 |
| Resident COVID-19 vaccinations up to date | 11.11% |
25.2%
14.1 pts worse
|
Numerator 6 · Denominator 54 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
2.1
0.4 pts better
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 0.9 · Expected 1.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
1.5
0.7 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.5 · Expected 1.0 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.1% |
87.5%
10.6 pts better
|
93.4%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.8% · Q2 97.6% · Q3 100.0% · Q4 97.3% · 4Q avg 98.1% |
| 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 | 3.7% |
3.4%
0.3 pts worse
|
3.3%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 2.4% · Q3 5.3% · Q4 5.4% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 77.4% |
17.1%
60.3 pts worse
|
11.4%
66 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 70.0% · Q2 86.5% · Q3 74.3% · Q4 79.4% · 4Q avg 77.4% |
| Percentage of long-stay residents who lose too much weight | 2.9% |
6.4%
3.5 pts better
|
5.4%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 2.8% · Q3 3.0% · Q4 0.0% · 4Q avg 2.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.6% |
17.3%
4.7 pts better
|
19.6%
7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 19.4% · Q3 11.4% · Q4 9.4% · 4Q avg 12.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.7% |
19.4%
7.7 pts better
|
16.7%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 11.8% · Q3 12.9% · Q4 14.3% · 4Q avg 11.7% · 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 | 23.0% |
18.1%
4.9 pts worse
|
16.3%
6.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.2% · Q2 22.1% · 4Q avg 23.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 27.1% |
18.4%
8.7 pts worse
|
14.9%
12.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.5% · Q2 32.4% · Q3 24.2% · Q4 41.4% · 4Q avg 27.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
0.9%
0.5 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.9% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.3% |
1.7%
0.4 pts better
|
1.7%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.8% · Q4 2.8% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.0% |
24.8%
0.8 pts better
|
19.8%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.9% · Q2 29.3% · Q3 24.0% · Q4 23.4% · 4Q avg 24.0% |
| Percentage of long-stay residents with pressure ulcers | 4.7% |
4.4%
0.3 pts worse
|
5.1%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 4.5% · Q3 6.9% · Q4 2.2% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 69.0% |
70.5%
1.5 pts worse
|
81.7%
12.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 71.7% · Q2 72.3% · Q3 77.7% · Q4 56.0% · 4Q avg 69.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.2% |
11.1%
1.9 pts better
|
12.0%
2.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.2% · Observed 9.1% · Expected 11.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.5% |
1.5%
About the same
|
1.6%
0.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.2% · Q3 1.2% · Q4 2.2% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 75.2% |
69.7%
5.5 pts better
|
79.7%
4.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 75.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 15.5% |
25.0%
9.5 pts better
|
23.9%
8.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 15.5% · Observed 15.9% · Expected 24.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-09-15 · Fire 2021-09-15
3 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2019-05-09 · Fire 2019-05-09
3 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2023-09-25
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-11-02
Inspection history
Recent health citations
G · Actual harm
2025-09-19
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Not marked corrected
F · Potential for more than minimal harm
2023-09-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-27
E · Potential for more than minimal harm
2023-09-25
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-11-27
D · Potential for more than minimal harm
2023-09-25
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-11-27
D · Potential for more than minimal harm
2023-09-25
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2023-11-27
D · Potential for more than minimal harm
2023-09-25
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-11-27
D · Potential for more than minimal harm
2023-09-25
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-11-27
D · Potential for more than minimal harm
2023-09-25
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-11-27
D · Potential for more than minimal harm
2023-09-25
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-11-27
B · Minimal harm
2023-09-25
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2023-11-27
B · Minimal harm
2023-09-25
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2023-11-27
D · Potential for more than minimal harm
2021-09-15
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2021-11-23
D · Potential for more than minimal harm
2021-09-15
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-11-23
D · Potential for more than minimal harm
2021-09-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-11-23
G · Actual harm
2019-05-09
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2019-06-20
D · Potential for more than minimal harm
2019-05-09
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2019-06-20
D · Potential for more than minimal harm
2019-05-09
F825 · Quality of Life and Care Deficiencies
Health
Provide or get specialized rehabilitative services as required for a resident.
Corrected 2019-06-20
Penalties and ownership
What sits behind the stars
Ownership
Pc Middlebury Opco LLC
5% Or Greater Direct Ownership Interest · Organization
Adetola, Adedayo
Operational/Managerial Control · Individual
Hoch, Robert
Operational/Managerial Control · Individual
Knights, Peter
Operational/Managerial Control · Individual
Lagana, Kristin
Operational/Managerial Control · Individual
Pc Middlebury Topco LLC
5% Or Greater Indirect Ownership Interest · Organization
Peace Capital Holdings Ii LLC
5% Or Greater Indirect Ownership Interest · Organization
Sms 2021 Trust
5% Or Greater Indirect Ownership Interest · Organization
Stein, Shalom
Corporate Officer · Individual
Tetreault, Marnie
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Apple Rehab Watertown
Watertown, CT
2-star overall rating with 2-star inspections with $25,058 in total fines with 13 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#2
Waterbury Center For Nursing & Rehabilitation Llc
Waterbury, CT
4-star overall rating with 4-star inspections with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Lutheran Home Of Southbury Inc
Southbury, CT
3-star overall rating with 3-star inspections with 13 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
Jump out