Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avalon Health Care Center At Stoneridge during CMS and state inspections, most recent first.
A resident with cognitive impairment and mood disorder was verbally abused by a staff member, who loudly told the resident to "shut up" while the resident was upset and seated at the nurse's station. Multiple staff witnessed the incident, and the resident reported being told not to speak and described the staff member as mean. The event was confirmed through staff statements and facility documentation, constituting a violation of the resident's right to be free from verbal abuse.
A witnessed incident of verbal abuse by a staff member toward a resident with cognitive impairment and anxiety was not reported to the Administrator or designee within the required two-hour window. The event, which involved inappropriate remarks and distress to the resident, was not disclosed by the witnessing staff until the following day, contrary to facility policy.
A resident with Parkinson's disease fell from a wheelchair during transport due to the absence of leg rests, contrary to facility policy. The nursing aide did not ensure the use of leg rests or inform the nurse of the resident's refusal, resulting in the resident sustaining injuries and requiring hospital evaluation.
A resident with multiple medical conditions was observed using a splint, but the facility failed to document its use in the care plan or physician's orders. Staff interviews revealed a lack of communication and documentation regarding the splint, and the facility's policies on care plans and assistive devices were not followed.
A resident with rheumatoid arthritis and fractures used a splint on their left arm without a physician's order in place. The facility failed to document the splint's use in the care plan or nurse aide care card. Staff interviews revealed assumptions and communication gaps regarding the responsibility for obtaining the necessary order and training. The facility's policy on assistive devices was not followed, resulting in a deficiency.
Verbal Abuse of Resident by Staff Member
Penalty
Summary
A deficiency occurred when a resident with cognitive impairment, anxiety, and a mood disorder was verbally abused by a staff member. The resident, who had memory recall deficits and exhibited verbal outbursts, was brought to the nurse's station during the night shift after being observed upset and requesting to return to bed. According to multiple staff witness statements and facility documentation, a nurse aide told the resident, "Well if you'd shut up, you wouldn't have to be out here," in a loud manner. The resident reported being left at the nurse's station for an extended period, told not to speak, and described the staff member as mean. The incident was corroborated by other staff members who overheard the exchange. The facility's investigation confirmed that the staff member's actions constituted verbal abuse, as defined by facility policy and the resident's rights documentation. The resident was noted to be upset following the incident and had difficulty sleeping, prompting a change in psychiatric medications. The staff member involved had previously completed elder abuse training, but still engaged in willful verbal abuse, violating the resident's right to be free from such treatment.
Failure to Timely Report Witnessed Verbal Abuse
Penalty
Summary
A witnessed allegation of staff-to-resident verbal abuse was not reported to the facility Administrator or designee within the required two-hour timeframe. The incident involved a resident with cognitive impairment and anxiety, who was observed to be upset after being placed in a recliner chair in front of the nurse's station and told by a nurse aide, "Well if you'd shut up, you wouldn't have to be out here." The resident expressed distress about being left at the station and instructed not to speak. The event was witnessed by another nurse aide, but it was not reported to the supervising nurse or administration during the shift when it occurred. The delay in reporting was confirmed through interviews and documentation review, which showed that the Director of Nursing was not notified until the following day, after a family member brought the incident to the attention of the nursing supervisor. Further investigation revealed that there were additional unreported instances of inappropriate staff communication with residents. The facility's policy required timely reporting of suspected or identified abuse, but this protocol was not followed in this case.
Failure to Use Wheelchair Leg Rests Leads to Resident Fall
Penalty
Summary
The facility failed to ensure the safety of a resident during wheelchair transport, resulting in a fall and injury. The resident, who had diagnoses including Parkinson's disease and was at risk for falls, was being transported by a nursing aide without the wheelchair leg rests in place. This was contrary to the facility's policy, which mandates the use of leg rests during transport to prevent injuries. The resident fell forward from the wheelchair after placing a foot on the floor, sustaining skin tears and a headache, and was subsequently sent to the hospital for evaluation. The resident's care plan had identified a risk for falls and included interventions such as ensuring the use of safety devices. However, during the incident, the nursing aide did not adhere to these interventions. The aide reported that the resident refused the leg rests, but did not attempt to re-approach or redirect the resident, nor did she inform the nurse of the refusal. Interviews with other staff indicated that the resident had not previously refused leg rests, and the facility's policy required staff to ensure leg rests are used and to notify a nurse if a resident refuses. The hospital evaluation revealed a subdural hematoma, although no fractures were found. The resident was admitted for observation, and a repeat CT scan showed no further concerns. The incident highlights a failure in following established safety protocols, as the nursing aide did not ensure the use of leg rests or communicate the resident's refusal to the nursing staff, leading to the resident's fall and subsequent injury.
Failure to Document and Plan for Assistive Device Use
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who was admitted with several medical conditions, including rheumatoid arthritis and multiple fractures. The resident was observed using a splint on the left arm, which was not documented in the physician's orders or the care plan. The care plan did not address the application, removal, or monitoring of the splint, nor did it include instructions for checking the resident's skin integrity related to the splint's use. Interviews with various staff members, including the Nursing Supervisor, MDS Coordinator, and Occupational Therapy Assistant, revealed that there was a lack of communication and documentation regarding the use of the splint. The Nursing Supervisor acknowledged that the care plan and physician's orders should have included details about the splint. The MDS Coordinator admitted that the care plan should have been updated to reflect the use of the splint, and the Occupational Therapy Assistant noted that the therapy department should have been notified to evaluate the device. The Director of Nursing Services and the Occupational Therapist confirmed that the resident's care plan should have included the use of the splint, and a physician's order was necessary to direct the appropriate care. The facility's policies on comprehensive care plans and assistive devices were not followed, leading to the deficiency in the resident's care plan documentation.
Lack of Physician's Order for Splint Use
Penalty
Summary
The facility failed to ensure a physician's order was in place for the use of a splint on a resident's left arm. The resident, who was admitted with conditions including rheumatoid arthritis and multiple fractures, was observed using a splint without a corresponding physician's order. The resident was dependent on staff for various activities and utilized a wheelchair. Despite the splint being used regularly, there was no documentation in the physician's orders, care plan, or nurse aide care card regarding its use. Interviews with various staff members, including nurses, nurse aides, and occupational therapists, revealed a lack of communication and assumption of responsibilities. The Charge Nurse and Nursing Supervisor acknowledged the absence of a physician's order and identified that it should have been obtained by the admitting nurse. The Occupational Therapist Assistance and Director of Rehabilitation also confirmed that a physician's order was necessary for the use of the splint, but it was not in place. The facility's practice required a physician's order, therapy evaluation, and staff training for assistive devices, but these steps were not completed. The Director of Nursing Services and other staff members assumed that the necessary documentation and training had been completed, but this was not the case. The facility's policy on assistive devices and equipment was not followed, leading to the deficiency. The lack of a physician's order and proper documentation for the splint's use was a clear oversight in the resident's care management.
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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 Mystic
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pendleton Rehabilitation And Nursing Center | 0.3 mi | — | 1 | 0 |
| Mystic Healthcare & Rehabilitation Center, Llc | 1.5 mi | — | 16 | 1 |
| Apple Rehab Mystic | 1.6 mi | — | 0 | 0 |
| Complete Care At Groton Regency | 5.2 mi | — | 13 | 0 |
| Royal Of Westerly Nursing Center | 6.3 mi | — | 9 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.