Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Apple Rehab Colchester during CMS and state inspections, most recent first.
A resident with multiple risk factors for falls was not fully assessed by nursing staff after an unwitnessed fall with severe hip pain; staff transferred the resident back to bed before a thorough RN assessment, and required fall risk assessments were not completed per facility policy despite a history of multiple falls.
A resident with cognitive impairment and multiple health conditions experienced a fall resulting in severe hip pain and a femoral fracture. Despite clear signs of distress, nursing staff delayed pain assessment and management, with ice and as-needed acetaminophen not administered for several hours. Facility policy requiring prompt pain intervention and documentation was not followed.
A medication cart was twice found unlocked and unattended in a hallway, with medications, a cell phone, and an open computer screen displaying resident information left exposed. A nurse admitted the cart and screen should have been secured, and the DON confirmed this violated facility policy requiring locked storage and confidentiality.
A deficiency was cited when a resident was not protected from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, due to insufficient safeguards and oversight by the facility.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, resulting in a deficiency related to resident safety.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
A resident with a history of falls and cerebellar ataxia was left unattended in a bed that was not returned to its lowest position after being raised for feeding, despite care plan directives. This lapse resulted in the resident falling from the bed and sustaining spinal fractures and a hematoma. Staff interviews and documentation confirmed the bed was not in the required position at the time of the incident.
A resident with dementia and behavioral disturbances was involved in multiple altercations with other residents, including hitting and slapping, which were witnessed by staff. Despite these incidents, the DON did not substantiate the abuse, attributing the behavior to the resident's condition rather than intentional harm. The facility's policy defines abuse as the willful infliction of injury, yet the DON's interpretation led to a failure in recognizing and addressing the abuse.
A facility failed to report allegations of abuse involving a resident with dementia and behavioral disturbances in a timely manner. The resident was involved in multiple incidents of physical aggression towards other residents, including hitting one resident in the ribs and another in the chest. The incidents were reported to the State Agency well beyond the required two-hour window, with delays ranging from 11 to 76 hours. The DON, new to the facility, believed the incidents were behavioral, not abusive, contributing to the reporting delays.
The facility failed to document and monitor behaviors for two residents with mental disorders, leading to inappropriate administration of PRN Trazodone. Despite physician orders requiring specific behaviors to justify medication use, nursing notes lacked evidence of such behaviors. The facility's policy mandated behavior monitoring and documentation, which was not followed, resulting in medication being administered without proper justification.
The facility failed to document medication administration for all residents during an electronic charting system outage. During a night shift, the system was down, and nurses were unable to document medications. The DON confirmed the lack of verification for medication administration. The facility's policy requires switching to paper MARs during downtimes, but this was not done, leading to incomplete documentation.
Failure to Assess and Complete Fall Risk Assessment After Resident Fall
Penalty
Summary
A deficiency occurred when nursing staff failed to fully assess a resident following a fall that resulted in pain and possible injury before transferring the resident back to bed. The resident, who had multiple diagnoses including muscle weakness, cognitive communication deficit, anxiety, depression, and schizoaffective disorder, was identified as being at high risk for falls. The care plan included interventions such as a low bed, encouraging the resident to request staff assistance for transfers and toileting, and therapy evaluations. Despite these interventions, the resident experienced an unwitnessed fall and was found on the floor complaining of severe left hip pain, with visible erythema and limited range of motion in the left lower extremity. Upon discovering the resident on the floor, staff, including an LPN, a nurse aide, and an RN, assisted the resident back to bed before a thorough assessment was conducted. The resident expressed significant pain during the transfer, repeatedly yelling out, but the staff proceeded to move the resident from the floor to a wheelchair and then to bed. The RN only performed a full assessment after the resident was back in bed, at which point the resident continued to exhibit pain with movement. Subsequent imaging revealed an acute left femoral intertrochanteric fracture, and the resident was later transferred to the hospital for surgical intervention. Additionally, a review of the clinical record showed that fall risk assessments were not completed as required by facility policy, either prior to or after the fall, despite the resident having a history of multiple falls. Facility policy mandated that fall risk assessments be performed upon admission, quarterly, annually, and after any change in condition, including after a fall. Interviews with staff and the DON confirmed that these assessments were not completed as required, and the resident's care plan was not updated with targeted interventions based on a current assessment.
Failure to Provide Timely Pain Management After Resident Fall
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including muscle weakness, cognitive communication deficit, anxiety, depression, and schizoaffective disorder, sustained a fall and subsequently experienced severe pain. The resident, who had a low BIMS score indicating significant cognitive impairment and dependence on staff for mobility and toileting, was found on the floor after an unwitnessed fall. Upon assessment, the resident complained of left hip pain rated as 10 out of 10, with visible distress and limited range of motion. Orders were obtained for a STAT x-ray, bedrest, and ice application, and the resident was to be treated for pain as needed. Despite clear signs of severe pain, interventions to manage the resident's pain were not implemented in a timely manner. Ice was not applied until the day shift, several hours after the fall, and as-needed acetaminophen was not administered until more than eight hours later, when the resident continued to report significant pain. Nursing staff interviews revealed that the resident was assisted back to bed without pain assessment or medication, and pain management interventions were delayed. Documentation showed that pain was not reassessed prior to the end of the shift, and the effectiveness of interventions was not evaluated as required by facility policy. Imaging later confirmed the resident had sustained an acute left femoral intertrochanteric fracture, and the resident was transferred to the hospital for surgical intervention. Facility policy required prompt development and implementation of pain management interventions and documentation of their effectiveness, but these steps were not followed after the resident's fall and complaints of severe pain.
Unattended and Unlocked Medication Cart with Exposed Resident Information
Penalty
Summary
A medication cart was observed on two separate occasions in the main hallway of the A Wing, positioned against the left side of the hall, first about halfway down and later about two-thirds down the hallway. On both occasions, the cart was found to be unlocked and unattended, with an open cup of applesauce, a pre-poured cup of nutritional supplement, and a cell phone left on top. Additionally, the computer screen attached to the cart was open and unlocked, displaying resident information. Multiple residents were seen walking by the unattended cart, though none approached it. A registered nurse was observed emerging from a resident's room shortly after each observation of the unattended cart. During an interview, the nurse acknowledged that the cart and computer screen should not have been left unlocked and unattended, especially with ambulatory residents present in the hallway. The Director of Nursing confirmed that facility policy requires medication carts and computer screens to be locked and secured at all times when not in use, and that items should not be left on top of the cart when unattended. The facility's Medication Administration policy also directs that medications be stored in a secure, locked area accessible only to authorized personnel, and that resident confidentiality be maintained.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report documents that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's protective measures and oversight.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report does not specify particular actions, inactions, or events, nor does it mention any specific residents or staff involved in the deficiency.
Failure to Maintain Bed in Lowest Position Leads to Resident Fall and Injury
Penalty
Summary
A deficiency occurred when staff failed to ensure that a resident's bed was returned to the lowest position prior to leaving the room, as required by the resident's care plan and facility policy. The resident had a history of falls, cerebellar ataxia, and some memory recall deficits, and was dependent on staff for activities of daily living. The care plan and nurse aide care card specifically directed that the bed be kept in the lowest position, with additional interventions such as floor mats and body pillows. On the day of the incident, a nurse aide raised the bed to waist height to feed the resident and did not return it to the lowest position before leaving the room, despite being aware of the care card instructions. As a result, the resident was found on the floor next to the bed with a bump on the head and was subsequently diagnosed with fractures of the C6 and C7 spine and a hematoma to the forehead. Interviews with nursing staff confirmed that the bed was not in the lowest position at the time of the fall, contrary to established protocols. Facility documentation and interviews indicated that the failure to follow the care plan and policy directly contributed to the resident's fall and resulting injuries.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by multiple incidents involving a resident with a history of dementia and behavioral disturbances. This resident was involved in several altercations with other residents, including hitting and slapping, which were witnessed by staff members. Despite these incidents, the Director of Nursing (DON) did not substantiate the abuse, attributing the behavior to the resident's condition rather than intentional harm. In one incident, a resident with dementia and behavioral disturbances hit their roommate, who also had severe cognitive impairments. The staff separated the residents and placed the aggressive resident under observation. However, the DON did not consider this abuse, citing the behavior as unintentional. Similar incidents occurred with other residents, where the aggressive resident hit or pushed them, yet the DON consistently failed to substantiate these as abuse cases. The facility's policy clearly defines abuse as the willful infliction of injury or harm, including physical acts like hitting and slapping. Despite this, the DON's interpretation of the incidents as non-abusive due to the resident's cognitive impairments led to a failure in recognizing and addressing the abuse, leaving residents vulnerable to further harm.
Failure to Timely Report Allegations of Abuse
Penalty
Summary
The facility failed to notify the State Agency of allegations of abuse in a timely manner for four residents. Resident #1, diagnosed with dementia and other mental health disorders, was involved in multiple incidents of physical aggression towards other residents. On one occasion, Resident #1 hit Resident #2, who also had severe cognitive impairments, in the ribs. The incident was reported to the State Agency 11 hours and 42 minutes after it occurred, exceeding the required two-hour reporting window. Another incident involved Resident #1 hitting Resident #3, who had Alzheimer's disease and dementia, in the chest. This incident was reported 76 hours and 44 minutes after it occurred, again failing to meet the timely reporting requirement. Additionally, Resident #1 was involved in an altercation with Resident #4, who had dementia with behavioral disturbances. The incident was reported 18 hours and 39 minutes after it occurred. The Director of Nursing (DON), who was new to the facility, indicated that she believed the incidents were behavioral rather than abusive, which contributed to the delay in reporting. The facility's policy requires that all allegations of abuse be reported to the State Agency within two hours, but this protocol was not followed in these cases.
Failure to Document and Monitor Behaviors for PRN Medication Administration
Penalty
Summary
The facility failed to accurately document and monitor the behaviors of two residents diagnosed with mental disorders, leading to inappropriate administration of PRN Trazodone. Resident #1, diagnosed with dementia, panic disorder, anxiety disorder, and depression, was administered Trazodone on multiple occasions in August 2024 without documented evidence of the required behaviors, such as anxiety, as per physician orders. The nursing notes did not reflect the necessary observations to justify the administration of the medication on specific dates, indicating a lapse in following the prescribed monitoring protocol. Similarly, Resident #5, with diagnoses including metabolic encephalopathy, dementia with behavioral disturbance, anxiety disorder, and depression, received PRN Trazodone without documented behaviors on several occasions in August 2024. The facility's policy required specific target behaviors to be identified and monitored every shift, with documentation of episodes, interventions, outcomes, and side effects. However, the nursing staff failed to document the necessary behaviors, leading to the administration of medication without proper justification. An interview with the DON confirmed the expectation for accurate documentation, but the reason for the lack of monitoring was not identified.
Failure to Document Medications During System Outage
Penalty
Summary
The facility failed to ensure proper documentation of medication administration during an electronic charting system outage for all fifty-seven residents. During the 11:00 PM to 7:00 AM shift, the electronic charting system was down, preventing nurses from documenting medications administered. An interview with the Director of Nursing (DON) confirmed that there was no verification available to confirm that medications were administered during this period. The facility's undated PCC eMAR Downtime Policy requires staff to switch to paper Medication Administration Records (MARs) during unplanned downtimes, but this procedure was not followed, resulting in incomplete documentation.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Colchester
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Complete Care At Harrington Court | 0.1 mi | ★★★★★ | 8 | 1 |
| Chestelm Health And Rehabilitation Center | 8.7 mi | ★★★★★ | 2 | 0 |
| Marlborough Health & Rehabilitation Center | 9 mi | ★★★★★ | 5 | 0 |
| Vanderman Place | 11.1 mi | ★★★★★ | 0 | 0 |
| Cobalt Lodge Health Care And Rehabilitation Center | 11.5 mi | ★★★★★ | 8 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.