Cycle 1
Health 2024-04-23 · Fire 2024-04-23
10 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cromwell, CT
Pilgrim Manor
4-star overall rating with 4-star inspections with $12,048 in total fines with 10 recent health deficiencies
52 Missionary Rd, Cromwell, CT
(860) 635-5511
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
54
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Covenant Living
Operator or chain grouping
Approved since
1987-02-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
15 facilities
Chain averages 4 overall / 4 health / 4 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.82
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.69
Licensed practical nurse staffing · state 0.84 · national 0.87
Aide hours / resident day
2.45
Nurse aide staffing · state 2.28 · national 2.35
Total nurse hours
3.96
All reported nurse hours · state 3.83 · national 3.89
Licensed hours
1.51
RN + LPN hours · state 1.54 · national 1.54
Weekend hours
3.59
Weekend nurse staffing · state 3.41 · national 3.43
Weekend RN hours
0.61
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.87
CMS adjusted RN staffing hours
Adjusted total hours
4.22
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
46%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
42%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,225
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
45.38
Composite VBP score used to determine payment impact.
Payment multiplier
0.9986
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.54
Baseline 17.96% · Performance 20.72% · Measure score 1.54 · Achievement 1.54 · Improvement 0
Healthcare-associated infections
4.42
Baseline 5.90% · Performance 6.51% · Measure score 4.42 · Achievement 4.42 · Improvement 0
Total nurse turnover
7.72
Baseline 14.00% · Performance 32.14% · Measure score 7.72 · Achievement 7.72 · Improvement 0
Adjusted total nurse staffing
4.48
Baseline 4.01 hours · Performance 4.35 hours · Measure score 4.48 · Achievement 4.48 · Improvement 1.45
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.19% |
10.72%
1.5 pts worse
|
No Different than the National Rate · Eligible stays 125 · Observed rate 12% · Lower 95% interval 8.01% |
| Discharge to community | 58.39% |
50.57%
7.8 pts better
|
No Different than the National Rate · Eligible stays 119 · Observed rate 57.98% · Lower 95% interval 49.11% |
| Medicare spending per beneficiary | 0.93 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 98.18% |
95.27%
2.9 pts better
|
Numerator 54 · Denominator 55 |
| Falls with major injury | 1.82% |
0.77%
1.1 pts worse
|
Numerator 1 · Denominator 55 |
| Discharge self-care score | 54.9% |
53.69%
1.2 pts better
|
Numerator 28 · Denominator 51 |
| Discharge mobility score | 50.98% |
50.94%
About the same
|
Numerator 26 · Denominator 51 |
| Pressure ulcers or injuries, new or worsened | 3.64% |
2.29%
1.4 pts worse
|
Numerator 2 · Denominator 55 · Adjusted rate 5.41% |
| Healthcare-associated infections requiring hospitalization | 6.51% |
7.12%
0.6 pts better
|
No Different than the National Rate · Eligible stays 76 · Observed rate 3.95% · Lower 95% interval 3.78% |
| Staff COVID-19 vaccination coverage | 2.59% |
8.2%
5.6 pts worse
|
Numerator 3 · Denominator 116 |
| Staff flu vaccination coverage | 45.32% |
42%
3.3 pts better
|
Numerator 63 · Denominator 139 |
| Discharge function score | 66.67% |
56.45%
10.2 pts better
|
Numerator 34 · Denominator 51 |
| 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 | 93.55% |
96.28%
2.7 pts worse
|
Numerator 29 · Denominator 31 |
| Resident COVID-19 vaccinations up to date | 76.92% |
25.2%
51.7 pts better
|
Numerator 20 · Denominator 26 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
2.1
1 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 0.9 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.1 |
1.5
1.4 pts better
|
1.8
1.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.1 · Observed 0.1 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.9% |
87.5%
11.4 pts better
|
93.4%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 95.7% · Q3 100.0% · Q4 100.0% · 4Q avg 98.9% |
| 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 | 2.7% |
3.4%
0.7 pts better
|
3.3%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 4.3% · Q3 2.0% · Q4 2.1% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.6% |
17.1%
16.5 pts better
|
11.4%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.3% · 4Q avg 0.6% |
| Percentage of long-stay residents who lose too much weight | 10.2% |
6.4%
3.8 pts worse
|
5.4%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 14.0% · Q3 13.3% · Q4 7.5% · 4Q avg 10.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.3% |
17.3%
About the same
|
19.6%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.4% · Q2 13.6% · Q3 18.8% · Q4 21.4% · 4Q avg 17.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.0% |
19.4%
13.4 pts better
|
16.7%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 10.3% · Q3 2.6% · Q4 5.6% · 4Q avg 6.0% · 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 | 36.2% |
18.1%
18.1 pts worse
|
16.3%
19.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 36.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 35.8% |
18.4%
17.4 pts worse
|
14.9%
20.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 48.6% · Q2 39.0% · Q3 38.1% · Q4 17.9% · 4Q avg 35.8% · 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 | 2.8% |
1.7%
1.1 pts worse
|
1.7%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 4.3% · Q3 2.1% · Q4 2.2% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.7% |
24.8%
0.9 pts worse
|
19.8%
5.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.5% · Q2 19.1% · Q3 34.1% · Q4 20.1% · 4Q avg 25.7% |
| Percentage of long-stay residents with pressure ulcers | 4.6% |
4.4%
0.2 pts worse
|
5.1%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 5.9% · Q3 6.2% · Q4 1.6% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.0% |
70.5%
28.5 pts better
|
81.7%
17.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.9% · Q2 98.7% · Q3 100.0% · Q4 100.0% · 4Q avg 99.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.6% |
11.1%
2.5 pts better
|
12.0%
3.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.6% · Observed 7.8% · Expected 10.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.1% |
69.7%
25.4 pts better
|
79.7%
15.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.1% |
25.0%
0.1 pts worse
|
23.9%
1.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.1% · Observed 23.4% · Expected 22.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2020-01-31 · Fire 2020-01-31
5 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2019-03-07 · Fire 2019-03-07
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-05-01
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 2025-05-22
D · Potential for more than minimal harm
2025-05-01
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-05-22
D · Potential for more than minimal harm
2025-05-01
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-05-22
D · Potential for more than minimal harm
2025-05-01
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-05-22
D · Potential for more than minimal harm
2024-05-24
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-06-14
G · Actual harm
2024-04-23
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 2024-05-16
D · Potential for more than minimal harm
2024-04-23
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-05-16
D · Potential for more than minimal harm
2024-04-23
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-05-16
D · Potential for more than minimal harm
2024-04-23
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-05-16
D · Potential for more than minimal harm
2024-04-23
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-05-16
D · Potential for more than minimal harm
2024-04-23
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-05-16
D · Potential for more than minimal harm
2023-05-22
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-06-07
D · Potential for more than minimal harm
2020-01-31
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2020-02-28
D · Potential for more than minimal harm
2020-01-31
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2020-02-28
D · Potential for more than minimal harm
2020-01-31
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2020-02-28
B · Minimal harm
2020-01-31
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2020-02-28
E · Potential for more than minimal harm
2019-03-07
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2019-03-27
Penalties and ownership
What sits behind the stars
$12,048
2024-04-23
Fine
Fine · fine $12,048
Fine
Ownership
Covenant Living Communities & Services
5% Or Greater Direct Ownership Interest · Organization
Aagaard, Jon
Corporate Director · Individual
Christensen, Pamela
Corporate Director · Individual
Covenant Living Communities & Services
Operational/Managerial Control · Organization
Cunliffe, Terri
Corporate Officer · Individual
Cunliffe, Terri
W-2 Managing Employee · Individual
Eastburg, Mark
Corporate Director · Individual
Erickson, David
Corporate Officer · Individual
Espinosa, Marc
Corporate Director · Individual
Hodgkinson, Donald
Corporate Director · Individual
Holt, Jody
Operational/Managerial Control · Individual
Holt, Jody
Corporate Officer · Individual
Holt, Jody
W-2 Managing Employee · Individual
Manlove, Matt
Corporate Director · Individual
Oxendale, Roger
Corporate Director · Individual
Stante, Marlene
Corporate Director · Individual
Vining, Anne
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Autumn Lake Healthcare At Cromwell
Cromwell, CT
4-star overall rating with 3-star inspections with 12 recent health deficiencies with 16 fire-safety deficiencies in the latest cycle
#2
Portland Care & Rehab Centre, INC
Portland, CT
5-star overall rating with 4-star inspections with $10,033 in total fines with 5 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#3
Apple Rehab Cromwell
Cromwell, CT
2-star overall rating with 2-star inspections with $27,991 in total fines with 16 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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