Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 Apple Rehab Cromwell during CMS and state inspections, most recent first.
Failure to Timely Report Alleged Threat of Harm: The DON and APRN became aware of a credible report that a resident’s co-conservator may harm the resident in a possible murder/suicide involving insulin. The facility contacted police and barred the person from the building, but did not notify the State Agency within the required timeframe. The reportable event was submitted weeks later, despite the facility abuse policy requiring reporting within 2 hours of notification.
Failure to complete a thorough investigation of an abuse allegation involving a resident with severe cognitive impairment. Facility emails and staff interviews documented concerns that a family co-conservator had threatened to harm the resident with insulin, and police later trespassed the family member from the property. However, the DON stated no incident report or documented investigation was completed, no staff interviews or signed statements were obtained, and the event was not found on the state reporting website.
Incomplete documentation of a threat of harm and visitor restriction. A resident with severe cognitive impairment and diagnoses including diabetes and autism had a care plan noting aggression and skin-picking. The DON documented that a co-conservator was no longer allowed in the building, but the chart did not explain why. Facility emails, a police report, and later MD/APRN interviews described concerns that the co-conservator had threatened to kill the resident and self, including a possible murder/suicide plan, yet the medical record lacked documentation of the allegation and the reason for the visitation ban.
A resident with CKD, chronic AFib, and hypotension, who had no cognitive impairment and required extensive ADL assistance, preferred morning showers but was given bed baths instead. The resident said staff told him/her a bed bath was easier and that staff never asked about a shower. Although the shower was scheduled on the NA assignment sheet and the Resident Care Card noted a shower preference, the shower did not occur because staff could not find the correct mechanical lift pad and the resident was not offered another time.
Failure to notify the provider when an ordered bed cradle could not be used. A resident with dementia, PVD, and purpura had a care plan for skin breakdown/skin tears and a physician order for a bed cradle, but an LPN found the cradle broken and did not notify the MD/APRN or enter it in the maintenance log. The DON and APRN confirmed they were not informed that the ordered intervention could not be implemented.
Failure to Suspend Accused Aide After Abuse Allegation: A resident with MS, depression, anxiety, osteoporosis, and neuropathy reported that a NA was loud, rude, verbally abusive, and aggressive during direct care. The DON did not document the report, did not remove the aide from the schedule or unit, and did not suspend the accused staff member as required by the facility abuse policy, which called for immediate suspension without pay pending investigation.
Failure to Report Alleged Abuse: A resident with MS, depression, anxiety, osteoporosis, neuropathy, paraplegia, and intact cognition reported that a nurse aide was loud, rude, verbally abusive, and aggressive during direct care, including slamming items and doors. The DON said she spoke with the reporting person but did not recall being told the aide yelled at the resident, did not report the allegation to the State Agency, and had no documentation of the conversation or investigation.
Failure to Investigate Alleged Verbal Abuse: A cognitively intact resident with MS, paraplegia, and extensive ADL dependence reported that a nurse aide was loud, rude, verbally abusive, and aggressive during care. The DON said she spoke with a third party about the allegation but did not document the details, could not produce an investigation record or staff education documentation, and the facility policy required a formal abuse investigation with interviews, statements, and RN documentation.
Failure to Transcribe Physician Orders: A resident with paranoid schizophrenia, insomnia, and anxiety had new psychotropic and sleep medication orders written by a psych APRN, but the orders were not entered into the EHR as required. Staff interviews and record review showed the paper order was supposed to be transcribed by nursing, yet the discontinuation of Zyprexa and the change in Melatonin dose remained missing from the chart for several days until surveyor inquiry prompted transcription.
A resident with a recent hip fracture fell after losing balance, and although orthostatic BPs were ordered for 3 days, the results could not be found in the chart or DON office. Staff also could not locate the resident's post-fall condition documentation for the 72-hour period expected by facility practice. In a separate finding, a resident with dementia and skin breakdown risk had an alternating pressure mattress ordered at 150 lbs., but surveyors found it set at 100 lbs.; the LPN and DON confirmed the setting was incorrect.
Failure to provide a bed hold notification for a resident admitted to the hospital. The resident had chronic osteomyelitis, DM2, and ESRD, with a wound vac ordered for the left heel and limited assistance needs. The record lacked a bed hold notification form, and an RN said the Business Office handled these notices but was unsure why none was completed; the facility also stated it did not have a bed hold policy.
A resident with significant mobility deficits and a physician's order for two-person assistance during bed-level care was left vulnerable when a nurse aide provided care alone, as the care card did not specify the required assistance. This led to the resident falling from the bed and sustaining a head laceration requiring hospital treatment. The deficiency was due to the facility's failure to update documentation and ensure staff compliance with the prescribed level of assistance.
A resident with a history of stroke, Barrett's esophagus, and dysphagia, requiring pureed food with thickened liquids and 1 to 1 supervision for feeding, consumed fluid unsupervised. This led to aspiration and subsequent health complications, including hospitalization for aspiration pneumonia. Despite the facility's dysphagia policy, lapses in supervision and positioning allowed the resident access to liquids. Multiple staff members, including RNs, an SLP, and a COTA, were involved in the incident, highlighting the need for consistent adherence to supervision protocols.
The facility failed to follow proper infection control practices, including improper storage of bedpans for two residents, inadequate cleanliness in the laundry area, and an LPN not using appropriate hand hygiene and PPE during wound care for a resident with a deep tissue injury.
The facility failed to obtain and honor Advance Directives for three residents upon admission, leading to discrepancies between the residents' preferences and the physician orders. One resident had a DNR form without a physician's signature, another had an incomplete form due to a nurse's delay, and a third had an inconsistency between the admission note and the lack of a completed consent form.
A resident with cognitive impairments reported that a Nurse Aide (NA) yelled at and pointed her finger in the resident's face. Another staff member witnessed the incident, and the Director of Nursing Services (DNS) confirmed it could be classified as abuse. The facility's investigation supported the allegation of verbal harassment, and the NA received a written disciplinary action.
The facility failed to prevent a Nurse Aide from working during an investigation of mistreatment involving a resident with dementia and anxiety disorder. Despite the incident being reported to the Administrator, the Director of Nursing Services was not informed until several days later, allowing the Nurse Aide to continue working. This action was against the facility's policy, which mandates immediate suspension of the accused individual pending investigation.
The facility failed to report allegations of mistreatment and neglect involving two residents to the State Agency in a timely manner. One resident reported being yelled at and pointed at by a Nurse Aide, while another resident was left in a wet incontinent brief for several hours on two occasions. The incidents were not reported as required by facility policy.
A facility failed to promptly investigate an allegation of mistreatment involving a resident with cognitive impairments. The incident, where a nurse aide yelled at and pointed her finger at the resident, was reported to the Administrator but the investigation was delayed. The Director of Nursing Services acknowledged the delay and the facility's policy requiring immediate investigation was not followed.
The facility failed to properly transcribe and follow physician orders for two residents, leading to deficiencies in their care. One resident did not receive the correct wound treatment, and another did not receive required Braden Scale assessments and weekly body audits. Additionally, a third resident did not have their vital signs monitored as directed following the administration of the Influenza vaccine and a subsequent change in condition.
The facility failed to ensure proper pressure ulcer care and prevention for two residents. One resident did not receive required Braden scales and skin assessments, and another had a low air loss mattress set incorrectly due to lack of staff training. These deficiencies were confirmed through clinical record reviews and staff interviews.
The facility failed to ensure that a resident's monthly weight and reweight were obtained after a significant weight loss. Despite the Dietician's request for a reweight, it was not completed promptly, showing a lapse in adherence to the facility's weight monitoring policy.
A resident with acute respiratory failure and Covid-19 had their oxygen incorrectly set at 3 liters instead of the prescribed 2 liters. A Nurse Aide, unaware of her scope of practice, set the oxygen level, while the responsible LPN was occupied with other tasks. The Director of Nursing confirmed that only licensed staff should set oxygen levels.
The facility failed to ensure an LPN was trained on the proper setting of a low air loss mattress for a resident with pressure ulcers. The mattress was set incorrectly, potentially affecting the healing process, and the LPN admitted to not receiving the necessary training.
The facility failed to secure a controlled substance and a medication storage room. An unlocked controlled drug box containing Lorazepam was found, and the medication storage room door was propped open, leaving it unsecured. The facility's policy requiring double locking of controlled substances and secure storage of medications was not followed.
The facility failed to include and have available consultations from outside vendors in the paper or electronic chart for a resident with a right tibia fracture and other conditions. Staff interviews revealed that consults were kept in locked filing cabinets in the Rehabilitation room, inaccessible after hours, and the facility lacked a policy for outside vendor consultations.
The facility failed to post required information on how to file a complaint with the State Agency. A resident reported being unaware of the grievance process, and observations confirmed the absence of such postings. The Administrator could not provide a relevant policy and acknowledged the oversight.
The facility failed to maintain a safe, clean, and homelike environment, with issues such as a duct-taped call bell, a hole in the tile flooring, and a cluttered shower room. The Director of Maintenance was unaware of these problems, and environmental rounds had not been conducted since the Infection Control Nurse resigned.
Failure to Timely Report Alleged Threat of Harm
Penalty
Summary
The facility failed to ensure the State Agency was notified timely after it became aware of a reported threat of harm involving a resident. Resident #1 had diagnoses including diabetes, autism, and acquired absence of right toes, and a quarterly MDS assessment identified severe cognitive impairment with a BIMS score of 3. The resident’s care plan noted a risk for skin issues due to picking and scratching and that the resident could be verbally and/or physically aggressive. Person #1, Person #2, and Person #4 were co-conservators for the resident. On 4/10/2026, the facility received emails from the external State protective agency case worker stating that Person #2 had concerns that Person #1 might harm the resident, including a possible murder/suicide, and that the abuse/neglect division had recommended no unsupervised contact between Person #1 and the resident. The emails also stated that Person #1 had access to insulin and that there was concern the resident would not return if taken out on a leave of absence. The DON documented that Person #1 was no longer allowed in the building, and the facility contacted local police after APRN #2 reported that Person #1 had the means and a plan for the alleged murder/suicide. The police responded to the facility the same day and trespassed Person #1 from the premises after being informed that Person #1 had reportedly verbalized wanting to end the resident’s misery by injecting insulin. The DON later stated she did not notify the State Agency because she believed it was an unsubstantiated threat made by a third party, even though she acknowledged that allegations of abuse should be reported and that APRN #2 had advised the threat was credible. Review of the State Agency reportable event website did not identify a timely report, and the facility later submitted the reportable event form 32 days after receiving the email with the threat. The facility abuse policy required an online report to DPH within 2 hours of notification.
Failure to Complete Investigation of Abuse Allegation
Penalty
Summary
The facility failed to complete a thorough investigation of an allegation of abuse involving a resident with diabetes, autism, acquired absence of right toes, and severe cognitive impairment. The resident’s care plan identified a risk for skin picking and scratching and noted the resident could be verbally and/or physically aggressive. The resident also had co-conservators, including a family member who was later barred from the building after staff were notified that the family member was no longer allowed on the premises. The allegation involved a reported threat that the family member intended to harm the resident with insulin and that there was concern for a possible murder-suicide. Facility emails documented that the external protective agency had concerns about unsupervised contact and that the family member had access to insulin and a stockpile of insulin. The Medical Director later documented concern for the resident’s safety and noted that the external protective agency and corporate legal were updated, while the facility also contacted local police, who advised that the family member was not allowed on facility property. Despite awareness of the allegation, the DON stated she did not complete an incident report and had no documentation of an investigation. She reported no additional staff interviews were completed and no signed staff statements were obtained. The facility could not initially produce a police report, accident and incident report, involved party statements, or other documented investigation materials in the resident’s record or facility documentation. Review of the state reporting website also did not identify a reportable event submission for the allegation.
Incomplete Documentation of Threat of Harm and Visitor Restriction
Penalty
Summary
The facility failed to ensure the clinical record was complete and accurate to include documentation of a threat of harm to a resident. Resident #1 had diagnoses including diabetes, autism, and acquired absence of right toes, and a quarterly MDS assessment identified a BIMS score of 3, indicating severe cognitive impairment. The resident’s care plan identified risk for skin issues due to picking and scratching and noted the resident could be verbally and/or physically aggressive. Record review also showed that Person #1, Person #2, and Person #4 were co-conservators for the resident. On 4/10/2026, the DON documented that Person #1 was no longer allowed in the building, and staff were notified that Person #1 was not allowed on the premises. A body audit at that time noted no skin changes and that the resident appeared relaxed and followed simple commands. However, the record did not identify why Person #1 was prohibited from visiting, and it did not include documentation of the threat that led to the restriction. Additional record review showed a police report and facility emails describing concerns that Person #1 had threatened to kill the resident and him/herself, including mention of a possible murder/suicide plan and concern about the resident being taken on a leave of absence with Person #1. The Medical Director later documented being informed that Person #1 had made a threat to kill the resident and him/herself several weeks earlier, prompting police intervention and concern for the resident’s safety. Interviews with the APRN and DON confirmed the facility had been notified of the alleged threat and that the DON could not provide documentation in the medical record regarding the allegation or why Person #1 was not allowed to visit. The facility abuse policy required allegations of abuse by a visitor or family member to be reported immediately and documented in the resident’s record, and the nursing documentation policy directed that significant events be documented as soon as possible, ideally on the same shift.
Failure to Honor Resident Bathing Preference
Penalty
Summary
The facility failed to accommodate Resident #2’s choice for bathing and did not promote the resident’s self-determination regarding a preferred shower. Resident #2 had diagnoses including chronic kidney disease, chronic atrial fibrillation, and hypotension. The quarterly MDS identified a BIMS score of 15 with no cognitive impairment, extensive assistance needed for toilet use and bed mobility, and dependence on staff for transfers. The care plan identified the resident needed assistance with ADLs, including help with set up at the bedside or in the bathroom and assistance with tasks the resident could not perform. The resident stated that a morning shower was preferred, that it had been a long time since receiving one, and that staff told him/her a bed bath was easier for them to perform. The resident also stated staff never asked whether he/she wanted a shower. The resident’s shower was scheduled on the NA assignment sheet for Tuesday on the 7:00 AM to 3:00 PM shift, while the Resident Care Card directed a Tuesday shower on the 3:00 PM to 11:00 PM shift and noted the resident preferred showers and was dependent on staff for bathing. The resident later stated the shower did not occur because staff did not have the correct mechanical lift pad size until right before shift change and gave a bed bath instead, and the resident was not offered another time for a shower. NA #3 stated she was unaware the resident had not received the shower and would have offered one if she had known. LPN #1 stated the resident was supposed to receive a shower but did not due to difficulty finding the correct lift pad, and she should have followed up with the resident and informed the oncoming shift. The DON stated residents are to receive showers according to the Resident Care Card and that the facility would do what it could to accommodate a resident’s preferred shower day or time.
Failure to Notify Provider When Ordered Bed Cradle Could Not Be Used
Penalty
Summary
The facility failed to notify the physician when a physician order directing the use of a bed cradle could not be implemented for Resident #8. Resident #8 had diagnoses including dementia, peripheral vascular disease, and purpura, and a quarterly MDS showed a BIMS score of 3, dependence with chair/bed-to-chair transfers, maximal assistance needed for rolling, and risk for pressure injuries. The resident’s care plan identified risk for skin breakdown and skin tears, with interventions for gentle handling, skin inspection during care, and offloading heels while in bed. A physician order dated 10/2/25 directed that a bed cradle be applied to the bed and checked each shift for prevention/protection, but observation on 12/3/25 showed the bed cradle was not applied. An LPN stated the bed cradle was broken and had not been used since 11/30/25, that the issue had been reported to day shift on 12/1/25, and that she did not enter it into the maintenance log or notify the MD or APRN that the ordered bed cradle could not be used. The Director of Maintenance stated he had not been notified of the broken bed cradle until 12/3/25, and the DON stated nursing should have notified the APRN. The APRN stated she was not made aware the bed cradle could not be used as ordered and would have wanted notification; she also stated the bed cradle helped protect the resident from skin tears and that, if informed it was broken, she would have placed a hold on the order and ordered a different skin intervention.
Failure to Suspend Accused Aide After Abuse Allegation
Penalty
Summary
The facility failed to suspend an accused staff member according to its abuse policy after a report involving Resident #52. Resident #52 had diagnoses including MS, depression, anxiety, age-related osteoporosis, and hereditary and idiopathic neuropathy, and the quarterly MDS identified intact cognition, substantial to maximal assistance needs for bed mobility and upper body dressing, and full dependence for transfers, lower body dressing, and toileting hygiene. The care plan noted a right tibia fracture after a fall, risk for falls due to paraplegia, and the need for 2 staff with a mechanical lift for all transfers. Resident #52 stated that several months earlier, while speaking with Person #2, he/she became upset while describing a Nurse Aide who had provided aggressive care, was loud, rude, verbally abusive, and slammed items and doors while giving direct care to the resident and the roommate. Person #2 reported speaking with the DON about the incident and stated the DON removed the Nurse Aide from the resident’s assignment, while the DON stated she did not recall being told the aide yelled at the resident, did not document the conversation, did not remove the aide from the schedule, did not move the aide off the unit, and did not change the aide’s assignment, but only directed that the aide not care for Resident #52 going forward. The facility policy stated accused staff are to be immediately suspended without pay pending the investigation, but this did not occur.
Failure to Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of abuse to the State Agency for one resident who had multiple sclerosis, depression, anxiety, age-related osteoporosis, hereditary and idiopathic neuropathy, and intact cognition on the quarterly MDS. The resident was fully dependent for transfers, toileting hygiene, and lower body dressing, and the care plan identified a right tibia fracture after a fall, paraplegia, and the need for 2 staff with a mechanical lift for all transfers. During an interview, the resident stated that several months earlier a nurse aide had provided aggressive care, was loud, rude, verbally abusive, and slammed items and doors while giving direct care to the resident and the roommate. The Director of Nursing Services stated she had spoken with the reporting person about the allegation but did not recall being told that the nurse aide yelled at the resident, and said that was why she had never reported the allegation to the State Agency. She also stated she had not documented the details of the conversation and could only rely on memory. Although she said she investigated the matter and provided customer care education to the nurse aide, she was unable to provide documentation of the allegation or the investigation. The reporting person stated the nurse aide was verbally abusive and that the DON prohibited the nurse aide from entering the resident's room after the conversation.
Failure to Investigate Alleged Verbal Abuse
Penalty
Summary
The facility failed to conduct an investigation per its abuse policy after a resident reported that a nurse aide had been verbally abusive and aggressive during direct care. Resident #52 had multiple sclerosis, depression, anxiety, age-related osteoporosis, hereditary and idiopathic neuropathy, and was cognitively intact with a BIMS score of 15. The resident required substantial to maximal assistance with bed mobility and upper body dressing and was fully dependent on staff for transfers, lower body dressing, and toileting hygiene. The care plan identified the resident as having a right tibia fracture after a fall and being at risk for falls due to paraplegia, with transfers requiring two staff and a mechanical lift. During an interview, Resident #52 stated that a nurse aide was loud, rude, verbally abusive, and acted aggressively by slamming items and doors while providing care to the resident and the resident’s roommate. The resident said a third person reported the concern to the DON, after which the aide was removed from the assignment. The DON stated she spoke with the third person about the allegation but did not recall being told the aide yelled at the resident, and she did not document the details because she relied on memory. She said she conducted an investigation and provided customer care education, but could not produce documentation of either. The facility policy required nursing staff to document the incident, the Administrator/DNS or designee to initiate an investigation, interviews with witnesses and the accused, signed and dated statements, documentation of the outcome and corrective actions, and an RN assessment with nursing note documentation.
Failure to Transcribe Physician Orders
Penalty
Summary
The nursing facility failed to transcribe and implement new physician orders for Resident #7, whose diagnoses included paranoid schizophrenia, insomnia, and anxiety. The resident’s care plan identified a positive PASRR and included interventions for a yearly comprehensive psychiatric evaluation and ongoing evaluation of psychotropic medication effectiveness. A physician order signed by a psychiatric APRN on 11/25/25 directed that Zyprexa and Melatonin 6 mg be discontinued and that Melatonin 10 mg be started nightly, but the order was not entered into the electronic medical record at the time it was written. Record review and staff interviews showed the paper physician order sheets were not usually used, but facility policy required nurses to transcribe written paper orders into the electronic record. LPN #1 stated the 11:00 PM to 7:00 AM shift was responsible for reviewing the paper record every 24 hours to ensure orders were transcribed, and the DON confirmed the nurse on the shift when the order was written was responsible for transcription. A review of the electronic health record showed the discontinuation of Zyprexa and the change in Melatonin dose were missing for 7 days after the order was written. After surveyor inquiry, LPN #1 transcribed the orders into the electronic medical record.
Missed orthostatic BP documentation after fall and incorrect pressure mattress setting
Penalty
Summary
Resident #5, who had a diagnosis of fracture of the neck of the femur with subsequent encounter for closed fracture with routine healing, was identified as cognitively intact and at risk for falls due to psychotropic drug use, impaired safety awareness, and not always calling for assistance. After the resident was observed losing balance and falling to the floor with no complaints of pain or apparent injuries, the physician ordered orthostatic blood pressures to be obtained at bedtime for 3 days beginning 7/6/25. During record review, the nursing supervisor found that the first and third days were signed as completed, but the results of the orthostatic blood pressures could not be located in the clinical record or in the DON office. The nursing supervisor also could not locate documentation of the resident's condition for the 72 hours after the fall, which was expected per facility practice. Resident #44 had diagnoses including dementia, heart failure, and chronic obstructive pulmonary disease, and the quarterly MDS showed severe cognitive impairment, dependence for toileting hygiene and transfers, and use of a pressure reducing device for the bed. The care plan identified risk for skin breakdown due to decreased mobility and incontinence and directed staff to check the function of the air mattress every shift and set it to 150 lbs. A physician order also directed the alternating pressure mattress to be set at 150 lbs. and checked every shift. Survey observations found the mattress set at 100 lbs. on multiple occasions, and the LPN confirmed the setting was incorrect and had not been checked that shift. The DON also confirmed the mattress should have been set at 150 lbs. per the order.
Failure to Provide Bed Hold Notification
Penalty
Summary
The facility failed to ensure that a bed hold notification was provided for Resident #68 after the resident was admitted to the hospital. Resident #68 had diagnoses including chronic osteomyelitis, type 2 diabetes, and end stage renal disease, and was admitted following a surgical wound debridement and partial calcanectomy. The admission care plan included assisting with surgical follow-up appointments, providing treatment to the left heel as ordered, and changing the dressing 3 times a week. A physician’s order directed application of a wound vac to the left heel at 125 mm/Hg continuously with dressing changes on Tuesdays, Thursdays, and Saturdays. The resident’s MDS assessment identified the resident as cognitively intact and requiring limited assistance with bed mobility, transfers, and toilet use. A nurse’s note indicated the resident was admitted to the hospital due to concerns with osteomyelitis, but the clinical record did not include a copy of a bed hold notification form. During interview, RN #1 stated the Business Office was responsible for issuing bed hold notifications and was unsure why no bed hold notification form had been completed. The resident’s family representative picked up the resident’s belongings and the resident did not return to the facility, and the facility stated it did not have a bed hold policy.
Failure to Follow Two-Person Assist Order Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when staff failed to follow a physician's order requiring two staff members to assist a resident with bed-level activities, including turning and incontinent care. The resident, who had a history of stroke with right-sided hemiplegia and hemiparesis, morbid obesity, aphasia, and was on anticoagulant therapy, was dependent on staff for all activities of daily living and was at risk for falls. Despite these needs, the resident's care card did not specify the required two-person assist for turning and repositioning, and a nurse aide provided care alone during the incident. During the event, the nurse aide turned the resident without assistance, resulting in the resident falling off the bed and sustaining a scalp laceration that required hospital treatment and staples. Documentation and interviews confirmed that the resident had consistently required two-person assistance due to body size and right-sided weakness, and that this requirement was supported by physician orders and assessments. However, the care card was not updated to reflect this, leading to the nurse aide's decision to provide care alone unless the resident exhibited increased behaviors. Facility policies required that the care card be updated to reflect changes in the resident's plan of care, including assistance needs for positioning. The failure to update the care card and ensure staff followed the physician's order for two-person assistance directly contributed to the resident's fall and injury during routine care.
Aspiration Risk Management and Supervision Lapse
Penalty
Summary
The report details a deficiency in a nursing home related to the failure to ensure that liquids were not accessible to a resident on aspiration precautions. Resident #71, who had a history of cerebrovascular accident (stroke) with left-sided paralysis, Barrett's esophagus, and dysphagia, was identified as being at risk for aspiration. Despite being on a diet of pureed food with thickened liquids and requiring 1 to 1 supervision for feeding, Resident #71 was found to have consumed fluid unsupervised, leading to aspiration and subsequent health complications. Multiple staff members, including RNs, a Speech Language Pathologist (SLP), and an Occupational Therapy Assistant (COTA), were involved in the incident on 12/6/23. The SLP noted that Resident #71 attempted to self-feed and had difficulty following instructions, leading to the need for continued 1 to 1 supervision with meals. Interviews with staff members revealed that Resident #71 was found holding a cup of liquid unsupervised, resulting in coughing, aspiration, and ultimately hospitalization for aspiration pneumonia and other related complications. Observations and interviews indicated that despite the resident's known risk for aspiration and the facility's dysphagia policy in place, lapses in supervision and positioning led to the accessibility of liquids to Resident #71.
Infection Control Deficiencies
Penalty
Summary
The facility failed to follow proper infection control practices in several instances. For Residents #22 and #65, disposable medical equipment such as bedpans were improperly stored uncovered in the shared bathroom, despite facility policy requiring them to be covered and stored in individual bags. This was observed both before and after the room was cleaned by housekeeping staff. Interviews with the residents and the Director of Nursing Services (DNS) confirmed the improper storage practices, which were not in line with the facility's policy on bedpan storage. In the laundry area, the facility did not maintain a clean environment. Observations identified a moderate to significant coating of white/gray debris on various surfaces, including a wall-mounted fan, ceiling fan paddles, pre-dispensing chemical boxes and tubing, and dryer tops. Interviews with the laundry and maintenance supervisors revealed that they were unaware of the debris buildup, despite cleaning schedules indicating that these areas were regularly cleaned. This discrepancy suggests a failure in the facility's cleaning protocols and oversight. For Resident #44, who had a deep tissue injury to the coccyx, the facility failed to use appropriate hand hygiene and personal protective equipment (PPE) during wound care. An LPN was observed removing a soiled dressing and cleansing the wound without changing gloves or performing hand hygiene before applying a clean dressing. The DNS confirmed that the LPN did not follow the facility's policy, which requires changing gloves and sanitizing hands between handling soiled and clean dressings.
Failure to Obtain and Honor Advance Directives
Penalty
Summary
The facility failed to obtain and honor Advance Directives for three residents upon admission, leading to discrepancies between the residents' preferences and the physician orders. Resident #69 had a written Advance Directive Form indicating Do Not Resuscitate (DNR) status, but the form lacked a physician's signature, and a physician's order directed staff to perform Cardiopulmonary Resuscitation (CPR). The Director of Nursing (DNS) could not explain the discrepancy between the resident's preference and the physician's order, despite the resident's care plan indicating adherence to the resident's and physician's directives. Resident #474, who was cognitively intact and required assistance for transfers and personal hygiene, had an incomplete medical intervention consent form. The admitting nurse, RN #2, did not complete the form within the required 24 hours, believing the resident should sign it in the presence of a family member. The DNS and RN #5 were aware of the incomplete form but could not explain why it was backdated when it was eventually completed. The facility's policy required the form to be completed and signed within 24 hours of admission. Resident #572, admitted with diagnoses including atrial fibrillation and congestive heart failure, had an inconsistency between the admission nurse's note indicating DNR status and the lack of a completed Medical Interventions Consent Form. RN #4 did not complete the admission paperwork during her shift and passed the responsibility to the next shift. The form was eventually completed after surveyor inquiry, but the initial failure to complete it led to the resident being considered a full code. The facility's policy required the advance directives to be reviewed and completed upon admission, with a physician's order obtained regarding the code status.
Failure to Protect Resident from Verbal Harassment
Penalty
Summary
The facility failed to ensure that Resident #13 was not treated in a scolding manner. Resident #13, who has diagnoses including adjustment disorder with mixed anxiety and depressed mood, unspecified dementia, and anxiety disorder, reported an incident where Nurse Aide (NA) #3 yelled at and pointed her finger in the resident's face. This incident was corroborated by another staff member, NA #2, who witnessed NA #3 standing over Resident #13, bending at her waist, pointing in the resident's face, and yelling. The Director of Nursing Services (DNS) confirmed that the incident could be classified as abuse due to the willful action and confrontation by NA #3. The Administrator, who was also a witness, intervened to get assistance for Resident #13 on the day of the incident. Further interviews and record reviews revealed that NA #3 confronted Resident #13 about allegedly telling others that she was not providing care. NA #3 admitted to questioning Resident #13 but denied shaking her hand at the resident. The DNS provided documentation indicating that NA #3 received a written disciplinary action, and the facility's investigation supported the allegation of verbal harassment. The facility's policy on residents' rights mandates that residents be treated with consideration, respect, and full recognition of their dignity and individuality, which was not upheld in this case.
Failure to Suspend Staff During Abuse Investigation
Penalty
Summary
The facility failed to prevent a Nurse Aide (NA #3) from working during an investigation of mistreatment involving a resident with adjustment disorder, unspecified dementia, and anxiety disorder. The incident occurred when NA #3 was reported to have yelled at the resident and pointed her finger in the resident's face. Despite the report being made to the Administrator on 2/22/24, the Director of Nursing Services (DNS) was not informed until 2/28/24, and NA #3 continued to work at the facility during this period. The facility's policy mandates immediate suspension of the accused individual pending investigation, which was not followed in this case. The investigation summary and staff interviews confirmed that NA #3 worked on 2/27/24 and 2/28/24, even though the incident was under investigation. The DNS acknowledged that the staffing schedule should have been adjusted to prevent NA #3 from working during the investigation. The Administrator, who witnessed the incident, failed to notify the DNS promptly, leading to a delay in the investigation and non-compliance with the facility's abuse policy.
Failure to Report Allegations of Mistreatment and Neglect
Penalty
Summary
The facility failed to report an allegation of mistreatment involving two residents to the State Agency in a timely manner. Resident #13, who has diagnoses including adjustment disorder with mixed anxiety and depressed mood, unspecified dementia, and anxiety disorder, reported an incident where a Nurse Aide (NA) yelled at and pointed a finger in their face. This incident was witnessed by another NA and reported to the Administrator, but the Director of Nursing Services (DNS) was not informed until several days later. The DNS acknowledged that the incident should have been reported to the State Agency within two hours of notification, but it was not reported until prompted by the surveyor's inquiry. Resident #40, who has diagnoses including polyneuropathy, epilepsy, and adjustment disorder, experienced neglect in their care. The resident was left in a wet incontinent brief for several hours on two separate occasions and voiced concerns about developing a urinary tract infection. The DNS was unaware of these complaints until informed by the State Agency surveyor. The facility's policy requires immediate investigation and reporting of such incidents, but no Reportable Event document had been completed for these complaints. The VP of Clinical Services indicated they were still gathering data before submitting the report to the State Agency.
Failure to Investigate Allegation of Mistreatment Timely
Penalty
Summary
The facility failed to complete a thorough investigation after an allegation of mistreatment involving a resident with diagnoses including adjustment disorder, dementia, and anxiety disorder. The resident, who was moderately cognitively impaired and required extensive assistance, reported during a Resident Council meeting that a nurse aide had yelled at and pointed her finger in the resident's face over a month ago. The facility's investigation summary confirmed that the incident was reported to the Administrator on the day it occurred, but the investigation was not initiated or conducted in a timely manner. The Director of Nursing Services (DNS) acknowledged that the investigation should have been started immediately but was only formally initiated several days later when the incident was brought to her attention. The facility's policy mandates that all allegations of abuse or mistreatment be thoroughly investigated and acted upon immediately. However, the investigation into the incident involving the resident and the nurse aide was delayed, with witness statements only being obtained several days after the incident. The DNS was unsure when the investigation was fully completed, indicating a lack of timely and thorough investigation as required by the facility's policy. The Administrator, who was a witness to the incident, did not notify the DNS or initiate an investigation promptly, further contributing to the deficiency.
Failure to Follow Physician Orders and Conduct Required Assessments
Penalty
Summary
The facility failed to properly transcribe and follow physician orders for two residents, leading to deficiencies in their care. Resident #30, who was admitted with cellulitis, MRSA, and other conditions, did not receive the correct wound treatment as per the physician's updated orders. The orders to cleanse the wounds with Normal Saline and apply Calcium Alginate were not transcribed, resulting in the resident continuing to receive an outdated treatment. Additionally, the clinical record did not reflect any wound measurements upon admission until ten days later, when the wound physician measured them. The Director of Nursing Services (DNS) acknowledged that the updated treatment orders were not distributed to the floor nurses, leading to the incorrect treatment being administered. Resident #65, who had a right tibia fracture and was at risk for skin breakdown, did not receive the required Braden Scale assessments and weekly body audits as per physician orders. The clinical record showed that only the initial assessments were completed, and no further assessments were documented. The responsible nurse confirmed that these assessments should have been completed weekly but were not. The facility's policies on Braden Scale and body audits were not followed, resulting in a lack of ongoing monitoring for skin integrity. Resident #71, who had a cerebrovascular accident and dysphagia, did not have their vital signs monitored as directed by the physician following the administration of the Influenza vaccine and a subsequent change in condition. The clinical record lacked documentation of temperature monitoring after the vaccine and hourly vital signs following a hypoxic event. The Regional Nurse confirmed the omission and stated that staff should follow the APRN's orders as directed. These failures in following physician orders and facility policies led to deficiencies in the care provided to the residents.
Deficiencies in Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to ensure proper pressure ulcer care and prevention for two residents. Resident #31 was admitted with multiple diagnoses and was identified as being at mild risk for developing pressure ulcers. Despite physician orders and facility policy requiring weekly Braden scales and skin assessments, the clinical record lacked documentation for several scheduled assessments. Additionally, after the discovery of pressure ulcers on Resident #31's heels, a required Braden scale was not completed. Interviews with staff confirmed the absence of documentation and the failure to follow protocol after the onset of pressure ulcers. Resident #53, who had a history of cerebral vascular accident, dementia, and mitral valve insufficiency, was identified as being at moderate risk for pressure ulcers. A low air loss mattress was ordered for Resident #53 after the development of pressure ulcers. However, the mattress was not set according to the resident's weight, which could affect wound healing. The LPN responsible for setting the mattress was not trained on how to do so, and the incorrect setting was only discovered during an interview and observation with the Wound Physician. The Director of Nursing Services (DNS) confirmed that the low air loss mattress should be set according to the resident's weight and that the Charge Nurse is responsible for checking its function each shift. Despite the facility's policy and procedures, the lack of proper training and documentation led to deficiencies in pressure ulcer care for both residents.
Failure to Monitor Resident's Weight
Penalty
Summary
The facility failed to ensure that a monthly weight and reweight was obtained for Resident #53 after a significant weight loss. Resident #53, who had diagnoses including cerebral vascular accident, dementia, and mitral valve insufficiency, was weighed on 9/15/23 and not reweighed until 1/4/24. The resident was not weighed in February 2024. On 3/18/24, Resident #53 weighed 155 pounds, indicating a 21.5-pound loss since the previous weight on 1/4/24. Despite the Dietician's request for a reweight on 3/18/24, it was not completed promptly, and the resident had not been reweighed since then, showing a significant weight loss of 23.5 pounds over 87 days by 4/1/24. Interviews with the Dietician, Director of Nurses (DNS), and LPN #2 revealed that the facility's policy required reweights within 24 hours if there was a 5-pound discrepancy and monthly weights for residents. However, the policy was not followed, as Resident #53's weight from February was not completed, and the reweight requested on 3/18/24 was delayed. The Dietician expected a reweight the same day or the next day, but it was not done, indicating a lapse in the facility's adherence to its weight monitoring policy.
Failure to Administer Oxygen at Correct Setting
Penalty
Summary
The facility failed to administer oxygen at the correct setting for a resident with acute respiratory failure, Covid-19, and hypertension. The physician's order directed oxygen at 2 liters continuously to maintain oxygen saturation greater than 90%. However, observations on two separate occasions identified that the resident's oxygen was set at 3 liters instead of the prescribed 2 liters. The Treatment Administration Record indicated that the oxygen level had been checked and recorded as 2 liters, but this was not accurate according to the observations made by the surveyor. Interviews revealed that a Nurse Aide (NA) had set the oxygen level at 3 liters, unaware that this task was outside her scope of practice. The Licensed Practical Nurse (LPN) responsible for the resident's care admitted that she had not set the oxygen level that morning as she was busy with medication pass. The Director of Nursing confirmed that only licensed staff should set the oxygen levels for residents. The deficiency was identified when the surveyor observed the incorrect oxygen setting and confirmed it through interviews and record reviews.
Lack of Training on Low Air Loss Mattress Settings
Penalty
Summary
The facility failed to ensure that an LPN was trained on the proper setting of a low air loss mattress for a resident with pressure ulcers. The resident, who had a history of cerebral vascular accident, dementia, and mitral valve insufficiency, was identified as being at risk for developing pressure ulcers. Despite the care plan and treatment administration record specifying the use of a low air loss mattress and the need to check its function every shift, the LPN was observed to be unsure of how to set the mattress correctly. The mattress was set at 325, which was inappropriate for the resident's weight of 155 pounds, potentially affecting the healing of the pressure ulcers. The LPN admitted to not receiving training on setting the air mattress and had to rely on maintenance for assistance. The Wound Physician confirmed that the incorrect setting of the mattress could influence the healing process. The Director of Nursing stated that the training for setting the air mattress should have been part of the orientation process, but there was no documentation to confirm that the LPN had received this training. The deficiency was identified during an observation and interview with the Wound Physician and the LPN, highlighting a gap in the training and competency of the nursing staff in managing specialized equipment for residents at risk of pressure ulcers.
Failure to Secure Controlled Substances and Medication Storage Room
Penalty
Summary
The facility failed to properly secure a controlled substance and a medication storage room. During an observation of the East medication storage room, it was found that the controlled drug box inside the refrigerator was unlocked and contained an unopened bottle of Lorazepam, a schedule 4 controlled substance. Additionally, the padlock outside the refrigerator door was also found to be unlocked. The LPN present acknowledged the broken lock and stated that the Maintenance Department and the DNS had been notified, but no repairs had been made. The Director of Maintenance and the DNS both confirmed that they were unaware of the broken lock and that no maintenance request had been submitted. A review of the Facility Work Request Log did not show any documentation of the broken lock for maintenance to address. The facility's policy requires controlled substances stored in the refrigerator to be double locked, which was not adhered to in this case. Further observations revealed that the East medication storage room door was propped open with a garbage can, leaving it unsecured. This occurred while three visitors and four residents were in close proximity to the medication room, with no facility staff present in the area at that time. An LPN later admitted to propping the door open to quickly access supplies for a resident who had removed a dressing. The DNS confirmed that the medication storage room should have been secured and not left open. The facility's policy mandates that all medications and biologicals be securely stored in a locked cabinet, cart, or medication room, which was not followed in this instance.
Failure to Include and Access Orthopedic Consultations
Penalty
Summary
The facility failed to include and have available consultations from outside vendors in the paper or electronic chart for Resident #65, who had a right tibia fracture, history of falls, type 2 diabetes mellitus, and chronic kidney disease. The admission Minimum Data Set (MDS) assessment identified that Resident #65 was cognitively intact and required substantial assistance for bed mobility, was dependent for transfers, and required moderate assistance for personal hygiene. The Resident Care Plan indicated the need for follow-up with the orthopedic physician and other interventions. However, the clinical record did not contain any documentation or notes from the orthopedic provider that Resident #65 had seen. Interviews with staff revealed that orthopedic consults were not filed in the resident's chart and were instead kept in the Rehabilitation room's filing cabinets, which were locked and inaccessible after hours. The facility did not have a policy for outside vendor consultations, and staff could not access the consult sheets after therapy staff had left for the day. This lack of access to critical medical information could hinder the continuity of care for residents like Resident #65, who had multiple outside orthopedic appointments that were not documented in the clinical record.
Failure to Post Complaint Filing Information
Penalty
Summary
The facility failed to ensure the required information related to contact information and how to file a complaint to the State Agency was posted in the facility. During a Resident Council meeting, a resident stated they were not aware of how to file a grievance or make a complaint and had not observed any information within the facility to guide them. Subsequent observations on all units confirmed the absence of the required postings. The Administrator was unable to provide a policy for making residents aware of how to contact the State Agency and acknowledged the failure to post the necessary information.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for its residents. During an initial tour, it was observed that a resident's call bell was duct-taped to the wall, a room had a significant hole in the tile flooring, and the shower room used by 24 residents was cluttered with wooden pallets and boxes of supplies. The Director of Maintenance was unaware of these issues, indicating a lack of communication and oversight in maintaining the facility's environment. Additionally, environmental rounds had not been conducted since the Infection Control Nurse resigned over a month ago, further contributing to the oversight. Upon re-inspection, it was found that the North Unit shower room was leaking into an adjacent conference room, with missing grout and caulking in the tile joints. The Director of Maintenance acknowledged these issues and stated that they would be addressed promptly. The facility failed to provide an environmental condition and/or repair policy when requested, highlighting a gap in their procedural documentation and maintenance practices.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 953 citations issued within 25 miles in the last 12 months — including the 11 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Cromwell
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pilgrim Manor | 2.8 mi | ★★★★★ | 0 | 0 |
| Ledgecrest Health Care Center | 3.4 mi | ★★★★★ | 4 | 0 |
| Autumn Lake Healthcare At Cromwell | 3.4 mi | ★★★★★ | 0 | 0 |
| Wadsworth Glen Health Care And Rehabilitation Cent | 4.1 mi | ★★★★★ | 13 | 0 |
| Civita Care Center At Newington | 4.3 mi | ★★★★★ | 42 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 July 2026) and official state health department websites.