Cycle 1
Health 2024-12-10 · Fire 2024-12-10
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Windham, CT
Saint Josephs Living Center, Inc.
4-star overall rating with 4-star inspections with 9 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
14 Club Rd, Windham, CT
(860) 456-1107
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
113
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1988-10-12
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
Hours and turnover
RN hours / resident day
0.58
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.67
Licensed practical nurse staffing · state 0.84 · national 0.87
Aide hours / resident day
2.44
Nurse aide staffing · state 2.28 · national 2.35
Total nurse hours
3.68
All reported nurse hours · state 3.83 · national 3.89
Licensed hours
1.24
RN + LPN hours · state 1.54 · national 1.54
Weekend hours
3.41
Weekend nurse staffing · state 3.41 · national 3.43
Weekend RN hours
0.37
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.59
CMS adjusted RN staffing hours
Adjusted total hours
3.79
CMS adjusted total nurse staffing hours
Case-mix index
1.33
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
53%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,728
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
19.34
Composite VBP score used to determine payment impact.
Payment multiplier
0.9821
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.72
Baseline 18.87% · Performance 20.63% · Measure score 1.72 · Achievement 1.72 · Improvement 0
Healthcare-associated infections
0
Baseline 5.49% · Performance 8.11% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
4.08
Baseline 4.21 hours · Performance 4.24 hours · Measure score 4.08 · Achievement 4.08 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.35% |
10.72%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 77 · Observed rate 12.99% · Lower 95% interval 7.71% |
| Discharge to community | 61.77% |
50.57%
11.2 pts better
|
No Different than the National Rate · Eligible stays 67 · Observed rate 59.7% · Lower 95% interval 47.27% |
| Medicare spending per beneficiary | 0.77 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 49 · Denominator 49 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 49 |
| Discharge self-care score | 62.16% |
53.69%
8.5 pts better
|
Numerator 23 · Denominator 37 |
| Discharge mobility score | 45.95% |
50.94%
5 pts worse
|
Numerator 17 · Denominator 37 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 49 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 8.11% |
7.12%
1 pts worse
|
No Different than the National Rate · Eligible stays 49 · Observed rate 10.2% · Lower 95% interval 4.2% |
| Staff COVID-19 vaccination coverage | 1.75% |
8.2%
6.4 pts worse
|
Numerator 4 · Denominator 229 |
| Staff flu vaccination coverage | 44.91% |
42%
2.9 pts better
|
Numerator 128 · Denominator 285 |
| Discharge function score | 51.35% |
56.45%
5.1 pts worse
|
Numerator 19 · Denominator 37 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 24 · Denominator 24 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 46.67% |
25.2%
21.5 pts better
|
Numerator 14 · Denominator 30 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.5 |
2.1
0.4 pts worse
|
1.9
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.2 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
1.5
0.1 pts worse
|
1.8
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.5 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 84.0% |
87.5%
3.5 pts worse
|
93.4%
9.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 71.7% · Q2 82.4% · Q3 91.4% · Q4 89.8% · 4Q avg 84.0% |
| 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 | 4.5% |
3.4%
1.1 pts worse
|
3.3%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 5.5% · Q3 4.3% · Q4 2.0% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 26.0% |
17.1%
8.9 pts worse
|
11.4%
14.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.2% · Q2 25.3% · Q3 27.3% · Q4 29.2% · 4Q avg 26.0% |
| Percentage of long-stay residents who lose too much weight | 4.6% |
6.4%
1.8 pts better
|
5.4%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 1.2% · Q3 5.8% · Q4 7.0% · 4Q avg 4.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.5% |
17.3%
5.2 pts worse
|
19.6%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.9% · Q2 22.9% · Q3 23.3% · Q4 18.5% · 4Q avg 22.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 24.6% |
19.4%
5.2 pts worse
|
16.7%
7.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.6% · Q2 25.3% · Q3 25.3% · Q4 22.2% · 4Q avg 24.6% · 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 | 18.5% |
18.1%
0.4 pts worse
|
16.3%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.3% · Q2 20.8% · Q3 19.0% · Q4 13.7% · 4Q avg 18.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.5% |
18.4%
4.9 pts better
|
14.9%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.2% · Q2 11.4% · Q3 8.6% · Q4 14.8% · 4Q avg 13.5% · 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 | 0.8% |
1.7%
0.9 pts better
|
1.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.0% · Q3 0.0% · Q4 2.1% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 32.6% |
24.8%
7.8 pts worse
|
19.8%
12.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.3% · Q2 47.3% · Q3 19.3% · Q4 27.6% · 4Q avg 32.6% |
| Percentage of long-stay residents with pressure ulcers | 3.9% |
4.4%
0.5 pts better
|
5.1%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 3.7% · Q3 3.6% · Q4 3.3% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 77.2% |
70.5%
6.7 pts better
|
81.7%
4.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 56.4% · Q2 82.8% · Q3 83.5% · Q4 86.9% · 4Q avg 77.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.5% |
11.1%
2.4 pts worse
|
12.0%
1.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.5% · Observed 12.9% · Expected 10.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.6% |
1.5%
0.1 pts worse
|
1.6%
About the same
|
Short Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 3.0% · Q3 1.7% · Q4 0.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 81.6% |
69.7%
11.9 pts better
|
79.7%
1.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 81.6% |
| 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 22.6% · Expected 19.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-08-31 · Fire 2022-08-31
8 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2019-11-07 · Fire 2019-11-07
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-12-10
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2025-01-08
D · Potential for more than minimal harm
2024-12-10
K222 · Egress Deficiencies
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 2025-01-08
D · Potential for more than minimal harm
2024-12-10
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-01-08
D · Potential for more than minimal harm
2024-12-10
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-01-08
D · Potential for more than minimal harm
2024-12-10
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-01-08
D · Potential for more than minimal harm
2024-12-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-01-08
D · Potential for more than minimal harm
2024-12-10
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-01-08
D · Potential for more than minimal harm
2024-12-10
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-01-08
D · Potential for more than minimal harm
2024-12-10
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-01-08
D · Potential for more than minimal harm
2024-12-10
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-01-08
D · Potential for more than minimal harm
2024-12-10
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-01-08
F · Potential for more than minimal harm
2022-08-31
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-11-14
F · Potential for more than minimal harm
2022-08-31
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-11-14
F · Potential for more than minimal harm
2022-08-31
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-11-14
D · Potential for more than minimal harm
2019-11-07
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2019-11-20
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-12-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-21
D · Potential for more than minimal harm
2024-12-10
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2025-01-21
D · Potential for more than minimal harm
2024-12-10
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 2025-01-21
D · Potential for more than minimal harm
2024-12-10
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-01-21
D · Potential for more than minimal harm
2024-12-10
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 2025-01-21
D · Potential for more than minimal harm
2024-12-10
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-01-21
D · Potential for more than minimal harm
2024-12-10
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 2025-01-21
D · Potential for more than minimal harm
2024-12-10
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2025-01-21
D · Potential for more than minimal harm
2024-12-10
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-01-21
D · Potential for more than minimal harm
2024-07-24
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-08-23
D · Potential for more than minimal harm
2024-05-28
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-02
D · Potential for more than minimal harm
2024-05-28
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-07-02
E · Potential for more than minimal harm
2022-08-31
F800 · Nutrition and Dietary Deficiencies
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2022-10-12
E · Potential for more than minimal harm
2022-08-31
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 2022-10-12
D · Potential for more than minimal harm
2022-08-31
F657 · Resident Assessment and Care Planning Deficiencies
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 2022-10-12
D · Potential for more than minimal harm
2022-08-31
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-10-12
D · Potential for more than minimal harm
2022-08-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-10-12
D · Potential for more than minimal harm
2019-11-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-12-13
D · Potential for more than minimal harm
2019-11-07
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2019-12-13
D · Potential for more than minimal harm
2019-11-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-12-13
Penalties and ownership
What sits behind the stars
Ownership
Legacy Lifecare, Inc.
5% Or Greater Direct Ownership Interest · Organization
Alessandro, Joseph
Operational/Managerial Control · Individual
Anfang, Stuart
Operational/Managerial Control · Individual
Berman, Adam
Operational/Managerial Control · Individual
Berman, Adam
Corporate Director · Individual
Berman, Adam
Corporate Officer · Individual
Berman, Barry
Operational/Managerial Control · Individual
Birle, Hans
Operational/Managerial Control · Individual
Brudnick, Jeffrey
Operational/Managerial Control · Individual
Chelsea Jewish Lifecare Inc
Operational/Managerial Control · Organization
Chelsea Jewish Lifecare Inc
5% Or Greater Security Interest · Organization
Chelsea Jewish Lifecare Inc
5% Or Greater Mortgage Interest · Organization
Coe, Lisa
Operational/Managerial Control · Individual
Crescenzo, Donna
Operational/Managerial Control · Individual
Fiebelkorn, Douglas
Operational/Managerial Control · Individual
Fiebelkorn, Douglas
Corporate Director · Individual
Foreman, Sharon
Operational/Managerial Control · Individual
Gallup, Lorraine
Operational/Managerial Control · Individual
Gallup, Lorraine
Corporate Director · Individual
Goldsmith, Susan
Operational/Managerial Control · Individual
Goldsmith, Susan
Corporate Director · Individual
Greenspan, Howard
Operational/Managerial Control · Individual
Kowal, Marissa
Operational/Managerial Control · Individual
Lapointe, Laurence
Operational/Managerial Control · Individual
Lapointe, Laurence
Corporate Director · Individual
Legacy Lifecare, Inc.
Operational/Managerial Control · Organization
Maclellan, Genevieve
Operational/Managerial Control · Individual
Milewska, Nancy
Operational/Managerial Control · Individual
Milewska, Nancy
Corporate Director · Individual
Milewska, Nancy
Corporate Officer · Individual
Mullen, Elizabeth
Operational/Managerial Control · Individual
Mullen, Elizabeth
Corporate Director · Individual
O'brien, Terrence
Operational/Managerial Control · Individual
Reidy, Richard
Operational/Managerial Control · Individual
Reidy, Richard
Corporate Director · Individual
Richman, Gilda
Operational/Managerial Control · Individual
Santerre, Jennifer
Operational/Managerial Control · Individual
Santerre, Jennifer
Corporate Director · Individual
Santerre, Jennifer
Corporate Officer · Individual
Spieker, A. Gary
Operational/Managerial Control · Individual
Spieker, A. Gary
Corporate Director · Individual
Weiss, Judy
Operational/Managerial Control · Individual
Whitten, Robert
Operational/Managerial Control · Individual
Whitten, Robert
Corporate Director · Individual
Whitten, Robert
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Douglas Manor
Windham, CT
1-star overall rating with 1-star inspections with 24 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Vanderman Place
Willimantic, CT
2-star overall rating with 2-star inspections with 14 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Mansfield Center For Nursing And Rehabilitation
Storrs Mansfield, CT
3-star overall rating with 2-star inspections with $22,581 in total fines with 8 recent health deficiencies
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