Below average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Bel-air Manor Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
Three residents with diabetes did not have their blood glucose levels checked or insulin administered according to physician orders, with insulin often given at times not aligned with scheduled meals. Facility staff and policy required blood glucose monitoring and insulin administration before or with meals, but medication records and interviews showed these standards were not consistently met.
Surveyors found that various dry stock and frozen food items were not labeled with expiration dates, and the Dietary Director could not provide a policy or method for identifying expired items after original packaging was removed, despite facility policies requiring all food to be labeled and dated.
Two residents experienced significant, unplanned weight loss, but the facility failed to notify the APRN and family as required by policy. In both cases, weight loss was documented and confirmed, yet there was no evidence of timely communication to the provider or responsible party, and staff interviews confirmed the notifications did not occur.
A resident reported that a call bell was left unanswered for hours overnight, and observed an LPN sleeping at the nurse's station. Another resident was later found with a saturated brief and reported not receiving care overnight. Despite these incidents and facility policy requiring external reporting of suspected neglect, the DON did not notify authorities, addressing the matter only through the internal grievance process.
Surveyors identified that two residents did not have comprehensive care plans: one resident's use of side rail padding was not documented in the care plan or on aide care cards, and another resident's ongoing refusals of repositioning and offloading—contributing to a worsening pressure ulcer—were not reflected in the care plan until after surveyor inquiry. Staff interviews confirmed a lack of awareness and documentation regarding these care needs and behaviors.
A nurse administered Morphine ER tablets to a resident with chronic pain without checking the expiration date, as required by facility policy. The medication blister pack displayed an expired date, and doses were given after this date. The nurse later acknowledged not verifying the expiration before administration, resulting in a deficiency related to medication administration standards.
A resident with multiple medical conditions and a high risk for weight loss did not have weekly weights or a reweight obtained as ordered by the physician, despite significant weight loss. Staff interviews and record reviews confirmed that required weights were missed and not documented according to facility policy.
Surveyors found expired, unlabeled, and undated medications, as well as non-medication items and food, stored in medication rooms and carts. Staff acknowledged that these items should not be present, but could not explain their presence. Facility policy requires proper labeling, separation, and removal of expired medications, but these procedures were not followed.
A resident with severe malnutrition, dementia, and ongoing weight loss did not have meal intake percentages consistently documented by nurse aides, despite care plans and clinical notes indicating the need for close monitoring. Multiple days of missing documentation were identified, and staff interviews confirmed that accurate and complete charting was expected but not performed.
Two residents with documented MDROs were transferred to a hospital without their MDRO status, special instructions, or necessary precautions being communicated or documented in the transfer paperwork. Facility staff relied on verbal communication without retaining documentation, and the required information was not included in face sheets or electronic records. Facility policies did not clearly require notification of MDRO status upon transfer.
A resident with significant cognitive impairment and multiple medical conditions was not included in the development or implementation of their person-centered care plan. The facility could not provide documentation that a care conference was held or that the resident or their representative was invited, despite policy requiring such involvement.
A resident with major depressive disorder, anxiety disorder, and PTSD was admitted without a new PASRR Level 1 screening, as the facility relied on an outdated screen from a previous LTC stay. Staff interviews confirmed that a new screening should have been completed due to the resident's mental health diagnoses, but this was not done in accordance with policy and state procedures.
A resident with multiple chronic conditions was transferred to the hospital for acute symptoms, but the POA was not notified of the change in condition or transfer. The POA only learned of the hospitalization after being contacted by the hospital, and was later updated by staff. Additionally, medication changes were communicated to someone other than the POA, contrary to facility policy requiring immediate notification of the legal representative for significant changes.
A resident with severe cognitive impairment and a history of falls experienced a fall during a transfer, resulting in pain and an order for a left lower extremity x-ray. When the radiology provider reported a delay in obtaining the x-ray, nursing staff did not document that the physician or APRN was notified of the delay. Interviews confirmed that the APRN was not informed, and the nurse involved could not verify or document any notification to the on-call provider team. The DON stated that documentation of such notifications was expected, but it was not completed.
A resident with cognitive impairment and unable to consent was subjected to inappropriate touching and kissing by another resident, as observed on video and reported by a family member. The incident occurred despite facility policies prohibiting abuse and requiring consent for sexual expression.
Failure to Administer Insulin and Monitor Blood Glucose as Ordered
Penalty
Summary
The facility failed to ensure that blood glucose levels were obtained before meals and that insulin was administered prior to meals as ordered for three residents with diabetes. Physician orders for each resident specified that blood glucose monitoring and insulin administration should occur before meals, with specific sliding scale instructions or set doses. However, review of medication administration records revealed that insulin was frequently given at times not aligned with scheduled meal times, including after meals or significantly delayed from the prescribed schedule. For example, one resident with severe cognitive impairment and diabetes had insulin administered at times such as 10:00 AM and 12:05 PM, which did not correspond with the scheduled breakfast or lunch times. Another resident, who was dependent on staff for activities of daily living, received insulin doses at times such as 10:36 AM and 7:11 PM, rather than with meals as ordered. A third resident with severe cognitive impairment and diabetes also received insulin at times inconsistent with meal schedules, such as 5:56 PM and 1:10 PM, rather than before or with meals as directed by the physician. Interviews with nursing staff and the Director of Nursing Services confirmed that the facility's standard practice was to check blood glucose prior to meals and administer insulin either thirty minutes before or with meals. Despite these policies, documentation and staff interviews indicated that these practices were not consistently followed, resulting in the failure to meet professional standards of quality for medication administration as required by facility policy and physician orders.
Failure to Label and Date Food Items in Dietary Department
Penalty
Summary
During a tour of the Dietary Department, surveyors observed that multiple food items in both the basement dry stock and walk-in freezer were not labeled with expiration dates. Specifically, 16 bags of sliced white bread, two 1-gallon jars of coleslaw dressing, and four 1-pound cans of chicken base in the dry stock, as well as 12 packages each of hot dog and hamburger buns, two 5-pound beef chucks, a 5-pound bag of chicken tenders, and a 10-pound bag of chicken breast in the freezer, all lacked expiration dates. The Dietary Director was unable to provide a policy for expiration dating and stated that items were removed from their original boxes due to space constraints, making it unclear how expired items would be identified. Facility policies reviewed required all food to be labeled and dated for proper rotation and storage, but these procedures were not followed.
Failure to Notify Provider and Family of Significant Weight Loss
Penalty
Summary
The facility failed to notify the Advanced Practice Registered Nurse (APRN) and family or responsible party of significant, unplanned weight loss in two residents. In the first case, a resident with diagnoses including dysphagia, dementia, and a history of pressure wounds experienced a weight loss of over 10% in less than one month. The resident's care plan included monitoring for nutritional problems and regular weight checks. Despite documentation of the weight loss and a subsequent reweight confirming the loss, there was no evidence that the APRN or family were notified at the time the loss was identified. Interviews with nursing staff, the APRN, and the Director of Nursing confirmed that the expected notifications did not occur, and the APRN was unaware of the weight loss until much later. In the second case, another resident with dysphagia, aphasia, and diabetes mellitus was to be weighed weekly per physician's orders. The resident experienced a significant weight loss of over 14% in two weeks, but the only weights recorded were at the start and end of this period. The APRN and physician were not notified of the severe weight loss, and the dietician initiated a reweight order without provider notification. Interviews with nursing staff and APRNs confirmed that neither was aware of the weight loss, and the facility's own policies requiring provider and family notification were not followed. Facility policies directed that significant weight changes should be confirmed with a reweight and communicated to the dietician, provider, and family. In both cases, documentation and interviews revealed that these steps were not taken as required. The failures were identified through review of clinical records, facility documentation, and staff interviews, which consistently showed a lack of timely notification to the appropriate parties regarding significant changes in residents' conditions.
Failure to Report Allegation of Neglect to Authorities
Penalty
Summary
The facility failed to notify state and local authorities of an allegation of neglect involving a resident who reported that a call bell in another resident's room was not answered for several hours during the night. The reporting resident observed an LPN sleeping at the nurse's station and later noted that the call light remained unanswered until another nurse completed medication administration. The resident expressed concern that the unattended call light could have resulted in harm to the other resident. Additionally, the same resident overheard staff discussing that two residents had not been changed overnight due to unanswered call bells. A nurse aide found another resident with a saturated brief and pad, who reported not receiving care overnight. The nurse aide immediately reported this to the supervising RN, who also observed the resident's condition and reported it to the DON as a possible neglect incident. Despite these reports and the facility's policy requiring prompt reporting of suspected neglect to authorities, the DON did not notify state or local agencies, instead handling the matter solely through the facility's grievance process. The facility's own policies defined neglect as the failure to provide necessary care and required reporting such allegations to external authorities.
Failure to Maintain Comprehensive Care Plans for Side Rail Padding and Repositioning Refusals
Penalty
Summary
The facility failed to ensure that the Resident Care Plan (RCP) was comprehensive for two residents, specifically regarding the use of side rail padding and documentation of refusals for repositioning. For one resident with vascular dementia, muscle weakness, and cachexia, physician orders directed the use of quarter side-rails for mobility and transfer. However, side rail evaluations were either incomplete or lacked specific details about the number and length of side-rails. Observations showed the resident in bed with double-sided Velcro pads on both side-rails, but neither the active physician's orders nor the RCP documented the use of side-rail padding. Additionally, the Nurse Aide Care Card did not mention the use of side-rails or padding, and the Director of Nursing Services (DNS) was unaware of the reason for the padding or its absence from care documentation. For another resident with type 2 diabetes, chronic pain, and edema, the RCP identified a risk for skin breakdown and included interventions such as turning and repositioning every two hours and use of pressure redistribution devices. Despite these interventions, wound care notes and staff interviews revealed that the resident frequently refused repositioning, offloading, and an out-of-bed schedule, which contributed to the worsening of a coccyx wound to a Stage 3 pressure ulcer. Staff interviews confirmed that refusals had been ongoing for months, but the RCP did not reflect these refusals until after surveyor inquiry. The wound nurse and nurse aide both acknowledged the resident's non-compliance with repositioning and the lack of documentation in the care plan. Facility policy required that ongoing changes in residents' status be updated by nursing or the interdisciplinary team as needed, and that care plans be revised accordingly. However, the care plans for both residents were not updated to reflect the actual care being provided or the residents' behaviors, resulting in incomplete and non-comprehensive care plans that did not meet regulatory requirements.
Failure to Check Expiration Date Before Administering Narcotic Medication
Penalty
Summary
A deficiency occurred when a nurse failed to check the expiration date on a narcotic medication prior to administration for a resident with diagnoses including Parkinson's disease, chronic pain, and type 2 diabetes mellitus with polyneuropathy. The resident was receiving Morphine Sulfate Extended Release 15 mg tablets as part of a prescribed pain management regimen. During a review and observation of the medication cart, it was found that the blister pack of Morphine had an expiration date that had already passed, and the medication had been administered multiple times after this date. The nurse involved acknowledged not checking the expiration date before administering the medication and stated that this step should have been performed. Facility documentation showed that the medication was received from the pharmacy after the expiration date printed on the packaging, and the controlled substance disposition record confirmed that doses were administered from this pack after the listed expiration date. The facility's policy required nurses to check expiration dates before administering any medication and prohibited the administration of expired medications. The failure to verify the expiration date prior to administration led to the deficiency.
Failure to Obtain and Document Weekly Weights and Reweight for Resident with Significant Weight Loss
Penalty
Summary
A deficiency occurred when the facility failed to follow physician's orders for obtaining weekly weights and a reweight for a resident with significant weight loss. The resident, who had diagnoses including dysphagia, aphasia, and type 2 diabetes mellitus, was admitted with a care plan that identified risks for weight loss and required weekly weights on shower days. Despite these orders, documentation showed that weights were only recorded on two occasions over a period of several weeks, revealing a severe weight loss of 20.8 pounds (14.4%) in two weeks. Additionally, a physician's order for a reweight to verify this loss was not carried out as directed. Interviews with staff confirmed that nurse aides were responsible for obtaining weights and nurses were to check and transcribe them into the electronic health record. However, review of records and staff interviews indicated that the required weekly weights and the ordered reweight were not completed as per protocol. The facility's policy also required retaking weights after significant changes and notifying the dietician, but these steps were not documented as completed at the time of the survey.
Failure to Maintain Proper Medication Storage and Labeling
Penalty
Summary
Surveyors observed multiple failures in the facility's medication storage practices, including the presence of expired and unlabeled medications in both the medication room and medication carts. Specifically, expired Diphenhydramine capsules and Beneprotein packets were found in the South Wing medication room, along with opened, unlabeled, and undated containers of Miconazole Nitrate cream and Lactulose solution. Food items such as coffee creamers, sugar packets, and a foam takeout container with utensils were also stored alongside medications. Additionally, drawers contained non-medication items like curling irons, razors, charging cords, headphones, air pumps, glasses, and hearing aids. The Director of Nursing Services (DNS) confirmed that these items should not be present in the medication room and that expired or discontinued medications should be placed in designated bins for pharmacy return, not stored in cabinets or on countertops. Further observations revealed improper storage of medications in the nursing supervisor's office, where a box of Juven packets and multiple bottles of Kayexalate were found on a shelf. The nursing supervisor was unsure why the Juven packets were there and acknowledged that the Kayexalate bottles, intended for the Pyxis system, did not fit in the drawers and should not have been stored in the office. Medication carts were also found to contain expired medications, opened and unlabeled containers, loose pills, and non-medication items such as hairbrushes, glasses, lancets, and wound care products. Staff interviewed, including LPNs and the Infection Preventionist, recognized that expired medications and non-medication items should not be stored in the carts but could not explain why these items were present. The facility's policy requires that all medications be stored in properly labeled containers, separated by route of administration, and that medication storage areas remain clean and free of clutter. The policy also mandates that opened medication containers be dated and that expired medications be removed and destroyed. Despite these policies, the facility failed to maintain proper medication storage practices, as evidenced by the presence of expired, unlabeled, and non-medication items in medication storage areas and carts. No policy on medication cart cleaning was provided upon request.
Failure to Consistently Document Meal Intake for Resident with Significant Weight Loss
Penalty
Summary
The facility failed to ensure consistent documentation of meal intake percentages for a resident with significant weight loss and multiple complex medical conditions, including dementia, dysphagia, severe protein-calorie malnutrition, and type 2 diabetes mellitus. The resident's care plan required monitoring of dietary intake, and clinical notes indicated ongoing weight loss and poor oral intake, averaging around 50%. However, review of nurse aide documentation revealed multiple instances where meal intake percentages were not recorded for breakfast, lunch, and dinner over several days in April and May. This lack of documentation occurred despite the resident's ongoing nutritional decline and the need for accurate intake records to inform care decisions. Interviews with facility staff, including the dietician and Director of Nursing Services (DNS), confirmed that nurse aides were expected to document meal intake accurately and consistently for all residents, especially those with significant weight loss. The dietician relied on this documentation to calculate intake trends and guide treatment, while the DNS was unaware of the omissions until the review. The facility was unable to provide a specific policy regarding nurse aide documentation, though staff reported that training on electronic documentation was provided. The deficiency was identified due to the failure to maintain complete and accurate medical records in accordance with professional standards.
Failure to Communicate MDRO Status During Resident Transfers
Penalty
Summary
The facility failed to ensure that the MDRO (Multi-Drug Resistant Organism) colonization status, special instructions, or precautions for ongoing care were communicated to the receiving hospital at the time of transfer for two residents. In both cases, the residents had documented MDROs, including ESBL Klebsiella and MRSA, as confirmed by laboratory results and the facility's MDRO log. Despite this, nursing notes and transfer documentation did not indicate that this information was shared with the hospital during the transfer process. The facility's process relied on verbal communication, but there was no documentation to confirm that the MDRO status or necessary precautions were conveyed to the hospital. For both residents, the face sheets provided at transfer did not include MDRO diagnoses, and the electronic transfer/discharge documentation was not utilized. Interviews with facility staff, including the Infection Preventionist, DNS, and Regional Nurse, confirmed that the required information was not documented or retained. Additionally, the facility's policy on MDRO control did not specify the requirement to notify the hospital upon transfer, and the policy on MRSA only partially addressed inter-agency notification. These actions and omissions led to the deficiency in communicating critical infection control information during resident transfers.
Failure to Include Resident in Person-Centered Care Planning
Penalty
Summary
A deficiency occurred when the facility failed to include a resident in the development and implementation of their person-centered plan of care. The resident, admitted with diagnoses including dysphagia, aphasia, and Type 2 diabetes mellitus, was identified as having a decline in intellectual functioning and was noted as the guarantor and care conference contact. Despite being severely cognitively impaired and requiring substantial assistance with daily activities, the resident was documented as an active participant in assessment and goal setting, with a goal to return to the community. The facility was unable to provide evidence that a resident care conference (RCC) was held or that the resident or their alternate was invited to participate. There was no RCC attendance sheet, nor documentation from social services or the MDS coordinator indicating that the meeting took place or that the resident was invited. Facility policy required a care plan conference with the resident or responsible party within 48-72 hours of admission and quarterly thereafter, but interviews with staff confirmed that this did not occur for the resident in question.
Failure to Complete PASRR Level 1 Screening for New Admission with Mental Health Diagnoses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a Level 1 Pre-admission Screening and Resident Review (PASRR) was completed for a new admission with diagnoses of major depressive disorder, anxiety disorder, and post-traumatic stress disorder. The resident was admitted with a PASRR Level 1 screen dated several years prior from a previous LTC stay, which was negative at that time. The facility relied on this outdated PASRR Level 1 screen and did not conduct a new screening upon admission, despite the resident's current mental health diagnoses. Interviews with facility staff, including the Administrator and Social Worker, confirmed that the process involved reviewing PASRR outcomes received from the discharging facility. The Social Worker acknowledged that a new PASRR Level 1 screen should have been conducted for a resident admitted with mental disorders, but could not provide a reason for the omission. Facility policy and state procedures require that individuals with known or suspected serious mental illness be evaluated through the PASRR process prior to admission, which was not followed in this case.
Failure to Notify POA of Hospital Transfer and Medication Changes
Penalty
Summary
The facility failed to ensure timely notification of a resident's Power of Attorney (POA) regarding significant changes in the resident's condition, hospital transfer, and medication changes. Specifically, a resident with diagnoses including congestive heart failure, chronic kidney disease, tremors, and anxiety was transferred to the hospital for lethargy, altered mental status, low oxygen saturation, and bradycardia. Documentation did not show that the POA was notified of the change in condition or the hospital transfer. The POA only learned of the hospital admission after being contacted by the hospital and was later informed by facility staff upon the resident's return. The Director of Nursing confirmed that the supervising nurse was responsible for the notification, but the reason for the failure to notify was not identified. Additionally, the facility did not notify the correct legal representative regarding medication changes. Nursing notes indicated that another individual, not the POA, was informed about changes in the resident's medication regimen, including the initiation and discontinuation of Clonazepam and a neurology referral. Facility policy required immediate notification of the resident's legal representative for significant changes in treatment or condition, but this was not followed in these instances.
Failure to Document Provider Notification of Delayed X-ray After Resident Fall
Penalty
Summary
The facility failed to ensure that the clinical record for a resident was complete and accurate regarding physician or APRN notification when an ordered x-ray was delayed following a fall. The resident, who had diagnoses including Alzheimer's disease, dementia, and anxiety, was identified as a fall risk and required maximum assistance for transfers. After a fall during a transfer, the resident complained of left lower extremity pain, and an x-ray was ordered. However, when the radiology provider informed nursing staff that the x-ray would be delayed due to staffing issues, there was no documentation in the clinical record that the physician or APRN was notified of this delay. Interviews revealed that the APRN was not informed of the delay while present in the facility, nor was the on-call service notified, as confirmed by the APRN. Although a nurse stated she notified the on-call physician team, she could not verify whom she spoke to and did not document the notification in the clinical record. The Director of Nursing confirmed that the expectation was for nursing staff to document provider notifications, which was not done in this case. The facility also did not have a policy related to documentation.
Failure to Prevent Resident-to-Resident Sexual Abuse
Penalty
Summary
A deficiency occurred when a resident with cognitive impairment and lacking the capacity to consent was subjected to inappropriate physical contact by another resident. The incident was captured on a video camera installed in the cognitively impaired resident's room for virtual visitation purposes. The video showed an alert and oriented resident entering the room, kissing the cognitively impaired resident on the mouth, and touching the resident's breast. The incident was witnessed by the spouse of the cognitively impaired resident, who then informed facility staff. Documentation and interviews confirmed that the cognitively impaired resident was only alert to self, had baseline confusion, and required supervision or assistance with most activities of daily living. Facility records and staff interviews indicated that the resident who initiated the contact was aware of their actions and admitted to initiating the physical contact. The facility's abuse prevention policies explicitly prohibit any form of abuse, including sexual abuse, and only permit sexual expression between consenting adults. Despite these policies, the facility failed to prevent the incident, resulting in a substantiated case of sexual abuse due to the lack of consent capacity in the affected resident.
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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 Newington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Civita Care Center At Newington | 0.7 mi | ★★★★★ | 42 | 1 |
| Jefferson House | 1.7 mi | ★★★★★ | 0 | 0 |
| Grandview Rehabilitation And Healthcare Center | 2.8 mi | — | 14 | 1 |
| Autumn Lake Healthcare At New Britain | 3.4 mi | ★★★★★ | 0 | 0 |
| Monsignor Bojnowski Manor | 3.4 mi | ★★★★★ | 3 | 0 |
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