13 health deficiencies
Top issue: Resident Rights (4 deficiencies)
8 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Southbury, CT
3-star overall rating with 3-star inspections with 13 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
990 North Main Street, Southbury, CT
(203) 264-9135
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
120
Certified beds
Average residents
114
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Ascentria Care Alliance
Operator or chain grouping
Approved since
1991-10-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
5 facilities
Chain averages 4 overall / 4 health / 4 staffing / 4 quality stars
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
RN hours / resident day
0.70
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.98
Licensed practical nurse staffing · state 0.84 · national 0.87
Aide hours / resident day
2.49
Nurse aide staffing · state 2.28 · national 2.35
Total nurse hours
4.17
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
3.52
Weekend nurse staffing · state 3.41 · national 3.43
Weekend RN hours
0.24
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.75
CMS adjusted RN staffing hours
Adjusted total hours
4.46
CMS adjusted total nurse staffing hours
Case-mix index
1.28
Higher values indicate more complex resident acuity
RN turnover
46%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
43%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Program rank
8,515
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
26.49
Composite VBP score used to determine payment impact.
Payment multiplier
0.9842
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
0
Baseline 17.35% · Performance 23.01% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0.75
Baseline 5.56% · Performance 7.61% · Measure score 0.75 · Achievement 0.75 · Improvement 0
Total nurse turnover
6.20
Performance 38.35% · Measure score 6.20 · Achievement 6.20 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
3.65
Baseline 4.18 hours · Performance 4.12 hours · Measure score 3.65 · Achievement 3.65 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.52% |
10.72%
1.2 pts better
|
No Different than the National Rate · Eligible stays 230 · Observed rate 6.52% · Lower 95% interval 6.88% |
| Discharge to community | 62.62% |
50.57%
12 pts better
|
Better than the National Rate · Eligible stays 212 · Observed rate 61.79% · Lower 95% interval 54.76% |
| Medicare spending per beneficiary | 0.93 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 99.5% |
95.27%
4.2 pts better
|
Numerator 198 · Denominator 199 |
| Falls with major injury | 0.5% |
0.77%
0.3 pts better
|
Numerator 1 · Denominator 199 |
| Discharge self-care score | 61.76% |
53.69%
8.1 pts better
|
Numerator 84 · Denominator 136 |
| Discharge mobility score | 67.65% |
50.94%
16.7 pts better
|
Numerator 92 · Denominator 136 |
| Pressure ulcers or injuries, new or worsened | 0.5% |
2.29%
1.8 pts better
|
Numerator 1 · Denominator 199 · Adjusted rate 0.44% |
| Healthcare-associated infections requiring hospitalization | 7.61% |
7.12%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 166 · Observed rate 6.63% · Lower 95% interval 5.24% |
| Staff COVID-19 vaccination coverage | 1.35% |
8.2%
6.8 pts worse
|
Numerator 3 · Denominator 222 |
| Staff flu vaccination coverage | 21.2% |
42%
20.8 pts worse
|
Numerator 60 · Denominator 283 |
| Discharge function score | 70.59% |
56.45%
14.1 pts better
|
Numerator 96 · Denominator 136 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 117 · Denominator 117 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 50 · Denominator 50 |
| Resident COVID-19 vaccinations up to date | 29.2% |
25.2%
4 pts better
|
Numerator 33 · Denominator 113 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
2.1
0.3 pts better
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.5 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
1.5
0.2 pts better
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.1 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.6% |
87.5%
7.1 pts better
|
93.4%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.9% · Q2 91.8% · Q3 97.6% · Q4 89.7% · 4Q avg 94.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 93.6% |
93.5%
0.1 pts better
|
95.5%
1.9 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 93.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.0% |
3.4%
1.4 pts better
|
3.3%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 2.4% · Q3 2.4% · Q4 1.1% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
17.1%
17.1 pts better
|
11.4%
11.4 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 who lose too much weight | 8.0% |
6.4%
1.6 pts worse
|
5.4%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 8.0% · Q3 11.8% · Q4 9.3% · 4Q avg 8.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.3% |
17.3%
4 pts worse
|
19.6%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.1% · Q2 25.6% · Q3 19.0% · Q4 18.3% · 4Q avg 21.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.0% |
19.4%
0.4 pts better
|
16.7%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.4% · Q2 18.5% · Q3 19.0% · Q4 16.1% · 4Q avg 19.0% · 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 | 21.3% |
18.1%
3.2 pts worse
|
16.3%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.1% · Q2 12.6% · Q3 19.4% · Q4 29.7% · 4Q avg 21.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 32.0% |
18.4%
13.6 pts worse
|
14.9%
17.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.6% · Q2 32.0% · Q3 33.8% · Q4 27.6% · 4Q avg 32.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.9%
0.9 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.5% |
1.7%
0.2 pts better
|
1.7%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 1.2% · Q3 1.2% · Q4 1.2% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.5% |
24.8%
0.3 pts better
|
19.8%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.3% · Q2 23.8% · Q3 26.7% · Q4 16.4% · 4Q avg 24.5% |
| Percentage of long-stay residents with pressure ulcers | 6.0% |
4.4%
1.6 pts worse
|
5.1%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 7.4% · Q3 5.7% · Q4 6.5% · 4Q avg 6.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 77.7% |
70.5%
7.2 pts better
|
81.7%
4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 81.8% · Q2 82.0% · Q3 77.9% · Q4 68.3% · 4Q avg 77.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.7% |
11.1%
1.4 pts better
|
12.0%
2.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.7% · Observed 8.2% · Expected 9.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.5%
0.7 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.8% · Q4 2.7% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 88.0% |
69.7%
18.3 pts better
|
79.7%
8.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 88.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.2% |
25.0%
2.2 pts worse
|
23.9%
3.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.2% · Observed 23.3% · Expected 20.4% · Used in QM five-star |
Survey summary
Top issue: Resident Rights (4 deficiencies)
8 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
12 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Top issue: Infection Control (2 deficiencies)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Fire safety
Fire Safety
Establish staff and initial training requirements.
Corrected 2025-07-17
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-07-17
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-07-17
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2025-07-17
Fire Safety
Have an alternate power supply for its alarm system.
Corrected 2025-07-17
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-07-17
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2025-07-17
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2025-07-17
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-10-11
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-10-11
Fire Safety
Establish emergency prep training and testing.
Corrected 2023-10-11
Fire Safety
Meet other general requirements.
Corrected 2023-10-11
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-10-11
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2023-10-11
Fire Safety
Have an alternate power supply for its alarm system.
Corrected 2023-10-11
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-10-11
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-10-11
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-10-11
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-10-11
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2023-10-11
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-08-31
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2021-08-31
Inspection history
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2026-01-08
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2026-01-08
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2026-01-08
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2025-07-29
Health
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Corrected 2025-07-29
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-07-29
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-07-29
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-07-29
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-07-29
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-07-29
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-07-29
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-07-29
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2025-07-29
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-03-18
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2025-01-28
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-11-04
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-09-20
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-09-06
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-10-10
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-10-10
Health
Respond appropriately to all alleged violations.
Corrected 2023-10-10
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-10-10
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-10-10
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-10
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-10-10
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2023-10-10
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2021-08-31
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2021-08-31
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2021-08-31
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-08-31
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2021-08-31
Health
Provide and implement an infection prevention and control program.
Corrected 2021-08-31
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2021-08-31
Penalties and ownership
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Corporate Officer · Individual
Corporate Director · Individual
Corporate Officer · Individual
Corporate Officer · Individual
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