Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Pines At Bristol For Nursing & Rehabilitation, The during CMS and state inspections, most recent first.
Multiple residents with post-surgical and chronic pain conditions had newly delivered controlled narcotic medications, including Hydromorphone and Oxycodone, ordered for PRN pain control and documented on their care plans. Facility procedures required two nurses to perform shift-to-shift narcotic counts, reconciling tablets in the locked medication box with Controlled Substance Disposition Records (Proof of Use sheets). Despite these systems, audits revealed that full blister packs of narcotics and their corresponding Proof of Use sheets were missing from the narcotic lock boxes and books, with no doses documented as administered. The DON’s investigations linked the timing and handling of these medications to an LPN who had received or had access to the narcotics on the affected units and concluded that this nurse likely diverted the missing medications, resulting in misappropriation of residents’ controlled drugs.
A resident with dementia, a history of multiple falls, impaired cognition, and on anticoagulant therapy was care planned and assessed as high risk for falls and required extensive assistance for toileting and mobility. Despite this, a NA toileted the resident and left the resident unattended in the bathroom to obtain supplies, knowing the resident tended to get up unassisted and should not be left alone. The resident was subsequently found on the floor between the bed and dresser with facial injuries, including a lip laceration, contusions, hematoma, and loose teeth, requiring emergency evaluation and treatment. Therapy staff, nursing staff, and the DNS all acknowledged that the resident required supervision for toileting and should not have been left alone, indicating a failure to provide adequate supervision to prevent accidents.
Misappropriation of Controlled Narcotic Medications by Nursing Staff
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from misappropriation of their controlled narcotic medications, specifically Hydromorphone and Oxycodone, for three residents. One resident with lumbar compression fracture, spinal stenosis, and heart failure was admitted with severe back pain and had an order for Hydromorphone 2 mg every six hours as needed. The resident was alert, oriented, and required moderate assistance for walking, and the care plan directed staff to administer pain medications as ordered. A subsequent physician order discontinued the Hydromorphone. During a controlled medication audit on the same day, the facility identified that the original white Controlled Substance Disposition Record (Proof of Use Sheet) and the associated blister card of 28 Hydromorphone 2 mg tablets were missing from the locked medication cart. Earlier that morning, the narcotic count completed by two LPNs showed the count as correct, and a later audit by the ADNS also verified the count and Proof of Use sheets as correct. Later that afternoon, the DON found that the Proof of Use sheet for the Hydromorphone blister pack was missing from the narcotic book and, upon checking the locked medication box after the assigned nurse left the unit, determined that the blister pack of 28 tablets was not present. Another resident, admitted after a right hip replacement with osteoarthritis and effective pain control, had physician orders for Hydromorphone 2 mg and 4 mg by mouth every four hours as needed for moderate and severe pain, respectively, with instructions to hold for sedation or shortness of breath and report to the provider. The resident’s care plan identified pain related to osteoarthritis and a medical procedure, with interventions to administer medications as ordered. A narcotic audit identified that a newly delivered blister pack of fifteen Hydromorphone 2 mg tablets and the corresponding white disposition sheet were missing from the unit narcotics lock box. The Hydromorphone blister pack had been received from the pharmacy three days earlier, and the DON’s review showed that the Proof of Use sheet was missing from the narcotic book three days after delivery. The DON narrowed possible staff involvement to three nurses but was unable to determine which nurse was responsible. A state Drug Control Division report later documented that two blister packs of Hydromorphone had been delivered and that an LPN on the 3–11 PM shift had confirmed receipt of the Hydromorphone for this resident. A third resident, admitted with a displaced left femur fracture and left hip replacement, was cognitively intact with a BIMS score of 15 and reported occasional pain. The care plan identified pain related to the fracture, with interventions to evaluate pain relief effectiveness and respond immediately to pain complaints. A physician ordered Oxycodone 5 mg, one tablet every four hours as needed for moderate hip pain and two tablets for severe hip pain. A reportable event documented that a new blister pack of fifteen Oxycodone 5 mg tablets and the matching white Proof of Use sheet were missing from the narcotic lock box. The facility had received two blister packs of Oxycodone 5 mg, each containing fifteen tablets, but only one blister pack was present in the lock box, and the MAR showed that no Oxycodone doses had been administered. An audit identified that the Proof of Use sheet for the missing Oxycodone blister pack was not included in the narcotic count on a prior evening, with the number of sheets in the book decreasing between the afternoon and late-night counts. The DON’s investigation suspected diversion but did not determine how the Oxycodone went missing. Across all three incidents, the DON identified the same LPN in connection with each investigation and concluded that the missing narcotics for these residents were likely taken by that LPN, while the facility’s abuse policy defined misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful use of a resident’s belongings without consent. The facility’s established system required two nurses to complete shift-to-shift narcotic counts, comparing the number of tablets in the locked medication box to the remaining count on the Proof of Use sheets, including counting the sheets themselves and signing off at each shift change. Any discrepancy was to be reported to a supervisor for immediate investigation. Despite these procedures, the missing Hydromorphone and Oxycodone blister packs and their associated Proof of Use sheets were not detected until audits revealed that both the medications and documentation were absent from the narcotic lock boxes and books. In each case, the missing medications were newly delivered controlled substances that had not been documented as administered, and the facility’s investigations did not establish how the medications were removed, resulting in misappropriation of residents’ controlled narcotic medications in violation of the facility’s abuse policy and residents’ rights to be free from misappropriation of property.
Late Opioid Administration and Failure to Follow Narcan Policy
Penalty
Summary
The deficiency involves the facility’s failure to administer opioid pain medication in accordance with physician orders and to follow its own policy regarding naloxone (Narcan) administration and post‑administration transfer to the hospital for one resident with chronic pain syndrome and overactive bladder. The resident’s care plan called for medications to be administered as ordered and for physician notification with significant changes in pain. A standing order directed Oxycodone 2.5 mg by mouth every four hours, scheduled at midnight, 4 AM, 8 AM, 12 PM, 4 PM, and 8 PM. Review of the MAR and automated medication dispenser records showed that the 4 AM dose on the relevant date was not documented with a clear administration time, and an Oxycodone 5 mg tablet was removed from the automated dispenser at 6:30 AM, with half discarded at 6:32 AM, indicating the 4 AM dose was administered approximately 2.5 hours late. The infection control nurse and other staff confirmed that this timing was late relative to the 4 AM schedule. Further review showed that the next scheduled Oxycodone dose, due at 8 AM, was changed to a one‑time 5 mg dose per APRN order and was administered at 9:16 AM. Pharmacy records indicated this 5 mg tablet was removed from the emergency dispenser at 9:13 AM. Staff interviews revealed that the resident’s regularly scheduled 2.5 mg dose was not available in the medication cart, prompting the supervisor to obtain an order for a one‑time 5 mg dose and to remove the medication from the emergency dispenser. The infection control nurse and RN staff noted that the interval between the 6:32 AM administration of half of a 5 mg tablet and the 9:13 AM removal of the next 5 mg tablet was less than the ordered every‑four‑hours schedule, and that the medications were not administered on time as ordered. The deficiency also includes failure to follow facility policy regarding naloxone administration and subsequent evaluation. After the one‑time 5 mg Oxycodone dose, nursing documentation described the resident as very sedated, with low blood pressure and decreased respirations, and an APRN ordered Narcan per standing orders. The MAR showed Narcan 4 mg intranasal was administered at 12:20 PM and again at 12:40 PM, while other documentation and interviews indicated the second dose was given at 12:55 PM, significantly later than the facility’s Naloxone Standing Order, which directed that a second dose be given two to three minutes after the first if there was no or only partial response. Staff, including the infection control nurse and APRNs, acknowledged that the second dose was not given within the policy‑specified timeframe and could not identify a reason for the delay. Additionally, the facility’s Narcan Administration Policy required that residents who receive naloxone be evaluated for transport to an emergency department, but record review showed the resident was not transferred to the hospital after receiving two doses of Narcan, and staff interviews confirmed that the resident remained in the facility per APRN direction despite the policy requirement. Title: Late Opioid Administration and Failure to Follow Narcan Policy ShortSummary: A resident with chronic pain received Oxycodone on a schedule that did not follow the q4h physician order, with one dose given late and the next one‑time 5 mg dose administered less than four hours after the prior dose. Documentation and automated dispenser records confirmed the timing discrepancies. After the higher opioid dose, the resident became very sedated with low BP and decreased respirations, leading an APRN to order intranasal Narcan. The first Narcan dose was given, but the second dose was delayed well beyond the 2–3 minute interval required by facility policy, and the resident was not transferred to the ED for evaluation after receiving two Narcan doses, despite a written policy directing evaluation for transport following naloxone administration.
Failure to Supervise High-Risk Dementia Resident During Toileting Resulting in Fall With Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent accidents for a resident with dementia who required staff assistance for toileting and ambulation. The resident had multiple diagnoses including dementia, prior fall with fractured femur, stroke, anxiety, history of falls, atrial fibrillation, and was on Apixaban, an anticoagulant. The care plan and fall risk evaluation identified the resident as high risk for falls due to confusion, limited mobility, incontinence, psychotropic medication use, seizure disorder, vision impairment, and multiple prior falls. The MDS documented moderately impaired cognition, frequent bladder incontinence, occasional bowel incontinence, and a need for extensive assistance with transfers, toileting, and personal hygiene. On the date of the incident, a nurse aide toileted the resident and then left the resident alone in the bathroom to obtain a brief, despite knowing the resident had a habit of getting up unassisted, wandered at times, was at risk for falls, and should not be left alone in the bathroom. The aide reported that other staff were busy, so she left the resident unattended on the toilet with a wheelchair present while she went to get supplies. When she returned, the resident was found on the floor between the bed and dresser, bleeding from the mouth and clutching underwear. Nursing staff were called to assess the resident, who was observed face down on the floor, bleeding from the lips but awake and alert at baseline. The resident was transferred to the emergency room, where evaluation documented a lower lip laceration requiring Dermabond, facial contusion, hematoma, loose upper teeth, and headache, with a CT scan showing no acute findings. Subsequent nursing documentation noted facial contusions, subluxation of a tooth, ecchymosis and swelling to the lip, chin, neck, and below the eye, and later fading bruising with mild pain but ability to chew and drink. Interviews with therapy staff, nursing leadership, and nursing staff confirmed that the resident required assistance of one for toileting, had dementia, was at high risk for falls, and should not have been left unattended in the bathroom. The facility’s fall prevention policy stated that residents at high risk for falls would have interventions initiated to prevent falls, but in this case the resident was left unsupervised, leading to a fall with injury.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 824 citations issued within 25 miles in the last 12 months — including the 9 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Bristol
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ingraham Manor Rehab And Nursing | 0.4 mi | ★★★★★ | 6 | 1 |
| Civita Care Sheriden Woods | 1.1 mi | ★★★★★ | 33 | 0 |
| Village Green Rehabilitation And Healthcare Center | 2 mi | ★★★★★ | 1 | 0 |
| Countryside Manor Of Bristol | 3.4 mi | — | 0 | 0 |
| Apple Rehab Farmington Valley | 4.6 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Pines At Bristol For Nursing & Rehabilitation, The.
100% money-back within 48 hours.
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.