Cycle 1
Health 2024-06-18 · Fire 2024-06-18
13 health deficiencies
Top issue: Resident Assessment and Care Planning (5 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Brooklyn, CT
Pierce Memorial Baptist Home, Inc.
5-star overall rating with 4-star inspections with 13 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
44 Canterbury Road, Brooklyn, CT
(860) 774-9050
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
72
Certified beds
Average residents
68
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1974-03-31
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
0.91
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.64
Licensed practical nurse staffing · state 0.84 · national 0.87
Aide hours / resident day
2.25
Nurse aide staffing · state 2.28 · national 2.35
Total nurse hours
3.79
All reported nurse hours · state 3.83 · national 3.89
Licensed hours
1.55
RN + LPN hours · state 1.54 · national 1.54
Weekend hours
3.51
Weekend nurse staffing · state 3.41 · national 3.43
Weekend RN hours
0.72
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
1.01
CMS adjusted RN staffing hours
Adjusted total hours
4.23
CMS adjusted total nurse staffing hours
Case-mix index
1.23
Higher values indicate more complex resident acuity
RN turnover
20%
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
5,266
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
36.78
Composite VBP score used to determine payment impact.
Payment multiplier
0.9901
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.43
Baseline 18.25% · Performance 20.30% · Measure score 2.43 · Achievement 2.43 · Improvement 0
Healthcare-associated infections
2.13
Baseline 6.52% · Performance 7.20% · Measure score 2.13 · Achievement 2.13 · Improvement 0
Total nurse turnover
6.44
Baseline 36.23% · Performance 37.35% · Measure score 6.44 · Achievement 6.44 · Improvement 0
Adjusted total nurse staffing
3.70
Baseline 3.70 hours · Performance 4.13 hours · Measure score 3.70 · Achievement 3.70 · Improvement 1.58
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.45% |
10.72%
1.3 pts better
|
No Different than the National Rate · Eligible stays 107 · Observed rate 6.54% · Lower 95% interval 6.61% |
| Discharge to community | 53.37% |
50.57%
2.8 pts better
|
No Different than the National Rate · Eligible stays 83 · Observed rate 48.19% · Lower 95% interval 40.61% |
| Medicare spending per beneficiary | 0.8 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 60 · Denominator 60 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 60 |
| Discharge self-care score | 32.65% |
53.69%
21 pts worse
|
Numerator 16 · Denominator 49 |
| Discharge mobility score | 46.94% |
50.94%
4 pts worse
|
Numerator 23 · Denominator 49 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 60 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.2% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 62 · Observed rate 6.45% · Lower 95% interval 3.97% |
| Staff COVID-19 vaccination coverage | 3.05% |
8.2%
5.1 pts worse
|
Numerator 4 · Denominator 131 |
| Staff flu vaccination coverage | 42.75% |
42%
0.8 pts better
|
Numerator 56 · Denominator 131 |
| Discharge function score | 57.14% |
56.45%
0.7 pts better
|
Numerator 28 · Denominator 49 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 23 · Denominator 23 |
| Resident COVID-19 vaccinations up to date | 35.14% |
25.2%
9.9 pts better
|
Numerator 13 · Denominator 37 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
2.1
0.5 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.3 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
1.5
0.5 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.0 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.2% |
87.5%
11.7 pts better
|
93.4%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 98.4% · Q4 98.4% · 4Q avg 99.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.9% |
93.5%
3.4 pts better
|
95.5%
1.4 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.0% |
3.4%
1.6 pts worse
|
3.3%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 5.2% · Q3 6.6% · Q4 4.8% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.5% |
17.1%
16.6 pts better
|
11.4%
10.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% |
| Percentage of long-stay residents who lose too much weight | 5.0% |
6.4%
1.4 pts better
|
5.4%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 5.6% · Q3 7.0% · Q4 0.0% · 4Q avg 5.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.0% |
17.3%
3.3 pts better
|
19.6%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.8% · Q2 10.5% · Q3 14.8% · Q4 16.7% · 4Q avg 14.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 29.7% |
19.4%
10.3 pts worse
|
16.7%
13 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.7% · Q2 30.0% · Q3 30.6% · Q4 31.4% · 4Q avg 29.7% · 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 | 32.3% |
18.1%
14.2 pts worse
|
16.3%
16 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.7% · Q2 36.2% · Q3 41.0% · Q4 23.9% · 4Q avg 32.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 31.5% |
18.4%
13.1 pts worse
|
14.9%
16.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 37.7% · Q3 31.6% · Q4 32.1% · 4Q avg 31.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
0.9%
About the same
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 3.5% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.6% |
1.7%
1.9 pts worse
|
1.7%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 3.6% · Q3 1.8% · Q4 3.4% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.2% |
24.8%
5.4 pts worse
|
19.8%
10.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.8% · Q2 30.8% · Q3 28.0% · Q4 39.1% · 4Q avg 30.2% |
| Percentage of long-stay residents with pressure ulcers | 4.5% |
4.4%
0.1 pts worse
|
5.1%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 2.6% · Q3 7.1% · Q4 5.7% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
70.5%
29.5 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.6% |
11.1%
4.5 pts worse
|
12.0%
3.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.6% · Observed 13.8% · Expected 9.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.3% |
1.5%
0.2 pts better
|
1.6%
0.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.1% · Q3 2.4% · Q4 0.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 78.7% |
69.7%
9 pts better
|
79.7%
1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 78.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.3% |
25.0%
1.7 pts better
|
23.9%
0.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.3% · Observed 22.4% · Expected 22.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-03-17 · Fire 2022-03-17
3 health deficiencies
Top issue: Infection Control (1 deficiency)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2019-09-12 · Fire 2019-09-12
12 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-06-18
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2024-06-26
D · Potential for more than minimal harm
2024-06-18
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-06-26
F · Potential for more than minimal harm
2022-03-17
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-06-09
D · Potential for more than minimal harm
2022-03-17
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2022-06-09
D · Potential for more than minimal harm
2022-03-17
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-06-09
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-06-11
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 2025-06-26
D · Potential for more than minimal harm
2025-06-11
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 2025-06-26
D · Potential for more than minimal harm
2025-06-11
F940 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Corrected 2025-06-26
D · Potential for more than minimal harm
2025-05-05
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-05-24
D · Potential for more than minimal harm
2025-03-25
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 2025-04-10
D · Potential for more than minimal harm
2025-03-25
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-04-10
E · Potential for more than minimal harm
2024-06-18
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 2024-07-30
D · Potential for more than minimal harm
2024-06-18
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-07-30
D · Potential for more than minimal harm
2024-06-18
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-07-30
D · Potential for more than minimal harm
2024-06-18
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 2024-07-11
D · Potential for more than minimal harm
2024-06-18
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-07-11
D · Potential for more than minimal harm
2024-06-18
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-07-30
D · Potential for more than minimal harm
2024-06-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-30
D · Potential for more than minimal harm
2023-11-03
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-04-28
D · Potential for more than minimal harm
2023-11-03
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-04-28
D · Potential for more than minimal harm
2023-11-03
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-04-28
D · Potential for more than minimal harm
2023-03-21
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-04-30
D · Potential for more than minimal harm
2023-03-21
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-04-30
D · Potential for more than minimal harm
2022-03-17
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-04-28
D · Potential for more than minimal harm
2022-03-17
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2022-04-28
D · Potential for more than minimal harm
2022-03-17
F888 · Infection Control Deficiencies
Health
Ensure staff are vaccinated for COVID-19
Corrected 2022-04-28
D · Potential for more than minimal harm
2019-09-12
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2019-10-24
D · Potential for more than minimal harm
2019-09-12
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2019-10-24
D · Potential for more than minimal harm
2019-09-12
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 2019-10-24
D · Potential for more than minimal harm
2019-09-12
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2019-10-24
D · Potential for more than minimal harm
2019-09-12
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2019-10-24
D · Potential for more than minimal harm
2019-09-12
F761 · Pharmacy Service Deficiencies
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 2019-10-24
D · Potential for more than minimal harm
2019-09-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-10-24
Penalties and ownership
What sits behind the stars
Ownership
Apicella, Mary
Corporate Officer · Individual
Avena, Robert
Corporate Officer · Individual
Baule, Diana
W-2 Managing Employee · Individual
Chesser, Samuel
Corporate Officer · Individual
Crane, Micael
Corporate Officer · Individual
Jones, David
Corporate Officer · Individual
Kane, Mark
Corporate Officer · Individual
Mcmunn, William
Corporate Officer · Individual
Morse, Mary Patricia
Corporate Director · Individual
Morse, Mary Patricia
Contracted Managing Employee · Individual
Riesen, John
Corporate Officer · Individual
Stevens, Sandra
Corporate Officer · Individual
Thomas, Gregory
Corporate Officer · Individual
Wyand, Charles
Corporate Officer · Individual
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#3
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