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 July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Abbott Terrace Health Center during CMS and state inspections, most recent first.
A resident reported being hit by a staff member, but the LTC facility failed to report the allegation within the required timeframe. The incident was initially reported to a physical therapist, who informed a nurse, but the nurse did not escalate the report because the resident later denied the incident. The facility's policy requires immediate reporting of abuse allegations, but the incident was not reported to the appropriate authorities until two days later.
A resident with multiple diagnoses was found with medication left at her bedside, which she did not consume. An LPN left the medications intending to return but forgot, violating the facility's policy requiring staff to ensure medication is taken in their presence.
A resident with a history of falls and unsafe behaviors was not provided with a properly assessed wheelchair, leading to unsafe movements. Despite recommendations for specific wheelchair modifications, these were not implemented until after surveyor observations. Staff were unaware of the required modifications, and the resident was placed in a non-assigned wheelchair due to restlessness.
A resident with type II diabetes and dysphagia experienced a significant unverified weight loss due to the facility's failure to obtain and verify weekly weights as per the care plan. Despite the dietitian's repeated requests for re-weighs, the nursing staff did not respond, leading to a 21-pound weight loss without verification.
The facility failed to remove expired medications from medication carts and did not date a multiuse vial of insulin when opened. Observations revealed expired medications for several residents and an undated insulin vial. Interviews indicated confusion among staff about responsibility for checking expiration dates, with policies stating that licensed personnel should ensure compliance with storage requirements.
The facility failed to cohort residents with MDROs appropriately, did not review infection control policies annually, and neglected to conduct required environmental rounds and maintain water management logs. Two residents with different MDROs were placed together, and another resident without an MDRO history was cohorted with one who had a known MDRO. The infection control policies were not reviewed in 2022, and environmental rounds were incomplete in several months. Additionally, the facility did not maintain logs for water flushing and eyewash stations as required.
The facility failed to maintain an effective pest control program, leading to a resident environment infested with mice. Observations and interviews revealed mouse traps and droppings in resident rooms and common areas. Pest control services were suspended due to non-payment, resulting in increased mouse activity. The issue persisted despite attempts to mitigate it, such as purchasing food storage bins for residents.
The facility did not complete the required 12 hours of annual training for three nurse aides, missing essential topics like Resident Rights, Communication, and Behavioral Health. Training records for 2022 and 2023 were incomplete, and the Staff Development Nurse, who started in August 2023, could not locate the missing records. The Corporate Nurse was also unable to find the 2022 training records.
A resident with paraplegia and anxiety disorder, requiring total assistance for transfers, was not accommodated according to their preference to get out of bed following breakfast. Despite the availability of clean Hoyer pads in the laundry, staff did not retrieve one, resulting in the resident remaining in bed longer than desired. The nursing supervisor was not informed of the issue, and the resident was assisted out of bed later than preferred.
A resident transferred to the facility with diagnoses including schizophrenia and intellectual disabilities did not receive a required Level II PASRR evaluation. The Director of Social Work failed to request a new PASRR screening upon admission, despite the resident's serious mental health condition.
A resident with paraplegia and anxiety disorder had a care plan that failed to include their preference for getting out of bed after breakfast. Despite staff awareness, the resident often had to wait due to the unavailability of a Hoyer pad needed for transfers. The facility's policy required care plans to accommodate resident preferences, but this was not adhered to.
A resident with COPD, morbid obesity, and hypertension experienced chest pain and was transferred to the emergency department without a documented nursing assessment. Interviews revealed that the expected assessment was not completed, and the facility lacked policies for such assessments and chest pain protocol.
Two residents experienced deficiencies in care related to splint and treatment application. One resident, with left-sided weakness, did not have a splint consistently applied due to a lack of physician orders and documentation errors. Another resident, with contractures, did not receive prescribed rolled gauze treatment, which was inaccurately documented as completed by an LPN. These failures led to a decline in the residents' conditions.
A facility failed to maintain respiratory equipment and adhere to physician orders for a resident with COPD. The resident's oxygen tubing was not changed weekly as required, and the resident self-administered oxygen without a physician's order, despite being weaned off prior to admission. Staff were unsure of their responsibilities, and the facility's policy for oxygen administration was not followed.
A facility failed to provide constant supervision during a smoking session, leading to a resident with Parkinson's disease and identified as an elopement risk leaving the property unattended. The smoking attendant left the resident unsupervised, and the resident exited through a gate, walking about five minutes away before being brought back. The incident revealed lapses in supervision and record-keeping protocols.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of physical abuse involving a resident within the required timeframe as per their policy. The resident, who had intact cognition and required assistance with personal hygiene, reported to a physical therapist that the owner's daughter had hit them on the back. This allegation was made on 9/15/24, but the facility did not document or report the incident immediately as required. The resident's clinical records and facility documentation did not reflect any immediate communication, investigation, or protective measures following the reported abuse. Interviews with staff revealed that the allegation was not reported to the appropriate authorities or facility administrators until two days later, on 9/17/24. The resident had initially reported the incident to a physical therapist, who informed a nurse, but the nurse did not report it further because the resident later denied the incident when questioned. The facility's policy mandates that all allegations of abuse be reported to the administrator and state agency within two hours. However, due to a lack of proper documentation and communication among staff, this protocol was not followed. The delay in reporting and investigating the allegation of abuse resulted in a deficiency in the facility's compliance with its abuse reporting policy.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that a resident consumed her medication in the presence of a staff member, as required by their policy. The resident, who was admitted with diagnoses including chronic obstructive pulmonary disease, chronic respiratory failure, epilepsy, and hyperlipidemia, was observed with five medication tablets left in a cup at her bedside. The resident indicated that the medications were left for her to consume, but she did not want to take them. The medications included Januvia, Depakote Extended Release, Aspirin, AREDS, and Protonix, all of which were prescribed to be taken at 6:00 A.M. The incident was documented as a reportable event, and it was identified that an LPN left the medications at the bedside with the intention to return but forgot. The facility's policy on medication administration requires staff to stay with the resident until the medication is swallowed, which was not followed in this case. The Assistant Director of Nurses confirmed the LPN's actions during an interview, noting that the LPN received counseling and education regarding the incident.
Failure to Provide Properly Assessed Wheelchair for Resident
Penalty
Summary
The facility failed to provide a properly assessed seating system for a resident with a history of multiple falls and unsafe behaviors while seated in a wheelchair. The resident, who had diagnoses including vascular dementia and repeated falls, was observed in an adaptive wheelchair that was not correctly set up, leading to unsafe movements. Despite an occupational therapy evaluation recommending specific wheelchair modifications, these were not implemented until after surveyor observations. On the day of the survey, the resident was seen aggressively moving in the wheelchair, causing it to tip backward and connect with the wall, preventing a complete tip-over. Staff interviews revealed that the resident was placed in a non-assigned wheelchair due to restlessness and the need for supervision, but the staff was unaware of the specific wheelchair modifications required. The Assistant Director of Nurses confirmed that the recommended adaptive wheelchair was not provided until after the surveyor's observations.
Failure to Verify Resident Weight Discrepancy
Penalty
Summary
The facility failed to obtain and verify weights for a resident, leading to a significant weight discrepancy. Resident #88, who had diagnoses including type II diabetes, protein-calorie malnutrition, and dysphagia, was identified as being at nutritional risk following a recent hospitalization. The care plan required weekly weights, but the facility did not record weights for three successive weeks. A significant weight loss of 21 pounds (13%) was noted without a re-weight to verify the discrepancy. Despite the dietitian's requests for re-weighs through the facility's internal communication system, these requests were not responded to by the nursing staff. The facility's policy required re-weighs for weight changes of 5 pounds or more, but this was not adhered to in the case of Resident #88. The dietitian had made dietary amendments to address the potential weight loss, but the lack of re-weighs hindered the verification process. Interviews with the dietitian and the Regional Corporate Nurse confirmed that the nursing staff was responsible for completing weights and reporting discrepancies, which did not occur as required. This failure to follow protocol resulted in an unverified significant weight loss for the resident.
Expired Medications and Undated Insulin Vial Found in Medication Carts
Penalty
Summary
The facility failed to ensure expired medications were removed from medication carts and that a multiuse vial of insulin was dated when opened. During an observation of the 4th floor medication cart #2, it was found that a resident had five blister packs of expired medications, including Levetiracetam, Eliquis, and Clopidogrel, with expiration dates ranging from February to May 2024. Additionally, another resident's blister pack of Trazodone was also expired. An LPN indicated uncertainty about who was responsible for checking the medication cart, although it was suggested that the nurse on duty when medications arrive is responsible for putting them away and rotating stock. Further observations of the 4th floor medication cart #1 revealed a vial of Glargine insulin without an opening date and several expired medications for different residents, including Olanzapine, Darifenacin, Glipizide, Jardiance, and Mirtazapine. Interviews with nursing staff and pharmacy personnel indicated that all nurses were responsible for rotating stock and checking expiration dates, with the night shift nurse specifically tasked with this duty. The facility's policy requires medications to be stored according to manufacturer's specifications and state and federal requirements, with licensed personnel responsible for checking expiration dates.
Infection Control and Cohorting Deficiencies
Penalty
Summary
The facility failed to appropriately cohort residents with known Multidrug Resistant Organism (MDRO) colonization. Specifically, two residents with different MDROs were placed in the same room, contrary to the facility's policy that residents with colonized or infected MDROs should not be placed with roommates who are severely immunocompromised or have indwelling lines or open wounds. Additionally, another resident without a history of MDRO was cohorted with a resident with a known history of a colonized MDRO, which was against the facility's policy that residents with similar MDRO infections should be cohorted when possible. The facility also failed to review its infection prevention control program policies and procedures annually, as required. The review of the facility's Infection Control Program Policies and Procedure manual revealed that the policies and procedures manual was not reviewed in the year 2022. This oversight was acknowledged by the staff, who indicated that it was the responsibility of the infection prevention nurse at the time to ensure the review was completed. Furthermore, the facility did not conduct environmental rounds as required. Documentation showed that quarterly environmental rounds were not completed by the nursing department in several months across 2022 and 2023, and were also incomplete for the laundry and housekeeping department in April 2023. Additionally, the facility failed to maintain a monthly log for water flushing of low flow areas and eyewash stations, as per the Facility Water Management Plan Policy. The facility was unable to produce completed logs for the year 2022, indicating a lack of adherence to the established water management protocols.
Deficiency in Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a resident environment that was not free from pests. Observations in multiple rooms, including Resident #58's room, revealed the presence of mouse sticky traps and fecal droppings, indicating an ongoing issue with mice. Interviews with residents and staff confirmed sightings of mice and droppings in various areas, including resident rooms and the nurse's station. The Director of Maintenance acknowledged that pest control services had been suspended due to non-payment, leading to an increase in mouse activity, with approximately 40 mice trapped during the interim period. The pest control services were only reinstated in May 2024, and the facility had not conducted a comprehensive building-wide bait trap refresh for two to three years. The Administrator was aware of the suspension of services and the ongoing pest issue, but efforts to mitigate the problem, such as purchasing bins for resident food storage, were insufficient. The contracted pest control company confirmed that services had been suspended and that a more extensive treatment plan was necessary to address the widespread issue.
Deficiency in Nurse Aide Training Compliance
Penalty
Summary
The facility failed to ensure that three nurse aides (NA#7, NA#8, and NA#9) received the required minimum of 12 hours of training per year, including essential topics such as Resident Rights, Communication, and Behavioral Health. Training records for 2022 and 2023 were incomplete, with specific in-service records for Communication and Behavioral Health missing. Although a training schedule for 2023 was provided, it did not confirm the completion of these trainings. The Staff Development Nurse, who assumed her role in August 2023 and began working onsite in October 2023, confirmed conducting Abuse training for 2023 but could not locate records for other required trainings. The Corporate Nurse was also unable to find the 2022 training records. Despite requests, a policy regarding training was not provided, only the 2023 training schedule was available.
Failure to Accommodate Resident's Transfer Preferences
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of a resident, identified as Resident #20, who required assistance to get out of bed according to their preferences. Resident #20, who had diagnoses including paraplegia and anxiety disorder, was moderately cognitively impaired and required total assistance with transfers using a mechanical lift. The resident's care plan specified that they should be assisted out of bed to a manual wheelchair at 10:00 AM daily. However, observations and interviews revealed that Resident #20 preferred to get out of bed following breakfast, but often had to wait longer than desired due to the unavailability of a Hoyer pad, which was necessary for the transfer. On the morning of the observation, the nursing assistants identified that the required Hoyer pad was in the laundry and unavailable for use, with no alternative pads available. Despite the availability of clean Hoyer pads in the laundry room, the staff did not retrieve one, resulting in Resident #20 remaining in bed longer than preferred. The nursing supervisor was not informed of the issue, and the Director of Nursing Services confirmed that staff were expected to retrieve a pad from the laundry if not available on the linen cart. The deficiency was observed when the resident was finally assisted out of bed at 11:00 AM, later than their preferred time.
Failure to Conduct PASRR Evaluation for Transferred Resident
Penalty
Summary
The facility failed to ensure a referral was made to the state mental health authority for a resident who was transferred from another nursing home and had a previous negative Level I PASRR. The resident, who was admitted with diagnoses including schizophrenia, intellectual disabilities, anxiety, and depression, did not receive a Level II PASRR evaluation upon transfer. The admission Minimum Data Set (MDS) assessment indicated that the resident had intact cognition and required assistance with hygiene, transfers, and ambulation, but did not have a Level II PASRR evaluation despite having a serious mental illness and/or intellectual disabilities. The Director of Social Work (SW #1) acknowledged responsibility for submitting PASRR screening requests and admitted that a new PASRR screening should have been requested upon the resident's admission due to their serious mental health condition. The oversight occurred because the resident's qualifying diagnoses were not reviewed at the time of admission, leading to the failure to submit a request for a new PASRR screening. The facility did not provide a policy addressing the PASRR screening process.
Failure to Revise Care Plan for Resident's Transfer Preference
Penalty
Summary
The facility failed to revise the comprehensive care plan for a resident with paraplegia and anxiety disorder to include their preference for getting out of bed. The resident was identified as moderately cognitively impaired and required total assistance with transfers using a mechanical lift. Despite the resident's preference to get out of bed following breakfast, the care plan did not reflect this, and the resident often had to wait longer than desired due to the unavailability of a Hoyer pad, which was necessary for their transfer. Interviews with staff and the responsible party confirmed awareness of the resident's preference to get out of bed by 9:00 AM. However, the staff did not consistently comply with this preference, as evidenced by the resident remaining in bed until 11:00 AM on one occasion due to the Hoyer pad being in the laundry. The facility's policy required the interdisciplinary team to develop and revise comprehensive care plans to accommodate resident preferences, but this was not done in this case.
Failure to Complete Nursing Assessment After Change of Condition
Penalty
Summary
The facility failed to complete a nursing assessment following a change of condition for a resident with chronic obstructive pulmonary disease, morbid obesity, and hypertension. The resident required extensive two-person assistance with bed mobility and transfers, and was prescribed medication to manage heart disease. The resident experienced chest pain and was transferred to the emergency department, but the clinical record did not include a documented change of condition or nursing assessment prior to the transfer. Interviews with the Director of Nursing and registered nurses involved revealed that a nursing assessment was expected but not completed. RN #1, the Nursing Supervisor at the time, acknowledged the lack of assessment, while RN #2 could not recall any assistance provided or documentation made. The facility was unable to provide policies for completing an RN assessment following a change of condition or for chest pain protocol and cardiac assessment.
Deficiencies in Splint and Treatment Application for Residents
Penalty
Summary
The facility failed to ensure proper application and documentation of splint usage for Resident #124, who was admitted with diagnoses including schizophrenia, cardiovascular accident with left-sided weakness, and anxiety. Despite having intact cognition and functional limitations in range of motion, the resident's care plan included interventions for pressure ulcer prevention and splint application. However, observations and interviews revealed that the splint was not consistently applied, and there was no physician's order for the splint in the electronic system. The resident reported that the splint and ace bandage for swelling were not applied as required, and the nurse aide care card did not reflect the need for a splint. The Rehabilitation Director and occupational therapist confirmed that the splint order was not reinstated after the resident's hospital readmission, leading to a decline in the resident's range of motion. Resident #159, with diagnoses including aphasia, hemiplegia, and contracture of the left hand and forearm, also experienced deficiencies in care. The resident's care plan required rolled gauze and inter dry application to the left hand to prevent further contraction and maintain skin integrity. However, observations showed that the treatment was not consistently applied, and the Treatment Administration Record was inaccurately signed off as completed by LPN #8, who admitted to being distracted by other tasks. The DNS confirmed that signing the TAR indicates task completion, and any omissions should be reported and documented. The facility's failure to adhere to treatment protocols and ensure accurate documentation resulted in deficiencies for both residents. The lack of consistent application of prescribed treatments and failure to reinstate necessary orders upon readmission contributed to the decline in residents' conditions. The facility's policies on treatment administration and documentation were not followed, leading to these deficiencies.
Failure to Maintain Respiratory Equipment and Adhere to Physician Orders
Penalty
Summary
The facility failed to maintain respiratory equipment and provide respiratory services in accordance with physician orders for a resident diagnosed with Chronic Obstructive Pulmonary Disease (COPD) and myocardial infarction. The resident's care plan indicated an activity in daily living deficit, and physician orders required weekly changes of oxygen tubing. However, observations revealed that the oxygen tubing was not changed within the specified timeframe, and staff were unsure of their responsibilities regarding the tubing change. The facility's policy directed that oxygen tubing should be replaced and dated weekly, but this was not adhered to, as evidenced by the tubing being dated beyond the seven-day requirement. Additionally, the resident was observed using oxygen intermittently without a physician's order, despite having been weaned off oxygen prior to admission. Interviews with staff and the resident confirmed that the resident self-administered oxygen when experiencing shortness of breath, although there were no physician orders for such use. The Director of Nursing acknowledged that there should not have been orders for oxygen tubing changes if there was no order for oxygen use, highlighting a lack of adherence to the facility's policy for oxygen administration by nasal cannula.
Failure to Supervise Resident During Smoking Session
Penalty
Summary
The facility failed to provide constant supervision during a smoking session, leading to a resident leaving the facility property unattended. Resident #1, who had diagnoses including Parkinson's disease and was identified as an elopement risk, was left unsupervised during a smoking break. The resident's care plan included interventions such as routine checks and the use of a wander guard, but these measures were not effectively implemented. On the day of the incident, the smoking attendant left the smoking area to handle a pack of cigarettes, during which time Resident #1 exited through a gate that had been opened for a car. The resident walked about five minutes away from the facility before being brought back by the smoking attendant, who had to run through a neighboring business's parking lot to catch up with the resident. The nurse's notes failed to document that Resident #1 had left the facility property during the smoking session, indicating a lapse in proper record-keeping and supervision protocols. Interviews with the Director of Nursing (DON) and the smoking attendant confirmed that the facility's policy required constant supervision of residents during smoking sessions. The DON stated that smoking attendants should not leave residents unattended and should wait until all residents have finished smoking before returning them to the building. Despite these policies, the smoking attendant left the residents unsupervised, leading to the elopement incident. The facility's smoking and elopement policies were not adhered to, resulting in a significant safety breach for Resident #1.
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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 Waterbury
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mattatuck Health Care Facility, Inc. | 0.5 mi | — | 0 | 0 |
| Autumn Lake Healthcare At Bucks Hill | 2.6 mi | ★★★★★ | 0 | 0 |
| Waterbury Center For Nursing & Rehabilitation Llc | 2.7 mi | ★★★★★ | 1 | 0 |
| Cheshire House Health Care Facility & Rehab Center | 3.2 mi | ★★★★★ | 2 | 0 |
| Apple Rehab Watertown | 3.5 mi | ★★★★★ | 14 | 0 |
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