Cycle 1
Health 2024-09-13 · Fire 2024-09-13
7 health deficiencies
Top issue: Resident Rights (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cheshire, CT
Elim Park Baptist Home, Inc
5-star overall rating with 4-star inspections with $8,018 in total fines with 7 recent health deficiencies
140 Cook Hill Rd, Cheshire, CT
(203) 272-3547
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
90
Certified beds
Average residents
77
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1976-03-20
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
0.77
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.91
Licensed practical nurse staffing · state 0.84 · national 0.87
Aide hours / resident day
2.82
Nurse aide staffing · state 2.28 · national 2.35
Total nurse hours
4.50
All reported nurse hours · state 3.83 · national 3.89
Licensed hours
1.68
RN + LPN hours · state 1.54 · national 1.54
Weekend hours
4.22
Weekend nurse staffing · state 3.41 · national 3.43
Weekend RN hours
0.57
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.15
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.83
CMS adjusted RN staffing hours
Adjusted total hours
4.88
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
42%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
35%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
344
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
72.49
Composite VBP score used to determine payment impact.
Payment multiplier
1.0235
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
8.10
Baseline 24.03% · Performance 18.01% · Measure score 8.10 · Achievement 7.38 · Improvement 8.10
Healthcare-associated infections
8.82
Baseline 5.47% · Performance 5.20% · Measure score 8.82 · Achievement 8.82 · Improvement 5.21
Total nurse turnover
6.59
Baseline 46.59% · Performance 36.73% · Measure score 6.59 · Achievement 6.59 · Improvement 4.03
Adjusted total nurse staffing
5.48
Baseline 4.11 hours · Performance 4.64 hours · Measure score 5.48 · Achievement 5.48 · Improvement 2.67
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.64% |
10.72%
1.1 pts better
|
No Different than the National Rate · Eligible stays 298 · Observed rate 8.05% · Lower 95% interval 7.47% |
| Discharge to community | 71.79% |
50.57%
21.2 pts better
|
Better than the National Rate · Eligible stays 297 · Observed rate 68.35% · Lower 95% interval 66.87% |
| Medicare spending per beneficiary | 0.79 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 99.37% |
95.27%
4.1 pts better
|
Numerator 158 · Denominator 159 |
| Falls with major injury | 0.63% |
0.77%
0.1 pts better
|
Numerator 1 · Denominator 159 |
| Discharge self-care score | 65.25% |
53.69%
11.6 pts better
|
Numerator 77 · Denominator 118 |
| Discharge mobility score | 61.02% |
50.94%
10.1 pts better
|
Numerator 72 · Denominator 118 |
| Pressure ulcers or injuries, new or worsened | 0.63% |
2.29%
1.7 pts better
|
Numerator 1 · Denominator 159 · Adjusted rate 0.67% |
| Healthcare-associated infections requiring hospitalization | 5.2% |
7.12%
1.9 pts better
|
No Different than the National Rate · Eligible stays 151 · Observed rate 1.99% · Lower 95% interval 2.89% |
| Staff COVID-19 vaccination coverage | 3.31% |
8.2%
4.9 pts worse
|
Numerator 5 · Denominator 151 |
| Staff flu vaccination coverage | 49.67% |
42%
7.7 pts better
|
Numerator 149 · Denominator 300 |
| Discharge function score | 72.03% |
56.45%
15.6 pts better
|
Numerator 85 · Denominator 118 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 91 · Denominator 91 |
| Transfer of health information to patient | 97.96% |
96.28%
1.7 pts better
|
Numerator 48 · Denominator 49 |
| Resident COVID-19 vaccinations up to date | 32.53% |
25.2%
7.3 pts better
|
Numerator 27 · Denominator 83 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.6 |
2.1
1.5 pts better
|
1.9
1.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.5 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.7 |
1.5
0.2 pts worse
|
1.8
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.3 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
87.5%
12.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 93.4% |
93.5%
0.1 pts worse
|
95.5%
2.1 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 93.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.7% |
3.4%
0.3 pts worse
|
3.3%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.4% · Q3 5.7% · Q4 6.0% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.5% |
17.1%
13.6 pts better
|
11.4%
7.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 2.0% · Q3 2.0% · Q4 6.7% · 4Q avg 3.5% |
| Percentage of long-stay residents who lose too much weight | 5.2% |
6.4%
1.2 pts better
|
5.4%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 4.3% · Q3 2.2% · Q4 8.5% · 4Q avg 5.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.2% |
17.3%
1.1 pts better
|
19.6%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.1% · Q2 19.1% · Q3 14.9% · Q4 14.9% · 4Q avg 16.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.7% |
19.4%
0.3 pts worse
|
16.7%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.9% · Q2 21.6% · Q3 18.9% · Q4 23.1% · 4Q avg 19.7% · 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 | 25.5% |
18.1%
7.4 pts worse
|
16.3%
9.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.8% · Q2 19.3% · Q3 24.3% · Q4 23.8% · 4Q avg 25.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 31.6% |
18.4%
13.2 pts worse
|
14.9%
16.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.0% · Q2 21.7% · Q3 28.9% · Q4 41.3% · 4Q avg 31.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
0.9%
0.1 pts better
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.1% · Q4 2.3% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.3% |
1.7%
0.6 pts worse
|
1.7%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 5.2% · Q3 0.0% · Q4 0.0% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.8% |
24.8%
4 pts worse
|
19.8%
9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.5% · Q2 46.2% · Q3 24.5% · Q4 25.3% · 4Q avg 28.8% |
| Percentage of long-stay residents with pressure ulcers | 9.9% |
4.4%
5.5 pts worse
|
5.1%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 13.3% · Q3 15.6% · Q4 4.6% · 4Q avg 9.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.4% |
70.5%
25.9 pts better
|
81.7%
14.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 93.6% · Q2 95.5% · Q3 97.3% · Q4 99.1% · 4Q avg 96.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.1% |
11.1%
5 pts better
|
12.0%
5.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.1% · Observed 5.3% · Expected 9.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.0% |
1.5%
0.5 pts worse
|
1.6%
0.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 3.4% · Q3 1.7% · Q4 1.1% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 83.9% |
69.7%
14.2 pts better
|
79.7%
4.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 83.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.6% |
25.0%
1.6 pts worse
|
23.9%
2.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.6% · Observed 23.7% · Expected 21.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-06-07 · Fire 2022-06-07
3 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2019-10-25 · Fire 2019-10-25
10 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-09-13
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 2024-10-11
E · Potential for more than minimal harm
2024-09-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-11
E · Potential for more than minimal harm
2024-09-13
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-10-11
D · Potential for more than minimal harm
2024-09-13
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-10-11
D · Potential for more than minimal harm
2024-09-13
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-10-11
D · Potential for more than minimal harm
2024-09-13
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-10-11
B · Minimal harm
2024-09-13
F570 · Resident Rights Deficiencies
Health
Assure the security of all personal funds of residents deposited with the facility.
Corrected 2024-10-11
G · Actual harm
2023-11-27
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 2023-12-24
D · Potential for more than minimal harm
2023-06-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-06-07
E · Potential for more than minimal harm
2022-06-07
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 2022-08-11
E · Potential for more than minimal harm
2022-06-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-07-30
D · Potential for more than minimal harm
2022-06-07
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-07-30
D · Potential for more than minimal harm
2019-10-25
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2019-12-06
D · Potential for more than minimal harm
2019-10-25
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2019-12-06
D · Potential for more than minimal harm
2019-10-25
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-12-06
D · Potential for more than minimal harm
2019-10-25
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 2019-12-06
D · Potential for more than minimal harm
2019-10-25
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2019-12-06
D · Potential for more than minimal harm
2019-10-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-12-06
B · Minimal harm
2019-10-25
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2019-12-06
B · Minimal harm
2019-10-25
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2019-12-06
Penalties and ownership
What sits behind the stars
$8,018
2023-11-27
Fine
Fine · fine $8,018
Fine
Ownership
Bedard, Brian
Corporate Officer · Individual
Brennan, Terrence
Corporate Director · Individual
Detzler, Wayne
Corporate Director · Individual
Ecker, Roberto
Corporate Director · Individual
Hoffman, Vicki
Corporate Director · Individual
Nelson, Chris
Corporate Director · Individual
Pascetta, Michelle
Corporate Director · Individual
Pascetta, Michelle
Corporate Officer · Individual
Pascetta, Michelle
W-2 Managing Employee · Individual
Ponzani, Timothy
Corporate Director · Individual
Swanson, Geoffrey
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Skyview Rehab And Nursing
Wallingford, CT
1-star overall rating with 1-star inspections with 13 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#2
Masonicare Health Center
Wallingford, CT
3-star overall rating with 3-star inspections with $13,085 in total fines with 9 recent health deficiencies with 19 fire-safety deficiencies in the latest cycle
#3
Civita Care Center At Cheshire
Cheshire, CT
3-star overall rating with 3-star inspections with 17 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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