14 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Guilford, CT
4-star overall rating with 3-star inspections with $8,824 in total fines with 14 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
109 West Lake Avenue, Guilford, CT
(203) 488-9142
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Beds
75
Certified beds
Average residents
71
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1974-12-18
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
0.75
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.89
Licensed practical nurse staffing · state 0.84 · national 0.87
Aide hours / resident day
2.71
Nurse aide staffing · state 2.28 · national 2.35
Total nurse hours
4.35
All reported nurse hours · state 3.83 · national 3.89
Licensed hours
1.64
RN + LPN hours · state 1.54 · national 1.54
Weekend hours
4.01
Weekend nurse staffing · state 3.41 · national 3.43
Weekend RN hours
0.58
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
0.77
CMS adjusted RN staffing hours
Adjusted total hours
4.50
CMS adjusted total nurse staffing hours
Case-mix index
1.32
Higher values indicate more complex resident acuity
RN turnover
9%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
44%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Program rank
11,395
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
16.90
Composite VBP score used to determine payment impact.
Payment multiplier
0.9817
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
0
Baseline 21.71% · Performance 24.07% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 7.12% · Performance 8.12% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
3.21
Baseline 51.22% · Performance 50.56% · Measure score 3.21 · Achievement 3.21 · Improvement 0
Adjusted total nurse staffing
3.55
Baseline 4.26 hours · Performance 4.09 hours · Measure score 3.55 · Achievement 3.55 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.88% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 279 · Observed rate 8.6% · Lower 95% interval 7.26% |
| Discharge to community | 68.99% |
50.57%
18.4 pts better
|
Better than the National Rate · Eligible stays 275 · Observed rate 64.36% · Lower 95% interval 63.06% |
| Medicare spending per beneficiary | 0.86 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 96.32% |
95.27%
1 pts better
|
Numerator 157 · Denominator 163 |
| Falls with major injury | 1.23% |
0.77%
0.5 pts worse
|
Numerator 2 · Denominator 163 |
| Discharge self-care score | 42.16% |
53.69%
11.5 pts worse
|
Numerator 43 · Denominator 102 |
| Discharge mobility score | 50% |
50.94%
0.9 pts worse
|
Numerator 51 · Denominator 102 |
| Pressure ulcers or injuries, new or worsened | 3.07% |
2.29%
0.8 pts worse
|
Numerator 5 · Denominator 163 · Adjusted rate 2.85% |
| Healthcare-associated infections requiring hospitalization | 8.12% |
7.12%
1 pts worse
|
No Different than the National Rate · Eligible stays 168 · Observed rate 8.93% · Lower 95% interval 5.37% |
| Staff COVID-19 vaccination coverage | 1.45% |
8.2%
6.7 pts worse
|
Numerator 2 · Denominator 138 |
| Staff flu vaccination coverage | 5.07% |
42%
36.9 pts worse
|
Numerator 7 · Denominator 138 |
| Discharge function score | 49.02% |
56.45%
7.4 pts worse
|
Numerator 50 · Denominator 102 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 78 · Denominator 78 |
| Transfer of health information to patient | 98.18% |
96.28%
1.9 pts better
|
Numerator 54 · Denominator 55 |
| Resident COVID-19 vaccinations up to date | 34.94% |
25.2%
9.7 pts better
|
Numerator 29 · Denominator 83 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.7 |
2.1
0.6 pts worse
|
1.9
0.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 3.1 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.6 |
1.5
0.9 pts better
|
1.8
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.6 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 78.1% |
87.5%
9.4 pts worse
|
93.4%
15.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 79.2% · Q2 73.6% · Q3 80.7% · Q4 78.7% · 4Q avg 78.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.3% |
93.5%
4.8 pts better
|
95.5%
2.8 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.2% |
3.4%
0.2 pts better
|
3.3%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 3.8% · Q3 3.5% · Q4 1.6% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 13.5% |
17.1%
3.6 pts better
|
11.4%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 2.0% · Q3 14.0% · Q4 30.9% · 4Q avg 13.5% |
| Percentage of long-stay residents who lose too much weight | 5.6% |
6.4%
0.8 pts better
|
5.4%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 6.4% · Q3 5.7% · Q4 3.8% · 4Q avg 5.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.8% |
17.3%
5.5 pts better
|
19.6%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.6% · Q2 12.2% · Q3 9.3% · Q4 12.3% · 4Q avg 11.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.2% |
19.4%
6.2 pts better
|
16.7%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 10.5% · Q3 13.3% · Q4 18.8% · 4Q avg 13.2% · 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 | 24.2% |
18.1%
6.1 pts worse
|
16.3%
7.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 34.7% · Q4 28.1% · 4Q avg 24.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 25.4% |
18.4%
7 pts worse
|
14.9%
10.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.5% · Q2 10.9% · Q3 42.3% · Q4 27.3% · 4Q avg 25.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 4.9% |
0.9%
4 pts worse
|
1.0%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 3.0% · Q3 6.4% · Q4 5.5% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.9% |
1.7%
0.8 pts better
|
1.7%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.8% · Q4 1.8% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 35.5% |
24.8%
10.7 pts worse
|
19.8%
15.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 47.6% · Q2 43.6% · Q3 24.0% · Q4 29.1% · 4Q avg 35.5% |
| Percentage of long-stay residents with pressure ulcers | 4.4% |
4.4%
About the same
|
5.1%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 2.1% · Q3 5.1% · Q4 7.9% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 83.3% |
70.5%
12.8 pts better
|
81.7%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 73.1% · Q2 88.1% · Q3 83.3% · Q4 92.1% · 4Q avg 83.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.9% |
11.1%
0.8 pts worse
|
12.0%
0.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.9% · Observed 11.8% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.9% |
1.5%
0.4 pts worse
|
1.6%
0.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 3.8% · Q3 1.5% · Q4 0.0% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 70.2% |
69.7%
0.5 pts better
|
79.7%
9.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 70.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.9% |
25.0%
0.1 pts better
|
23.9%
1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.9% · Observed 26.1% · Expected 24.9% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (3 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Resident Rights (5 deficiencies)
9 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Top issue: Administration (2 deficiencies)
4 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Fire safety
Fire Safety
Establish emergency prep training and testing.
Corrected 2023-11-30
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2023-11-30
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 2023-11-30
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-11-30
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-11-30
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2023-11-30
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-11-30
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-11-30
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2023-11-30
Fire Safety
Establish emergency prep training and testing.
Corrected 2021-11-19
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2021-11-19
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-11-19
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2021-11-19
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 2021-11-19
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2021-11-19
Fire Safety
Provide properly protected cooking facilities.
Corrected 2021-11-19
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-11-19
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2021-11-19
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2019-06-28
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2019-06-18
Fire Safety
Provide properly protected cooking facilities.
Corrected 2019-06-20
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-06-10
Inspection history
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-11-21
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2025-11-21
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-12-06
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-02-28
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-12-11
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-12-11
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-12-11
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-12-11
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 2023-12-11
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2023-12-11
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-12-11
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-11
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-12-11
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2023-12-11
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-12-11
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2023-12-11
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2023-07-31
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-07-31
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2021-11-17
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2021-11-17
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2021-11-17
Health
Give residents a notice of rights, rules, services and charges.
Corrected 2021-11-17
Health
The resident has the right to receive notices in a format and a language he or she understands.
Corrected 2021-11-17
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2021-11-17
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2021-11-17
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2019-06-07
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 2019-06-26
Health
Provide and implement an infection prevention and control program.
Corrected 2019-06-07
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2019-06-07
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2019-06-26
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2019-06-12
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2019-06-12
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2019-06-07
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2019-06-07
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2019-06-12
Penalties and ownership
Fine · fine $8,824
Fine
5% Or Greater Direct Ownership Interest · Individual
W-2 Managing Employee · Individual
Corporate Director · Individual
W-2 Managing Employee · Individual
Nearby options
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Guilford, CT
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Madison, CT
3-star overall rating with 2-star inspections with $15,593 in total fines with 12 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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