Inspection Reports for The Pines at Bristol Center for Health and Rehabilitation
CT, 06010
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 5, 2025, found that previously cited violations had been corrected, with only one deficiency noted related to earlier issues. Earlier inspections showed a pattern of deficiencies primarily involving resident care documentation, medication management, infection control, and staffing adequacy. Several complaint investigations were conducted, with most complaints found unsubstantiated, except for a substantiated complaint in December 2021 involving misappropriation of controlled medications and failure to report incidents timely. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s inspection history shows improvement over time, with recent follow-up audits confirming correction of prior deficiencies.
Deficiencies (last 7 years)
Deficiencies (over 7 years)
3.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
41% better than Connecticut average
Connecticut average: 5.6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
94% occupied
Based on a June 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Follow-Up
Census: 124
Capacity: 132
Deficiencies: 1
Date: Jun 5, 2025
Visit Reason
Desk audit conducted to review the implementation of the plan of correction for violations previously cited in the facility.
Findings
All violations numbered 1 through 12 were found to be corrected as of the desk audit conducted on 6/5/2025.
Deficiencies (1)
Violations #1 through #12 from the prior inspection
Report Facts
Violations corrected: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brian Nyberg | Administrator | Notified via telephone that all violations were corrected |
Inspection Report
Complaint Investigation
Census: 126
Capacity: 132
Deficiencies: 0
Date: Apr 28, 2025
Visit Reason
The inspection visit was conducted as a complaint investigation related to Complaint Investigation #44070.
Complaint Details
Complaint Investigation #44070 was the basis for the visit. No violations were found, indicating the complaint was not substantiated.
Findings
No violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection.
Report Facts
Licensed Bed/Bassinet Capacity: 132
Census: 126
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brian Nyberg | Administrator | Personnel contacted during inspection |
| Lily Jaglall | DNS | Personnel contacted during inspection |
Inspection Report
Renewal
Census: 126
Capacity: 132
Deficiencies: 0
Date: Mar 26, 2025
Visit Reason
The inspection was conducted as a licensing inspection for renewal and included complaint investigations #27449 and #42771.
Complaint Details
Complaint investigations #27449 and #42771 were part of the inspection process.
Findings
Violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified during the inspection. The report references attached violation letters and narrative reports for details.
Report Facts
Licensed Bed Capacity: 132
Census: 126
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brian Nyberg | Administrator | Personnel contacted during inspection |
| Lulavettie Jaglal | DNS | Personnel contacted during inspection |
Inspection Report
Complaint Investigation
Census: 125
Capacity: 132
Deficiencies: 0
Date: Mar 19, 2025
Visit Reason
The inspection visit was conducted as a complaint investigation related to Complaint Investigation #40833 and #43307.
Complaint Details
Complaint Investigation #40833 and #43307 were reviewed, and no violations were substantiated.
Findings
No violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bryan Nyberg | Administrator | Personnel contacted during the inspection. |
Inspection Report
Follow-Up
Census: 123
Capacity: 132
Deficiencies: 0
Date: Apr 20, 2023
Visit Reason
A desk audit was completed on 4/20/23 to review the Plan of Correction for the Violation letter dated 3/16/23.
Findings
All violations identified in the previous inspection were corrected as of 4/20/23, confirmed by telephone notification to the Administrator.
Report Facts
Licensed Bed/Bassinet Capacity: 132
Census: 123
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Karen Chadderton | Administrator | Notified via telephone that all violations were corrected |
| Melissa Talamini | NC | Completed desk audit and submitted report |
Inspection Report
Renewal
Census: 127
Capacity: 132
Deficiencies: 0
Date: Feb 2, 2023
Visit Reason
The inspection visit was conducted as a licensing renewal inspection and included review of a complaint investigation (Complaint Investigation #CT33506).
Complaint Details
Complaint Investigation #CT33506 was reviewed during this inspection.
Findings
Violations of the General Statutes of Connecticut and/or regulations were identified at the time of this inspection. The report includes approval for issuance of license.
Report Facts
Licensed Bed/Bassinet Capacity: 132
Census: 127
Inspection Report
Complaint Investigation
Census: 129
Capacity: 132
Deficiencies: 0
Date: Jan 10, 2023
Visit Reason
The inspection visit was conducted as a complaint investigation related to complaint investigation numbers 33605 and 33607.
Complaint Details
Complaint investigation numbers 33605 and 33607 were the basis for the visit. No violations were found.
Findings
No violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection.
Report Facts
Licensed Bed/Bassinet Capacity: 132
Census: 129
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Agnesa Rizvani | DNS | Personnel contacted during inspection |
| Karen Chadderton | Administrator | Personnel contacted during inspection |
| Errolee Bryan Miller | FLIS Staff who signed the report and submitted the report |
Inspection Report
Census: 126
Capacity: 132
Deficiencies: 0
Date: Mar 11, 2022
Visit Reason
A desk audit was conducted to review the implementation of the plan of correction from the violation letter dated 1/11/2022.
Findings
Violations #1 through #2 have been corrected, and the DNS was notified of the corrections. No new violations were identified during this inspection.
Report Facts
Licensed Bed Capacity: 132
Census: 126
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Agnesa Rizvani | DNS | Personnel contacted during the inspection |
| Fran Ferraiolo | RN | Signature of FLIS staff and report submitter |
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Jan 3, 2022
Visit Reason
An unannounced visit was conducted on January 3, 2022, by a representative of the Facility Licensing and Investigations Section of the Department of Public Health to investigate violations of Connecticut State regulations and statutes at The Pines At Bristol For Nursing & Rehabilitation.
Findings
The report identifies deficiencies related to incomplete and inconsistent documentation of weekly skin assessments and pressure ulcer risk evaluations for Resident #1, including failure to ensure the resident had the ordered Low Air Loss mattress in place. The facility was found noncompliant with state regulations regarding skin care and pressure ulcer management.
Deficiencies (2)
Failure to complete and document weekly skin assessments and pressure ulcer risk assessments consistent with facility policy for Resident #1.
Failure to ensure Resident #1 had the physician-ordered Low Air Loss mattress in place, with the resident's bed observed to have a regular mattress instead.
Report Facts
Dates of documentation reviewed: Nov 4, 2021
Dates of documentation reviewed: Nov 13, 2021
Dates of documentation reviewed: Dec 1, 2021
Dates of documentation reviewed: Jan 3, 2022
Measurement of skin discoloration: 1.8
Measurement of skin discoloration: 1.6
Measurement of deep tissue injury: 1
Measurement of deep tissue injury: 1
Audit frequency: 4
Audit frequency: 3
Compliance deadline: Feb 7, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Janet Peynado-Daley | Supervising Nurse Consultant | Signed the notice letter regarding violations and plan of correction instructions |
| Karen Chadderton | Administrator | Facility administrator addressed in the notice letter |
| Assistant Director of Nursing | Interviewed on 1/3/22 regarding mattress order and facility practices | |
| Director of Nursing | Responsible for oversight of plan of correction and compliance |
Inspection Report
Complaint Investigation
Census: 122
Capacity: 132
Deficiencies: 4
Date: Dec 2, 2021
Visit Reason
An unannounced visit was made to The Pines at Bristol for Nursing & Rehabilitation on December 2, 2021, for the purpose of conducting a complaint investigation with additional information received through December 6, 2021.
Complaint Details
Complaint Investigation # CT 31204 was conducted following allegations of misappropriation of controlled medications by Administrator #2. The complaint was substantiated with findings of noncompliance.
Findings
Violations of Connecticut State regulations were identified related to misappropriation of controlled narcotic medications, failure to ensure discontinued narcotics were removed or securely stored, and failure to report allegations of misappropriation of resident property. The facility was found noncompliant and required to submit a plan of correction.
Deficiencies (4)
Facility failed to ensure discontinued controlled narcotic medications were removed from the facility by an employee, leading to misappropriation of medications by Administrator #2.
Facility failed to report an allegation of misappropriation of residents' personal property to the state agency at the time the incident was reported.
Facility failed to ensure discontinued controlled narcotic medications were stored in a secure locked area until destruction was conducted.
Facility failed to ensure staff wore required personal protective equipment when assisting a resident on precautions related to COVID-19.
Report Facts
Census: 122
Total Capacity: 132
Controlled Substance Tablets: 30
Controlled Substance Tablets: 10
Controlled Substance Tablets: 15
Additional Blister Packs: 10
Additional Blister Packs: 9
Narcotic Medications: 2
Non-narcotic Medications: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Karen Chadderton | Administrator | Personnel contacted during the inspection. |
| Barbara Andrews | Director of Nursing | Named in relation to findings and plan of correction. |
| Karen Gworek | Supervising Nurse Consultant | Author of the violation letter dated December 15, 2021. |
| Raymond Wilkens | Administrator | Named in follow-up reports and plan of correction correspondence. |
| Jacquelyn Harris | Nurse Consultant | Notified of correction of violations. |
| Maureen Golas Markure | Supervising Nurse Consultant | Author of monitoring survey letters. |
Inspection Report
Complaint Investigation
Census: 122
Capacity: 132
Deficiencies: 4
Date: Dec 2, 2021
Visit Reason
An unannounced visit was made to The Pines at Bristol for Nursing & Rehabilitation on December 2, 2021, for the purpose of conducting a complaint investigation with additional information received through December 6, 2021.
Complaint Details
Complaint Investigation #CT 31204. The complaint involved misappropriation of medications and failure to report incidents. The complaint was substantiated with multiple findings including medication misappropriation by Administrator #2 and failure to report to the state agency.
Findings
Violations of Connecticut State Agencies regulations were identified related to misappropriation of medications, failure to ensure discontinued controlled narcotic medications were removed, failure to report misappropriation of resident property, and failure to maintain confidentiality of residents' medical information. The facility failed to ensure proper handling and storage of controlled substances and failed to report incidents timely to the state agency.
Deficiencies (4)
Facility failed to ensure residents' medical information remained confidential.
Facility failed to ensure discontinued controlled narcotic medications were not removed from the facility by an employee.
Facility failed to report an allegation of misappropriation of residents' personal property to the state agency at the time the incident was reported.
Facility failed to ensure discontinued controlled narcotic medications were stored in a secure locked area until destruction was conducted.
Report Facts
Census: 122
Total Capacity: 132
Tablets of Tramadol: 30
Tablets of Oxycodone: 10
Tablets of Oxycodone: 15
Residents' blister packs: 10
Residents' non-narcotic medications: 9
Narcotic analgesic medications: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Karen Chadderton | Administrator | Named as personnel contacted and involved in findings |
| Barbara Andrews | Director of Nursing | Named as personnel contacted and signer of plan of correction |
| Karen Gworek | Supervising Nurse Consultant | Author of the important notice letter |
| Administrator #2 | Identified as having taken controlled medications for personal use and involved in misappropriation findings | |
| Administrator #1 | Current Administrator involved in findings and interviews |
Inspection Report
Monitoring
Census: 112
Capacity: 132
Deficiencies: 3
Date: Aug 6, 2021
Visit Reason
An unannounced visit was made to The Pines At Bristol For Nursing & Rehabilitation on August 6, 2021 by a representative of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting a monitoring survey.
Complaint Details
The inspection was complaint-related as indicated by the complaint survey conducted on 8/06/21 resulting in deficiencies F-600 (Free From Abuse/Neglect), F-725 (Sufficient Nursing Staff), and F-880 (Infection Control). The facility disputed the neglect finding and staffing adequacy in their informal dispute resolution request.
Findings
The facility was found to have violations related to abuse/neglect, insufficient staffing to meet resident needs, and failure to ensure staff wore required personal protective equipment during infection control precautions. Deficiencies were documented with specific resident cases and staffing observations.
Deficiencies (3)
Facility failed to ensure residents were free from neglect and failed to ensure care was provided timely in accordance with the plan of care for Residents #2 and #3.
Facility failed to ensure sufficient staffing to meet the needs of residents, with observations of inadequate nursing assistants on duty.
Facility failed to ensure staff wore required personal protective equipment when assisting a resident on precautions, specifically Resident #1.
Report Facts
Licensed Bed Capacity: 132
Census: 112
Residents involved in neglect finding: 2
Residents involved in infection control finding: 1
Residents on third floor: 32
Nursing assistants on 3-11 PM shift: 2
Residents out of bed at 5:30 PM: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ray Wilkins | Administrator | Administrator named in relation to staffing and neglect findings. |
| Maureen Golas Markure | Supervising Nurse Consultant | Supervising Nurse Consultant involved in correspondence and oversight. |
| RN #1 | Registered Nurse interviewed regarding resident care and infection control observations. | |
| NA #2 | Nursing Assistant interviewed regarding resident care and staffing. | |
| NA #3 | Nursing Assistant interviewed regarding resident care and staffing. | |
| LPN #1 | Licensed Practical Nurse interviewed regarding resident care and staffing. |
Inspection Report
Abbreviated Survey
Census: 114
Capacity: 132
Deficiencies: 0
Date: Jun 26, 2020
Visit Reason
A COVID-19 Focused Survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including proper infection prevention and control practices to prevent the development and transmission of COVID-19.
Findings
The COVID-19 Focused Infection Control Survey found the facility compliant with no deficiencies cited related to infection prevention and control practices.
Inspection Report
Routine
Census: 111
Capacity: 132
Deficiencies: 0
Date: Jun 11, 2020
Visit Reason
A COVID-19 Focused Survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including proper infection prevention and control practices to prevent the development and transmission of COVID-19.
Findings
The survey found the facility compliant with no deficiencies cited related to infection prevention and control practices for COVID-19.
Inspection Report
Routine
Census: 115
Capacity: 132
Deficiencies: 0
Date: Jun 4, 2020
Visit Reason
A COVID-19 Focused Survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including proper infection prevention and control practices to prevent the development and transmission of COVID-19.
Findings
The survey found no deficiencies related to infection prevention and control practices for COVID-19 at the facility.
Report Facts
Capacity: 132
Census: 115
Inspection Report
Routine
Census: 122
Capacity: 132
Deficiencies: 0
Date: May 14, 2020
Visit Reason
The inspection visit was conducted for the purpose of an Infection Control (IC) Survey related to COVID-19.
Findings
The report does not provide detailed findings or deficiencies but indicates the visit was focused on infection control measures related to COVID-19.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Barbara Andrews | Director of Nurses | Personnel contacted during the inspection. |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: May 14, 2020
Visit Reason
A COVID-19 Focused Survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including proper infection prevention and control practices to prevent the development and transmission of COVID-19.
Findings
The survey found no deficiencies related to infection prevention and control practices for COVID-19 at Pines at Bristol.
Inspection Report
Abbreviated Survey
Deficiencies: 2
Date: May 4, 2020
Visit Reason
A COVID-19 Focused Survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including proper infection prevention and control practices to prevent the development and transmission of COVID-19.
Findings
The facility failed to ensure appropriate infection control practices were implemented to prevent and control the spread of infection, including failure to separate a COVID-19 positive resident from a COVID-19 negative resident sharing a semi-private room, and failure to maintain proper isolation precautions such as pulling curtains between residents on droplet precautions.
Deficiencies (2)
Failure to separate Resident #1 (COVID-19 positive) and Resident #2 (COVID-19 negative) who shared a semi-private room until 5/4/2020 despite availability of a private room.
Failure to pull curtain between two residents in a room where one resident was on droplet precautions due to symptoms, until surveyor inquiry.
Report Facts
Date of positive COVID-19 test: Apr 30, 2020
Date of negative COVID-19 test: Apr 30, 2020
Date of retest: May 8, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nurses (DON) | Interviewed regarding failure to separate residents and infection control practices | |
| Housekeeping Supervisor | Interviewed regarding delay in terminal cleaning of room for Resident #2 |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: May 3, 2020
Visit Reason
This document is a plan of correction submitted by The Pines at Bristol Center for Health and Rehabilitation in response to a focused infection control survey conducted on May 3, 2020.
Findings
Resident #2 had a room change into a private room and was retested for COVID-19 with a negative result. The facility conducted a point prevalence survey on 05/08/2020, and no residents suffered ill effects from the alleged deficient practice related to infection control and cohorting.
Deficiencies (1)
Failure to properly cohort COVID-19 residents according to facility policy and CDC guidance.
Report Facts
Completion Date: Jun 5, 2020
Retest Date: May 8, 2020
Survey Date: May 3, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ray Wilkens | Administrator | Signed the plan of correction letter |
Inspection Report
Plan of Correction
Census: 127
Capacity: 132
Deficiencies: 1
Date: Mar 8, 2019
Visit Reason
Desk audit review was conducted on 3/8/19 by a representative of the FLIS Department for the purpose of reviewing the Plan of Correction for the violation letter dated 2/14/19.
Findings
The review of information identified violations 1.a, 2.a, and 3.a have been corrected.
Deficiencies (1)
Violations identified in the violation letter dated 2/14/19
Report Facts
Licensed Bed: 132
Census: 127
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Beatrice Vincent | DNS | Personnel contacted during inspection |
| Josie Dumond | RNC Certified Nurse Consultant | Conducted desk audit review |
Inspection Report
Complaint Investigation
Census: 128
Capacity: 132
Deficiencies: 5
Date: Oct 5, 2018
Visit Reason
The inspection was conducted as a complaint investigation triggered by complaint #24163, involving allegations of noncompliance with Connecticut State regulations.
Complaint Details
Complaint #24163 was substantiated, involving a resident who left the facility unattended due to an inactive wander guard alarm system. The investigation included interviews, record reviews, and video footage analysis.
Findings
The facility was found noncompliant due to failure to ensure the alarm system for a resident at risk of elopement was activated, allowing the resident to leave unattended. Additional deficiencies related to resident care plans, staff response, and infection control were identified.
Deficiencies (5)
Failure to ensure the alarm system was activated for a resident at risk of elopement, resulting in unauthorized leave.
Failure to accurately reflect resident care plan and code status for advanced directives.
Failure to immediately report and investigate an allegation of abuse involving a resident.
Failure to ensure infection control practices, including accurate documentation of residents with MDRO.
Failure to follow interventions to prevent falls, resulting in resident injury.
Report Facts
Licensed Bed Capacity: 132
Census: 128
Inspection Date: Oct 5, 2018
Complaint Number: 24163
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Raymond Wilkens | Administrator | Named in relation to findings about elopement and plan of correction. |
| Karen Gworek | Supervising Nurse Consultant | Signed violation letter and involved in complaint investigation. |
| Julie Sikorski | Acting Director of Nursing | Mentioned in relation to complaint investigation and inspection. |
| Norma Schuberth | Supervising Nurse Consultant | Signed plan of correction letter. |
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