Below average — CMS composite of the measures below.
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 Apple Rehab Saybrook during CMS and state inspections, most recent first.
A resident with catatonic disorder, major depressive disorder, anxiety, delusional disorder, and unspecified psychosis had physician orders for lorazepam 0.5 mg multiple times daily for restlessness and catatonia. Over several days, multiple scheduled lorazepam doses were not administered because the medication was unavailable, and eMAR notes only indicated that the drug was on order, with no documentation that a provider was notified. The psychiatric APRN and a regional RN both reported they were unaware of the missed doses and stated that the provider should have been notified and the pharmacy contacted, while facility policy required immediate physician notification, informing the resident or responsible party, contacting the pharmacy to expedite delivery, documenting all actions, and notifying a supervisor when medications are unavailable.
A resident with multiple psychiatric diagnoses and cognitive deficits was started on Abilify, later increased in dose, to address delusional disorder and psychosis. Despite physician orders and psychiatric APRN notes documenting the initiation and adjustment of this antipsychotic, the Resident Care Plan over the following weeks did not include any care plan addressing the antipsychotic use, such as monitoring for side effects or ongoing behaviors. The DON, Regional Nurse, and MDS Coordinator acknowledged that residents on antipsychotics are required to have a corresponding care plan and that both nursing staff and the MDS Coordinator are responsible for initiating it, but the resident was missed, and the care plan was not revised in accordance with facility policy.
A resident with multiple psychiatric diagnoses and a high fall risk experienced several falls, but the facility failed to ensure RN post-fall assessments were consistently completed and documented, and that the resident remained in place until assessed. In multiple incidents, LPNs completed SBAR forms without full assessments, including missing range-of-motion evaluations, and in one case an LPN, with a NA, moved the resident from the floor to a wheelchair before an RN could assess the resident. Although supervisors and providers were notified and the resident was sometimes sent to the ED, the clinical record lacked required RN assessment notes after several falls, contrary to facility policy and the DON’s stated expectations.
A resident with psychiatric conditions, cognitive deficits, impaired balance, and dependence for transfers experienced two falls after being placed in a tilt‑in‑space wheelchair that staff reclined to an almost lying position to prevent the resident from climbing out. On one occasion, the resident was found on the floor in the dining area with a laceration after the wheelchair had been reclined flat; on another, the wheelchair tipped backwards at the nurse’s station and the resident slid out over the headrest. Staff reported routinely reclining the chair for safety and rest because the resident leaned and lunged forward and could not always be closely observed. Therapy later found the wheelchair’s tilt stop was broken, allowing it to recline beyond forty‑five degrees, and the OT stated it was unsafe to use the reclining function in this way, while the DON reported being unaware that staff had been reclining the resident in the wheelchair before the falls.
A resident with multiple psychiatric diagnoses, including catatonic disorder, depression, anxiety, delusional disorder, and unspecified psychosis, was started on Abilify and later had the dose increased due to ongoing restlessness and yelling out. Facility policy required that specific target behaviors be identified and monitored every shift and that a behavior flow sheet be initiated whenever an antipsychotic is started. However, review of the eMAR for two consecutive months showed no documentation of targeted behavior monitoring related to the Abilify use. In interviews, the psychiatric APRN, DON, and a regional RN acknowledged that behavior monitoring, including restlessness, impulsiveness, delusions, hallucinations, and paranoia, should have been initiated when the antipsychotic was ordered and confirmed.
A resident with a history of aggressive behavior and cognitive impairment was placed in a shared room with another resident who had severe cognitive and physical limitations. Staff witnessed the aggressive resident forcibly removing the roommate from the room, resulting in physical injuries. The incident occurred despite prior knowledge of the resident's behavioral risks and facility policy prohibiting abuse.
A resident with cognitive impairment and a history of behavioral issues made a verbal threat in the dining room, which was reported by a nursing assistant to a supervisor who failed to act or investigate. The incident was not reported to the State Agency or documented as required by facility policy, and an investigation was not initiated until days later after further reporting.
A resident with cognitive impairment and a history of behavioral issues made a verbal threat to choke someone, which was reported by a nursing assistant to a supervising nurse on two occasions without action. The incident was later reported to another nurse and administration, but no investigation or incident report was initiated, contrary to the facility's abuse policy.
Several residents did not receive prescribed medications due to unavailability, and nursing staff failed to notify the provider as required. Documentation was incomplete or missing regarding the reasons for missed doses and provider notification, with staff interviews confirming that notifications were not made or were assumed to be handled by others. The facility's policy required provider notification and documentation for medication errors, but this was not followed.
The facility did not ensure that nurse aide documentation for showers and body audits was complete for three residents with cognitive and physical impairments, as required by physician orders and policy. Additionally, the facility failed to retain the medical record for a resident for the required period, with both the Administrator and DNS unable to locate it. These deficiencies were identified through record review and staff interviews.
The facility failed to review its infection control policies annually, conduct quarterly environmental rounds, and complete monthly infection surveillance reports. Additionally, quarterly water management meetings were not documented due to high staff turnover and lack of proper documentation maintenance.
The facility failed to ensure proper medication administration for two residents who had medications left at their bedside without a self-administration order, and for another resident who received medications late. The responsible nurse admitted to leaving medications unattended, contrary to facility policy. Additionally, a new LPN administered medications outside the prescribed time frame without notifying the provider.
A facility failed to provide necessary podiatry services to a resident with type 2 diabetes mellitus. Despite physician orders and requests for podiatry services due to long toenails, the resident was not seen by a podiatrist from September to December. The resident was marked as Do Not Treat because the facility did not provide required documentation for podiatry payment. Interviews revealed that nursing staff were not allowed to trim toenails for diabetic residents, and the DNS acknowledged the oversight in not supplying the missing information to the podiatric service provider.
The facility failed to complete and review its antibiotic surveillance tracking report at quarterly medical staff meetings, as required by its antibiotic stewardship program. Documentation from August 2022 to September 2023 was missing, and the Infection Preventionist did not present necessary reports on antibiotic usage and infection rates. Interviews confirmed the lack of adherence to policies requiring monitoring and reporting of antibiotic use patterns and resistance trends.
The facility failed to offer and administer pneumococcal vaccinations to two residents upon admission. One resident, with conditions including anemia and heart failure, did not receive the vaccine despite giving consent. Another resident, with conditions such as hypertension and diabetes, was not offered the vaccine, and consent was not documented. The facility's policy required offering the vaccine according to CDC guidelines, but the process was not followed, and documentation was incomplete.
Two residents had incomplete MDS assessments, missing critical sections on cognitive function, mood, behaviors, and participation in goal setting. One resident, with diabetes and liver cirrhosis, had no documented reason for the incomplete assessment. Another resident, with hemiplegia and depressive episodes, could communicate but lacked documentation for the incomplete assessment. The Corporate Director of Social Services noted the oversight due to a vacant social worker position.
A resident with severe cognitive impairment and multiple diagnoses had an outdated care plan that was not reviewed or revised quarterly as required. The care plan included resolved issues such as anti-coagulant therapy and skin conditions, which were not reflected in current physician's orders. The RN responsible for updates was unfamiliar with the electronic system and failed to document reviews, leading to non-compliance with facility policy.
The facility did not complete annual performance reviews for two nurse aides, hired in 1983 and 2002, for the years 2023 and 2024. The DNS admitted to not prioritizing these reviews, despite receiving monthly reminders from HR. The facility's policy requires annual performance evaluations.
The facility failed to maintain completed and signed vaccination consent forms for two residents who received COVID-19 booster vaccines. Despite documentation confirming vaccine administration, the facility could not provide the required consent forms during a survey. Interviews with staff revealed that the facility's policy required written consent to be obtained and retained in the resident's clinical records, but these were not found.
Failure to Notify Provider and Obtain Antianxiety Medication Resulting in Multiple Omitted Doses
Penalty
Summary
The deficiency involves the facility’s failure to notify the provider when an antianxiety medication was unavailable, resulting in multiple omitted doses for a resident with significant psychiatric diagnoses. The resident’s conditions included catatonic disorder, major depressive disorder, anxiety disorder, delusional disorder, and unspecified psychosis, and the admission MDS showed a BIMS score of 10/15, indicating some memory recall deficits. The resident’s care plan documented that the resident was receiving antianxiety medication, with interventions to administer medications as ordered and update the provider of any concerns, complications, or changes in condition. A physician’s order directed lorazepam 0.5 mg by mouth three times daily for restlessness and catatonia, and later an order changed the lorazepam to 0.5 mg four times daily. Review of the MAR showed that lorazepam doses were not administered on multiple occasions because the medication was unavailable. On one date, two scheduled doses were omitted due to unavailability, with no documentation in the eMAR notes that the provider was notified. On subsequent dates, six additional lorazepam doses were omitted for the same reason, and the eMAR notes only indicated that the medication was not available and was on order, without any indication that the provider was notified. The psychiatric APRN stated she was not aware of any missed lorazepam doses and that a provider should have been notified, and the Regional Nurse similarly stated that a provider should have been notified for all missed doses and that the pharmacy should have been contacted for STAT delivery. The facility’s Medication Administration policy required that when medications are unavailable, the physician be notified immediately, the resident or responsible party be informed, the pharmacy or alternative suppliers be checked to expedite delivery, all actions be documented in the medical record, and the supervisor be notified, but the documentation reviewed did not show that these steps occurred.
Failure to Update Care Plan for New Antipsychotic Medication
Penalty
Summary
The deficiency involves the facility’s failure to review and revise a resident’s care plan to address the initiation and subsequent dose increase of an antipsychotic medication. The resident had multiple psychiatric diagnoses, including catatonic disorder, major depressive disorder, anxiety disorder, delusional disorder, and unspecified psychosis, and an admission MDS showing a BIMS score of 10/15 with some memory deficits and need for assistance with ADLs. On one date, a psychiatric APRN documented concerns about possible undiagnosed bipolar disorder, depression, or significant trauma history and ordered a trial of Abilify 2 mg daily for delusional disorder, which was entered as a physician’s order. A later psychiatric APRN note documented ongoing restlessness and yelling out and directed an increase of Abilify to 5 mg daily for psychosis, which was also entered as a physician’s order. From the time Abilify was first ordered through a later review date, the Resident Care Plan did not include any care plan addressing the use of this antipsychotic medication. The RCP from the initial Abilify order date through the survey review date lacked documentation of a care plan to address the antipsychotic, including monitoring for side effects and continued behaviors. During interviews, the DON and Regional Nurse (RN #7) stated that any resident on antipsychotic medications should have a care plan to guide care, and that both nursing staff and the MDS Coordinator are responsible for initiating such care plans; they were unable to explain why a care plan had not been developed despite the medication having been ordered 15 days earlier and noted the resident was missed in weekly psychotropic risk meetings. The MDS Coordinator confirmed that a care plan should have been developed to target the antipsychotic use. The facility’s Care Planning policy required a comprehensive, individualized care plan developed by the IDT, based on identified needs, and reviewed and updated as necessary to reflect changes in resident status, but this was not done for the addition of Abilify for this resident.
Failure to Complete RN Post-Fall Assessments and Keep Resident in Place After Falls
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing services met professional standards of quality for a resident with a history of falls and identified as a high fall risk. The resident had multiple psychiatric diagnoses, including catatonic disorder, major depressive disorder, anxiety disorder, delusional disorder, and unspecified psychosis, and required one-person assistance for transfers, ambulation, and positioning. The care plan identified numerous fall-prevention interventions, including environmental modifications, toileting schedules, therapy involvement, and close observation. Despite these identified needs and risks, the facility did not consistently complete required RN post-fall assessments or adhere to its own policy that an RN assess the resident immediately after each fall and before the resident was moved. On one fall dated 11/21/25, documentation showed the resident got out of bed without assistance, fell, and struck the face and head, sustaining two lacerations above the left eyebrow. The charge nurse, an LPN, completed the SBAR and arranged transfer to the ED, but the nurse’s notes did not document that the nursing supervisor (an RN) assessed the resident following the fall, and the SBAR lacked range-of-motion assessment. On 12/3/25, the resident was found lying on the floor on the left side with minimal swelling to the left temporal region; the nursing supervisor, APRN, and family were notified and neuro checks were initiated, but again the nurse’s notes did not document that an RN assessment was completed, and the SBAR completed by the LPN did not include range of motion. On 11/23/25, the resident was found on the floor after attempting to transfer from a wheelchair. The charge nurse, an LPN, later reported that she panicked, did not immediately call the RN supervisor, and instead enlisted a nurse aide to help move the resident from the floor to the wheelchair before an RN assessment. She then cleansed the laceration to the right side of the resident’s head and only afterward notified the RN supervisor. The RN supervisor’s subsequent note documented that the resident was already in the wheelchair, had a laceration near the right eye, and could move all extremities, and the resident was sent to the ED. On 12/22/25, the resident was observed sliding backward out of the wheelchair to the floor and possibly hitting the back of the head; the RN supervisor was notified and reportedly assessed the resident immediately, but there was no RN assessment note in the record, the SBAR was incomplete, and range of motion was not assessed. The DON stated that a full RN assessment was required after each fall and prior to moving a resident, and was unaware that full RN assessments had not been completed after several of the resident’s falls.
Improper Wheelchair Reclining and Positioning Leading to Resident Falls
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was safely positioned in a tilt‑in‑space wheelchair and not reclined beyond forty‑five degrees, which contributed to two falls. The resident had multiple psychiatric diagnoses, including catatonic disorder, major depressive disorder, anxiety disorder, delusional disorder, and unspecified psychosis, and had a BIMS score of 10/15 indicating some memory deficits. The admission assessment and care plan identified impaired balance, substantial assistance needs for bed mobility, and dependence on staff for transfers, with fall‑risk interventions such as encouraging time at the nurse’s station, scheduled toileting, and removal of the walker. On one occasion, nursing staff responded to a report of a fall and found the resident lying on the right side in the dining room with a 2 cm laceration to the right eyebrow. At that time, the resident’s wheelchair was found reclined so that the resident had been lying flat, and staff reported the chair had been reclined to prevent the resident from climbing out, although they could not identify who reclined it. The resident had been assisted back into the wheelchair by two staff, and the incident was documented, including notification of family, the DON, and the provider. On a subsequent occasion, the resident was again in a reclined position in a tall‑back custom wheelchair near the nurse’s station when the wheelchair tipped backwards and the resident slid out over the headrest. Staff reported that the resident had a history of leaning and lunging forward in the wheelchair and that they often reclined the wheelchair to an almost lying position to prevent the resident from getting out, to help the resident rest, and because staff could not always watch the resident. Therapy later identified that the tilt stop on the wheelchair was broken, allowing the chair to be fully reclined beyond forty‑five degrees, and the OT stated staff should never have used the reclining function to keep the resident in the chair and that reclining beyond forty‑five degrees was not safe. The DON reported being unaware that staff had been reclining the resident in this manner prior to the falls, and there was no facility policy on wheelchair positioning available for review.
Failure to Implement Targeted Behavior Monitoring for Antipsychotic Use
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to implement targeted behavior monitoring for a resident who was started on an antipsychotic medication. The resident had diagnoses including catatonic disorder, major depressive disorder, anxiety disorder, delusional disorder, and unspecified psychosis, and an admission MDS BIMS score of 10/15 indicating some memory recall deficits. On 12/23/25, a psychiatric APRN documented concerns about possible undiagnosed bipolar disorder, depression, or significant trauma history and ordered a trial of Abilify 2 mg daily for delusional disorder. Facility policy dated 06/2019 required that residents receiving antipsychotic medications have specific target behaviors identified and monitored every shift, and that a behavior flow sheet be initiated any time a resident is started on an antipsychotic. Despite these requirements, review of the December 2025 eMAR showed no documentation that targeted behaviors were monitored every shift after Abilify was initiated. On 1/2/26, the psychiatric APRN documented that the resident continued to exhibit restlessness and yelling out and increased the Abilify dose to 5 mg daily for psychosis, with additional behaviors of concern including avolition and impulsiveness. Review of the January 2026 eMAR again failed to show targeted behavior monitoring every shift related to the Abilify use. In interviews, the psychiatric APRN stated that behavior monitoring should have been implemented upon initiation of Abilify, including monitoring restlessness, impulsiveness, delusions, hallucinations, and paranoia. The DON and a Regional Nurse (RN #7) also confirmed that targeted behavior monitoring should have been initiated when the Abilify order was started and that Nursing Supervisors or Nursing Administration who confirmed the order should have ensured an order for targeted behavior monitoring was put into place.
Failure to Prevent Resident-to-Resident Abuse Resulting in Physical Harm
Penalty
Summary
A resident with a history of Wernicke's encephalopathy, alcohol dependence, and atrial fibrillation, and who had demonstrated moderately impaired cognition, was involved in multiple incidents of aggressive behavior toward roommates. The resident's care plan identified previous altercations, including grabbing a roommate's shirt and making verbal threats. Despite these documented behaviors and recommendations for staff intervention and psychiatric support, the resident was returned to a shared room after a period in a private room, following the discharge of a previous roommate. A new roommate, who had severe cognitive impairment and was dependent on staff for mobility and transfers, was admitted to the same room. Shortly after, staff witnessed the first resident dragging the new roommate by the arm and throwing them into the hallway. The new roommate sustained superficial abrasions and a skin tear, and was transferred to the hospital for evaluation. Interviews with staff confirmed that the aggressive resident had a known history of altercations related to noise and that staff were aware of the risks associated with placing another resident in the same room. The facility's abuse policy prohibits mistreatment of any kind, including resident-to-resident abuse. Despite this, the decision to place a vulnerable resident in a shared room with a resident known for aggressive behavior resulted in physical harm. Staff interviews and documentation indicated that the aggressive resident should not have had a roommate due to prior incidents and impaired judgment, yet this precaution was not maintained.
Failure to Timely Report and Investigate Resident Threat
Penalty
Summary
The facility failed to act promptly on a report of a verbal threat made by a resident with a history of behavioral issues, including a prior altercation with a roommate. The resident, who had moderately impaired cognition and diagnoses including Wernicke's encephalopathy and a history of alcohol dependence, made a threatening statement in the dining room that was overheard by a nursing assistant. The nursing assistant reported the incident immediately to a nursing supervisor, who did not respond or investigate the situation. The assistant reported the incident again the following day to the same supervisor, who again did not act. The incident was finally reported to another supervisor two days later, who then initiated a psychiatric consult and placed the resident under observation. Despite the eventual response, the facility did not complete an incident report or initiate an investigation at the time the threat was first reported. The State Agency was not notified of the verbal threat, contrary to facility policy, which requires immediate reporting and investigation of suspected abuse or threats. Interviews with staff and the administrator confirmed that the incident was not acted upon in a timely manner, and documentation failed to show that required notifications and investigations were completed as per policy.
Failure to Investigate Resident's Verbal Threat in Accordance with Abuse Policy
Penalty
Summary
A resident with a history of Wernicke's encephalopathy, alcohol dependence, and atrial fibrillation, and who had previously exhibited behavioral issues including a prior altercation with a roommate, made a verbal threat in the dining room stating an intention to choke someone. This threat was overheard by a nursing assistant, who immediately reported the incident to the supervising nurse on two consecutive days. The supervising nurse did not respond to the report or assess the resident at that time. The nursing assistant subsequently reported the incident to another nurse, who then notified administration. Despite being notified, the administrator did not initiate an investigation, citing that the threat was not directed at a specific individual. No incident report was completed, and the facility failed to follow its abuse policy, which required immediate reporting, notification of administration, and initiation of an investigation for any suspected abuse or mistreatment. Interviews confirmed that the required steps, including documentation and investigation, were not taken in response to the verbal threat.
Failure to Notify Provider of Missed Medication Doses
Penalty
Summary
The facility failed to notify the appropriate medical provider in a timely manner regarding multiple missed or omitted medication doses for three residents recently admitted with complex medical conditions. For one resident with a left femur fracture and hypothyroidism, several prescribed medications, including antihypertensives, cholesterol-lowering agents, antidepressants, and thyroid replacement therapy, were not administered on multiple occasions due to unavailability from the pharmacy or other reasons. Documentation did not show that the provider was notified of these missed doses, and nursing notes lacked explanations or follow-up for several omissions. Another resident with Parkinson's disease and constipation did not receive prescribed doses of Carbidopa-Levodopa and Linzess because the medications were not available. Nursing staff documented the omissions but did not notify the provider as required, instead passing the information to the next shift or assuming another nurse would handle the notification. There was no documentation in the clinical record that the provider was informed of these missed doses. A third resident with hypertension, atrial fibrillation, and congestive heart failure missed doses of Apixaban, Carvedilol, and Allopurinol due to the medications not being available from the pharmacy. Nursing notes indicated the medications were not administered, but there was no evidence that the provider was notified. Interviews with nursing staff revealed a lack of clarity regarding responsibility for provider notification and documentation, and the facility's policy required such notifications and documentation for medication errors, but this was not followed in these cases.
Incomplete Documentation of Showers and Missing Medical Record
Penalty
Summary
The facility failed to ensure complete and accurate documentation of showering and body audits for three residents with varying degrees of cognitive and physical impairment. For one resident with severe dementia and dependence on staff for bathing, nurse aide documentation did not show that showers were provided on scheduled days as required by physician orders and facility policy. Similarly, another resident with intact cognition and a history of falls did not have documentation of showers or body audits on the required dates, despite being scheduled for weekly showers and having a physician order for body audits. A third resident with moderate cognitive impairment and left-sided hemiplegia also lacked documentation of showers and body audits on the specified days, even though both the care plan and physician orders required these interventions. Interviews with the Director of Nursing Services (DNS) revealed inconsistencies between the unit shower schedules and the physician orders for body audits, with the DNS unable to explain the discrepancies. The DNS stated that nurse aides are expected to follow the shower schedules and document care provided or refused, and that any missed or refused showers should be reported to the nurse for reassignment. However, the documentation review showed that tasks were left blank or marked as not applicable, indicating a lack of compliance with documentation requirements. Additionally, the facility failed to retain the complete medical record for another resident as required by its own policy, which mandates retention of medical records for at least seven years after discharge or last encounter. Both the Administrator and DNS confirmed that they were unable to locate the clinical record for this resident. Facility policies reviewed directed that all care provided, including showers and ADLs, must be documented and that medical records must be retained for the specified period.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to ensure that its infection prevention and control program policies and procedures were reviewed annually. The Infection Control Program Policies and Procedure manual was reviewed in March 2022 and August 2024, but there was no documentation of a review in 2023. Interviews with the Regional Director of Nursing Services (RN) and the Infection Preventionist (IP) Nurse revealed that the review was the responsibility of the Director of Nursing Services (DNS) and the Administrator, but they were not employed at the facility during the time the review was due. Additionally, there was no policy available related to the annual review of the infection control policy and procedures manual. The facility also failed to conduct quarterly environmental rounds for infection control. Documentation was missing for the last quarter of 2022 and the first three quarters of 2023. The responsibility for completing these rounds lay with the previous IP nurse, who was no longer employed at the facility. Furthermore, the facility did not complete monthly surveillance infection reports and analysis of infection trends from August 2022 to April 2024, nor were these presented at the quarterly Medical Staff Meetings. The IP nurse was responsible for tracking and analyzing infection rates, but the reports were not located, and the previous IP nurse could not be contacted for them. Lastly, the facility did not document quarterly water management plan meetings for several quarters, including October 2022, January 2023, July 2023, and October 2023. The Director of Maintenance and the Administrator, who had only recently started working at the facility, were unable to locate the meeting minutes. The responsibility for maintaining the water management plan binder, which included meeting minutes, was with the Administrator, but due to high turnover, these documents were not available.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to ensure medications were administered as ordered for two residents, Resident #24 and Resident #55, who were observed with medications left at their bedside without a self-administration order. Resident #24, who was cognitively intact and dependent on care for various activities, was found with a medicine cup containing six pills on the bedside table. The nurse responsible, RN #7, admitted to leaving the medications at the bedside and acknowledged that it was her responsibility to ensure the resident took the medications. The facility's policy requires that nurses stay with residents until medications are taken, which was not followed in this instance. Similarly, Resident #55, who had moderate cognitive impairment and required assistance with personal hygiene, was found asleep with a medicine cup containing five pills left at the bedside. The resident was unaware of the medications being there until woken up by RN #7, who then administered the medications. Again, there was no self-administration order for this resident, and the facility's policy was not adhered to, as the nurse left the medications unattended. Additionally, the facility failed to administer medications according to prescribed times for Resident #50, who had diagnoses including chronic systolic congestive heart failure and hypokalemia. The resident reported receiving medications late, and the electronic medication administration audit confirmed that several medications were administered outside the expected time frame. LPN #2, who was new to the facility, admitted to being late in passing medications and was not familiar with the residents and their medications. The facility's policy requires medications to be administered within a two-hour window, and any deviations should be documented and reported to the provider, which was not done in this case.
Failure to Provide Podiatry Services for Diabetic Resident
Penalty
Summary
The facility failed to ensure that a resident with type 2 diabetes mellitus, identified as Resident #53, received necessary podiatry services. The resident's care plan, dated August 14, 2023, included interventions for foot care due to the risk of hypoglycemia associated with diabetes. Despite physician orders for podiatry services as needed, the resident was not seen by a podiatrist from September 2024 through December 2024. Nurse's notes from September 10, 2024, and December 2, 2024, indicated that the resident had long toenails and requests for podiatry services were sent, but the resident was not treated due to missing information required for processing podiatry payment. The podiatrist visited the facility on October 28, 2024, and December 31, 2024, but Resident #53 was marked as Do Not Treat (DNT) because the facility did not provide the necessary medical necessity documentation. Interviews with facility staff revealed that the nursing staff was not permitted to trim the toenails of residents with diabetes, and the Director of Nursing Services acknowledged the oversight in not following up with the podiatric service provider to supply the missing information. The facility's Ancillary Services policy stated that podiatry services would be provided as required by the resident's conditions, but this was not adhered to in the case of Resident #53.
Failure in Antibiotic Stewardship Program Monitoring
Penalty
Summary
The facility failed to ensure that its antibiotic surveillance tracking report, which monitors antibiotic use, patterns, and resistance trends, was completed and reviewed at the quarterly medical staff meetings for multidisciplinary collaboration. During a review of the antibiotic stewardship program from August 2022 to December 2024, it was found that there was no documentation of monthly reviews of the program from August 2022 to September 2023. Additionally, the quarterly Medical Staff Meeting agendas and documentation for 2023 and the first quarter of 2024 did not include any information related to infection control and antibiotic usage presented by the Infection Preventionist. Interviews with the Regional Director of Nursing Services and the Infection Preventionist revealed that the monthly Antibiotic Tracking tool and at-risk meeting minutes were only available from September 2023 to April 2024. The Infection Preventionist was responsible for providing a report on antibiotic usage and monthly infection rates at the quarterly medical staff meetings, but this was not done. The Director of Nursing Services and the Administrator confirmed that it was the responsibility of the Infection Preventionist to submit a written infection control report prior to the meetings, but no such report was found from the previous Infection Preventionist. The facility's policies required monitoring and reporting of antibiotic use patterns and resistance trends, but these were not adhered to, leading to the deficiency.
Failure to Administer Pneumococcal Vaccinations
Penalty
Summary
The facility failed to offer and administer pneumococcal vaccinations to two residents, Resident #20 and Resident #55, upon their admission. Resident #20, admitted in March 2023 with conditions including anemia, acute respiratory failure with hypoxia, and heart failure, was cognitively intact according to a quarterly MDS assessment. Despite giving consent for the pneumococcal vaccine in October 2024, the facility did not administer the vaccine, and there was no documentation of a change in the resident's decision. Interviews with the Regional Director of Nursing Services and the Infection Preventionist Nurse revealed that the vaccine could have been offered upon admission, but it was not administered despite consent being obtained. Resident #55, admitted in March 2024 with diagnoses including anemia, hypertension, type 2 diabetes mellitus, and benign prostatic hyperplasia, had moderate cognitive impairment. The facility's records did not show that the pneumococcal vaccine was offered or assessed for past immunization. Although consent was obtained in September 2024, the vaccine was not administered, and there was no documentation of a change in decision. The facility's policy required offering the vaccine according to CDC guidelines upon admission, but the process was not followed, and the necessary documentation was incomplete. The responsibility for assessing and offering the vaccine was attributed to a previous Infection Preventionist Nurse.
Incomplete MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the completion of annual Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in their care documentation. Resident #5, diagnosed with type 2 diabetes mellitus, cirrhosis of the liver, and dependence on renal dialysis, had an incomplete MDS assessment. The assessment lacked information in sections C, D, and E, which cover cognitive function, mood, and behaviors, respectively. There was no documentation explaining why these sections were incomplete. The Corporate Director of Social Services, who had been assisting due to a vacant social worker position, confirmed that the social workers are responsible for these sections and should document any refusal by the resident to participate in the assessment. Similarly, Resident #17, admitted with hemiplegia, hemiparesis, lymphedema, and depressive episodes, also had an incomplete MDS assessment. The assessment was missing information in sections C, D, E, and Q, which include cognitive function, mood, behaviors, and participation in assessment and goal setting. Despite the resident's ability to communicate using gestures and a tablet, there was no documented reason for the incomplete assessment. The Corporate Director of Social Work acknowledged the oversight, noting that the facility had not identified the missing work until after the previous social worker left. Attempts to contact the former social worker responsible for these assessments were unsuccessful.
Failure to Maintain Comprehensive and Updated Care Plan
Penalty
Summary
The facility failed to ensure that the care plan for a resident with diagnoses including type 2 diabetes mellitus, cerebrovascular disease, and hemiplegia and hemiparesis was comprehensive and up-to-date. The care plan, dated 8/13/23, lacked documentation of reviews or revisions, despite multiple MDS assessments being completed. The care plan contained outdated concerns such as the risk of bruising and abnormal bleeding related to anti-coagulant therapy, a resolved rash to the groin, and a resolved skin impairment to the right ankle. These issues were no longer relevant, as confirmed by the absence of corresponding physician's orders and the acknowledgment by RN #1 that these problems had been resolved. RN #1, responsible for updating the care plan, admitted to not being familiar with the facility's electronic health record system and had been documenting care plan reviews on paper, but failed to provide any documentation of such reviews. The DNS confirmed that RN #1 was responsible for reviewing the care plan quarterly and was aware that updates were behind schedule. The facility's policy mandates that care plans be reviewed and updated at least quarterly and as necessary to reflect changes in the resident's status, which was not adhered to in this case.
Failure to Conduct Annual Performance Reviews for Nurse Aides
Penalty
Summary
The facility failed to ensure that annual performance reviews were completed for two of the three nurse aides reviewed. Specifically, the employee files for NA #4 and NA #9 did not contain performance evaluations for the years 2023 and 2024. NA #4 was hired on September 12, 1983, and NA #9 was hired on April 20, 2002. During an interview, the Regional Nurse (RN #5) confirmed that the performance reviews for these years had not been conducted but did not provide a reason for this oversight. The Director of Nursing Services (DNS) acknowledged responsibility for completing the performance reviews and admitted to not prioritizing them, despite receiving monthly emails from human resources indicating which employees were due for evaluations. The facility's Performance and Review policy mandates a formal and documented performance review at the end of an employee's introductory period and at least annually thereafter.
Failure to Maintain Vaccination Consent Forms
Penalty
Summary
The facility failed to ensure that completed and signed vaccination consent forms were included in the medical records for two residents. Resident #20, who had diagnoses including anemia, acute respiratory failure with hypoxia, and heart failure, was cognitively intact and dependent on care for personal hygiene. The facility's records did not contain a copy of the COVID-19 booster vaccine consent form for Resident #20, which was administered in June 2023. Despite a physician's order and documentation in the Medication Administration Record (MAR) confirming the administration of the vaccine, the facility could not provide a signed consent form upon request during the survey. Similarly, Resident #53, who had diagnoses including type 2 diabetes mellitus, hypertension, and cerebrovascular disease, was severely cognitively impaired and dependent on care. The facility's records also lacked a completed COVID-19 booster vaccine consent form for Resident #53, administered in December 2023. Although the MAR confirmed the administration of the vaccine and the immunization record indicated consent was confirmed, the facility was unable to provide a signed consent form. Interviews with the Regional Director of Nursing Services and the Infection Preventionist revealed that the facility's policy required written consent to be obtained and retained in the resident's clinical records, but these were not found for the residents in question.
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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 Old Saybrook
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Gladeview Health Care Center | 1.2 mi | ★★★★★ | 1 | 0 |
| Essex Meadows Health Center | 3 mi | ★★★★★ | 2 | 0 |
| Bride Brook Rehabilitation & Nursing Center | 7 mi | ★★★★★ | 0 | 0 |
| Aaron Manor Nursing & Rehabilitation | 8.6 mi | ★★★★★ | 0 | 0 |
| Civita Care Bayview | 11.1 mi | ★★★★★ | 52 | 1 |
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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.