Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mattatuck Health Care Facility, Inc. during CMS and state inspections, most recent first.
The facility failed to ensure licensed nurses were certified in CPR and available to provide basic life support. The DNS lacked documentation of current CPR certifications and did not hold a current certification herself. Some RNs had expired certifications, and no policy on CPR certification requirements was provided.
The facility failed to designate a qualified individual to oversee the infection prevention and control program. The DNS, who is not certified in infection prevention, has been functioning in this role while also managing other responsibilities. A contracted Infection Preventionist works only 5 hours a month, leaving the DNS to oversee the program daily without the necessary qualifications. The facility assessment tool suggests the position requires 5-8 hours per month, although no outbreaks have been reported recently.
A resident with cognitive impairment and a history of cellulitis had their thumb cut during nail care, which later became infected. The facility failed to notify the physician until days after the injury and did not inform the resident's representative until the condition worsened, leading to a hospital visit. This delay violated the facility's policy on change in condition.
A facility failed to update care plans for two residents after significant incidents. One resident with schizophrenia and self-injury behaviors sustained a head injury, but their care plan lacked interventions for self-harm. Another resident with major depressive disorder eloped and attempted suicide, yet their care plan was not revised to address elopement and self-harm risks. The facility did not provide policies related to care planning or self-injury, highlighting a deficiency in care planning and risk management.
The facility failed to properly monitor and reassess a resident's high blood glucose levels, did not implement behavior monitoring or conduct neurological checks for a resident with self-harm behaviors, and neglected to document ongoing assessments of another resident's thumb injury. These deficiencies highlight lapses in monitoring and documentation practices, impacting the care provided to residents with diabetes, schizophrenia, and a thumb injury.
A resident with a history of depression and suicidal ideations eloped from the facility and attempted suicide. The facility failed to conduct an elopement assessment or update the care plan to reflect the resident's risks. Staff interviews revealed a lack of awareness and documentation regarding the resident's suicide attempt and elopement risk.
The facility failed to verify a nurse aide's certification, as required by regulations. The aide was initially hired without confirmation of training completion, and subsequent registry checks showed no record of certification. The Office Manager and DNS assumed certification was completed during the aide's employment elsewhere, but no documentation was provided. The aide's certification remains unverified due to her absence following an accident.
The facility inaccurately reported staffing data in the PBJ, leading to reports of low weekend staffing and lack of 24-hour licensed nurse coverage. The DNS and Office Manager stated that the facility maintained 24-hour coverage, attributing errors to manual data entry mistakes.
Deficiency in CPR Certification and Availability
Penalty
Summary
The facility failed to ensure that licensed nurses were certified in cardiopulmonary resuscitation (CPR) for Healthcare Providers and were available immediately to provide basic life support, including CPR. During an interview and review of facility documentation, it was found that the Director of Nursing Services (DNS) did not have documentation of current CPR certifications for the licensed nurses. The DNS indicated that the facility was not a sub-acute unit and that the staff had been trained to call 911 during any crisis. However, there was no policy in place regarding CPR or documentation of CPR competencies, and the DNS herself did not hold a current CPR certification. Subsequent to the surveyor's inquiry, documentation of CPR certifications was provided for some registered nurses (RNs), but it was found that one RN's certification had expired over six months ago, although the DNS mentioned that the RN had recently taken a recertification program but had not yet received the updated certificate. Despite requests, the facility did not provide a policy related to CPR certification requirements, highlighting a deficiency in ensuring that licensed nurses are adequately certified and available to provide necessary life support measures.
Inadequate Designation of Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified individual to oversee the infection prevention and control program. The Director of Nursing Services (DNS) reported that a contracted Infection Preventionist has been in place since December 2021, working approximately 5 hours per month. However, the DNS, who has been functioning in the role of infection control nurse, is not certified in infection prevention and has not completed the specialized training required for the position. The DNS also holds multiple roles, including supervisor, charge nurse, and staff development, which may impact her ability to focus on infection control. Interviews and facility documentation confirmed that the contracted Infection Preventionist works only 5 hours a month, and the DNS oversees the program daily without the necessary qualifications. The facility assessment tool indicated that the infection prevention and control position requires 5-8 hours per month, depending on the presence of outbreaks, although no outbreaks have been reported in the past six months.
Failure to Notify Physician and Resident Representative of Injury
Penalty
Summary
The facility failed to immediately notify the physician and the resident representative when a resident's thumb was cut during nail care and subsequently became infected. The incident involved a resident with a history of schizoaffective disorder, bipolar disorder, and cellulitis, who was admitted to the facility in March 2016. The resident, who had moderately impaired cognition and was dependent on staff for personal care, had their thumb clipped by a nursing assistant during nail care on June 29, 2024. Although the area was initially cleansed and bandaged, it began oozing by July 1, 2024, but the physician was not notified until July 2, 2024, when the thumb showed signs of discoloration and inflammation. The facility's policy required immediate notification of the physician and resident representative in the event of a change in condition. However, the resident representative was not informed until July 6, 2024, when the resident's thumb had become swollen and blistered, prompting a hospital visit. The delay in notifying both the physician and the resident representative constituted a failure to adhere to the facility's policy on change in condition, which mandates prompt communication to ensure the best possible care during critical illness.
Failure to Update Care Plans for Residents with Self-Injury and Elopement Incidents
Penalty
Summary
The facility failed to update the care plan for a resident with a history of schizophrenia and self-injury behaviors. The resident, who had intact cognition and was independent in most activities, sustained a head injury after intentionally hitting their head against a concrete wall. Despite the incident and the resident's history of head-banging behaviors, the care plan was not updated to include interventions for self-injury. Interviews with staff revealed that the resident had a known history of such behaviors, which were reportedly linked to sugar intake, but no effective interventions were in place. Another resident, with diagnoses including major depressive disorder and major neurocognitive disorder, eloped from the facility and attempted suicide. The resident, who had intact cognition and required assistance with daily activities, was found at a hospital after overdosing on Benadryl and alcohol. Despite the serious nature of the incident, the resident's care plan was not revised to address the new risks of elopement and self-harm. Interviews indicated that the resident had a history of suicidal ideation but had not previously attempted elopement or self-harm while at the facility. The facility's failure to update care plans for both residents after significant incidents highlights a deficiency in care planning and risk management. The facility did not provide policies related to care planning or self-injury, and the assessment tool indicated a need for specific interventions for psychiatric symptoms and behaviors. The lack of updated care plans and interventions for these residents represents a significant oversight in ensuring their safety and well-being.
Deficiencies in Monitoring and Documentation for Residents
Penalty
Summary
The facility failed to ensure proper monitoring and reassessment of blood glucose levels for a resident with type 2 diabetes mellitus. The resident had several instances of high blood glucose readings, which required the administration of 15 units of Humalog insulin. However, the facility did not reassess the blood glucose levels after these high readings, as expected by the Advanced Practice Registered Nurse (APRN) and the Medical Doctor (MD). The facility's policy did not specify when to recheck high blood glucose levels or notify the provider, leading to a lack of timely reassessment and potential adjustment of insulin dosage. Another deficiency involved a resident with schizophrenia who engaged in self-harm by hitting their head against a concrete wall, resulting in a head injury. The facility failed to implement appropriate behavior monitoring related to self-harm, did not conduct neurological monitoring following the head injury, and did not document the wound assessment and care in the medical record. The facility also did not obtain or document the hospital discharge summary related to the resident's evaluation and treatment, which included a psychiatric assessment and placement of a staple in the head wound. Additionally, the facility did not conduct ongoing assessments of a resident's thumb, which was discolored and inflamed after being clipped during nail care. The facility failed to document the condition of the thumb for several days, despite the resident being treated with antibiotics for a suspected infection. The lack of documentation and assessment led to the resident being sent to the emergency room for further evaluation and treatment, where they were diagnosed with Paronychia and Felon of the finger.
Failure to Assess and Monitor Resident Post-Elopement and Suicide Attempt
Penalty
Summary
The facility failed to complete an elopement assessment and ensure adequate monitoring for a resident who had previously eloped and attempted self-harm. The resident, admitted with diagnoses including major depressive disorder and major neurocognitive disorder, was reported missing from the facility and later found at a hospital after a suicide attempt. Despite a history of suicidal ideations, the resident's care plan did not reflect the risk of elopement or self-harm, and no elopement risk assessments were conducted following the incident. The resident was last seen at the facility before eloping through the front entrance. The facility's documentation indicated that the resident had not shown any behaviors related to wandering or self-harm prior to the elopement. However, a hospital discharge summary revealed that the resident had been experiencing worsening depression and increased suicidal thoughts in the months leading up to the incident. Upon readmission, the resident's care plan was not updated to address the new risks, and no specific monitoring for self-harm was implemented. Interviews with facility staff, including a nurse aide and an APRN, confirmed a lack of awareness and documentation regarding the resident's suicide attempt and elopement risk. The DNS acknowledged that an elopement assessment should have been completed and the care plan updated. The facility's policy required staff to know the whereabouts of residents at all times, but no specific policies on elopement or self-harm were provided upon request.
Failure to Verify Nurse Aide Certification
Penalty
Summary
The facility failed to verify the certification of a nurse aide, referred to as NA #2, as required by regulations. NA #2 was initially hired in April 2020, but her personnel file did not confirm completion of a nurse aide training program. The Connecticut State Nurse Aide Registry Verification Reports from October 2023 and September 2024 showed no record of NA #2's certification. The Office Manager admitted that she did not verify NA #2's certification upon rehire, assuming it was completed during NA #2's employment at another facility. The Director of Nursing Services (DNS) also believed NA #2 had completed the training and certification, attributing the registry issue to a possible name spelling discrepancy. Despite assurances from NA #2 that she had completed the necessary training and certification, the facility could not provide documentation to confirm this. The DNS was unable to obtain a copy of NA #2's certification due to her absence following an accident. The facility did not have a policy for competent nurse staffing available for review, and the DNS stated that NA #2 would not be allowed to return to work without certification verification. The report highlights the facility's failure to ensure proper verification of nurse aide certification, which is a regulatory requirement.
Inaccurate PBJ Staffing Data Entry
Penalty
Summary
The facility failed to ensure accurate staffing data was entered in the Payroll-Based Journal (PBJ), resulting in reports of excessively low weekend staffing and lack of 24-hour licensed nursing coverage on multiple dates throughout the fiscal year 2024. The PBJ Staffing Data Reports for each quarter identified specific infraction dates where the facility did not meet the required staffing levels. Interviews with the Director of Nursing Services (DNS) and the Office Manager revealed discrepancies in the reported data, with both asserting that the facility maintained 24-hour licensed nurse coverage. The DNS indicated that any gaps in staffing were due to sick calls from nurse aides, which were sometimes not fully covered, but the facility was still able to meet residents' needs due to their higher level of functioning and independence. The Office Manager acknowledged that the process of manually entering staffing data from timecards into a spreadsheet and then into the PBJ program was prone to typographical errors. She admitted to accidentally omitting information or entering it under incorrect dates, which led to the reported infractions. The facility assessment did not include documentation regarding PBJ, further complicating the accuracy of the data submitted. The Office Manager expressed the intention to submit PBJ data more frequently to reduce the likelihood of errors in the future.
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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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How nearby facilities compare on the same public inspection record.
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| Abbott Terrace Health Center | 0.5 mi | — | 0 | 0 |
| Waterbury Center For Nursing & Rehabilitation Llc | 2.1 mi | ★★★★★ | 1 | 0 |
| Autumn Lake Healthcare At Bucks Hill | 2.4 mi | ★★★★★ | 0 | 0 |
| Apple Rehab Watertown | 2.9 mi | ★★★★★ | 14 | 0 |
| Cheshire House Health Care Facility & Rehab Center | 3.7 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.