Above average — CMS composite of the measures below.
The next survey window likely opens around December 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 Complete Care At Groton Regency during CMS and state inspections, most recent first.
Resident areas on the C/D and E/F units were found with rust-stained drop ceiling frames, damaged wallpaper, bowed or broken ceiling tiles, loose cove base molding with debris or black growth behind it, missing thresholds, and chipped flooring tiles. Facility interviews showed the QAPI plan addressed only Units A and B, and leadership reported no written plan or timeline for repairs on the other units; maintenance relied on requests and limited rounds rather than a building-wide audit.
A resident with severe cognitive impairment, delusions, and a history of physical and verbal aggression was known to wander, resist care, and be difficult to redirect, yet the care plan did not address the risk of entering other residents’ rooms. After this resident slapped another resident in a bathroom, staff documentation continued to show wandering into rooms, agitation, and aggression toward staff and others. Later, the same aggressive resident entered another resident’s room, yelled, demanded compliance, then slapped the resident’s face and grabbed the resident’s arm, resulting in resident-to-resident abuse that was not prevented by effective behavioral interventions or care plan measures.
Care plan did not reflect secured unit placement. Two residents living on a secured dementia unit had records showing dementia, wandering risk, behavioral monitoring, and other significant cognitive or physical impairments, but their care plans did not identify residence on the secured unit or unit-specific interventions. Interviews with the UM and Social Services Director confirmed the care plans were not updated to address the residents’ secured-unit placement, despite facility policy requiring interdisciplinary review and resident-specific interventions.
Failure to Place a Resident With an Open Wound on EBP: A resident with severe cognitive impairment and an open sacral wound was not placed on EBP despite facility staff stating that any resident with an open wound should be on EBP. The resident’s wound care was performed by an LPN and an NA using gloves but no gown, and the EBP signage outside the room was believed to apply to the roommate with a foley catheter rather than this resident. The resident was not listed on the facility’s EBP list or identified in the chart locations staff used to track EBP status.
A resident with dementia, AFib, and anxiety disorder was found not up to date with the COVID-19 vaccine. Although the POA gave consent for the COVID-19 vaccine and boosters, the chart did not show that the 2025-2026 booster was given or refused, and the IP RN stated the resident should have been offered the vaccine when the facility began administering it.
A resident with a positive Level II PASRR was coded incorrectly on the MDS as not having a serious mental illness or related condition, even though the PASRR record showed a positive Level II status. In addition, three residents with diagnoses including dementia, bipolar disorder, PTSD, heart failure, atrial fibrillation, and spinal stenosis had section C of the MDS marked “not assessed,” meaning the BIMS and any alternate cognition assessment were not completed during the look-back period.
A resident requiring extensive assistance for daily living, who was alert and oriented, was subjected to disrespectful language by an RN during a medication pass. The RN uttered an inappropriate phrase while assisting the resident, which was later confirmed by facility documentation and acknowledged as unprofessional by the DON. Facility policy requires staff to treat residents with respect and dignity at all times.
A resident who required extensive assistance was left unattended with a partially administered dose of sodium polystyrene sulfonate mixture during a medication pass. After the LPN left the medication on the bedside table and stepped away, the resident was found on the floor with wet marks and reported vomiting after taking the medication. Facility policy and the DON confirmed that staff are required to observe residents taking their medications in full before leaving.
The facility failed to keep the Main dining room open on weekends, resulting in residents receiving meals in their rooms. Staff confirmed the closure was due to a staffing shortage, and the decision was made collaboratively between dietary and nursing departments. The DNS acknowledged low participation on weekends and a QAPI project was initiated to address the issue.
The facility failed to ensure adequate staffing to transport residents to the dining room on weekends, resulting in the closure of the dining room during these times. Staff and residents confirmed that meals were delivered to residents' rooms instead. The facility's QAPI documentation identified the goal of reopening the dining room by a specific date, but staffing shortages persisted.
The facility failed to ensure expired food was dated and removed from the refrigerator. During a tour, two large plastic zip bags of sliced ham and two undated peaches were found. The Food Service Directors acknowledged the oversight despite daily checks, and the facility's guide directs that ready-to-eat foods should be stored for up to seven days.
The facility failed to complete a Significant Change in Status MDS assessment for a resident admitted to hospice care. Despite the resident's severe cognitive impairment and multiple diagnoses, the required assessment was not completed within the mandated 14-day window due to the absence of an MDS Coordinator at the time.
The facility failed to ensure accurate documentation of advanced directives for a resident, resulting in the misfiling of another resident's DNR form in the clinical record. Interviews revealed that the Unit Coordinator did not verify names on documents before filing, contrary to facility policy.
Resident Areas Not Kept in Good Repair
Penalty
Summary
The facility failed to ensure resident areas were kept in good repair on the C/D and E/F nursing units. Survey observations on multiple days identified resident rooms with drop ceiling frames showing excessive rust-like staining, wallpaper and wallpaper borders that were discolored, ripped, or hanging off the wall, ceiling tiles that were bowed, bulged, or broken, cove base molding that was not adhered to the wall with dirt, debris, or black growth behind it, missing room thresholds, and chipped flooring tiles. Facility interviews and document review showed that the environmental concerns on the C/D and E/F units were not included in the facility’s QAPI plan dated 10/21/25, which addressed renovation plans for Units A and B only. The Regional Maintenance Director stated the rooms throughout the facility were being redone, but the Administrator confirmed there was no written plan or timeline for repairs on the C, D, E, or F units. The Maintenance Director stated he had not completed a building audit and relied on maintenance requests or empty rooms to identify needed repairs, while EVS and nursing leadership described their rounds as focused on cleanliness or infection control rather than general maintenance issues.
Failure to Prevent Resident-to-Resident Abuse by Aggressive, Wandering Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from abuse by not implementing effective interventions for a resident with known wandering and aggressive behaviors. One resident had diagnoses including Alzheimer’s disease, anxiety disorder, and cognitive communication deficit, with an MDS showing severely impaired cognition, delusions, physical and verbal behaviors directed toward others, and rejection of care. The care plan identified this resident as resistive to care, physically and verbally aggressive, yelling, hitting, and pacing, with instructions to postpone care if combative and to monitor for anxiety, aggression, and delusions. Physician orders directed staff to monitor targeted behaviors of delusions and physical and verbal aggression toward staff and residents. Despite these known behaviors, the resident entered another resident’s bathroom and, after being told to leave, slapped that resident on the left cheek with an open hand. This first resident-vs-resident incident occurred in the context of documented wandering, agitation, and aggression, including notes that the aggressive resident hit staff, threw a cup of juice at staff, was verbally aggressive, refused to use a walker, refused to stop wandering into other residents’ rooms, and was not easily redirected. The care plan developed after the first incident identified that the resident used to work in a prison and was triggered when told “no,” and included interventions such as diversion, removal from the environment, and observation for non-verbal signs of physical aggression. However, the care plan did not address the possibility of this resident wandering into other residents’ rooms. Subsequently, another resident with Alzheimer’s disease, anxiety disorder, bilateral hearing loss, and moderate cognitive impairment, who had a care plan noting potential physical behaviors, lack of personal space boundaries, and yelling, was assaulted when the aggressive resident again entered a resident room. In this second incident, the aggressive resident entered the room, yelled at the other resident, demanded compliance, then slapped the resident on the left side of the face and grabbed the right upper arm. The psychiatric evaluation documented that the aggressive resident had a previous resident-to-resident incident and recent episodes of physical aggression without evidence of infection. The facility’s failure to incorporate the known wandering and room-entry behavior into the care plan and to implement effective interventions to prevent further resident-to-resident contact contributed to this second incident of abuse.
Care Plan Did Not Reflect Secured Unit Placement
Penalty
Summary
The facility failed to ensure the comprehensive care plan was reviewed and revised to reflect each resident’s changing goals, preferences, and needs, including placement and continued placement on a secured unit. For Resident #4, the record showed a consent form for the E/F secured unit identifying dementia and wandering risk, with verbal consent obtained from the responsible party and signed by facility staff. The physician’s orders later directed staff to monitor target behaviors of agitation and insomnia, and the resident’s responsible party stated she had no concerns with the resident’s placement on the secured unit because of wandering behaviors, confusion, and safety decline. Interviews with the Unit Manager and Social Services Director identified that admission to the secured unit was interdisciplinary and that social services was responsible for updating the care plan to reflect residence on the secured unit. However, the Social Services Director stated Resident #4’s care plan failed to identify interventions related to being on a secured unit. The facility’s Comprehensive Care Plans policy required the care plan to describe services needed to attain or maintain the resident’s highest practicable physical, mental, and psychosocial well-being, along with resident-specific interventions, and the Secure Dementia Care Unit Policy required quarterly and periodic interdisciplinary reviews for residents on the secured unit. For Resident #73, diagnoses included hemiplegia and hemiparesis following cerebrovascular disease affecting the left non-dominant side, Alzheimer’s disease, and vascular dementia with other behavioral disturbances. The quarterly MDS showed moderately impaired cognition, no behaviors, dependence for position changes, transfers, and mobility, and no alarms or restraints. The resident was observed living on the secured unit and stated he/she could not leave without permission. Although the care plan addressed behaviors such as irritability, restlessness, swearing, yelling, and forgetting care, it did not identify that the resident resided on a secure unit. The Unit Manager and Social Services Director both stated the care plan failed to address the resident’s residence on the secure unit and/or interventions for care on the unit.
Failure to Place Resident With Open Wound on EBP
Penalty
Summary
The facility failed to appropriately track and place a resident with an open sacral wound on Enhanced Barrier Precautions (EBP) to ensure the appropriate PPE was used during wound care. Resident #23 had diagnoses including vascular dementia, a non-pressure chronic ulcer of skin with fat layer exposed, and anxiety disorder, and the quarterly MDS identified severely impaired cognition, dependence on staff for bed mobility, personal hygiene, dressing, eating, and transfers, and non-ambulatory status. The care plan identified the resident as at risk for skin breakdown with interventions including a low air mattress, treatment per provider order, and weekly wound assessment. The physician ordered daily sacral wound care with cleansing, xeroform, and a dry protective dressing. Wound evaluations documented an end stage skin failure wound to the sacrum with moderate serosanguinous exudate, measuring 3 cm by 0.8 cm by 0.2 cm on 12/18/25 and 0.5 cm by 0.8 cm by 0.2 cm on 1/22/26. Although facility staff stated that any resident with an open wound should be on EBP, the facility’s EBP list dated 1/13/26 did not include Resident #23. During observation, EBP signage was posted outside the room, but staff identified it as being for the roommate with a foley catheter. During wound care, an LPN and an NA provided treatment and repositioning while wearing gloves but not a gown. Interviews confirmed the resident was not on EBP in the chart, on the list, or in the other locations staff used to identify EBP status, and the wound nurse stated it was her responsibility to ensure the resident was placed on EBP because the resident had an open sacral wound.
COVID-19 Booster Not Offered or Documented
Penalty
Summary
The facility failed to ensure that the COVID-19 booster vaccination was offered or that the resident’s vaccination history was assessed for one resident reviewed for immunizations. The resident had diagnoses of dementia, atrial fibrillation, and an anxiety disorder, and the quarterly MDS identified severely impaired cognition and that the resident was not up to date with the COVID-19 vaccination. Review of the COVID-19 Vaccine Administration and Consent Form showed the resident’s POA gave permission for the COVID-19 vaccine and boosters, but the physician’s orders, preventative health care report, and progress notes did not show that the resident received the 2025-2026 COVID-19 booster or that the vaccine was refused when attempted. The Infection Preventionist stated that a prior consent from August 2025 reflected refusal, but the new consent signed in October 2025 was not seen, and the resident should have received the vaccine because the facility had started administering it to residents. The POA still wanted the resident to be offered the vaccine.
Incorrect PASRR Coding and Missing Cognitive Assessments
Penalty
Summary
The facility failed to ensure an accurate PASRR assessment for Resident #15. The resident’s diagnoses included schizoaffective disorder bipolar type, pseudobulbar affect, and post-traumatic stress disorder. A PASRR Level II screening dated 2/7/2023 identified the resident as having a positive Level II PASRR, but the annual MDS assessment dated [DATE] was coded “no” in the PASRR section for whether the resident was currently considered by the Level II PASRR process to have a serious mental illness, intellectual disability, or related condition. The correct response should have been “yes,” which would have led to additional PASRR-related questions. During interview, the Director of Social Services stated social workers were responsible for completing section A1500 on admission, annual, and significant change MDS assessments. He stated that during his initial orientation, a per diem MDS Coordinator had been completing the PASRR section, and he acknowledged that Resident #15 had a positive Level II PASRR assessment and the MDS should have been coded accurately. The MDS Coordinator stated she was responsible for coding the PASRR section of the MDS assessment dated [DATE], obtained information from the electronic record, saw a document titled level of care in the miscellaneous section, but did not open it. She stated the assessment was coded incorrectly and that she had submitted a correction because MDS assessments should be coded accurately. The facility also failed to complete the Brief Interview for Mental Status or an alternate staff assessment of cognition for Resident #12, Resident #14, and Resident #44. Resident #12 had diagnoses including vascular dementia, anxiety, and type 2 diabetes mellitus; Resident #14 had bipolar disorder, PTSD, and type 2 diabetes mellitus; and Resident #44 had heart failure, atrial fibrillation, and spinal stenosis. Their quarterly or annual MDS assessments dated [DATE] identified section C as “not assessed,” meaning the BIMS was not completed and cognition was not assessed by staff. The Director of Social Work stated the social worker was responsible for conducting the BIMS and completing section C during the seven-day look-back period, and that “not assessed” meant neither the BIMS nor an alternate staff assessment had been completed. He could not provide a reason why the interviews or staff assessments were not completed. The MDS Coordinator stated she coded section C as not assessed because there was no BIMS completed during the seven-day look-back period and noted she had explored why the cognitive function was not assessed.
Failure to Maintain Respectful Communication During Medication Administration
Penalty
Summary
A resident with a history of congestive heart disease, anxiety, and Type 2 diabetes mellitus, who required extensive assistance with activities of daily living, reported being treated without respect during medication administration. The resident, who was alert and oriented, informed the assigned RN that they could not take medications without applesauce. The RN left to obtain applesauce and, upon returning, observed the resident fumbling with the bed remote. During this interaction, the RN uttered 'Jesus Christ' under their breath before taking the remote from the resident. The resident later alleged that the RN used inappropriate language and demeanor during the encounter. Facility documentation confirmed the incident, and the RN acknowledged making the statement, expressing uncertainty about why it was said. The Director of Nursing Services confirmed that such language was considered poor bedside manner and offensive, and that facility policy required staff to maintain professionalism and respect at all times. The facility's Resident Rights policy directed that residents have the right to be treated with respect and dignity.
Resident Left Unattended with Medication Leading to Fall
Penalty
Summary
A deficiency occurred when a resident, admitted with diagnoses including congestive heart disease, anxiety, and Type 2 diabetes mellitus, was left unattended with a partially administered dose of sodium polystyrene sulfonate mixture. The resident required extensive assistance with activities of daily living due to recent hospitalization, fatigue, activity intolerance, and confusion. During a medication pass, an LPN administered half of the resident's medications and, upon the resident's request for more applesauce, took the remaining pills to the medication cart but left the half-filled cup of sodium polystyrene sulfonate mixture on the bedside table in front of the resident. Shortly after, the LPN heard a noise and found the resident lying on the floor with wet marks on their clothing, and the resident reported vomiting after consuming the liquid medication. The LPN later acknowledged that the medication should not have been left unattended and was unsure if the resident had consumed the remaining mixture before the fall. Facility policy and the DON confirmed that staff are required to observe residents taking their medications in full before leaving them or their room, and the policy directs staff to observe resident consumption of medication.
Dining Room Closure on Weekends
Penalty
Summary
The facility failed to ensure the Main dining room was open and utilized for resident dining consistently on the weekends. Observations and interviews revealed that approximately 30 residents were eating in the dining room during the week, but the dining room had been closed on weekends for several weeks. Dietary aides and the Food Service Director confirmed that meals were delivered to residents' rooms on weekends due to a staffing shortage, and the decision to close the dining room on weekends was made collaboratively between the dietary and nursing departments. Interviews with nursing staff corroborated that the dining room was closed on weekends, and residents were not transported to the dining room for meals. The Director of Nursing Services (DNS) acknowledged that the dining room was available every day but had low participation on weekends. The facility had initiated a Quality Assurance and Performance Improvement (QAPI) project to increase weekend participation in the dining room, with a goal to reopen it by a specified date. Despite the QAPI plan, the DNS denied a staffing shortage after reviewing the QAPI materials. The facility's policy on promoting and maintaining resident dignity during mealtime emphasized treating residents with respect and enhancing their quality of life, which was not upheld due to the dining room closure on weekends.
Inadequate Staffing Leads to Dining Room Closure on Weekends
Penalty
Summary
The facility failed to ensure adequate staffing to transport residents to the dining room on weekends, resulting in the closure of the dining room during these times. Multiple residents reported that the dining room had been closed on weekends for several weeks, and staff interviews confirmed this. The facility's Quality Assurance and Performance Improvement (QAPI) documentation identified the goal of reopening the dining room by a specific date, with plans to reach safe staffing levels through training new nursing assistants (NAs). However, staffing schedules showed a shortage of NAs on the weekends, and dietary aides confirmed that meals were delivered to residents' rooms instead of using the dining room. Interviews with various staff members, including dietary aides, the Food Service Director (FSD), nursing assistants, and the Director of Nursing Services (DNS), revealed that the decision to close the dining room on weekends was due to insufficient staff to transport residents. The DNS and other staff members acknowledged the low participation rate in the dining room on weekends and the ongoing QAPI efforts to address this issue. Despite the facility's action plan, the dining room remained closed on weekends, and the facility was aware of the staffing shortages during these times.
Expired Food Not Properly Dated and Removed
Penalty
Summary
The facility failed to ensure expired food was dated and removed from the refrigerator. During an initial tour of the dietary department, two large plastic zip bags full of sliced ham were found with a handwritten date, and two peaches in a plastic produce bag were undated. The Food Service Director (FSD #2) acknowledged that the ham should be discarded three days past the labeled date and could not explain why the peaches were undated. Another Food Service Director (FSD #1) confirmed that the ham should have been discarded seven days past the labeled date and admitted that the oversight occurred despite daily checks of the refrigerator by herself and the Dietary Manager in Training. The facility's Food Storage and Retention Guide directs that ready-to-eat prepared foods should be stored in the refrigerator for up to seven days, with Day 1 being the day of preparation.
Failure to Complete Significant Change MDS Assessment for Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change in Status MDS assessment for a resident when they were admitted to hospice care. Resident #12, who had diagnoses including dementia, adult failure to thrive, bipolar disorder, and malignant neoplasm of the colon, was admitted to hospice on 6/28/23. Despite the physician's order and the Resident Care Plan indicating the need for hospice services, the facility did not complete the required MDS assessment within the 14-day window as mandated by the Resident Assessment Instrument (RAI) 3.0 manual. The MDS record review from 6/28/23 to 7/11/23 confirmed this omission. Interviews with the MDS Coordinator and LPN revealed that they were aware of the requirement but had only started working at the facility in July 2023, after the resident's hospice admission, and noted that the facility lacked an MDS Coordinator at that time. The Director of Nursing Services (DNS) also confirmed the absence of an MDS Coordinator during the critical period. The deficiency was identified during a clinical record review and interviews conducted on 3/25/24. The staff responsible for MDS assessments acknowledged that a significant change MDS assessment should have been completed for Resident #12 by 7/12/23. The failure to complete this assessment was attributed to the absence of an MDS Coordinator at the time of the resident's hospice admission. This oversight resulted in non-compliance with the RAI 3.0 manual's requirement for a significant change MDS assessment following a resident's enrollment in a hospice program.
Failure to Ensure Accurate Documentation of Advanced Directives
Penalty
Summary
The facility failed to ensure the clinical record of Resident #119 contained accurate documentation pertaining to advanced directives. Resident #119, who had diagnoses including cerebrovascular disease, type 2 diabetes mellitus, and aphasia, was identified as having intact cognition and required moderate assistance with various activities of daily living. The care plan and physician's order indicated that Resident #119 had full code status. However, the clinical record did not contain a completed Resident/Patient Health Care Instructions form for Resident #119, but instead contained a form for another resident, Resident #379, who had a DNR code status and had been discharged from the facility. Interviews with the Unit Manager, Unit Coordinator, and DNS revealed that the misfiling occurred because the Unit Coordinator did not verify the names on the documents before filing them, assuming that all records in the chart belonged to the resident. The DNS confirmed that it is the responsibility of the nurse, unit manager, and unit coordinator to file documents and that the resident's name should be double-checked, especially if the names are similar. The facility's policy on the maintenance of clinical records requires that medical records be completely and accurately documented, which was not adhered to in this case.
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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 Groton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fairview | 2.7 mi | ★★★★★ | 3 | 0 |
| Beechwood Health & Rehabilitation Center | 3.4 mi | ★★★★★ | 3 | 0 |
| Harbor Village North Health And Rehabilitation Cen | 3.4 mi | ★★★★★ | 22 | 0 |
| Mystic Healthcare & Rehabilitation Center, Llc | 3.7 mi | ★★★★★ | 20 | 1 |
| Apple Rehab Mystic | 4.1 mi | ★★★★★ | 5 | 0 |
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