Below average — CMS composite of the measures below.
A standard survey is most likely before 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 Mozaic Senior Life during CMS and state inspections, most recent first.
Physical restraint used by tying a self-releasing seat belt. A resident with Alzheimer’s disease and insomnia was found with an alarmed seat belt tied closed while seated in a wheelchair. An NA admitted tying and re-tying the belt with wipes to keep the resident from getting up, stating it was for safety and that she knew it was a restraint. An OT observed the tied belt, the LPN was not notified, and the DON stated the belt should not have been tied.
Delayed Reporting of Restraint Use: A resident with Alzheimer’s disease was observed by OT with a tied self-releasing seat belt on the wheelchair, but the observation was not immediately reported to nursing leadership. The assigned NA later admitted she wrapped the belt with disposable wipes and re-tied it after toileting because the resident kept trying to get up, and she knew it would be considered a restraint. The charge LPN was not notified, and the DON did not learn of the incident until the next morning.
Incomplete Abuse Investigation: A resident with Alzheimer's disease and insomnia had an alarmed seat belt tied closed by an NA while the resident was in a wheelchair. The NA stated she did it to keep the resident from getting up and knew it would be considered a restraint, but the facility's abuse investigation did not include interviews with all staff working the shift, including another NA, an LPN, and the RN supervisor, despite policy requiring interviews of all involved persons and witnesses.
Unsafe hot water temperatures were not monitored in resident rooms and bathrooms. Surveyors found water above 120 degrees Fahrenheit in many rooms, including one resident bathroom at 121.6 degrees Fahrenheit. The resident reported the water had been very hot since admission and was difficult to regulate in the shower. Facility logs showed repeated high readings at the mixing valves, but staff only checked those valves and did not routinely check resident areas or rooms after elevated readings.
A resident with severe cognitive impairment and hospice-related weight loss risk was repeatedly seated apart from other residents during meals, including being placed away from the dining tables or left facing others while they ate, and staff stated this was done because the resident needed feeding and puree food could make a mess. Another resident with a urinary collection device had the bag visible from the hallway without a privacy cover, and staff acknowledged the bag should have been covered but did not have the proper cover available.
A resident with MS, depression, functional urinary incontinence, and total dependence for care voiced concerns that an NA spoke demeaning, responded slowly to the call bell, and provided care alone despite needing 2-person assistance. A meeting with the resident, DON/DNS, and the NA occurred, but the grievance discussion and resolution were not documented or retained.
Failure to Report Two Allegations of Neglect: A cognitively intact resident who was totally dependent for incontinent care reported that staff did not provide overnight incontinent care and did not answer the call bell on two occasions. The RN supervisor and other nursing leaders were aware of the concerns, but the record lacked documentation of an assessment or reportable event, and staff could not show that the allegations were reported to the SA as required by policy.
Failure to Investigate Allegations of Neglect: A cognitively intact resident with urinary incontinence and dependence for care reported on two occasions that overnight staff did not provide incontinent care and did not answer the call bell. An LPN notified supervision, and the resident was later documented as having waited 12 hours between shifts for care, but the RN supervisor, ADNS, and DON could not produce or describe an investigation for either allegation despite the facility abuse policy requiring investigations of neglect.
Failure to follow care plans affected three residents. One resident with Alzheimer's disease, depression, and anxiety had a significant weight loss, and ordered nutritional shake intake was not documented as required; meal percentages were also missing many times. A second resident with Parkinson's disease and dementia had repeated missing meal intake documentation. A third resident with MS and depression was care planned for 2-staff assistance for bed mobility and care related to behaviors, but observations showed one NA providing care alone and staff acknowledged the plan was not consistently followed.
Care Plan Not Updated After Allegations of Neglect: A cognitively intact resident with MS, depression, functional urinary incontinence, and a UTI reported two separate overnight incidents in which staff did not provide incontinent care and did not answer the call bell. The resident’s care plan was not updated to reflect these allegations of neglect, and the RCC stated she had not been made aware of the concerns even though nursing and social work were also responsible for ensuring the care plan was revised as needed.
Failure to Follow Ordered Utensil Restrictions: A resident with severe cognitive impairment and a history of throwing utensils was ordered to use plastic silverware at meals, but surveyors observed the resident eating with metal utensils in the dining room. An NA and a homemaker both knew the resident required plastic utensils, yet metal silverware remained in use at the table, and the DON confirmed staff were expected to follow the provider order and care plan.
A resident with dementia, pulmonary fibrosis, and HF who was dependent for mobility and at risk for pressure ulcers developed a new pressure injury that was not promptly assessed by an RN, was documented inconsistently by nursing staff, and did not have all ordered wound treatments carried out as written. During wound care, an RN packed the wound and covered it but did not apply the ordered miconazole to the peri-wound before dressing placement. The resident’s care plan also called for a group 2 low air loss mattress set to alternating therapy, but the mattress was found set to static and firm, and staff gave conflicting accounts about who was responsible for ensuring the correct settings.
A resident with chronic pain syndrome and other diagnoses received a significant fentanyl patch medication error when an LPN applied three 25 mcg/hr patches instead of the ordered total dose of 37.5 mcg/hr. The MAR was signed off as if the correct dose had been given, and later documentation showed the excess patches were discovered and removed. The DON and pharmacy director stated there was no adverse effect, but the error involved a transdermal narcotic and did not follow the facility’s medication administration checks.
An unlocked medication cart and open medication room door were observed in one unit, with the cart visible from the hallway while residents and a visitor were nearby. An LPN stated she left the cart unlocked when she hurried to help a NA, and the DON confirmed policy required medication carts and medication rooms to be locked when nurses were not in view of the area.
Infection control practices were not followed during wound care, PPE use, and urinary device care. An RN performing wound treatment for a resident with a Stage 4 pressure injury failed to clean the bedside surface, perform hand hygiene after glove removal, and keep clean and soiled tasks separated; the antifungal cream tube was also handled and returned to the cart without being disinfected. For another resident on EBP, an LPN and RN donned PPE without hand hygiene and changed gloves without hand hygiene during wound care. A third resident’s urinary drainage bag was observed hanging low with part of the bag resting on the floor.
A facility failed to notify the State Ombudsman’s Office when a cognitively intact resident with multiple fractures, DM, and small cell lung cancer was transferred to the hospital after severe hypoglycemia with tremors, non-verbal status, and inability to follow commands. The APRN directed ER transfer, the NOK was notified, and the resident was later admitted to the hospital; SW documentation also noted bed hold education was provided and declined. During interview, SW stated the ombudsman was not notified and believed the notification policy did not apply to short-term rehab residents.
A nurse administered 40 units of Humalog insulin instead of the prescribed 14 units to a resident with diabetes, heart failure, and hypertension. The error occurred after the nurse became flustered by earlier shift disruptions, leading to a failure to follow the five rights of medication administration and resulting in an overdose of 26 units.
A resident with severe cognitive impairment and total dependence on staff for mobility was found with unexplained fractures to the right humerus and left femur. Despite care plans requiring two-person Hoyer lift transfers and specialized wheelchair supports, staff and facility records did not document any falls or incidents, and interviews with multiple staff revealed no observed abnormalities prior to the injuries. Medical evaluation determined the fractures were consistent with trauma, but the facility was unable to identify the cause.
A resident with neurocognitive disorder and other medical conditions, who required assistance with ambulation, was observed ambulating independently multiple times during the night. Despite care plan and physician's orders, staff failed to provide the necessary assistance, leading to a fall and significant injury. The resident was transferred to the hospital, where a CT scan revealed a hematoma, and the resident subsequently expired.
A resident with neurocognitive disorder and a history of falls was not provided with a comprehensive care plan that included their resistive behaviors. The resident fell and was found on the floor, later expiring at the hospital due to a significant hematoma. Staff interviews revealed the resident often ambulated independently despite requiring assistance, and the care plan did not address these behaviors.
Physical restraint used by tying a self-releasing seat belt
Penalty
Summary
The facility failed to ensure a resident was free from the use of a physical restraint when staff tied the resident’s self-releasing alarmed seat belt closed. The resident had diagnoses of Alzheimer’s disease and insomnia, and the quarterly MDS identified no cognitive assessment completed, no behaviors, maximal assistance with transfers, and no physical restraints. The care plan identified fall risk, memory deficits, and altered ADLs, with interventions for frequent safety checks and a physician order for a seat belt alarm with function and placement checks each shift. On 4/22/26, an OT observed the resident seated in a wheelchair with the alarmed seat belt tied closed with what appeared to be a washcloth or cloth, and there was no staff nearby at the time. A facility reportable event later documented that the resident’s alarmed seat belt had been tied in place for much of the evening shift. The investigation found that the resident was able to release the seat belt independently, but NA #1 tied it closed between approximately 3:30 PM and 3:45 PM and re-tied it after toileting throughout the shift. NA #1 stated she tied the seat belt with disposable wipes so the resident would not get up and fall, and she acknowledged she knew tying the seat belt would be considered a restraint. LPN #1 stated she was not notified that the resident was restless or trying to get up and did not recall seeing the seat belt tied. The DNS stated seat belts should not be tied to prevent a resident from getting up and that tying the seat belt would be considered a restraint. The facility abuse policy defined abuse to include willful unreasonable confinement.
Delayed Reporting of Restraint Use
Penalty
Summary
The facility failed to ensure staff reported an allegation of abuse or physical restraint use in a timely manner for one resident with Alzheimer’s disease and insomnia. The resident’s quarterly MDS identified no cognitive assessment completed, no behaviors, maximal assistance with transfers, and no physical restraints. The care plan identified fall risk, memory deficits, and ADL impairment, with interventions for frequent safety checks. A physician order directed use of a seat belt alarm with function and placement checks every shift. On 4/22/26, an OT observed the resident seated in a wheelchair with the self-releasing seat belt tied closed with what appeared to be a washcloth or similar material, and no staff were nearby. The OT emailed the DNS rather than immediately contacting nursing leadership or other staff. The resident’s assigned NA later stated she had wrapped disposable cleaning wipes around the Velcro portion of the alarmed seat belt so the resident could not remove it, and she re-tied it after toileting throughout the shift until the resident went to bed. The NA stated she knew tying the alarmed seat belt would be considered a restraint but did not notify the nurse or nursing supervisor. The charge LPN stated she was not notified of the resident’s restlessness or the tied seat belt, and the DNS stated she was not informed until the next morning, about 16 hours after the observation. The facility abuse policy required observed abuse to be reported immediately to the Nursing Director.
Incomplete Abuse Investigation
Penalty
Summary
The facility failed to conduct a complete and thorough investigation of an allegation of abuse involving Resident #1, who had diagnoses of Alzheimer's disease and insomnia and required maximal assistance with transfers. The resident's care plan identified fall risk, memory deficits, and ADL impairment, and a physician order directed use of a seat belt alarm with function and placement checks every shift. Facility documentation and interviews showed that the resident's self-releasing alarmed seat belt was observed tied in place by OT #1, and the facility later determined the belt had been tied closed for much of the evening shift. NA #1, who was assigned to the resident that shift, stated she tied the belt using disposable cleaning wipes because the resident kept trying to get out of the wheelchair and she wanted to prevent a fall. She also stated she knew tying the seat belt would be considered a restraint and that she did not report the situation to the nurse or nursing supervisor. The investigation was incomplete because the facility did not interview all staff who worked the 3 PM to 11 PM shift on the unit where the incident occurred. Review of the reportable event investigation showed that NA #1 was interviewed, along with staff from the prior shift, but NA #3, LPN #1, and RN #3, who were all working during the shift of the incident, were not interviewed. The DON stated she did not interview any staff members from that shift and acknowledged she should have interviewed all staff who worked the shift, but did not think it was necessary because NA #1 had already admitted to tying the belt. The facility abuse policy directed staff to identify and interview all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegation.
Unsafe Hot Water Temperatures Not Monitored in Resident Areas
Penalty
Summary
The facility failed to maintain safe water temperatures and failed to monitor water temperatures in resident rooms and bathrooms to ensure residents were free from potential burns. On 9/22/2025, survey observations found hot water temperatures above 120 degrees Fahrenheit in 25 of 46 rooms observed, ranging from 120.2 degrees Fahrenheit to 148.5 degrees Fahrenheit. In one resident bathroom, the faucet water temperature measured 121.6 degrees Fahrenheit. The resident, who had diagnoses including paroxysmal atrial fibrillation, chronic systolic congestive heart failure, and cardiomyopathy, had a BIMS score of 15 and required partial/moderate assistance for personal hygiene while being independent with oral hygiene, transfers, and walking 150 feet. The resident stated the bathroom water was "hot as anything," had been hot since admission in February 2024, and was especially difficult to regulate in the shower because it was so hot it took a while. Review of the facility's monthly domestic hot water temperature log from 8/1/2025 through 9/21/2025 showed water temperatures recorded high on 23 of 52 days, above 120 degrees Fahrenheit, with no documented plan of correction or measures to protect residents. Interviews with maintenance and physical plant staff showed temperatures were checked daily only at mixing valves in the boiler room, not in resident rooms or care areas, and staff were unaware they should check resident areas after elevated readings. Staff stated they generally adjusted the mixing valves when readings were high, but resident room temperatures were not checked unless there was a complaint. The facility's operations and maintenance manual stated mixing valves and/or anti-scald valves are necessary to reduce final water temperature to no more than 120 degrees Fahrenheit in patient/resident areas to prevent scalding.
Dignified dining and urinary device privacy failures
Penalty
Summary
Resident #245, who had diagnoses including Alzheimer's disease, dementia, and osteoarthritis, was identified as having severe cognitive impairment on the quarterly MDS and required set up/clean up assistance with eating. The resident's care plan noted hospice status and risk for unintentional weight loss, with interventions to assist with meals as needed, monitor preferences, and offer substitutions. Meal intake documentation showed variable intake, and observations during meals showed the resident sitting alone or away from other residents while dining, including being positioned in a wheelchair with the back to the dining area or sitting in the living room facing residents who were eating. During lunch observations, a NA assisted the resident while seated apart from the other residents, and the resident was not placed at the dining tables with the rest of the group. The NA stated the resident was kept separate because the resident was puree consistency and would make a mess if seated at the table with others. Another observation showed the resident alone in the living room during lunch and later sitting alone facing residents eating breakfast, without food or assistance at that time. An LPN stated the resident did not dine with other residents because staff did not want the resident to be seen not eating and placed the resident away from others while the rest of the residents ate. Resident #250 had diagnoses including urinary retention, UTI, and a sacral pressure ulcer, and had a physician order to check the urinary collection device and provide care every shift. Although the resident was cognitively intact and had a care plan identifying an indwelling urinary collection device, observations showed the resident's door open and the urine collection bag visible from the hallway without a privacy cover. A NA and an LPN both observed the uncovered bag and stated it should be covered for privacy; the NA said no privacy cover was available and placed a pillowcase over the bag after surveyor inquiry. The DON stated urinary collection device bags should always be covered for privacy and that covers were in stock, but could not explain why the resident's bag was not maintained with a privacy cover.
Failure to Document Resident Grievance Resolution
Penalty
Summary
The facility failed to document and retain the resolution of a grievance after a resident orally expressed concerns about care. Resident #272 had diagnoses including MS, major depression, functional urinary incontinence, and UTI, and was assessed as cognitively intact with total dependence for incontinent care, dressing, bathing, and maximum assistance of 2 staff members for bed mobility. The resident’s care plan did not reflect concerns related to the 11:00 PM to 7:00 AM shift, call bell response, or any resolution to the concern, despite a physician’s order for 2 staff members for bed mobility. Resident #272 reported concerns with NA #11, stating the NA spoke in a demeaning manner, did not always answer the call bell timely, and did not always return promptly after the call bell was answered. The resident said a meeting was held with the DNS and that the issue was discussed, but the resident could not recall the date. The DNS confirmed that a meeting occurred with the resident and NA #11 but admitted it was not documented. The DNS recalled discussion about call bell timeliness and returning for care, while NA #11 stated the resident also expressed that she talked too loudly and made the resident feel reprimanded. The Administrator was aware of the meeting but was unsure why there was no documentation, and the Director of Post Acute Services verified that the meeting took place with no documentation of the discussion or conclusion.
Failure to Report Two Allegations of Neglect
Penalty
Summary
The facility failed to ensure that two allegations of neglect involving a resident were reported to the State Agency. The resident had diagnoses including multiple sclerosis, major depression, functional urinary incontinence, and a UTI. The quarterly MDS identified the resident as cognitively intact with a BIMS score of 15 and totally dependent on staff for incontinent care, dressing, and bathing, with maximum assistance of 2 staff needed for bed mobility. The care plan directed incontinent care every 2 to 3 hours, barrier cream application, skin assessments during daily care, weekly skin assessments by nurses, and physician notification for signs of a UTI. On 8/25/25, the resident told an LPN that staff had not offered assistance and that incontinent care was not provided during the prior overnight shift, and that staff had not answered the call bell. The resident’s responsible party was aware, and the nursing supervisor was notified and spoke with the resident. However, the record reviewed for the days surrounding the allegation did not include documentation by the RN supervisor of an assessment or other information related to the allegation, and the RN supervisor stated she did not document the concern or perform a skin assessment for incontinence-related skin damage. She also stated she made the ADNS aware but could not state the facility policy for documentation on allegations of neglect or reportable events. On 9/8/25, the resident again expressed concern that incontinent care had not been provided during the overnight shift, and the LPN immediately notified the nursing supervisor. A physician note later documented that the resident had a conflict with the third shift NA, had not asked for assistance when incontinent, and had waited 12 hours between shifts for incontinent care. Interviews with the DNS, ADNS, supervisors, and other staff showed awareness of the allegations or lack of awareness depending on the shift, but no one could provide documentation that either allegation had been reported to the State Agency. The facility abuse policy required alleged abuse or neglect to be reported to the Connecticut Department of Public Health immediately, but no later than 2 hours.
Failure to Investigate Allegations of Neglect
Penalty
Summary
The facility failed to investigate two allegations of neglect made by Resident #272 regarding not receiving incontinent care and not having call bell needs answered. Resident #272 had diagnoses including multiple sclerosis, major depression, functional urinary incontinence, and UTI, and was assessed as cognitively intact with a BIMS score of 15. The care plan directed incontinent care every 2 to 3 hours, barrier cream use, skin assessments during daily care, weekly nursing skin checks, and physician notification for signs of UTI. On 8/25/25, LPN #5 documented that Resident #272 reported not being offered assistance and not receiving incontinent care during the prior overnight shift, and that staff had not answered the call bell. The nursing supervisor, RN #4, was notified and spoke with the resident, who stated the brief was wet. However, the record reviewed from 8/23/25 through 8/27/25 did not include documentation by RN #4 of an assessment or any information related to the allegation. RN #4 stated she informed the ADNS but did not document the concern or perform a skin assessment for incontinence-related skin damage. On 9/8/25, LPN #5 documented another concern from Resident #272 that incontinent care had not been provided during the prior overnight shift. The physician later documented that the resident had a conflict with the third shift NA, had not asked for assistance when incontinent, and had waited 12 hours between shifts for incontinent care. Interviews with the DNS, ADNS, and other nursing staff confirmed that the allegations should have been investigated under the facility abuse policy, which stated that allegations of neglect would be investigated, but no investigation documentation could be located for the 8/25/25 allegation and no investigation was initiated for the 9/7/25 into 9/8/25 allegation.
Failure to Follow Care Plans for Nutrition, Meal Documentation, and Two-Staff Assistance
Penalty
Summary
The facility failed to follow resident care plans for three residents with identified needs related to nutrition, mood and behavior, and care planning. Resident #157 had diagnoses of Alzheimer's disease, depression, and anxiety, was severely cognitively impaired, and was identified on the care plan as being at risk for unintended weight loss related to dementia and depression with variable intake. The care plan directed staff to record meal percentages, monitor weight, report significant weight changes, and provide the ordered diet. The resident's weight declined from 110.8 pounds to 97.4 pounds, a loss of 13.4 pounds. For Resident #157, a physician's order directed staff to give a 4-ounce nutritional shake and document the percentage consumed daily, but the MAR did not include documentation of the percentage taken. Review of meal records showed that from 5/15/25 through 9/25/25, 402 meals were served and the facility failed to document the percentage eaten 149 times. For Resident #259, who had Parkinson's disease, dementia, and hypertension and was severely cognitively impaired and dependent for eating and bathing, the care plan identified inadequate oral intake related to altered appetite secondary to COVID-19 and directed staff to record meal percentages and assist with meals as needed. Review of meal records showed that from 4/23/25 through 9/26/25, 471 meals were served and the facility failed to document the percentage eaten 167 times. For Resident #272, who had multiple sclerosis, major depression, functional urinary incontinence, and a urinary tract infection, the quarterly assessment showed cognitive intactness and total dependence for incontinent care, dressing, bathing, and maximum assistance of 2 staff for bed mobility. The care plan and physician's order directed 2 staff members for bed mobility and care related to accusatory behaviors. The resident stated that 2 staff members did not always provide care, and observations showed one NA providing a full bed bath and incontinent check without another staff member present. The NA and RN responsible for the care plan acknowledged that the resident required 2 staff, and an LPN stated she was unaware that the resident was care planned for 2 staff members.
Care Plan Not Updated After Allegations of Neglect
Penalty
Summary
The facility failed to ensure Resident #272’s Resident Care Plan was updated when allegations of neglect were made regarding a lack of incontinent care. Resident #272 had diagnoses including multiple sclerosis, major depression, functional urinary incontinence, and a urinary tract infection. The quarterly MDS identified the resident as cognitively intact with a BIMS score of 15 and totally dependent on staff for incontinent care, dressing, bathing, and requiring maximum assistance of 2 staff for bed mobility. The care plan in effect from 7/16/25 through 9/26/25 did not reflect two allegations of neglect related to incontinent care that occurred on 8/24/25 into 8/25/25 and on 9/7/25 into 9/8/25. A nursing note documented that the resident reported not being offered assistance, not receiving incontinent care on the overnight shift, and staff not answering the call bell; the responsible party was aware and the nursing supervisor was notified. A second nursing note documented another concern that the resident did not receive incontinent care on the overnight shift, and the nursing supervisor was immediately notified. During interview and review of the care plan, the Resident Care Coordinator stated she had not been made aware of the allegations of neglect and said she would have updated the care plan if informed. She also stated nursing or social workers were responsible for ensuring the care plan was updated when allegations of neglect occurred, and the facility policy directed that the interdisciplinary team review and revise the care plan after each comprehensive and quarterly MDS assessment and as needed.
Failure to Follow Ordered Utensil Restrictions
Penalty
Summary
The facility failed to follow a physician order and the resident care plan for a resident with Alzheimer’s disease, anxiety, and epilepsy who had severely impaired cognition and a history of verbal and physical behaviors toward others. The quarterly MDS indicated the resident was dependent on staff for personal hygiene, dressing, and chair/bed-to-chair transfers, and the care plan identified the resident as at risk for an ADL problem after being observed throwing silverware across the table toward another resident. The care plan and resident care card both directed staff to provide plastic silverware at mealtimes. Observations on 9/22/25 and 9/25/25 showed the resident eating in the dining room with metal utensils instead of the ordered plastic utensils. A nurse aide observed the resident using a metal fork to eat spaghetti and did not remove the metal silverware after surveyor inquiry. A homemaker later stated she set the table, knew the resident needed plastic silverware because of the history of throwing utensils, and believed the resident had taken another resident’s silverware. At that time, plastic silverware was not on the resident’s table, and the two other residents at the table were also using metal silverware. The DON stated staff were expected to follow provider orders and the care plan, and that nurses, nurse aides, and homemakers were responsible for ensuring the resident received plastic silverware.
Delayed wound assessment, incomplete treatment application, and incorrect air mattress settings
Penalty
Summary
Resident #21, who had Alzheimer’s disease, pulmonary fibrosis, and heart failure, was identified as severely cognitively impaired, at risk for pressure ulcers, wheelchair dependent, and dependent for bed mobility and transfers. The resident’s care plan identified a potential for altered skin integrity related to staff assistance with positioning and bowel and bladder incontinence, with interventions to offload heels and monitor skin for redness, irritation, or breakdown. On 11/29/24, an LPN documented an open area on the right buttock measuring 5.0 cm by 4.0 cm by 0.1 cm, with a darkened area connected at the coccyx, and applied barrier cream. The note documented notification of the APRN and responsible party, but did not document notification of the in-house RN supervisor or wound nurse. The clinical record did not identify an RN assessment of the new wound until 11/30/24 at 9:58 AM, approximately 24 hours after the wound was first observed. That RN assessment described a deep tissue pressure ulcer to the left gluteal/sacral area, which differed from the earlier LPN documentation of a right buttock open area. The assessment measured the area as 5.0 cm by 8.0 cm by less than 0.1 cm and described intact maroon discoloration. Interviews with nursing staff and the DON indicated that when a new wound was discovered, a pressure ulcer packet and RN documentation were expected, and if the wound nurse was unavailable, the RN supervisor should have assessed the resident and documented the finding on the day of discovery. A physician order for wound treatment directed cleansing the left gluteal wound, packing with Mesalt, covering with a dry dressing, and applying miconazole 2% cream to the gluteal area daily, with instruction not to apply it onto the wound. During observed wound care, the RN cleansed the wound, packed it with Mesalt, and applied a dry dressing, but did not apply the miconazole to the peri-wound area before covering the wound. The RN stated the cream would be applied later during incontinent care and could not explain how it would be applied without removing the dressing. The RN later acknowledged the miconazole should have been applied to the peri-wound before the dressing was placed and that the order was separate from the Mesalt treatment order. The resident’s care plan also identified a left gluteal stage 4 pressure ulcer and directed offloading, frequent turning and positioning, and checking the placement and function of a group 2 low air loss mattress set to alternating therapy every shift. The clinical record did not identify a physician order for the mattress placement or monitoring. Observations throughout the day showed the resident lying in bed with the air mattress functioning, but the pump was set to static and firm at the highest setting. Staff interviews showed the LPN believed the mattress sign-off only confirmed that the mattress was in place and functioning, while the RN stated the mattress should not be set to static and firm and later adjusted it to alternating and medium. The RN also stated the mattress settings were not the same for all residents and that the responsibility for ensuring correct settings was his, while the maintenance supervisor stated he set mattresses to medium and nurses were responsible for adjustments.
Significant fentanyl patch medication error
Penalty
Summary
The facility failed to prevent a significant medication error involving a transdermal fentanyl patch for Resident #228, who had diagnoses including progressive neuropathy, asthma, and chronic pain syndrome. The resident’s care plan identified chronic pain and directed staff to update the physician with new or increased pain, administer medications per current orders, and observe and record complaints of pain. Physician orders required fentanyl patches totaling 37.5 mcg/hr. every 72 hours and to check patch placement every shift. On 6/8/25, LPN #8 documented that a new fentanyl patch was placed on the resident’s left upper arm, but the note did not identify the dosage or number of patches applied. Later documentation showed a fentanyl patch was present on the left upper arm, and on 6/9/25 staff removed a total of 75 mcg/hr. of fentanyl, which was double the ordered dose. The on-call APRN was notified, new orders were received for the correct fentanyl dose, and the resident’s vital signs were monitored. A reportable event form documented that three fentanyl 25 mcg/hr. patches were observed on the left upper arm when the order was for a total of 37.5 mcg/hr. The MAR showed LPN #8 signed off both fentanyl orders totaling 37.5 mcg/hr. as administered and documented removal of the old patches, but the written discussion later stated she had inadvertently placed three fentanyl 25 mcg/hr. patches instead of the ordered patches. The DON stated she did not consider the error significant because no harm occurred, and the pharmacy regional director stated the significance of a narcotic medication error was patient specific and she would not consider this error significant due to no adverse effect. The facility policy required verification of the 5 rights, comparison of narcotics to the MAR and medication container, and reading labels multiple times before preparation.
Unlocked Medication Cart and Medication Room
Penalty
Summary
The facility failed to safely store medications and biologicals in 1 of 21 units, the [NAME] House. On 9/22/25 at 9:38 AM, the [NAME] House nurses' station/medication room door was observed unlocked and fully open while the charge nurse was at the end of the unit with her medication cart out of sight of the medication room door. Later that day at 11:37 AM, the same door was again observed unlocked and open, and the medication cart stored in the room was unlocked and visible from the hallway. Two residents were self-propelling in wheelchairs in the hallway, and one visitor was in the dining area outside the nurses' station/medication room, with no staff visible in the area. During interview and observation with an LPN on 9/22/25 at 11:46 AM, the facility policy was identified as requiring medication carts to be locked when not in use. The LPN stated it was her responsibility to lock the medication cart, but she did not do so because she ran out in a hurry to help a NA in a resident's room. After surveyor inquiry, she locked the medication cart and then closed and locked the nurses' station/medication room door when not occupied. The DNS later confirmed on 9/29/25 that facility policy required medication carts and medication rooms to be locked when nurses were not in view of the area, and that nursing staff on the unit were responsible for keeping them locked.
Infection Control Failures During Wound Care, PPE Use, and Urinary Device Care
Penalty
Summary
The facility failed to perform hand hygiene and maintain clean conditions during wound care for a resident with severe cognitive impairment, pulmonary fibrosis, heart failure, and a Stage 4 left gluteal pressure injury. The resident had a care plan for wound management and physician orders for cleansing the wound, packing it with Mesalt, covering it with a dry dressing, and applying miconazole cream to the gluteal area without applying it to the wound. During observation of the wound treatment, the RN placed wound care supplies on the resident’s bedside table without first cleansing the surface, removed a soiled dressing and changed gloves without performing hand hygiene, and continued wound care without hand hygiene between contaminated and clean tasks. During the same wound care, the RN sprayed wound cleanser onto the wound, wiped it with gauze, placed soiled gauze on the bed, and then picked up Mesalt and packed the wound without changing gloves or performing hand hygiene. The RN later applied miconazole to the peri-wound and buttocks area, covered the resident with a blanket while still wearing soiled gloves, and removed the gloves without hand hygiene. The tube of miconazole was then handled and placed back on the treatment cart without being disinfected or bagged after it had been brought into the resident’s room. The RN stated he should have sanitized the bedside table, performed hand hygiene after removing soiled gloves and after removing the old dressing, and cleansed the outside of the antifungal cream tube before placing it back on the cart. The facility also failed to follow infection control practices for another resident on Enhanced Barrier Precautions who had diabetes, rhabdomyolysis, Alzheimer’s disease, severe cognitive impairment, dependence for hygiene, dressing, and transfers, and a wound requiring treatment every shift. Observation showed an LPN and an RN put on gloves and gowns without performing hand hygiene before entering the room. During care, the RN removed soiled gloves and put on clean gloves without hand hygiene, and the LPN also changed gloves without hand hygiene before cleaning the wound and applying Triad paste. After care, the RN performed hand hygiene outside the room, while the LPN did not. The LPN stated she did not perform hand hygiene before applying PPE or between glove changes because she did not feel cleansing items were available in the room, and the RN stated he should have performed hand hygiene when changing gloves but did not because there was no hand sanitizer in the room. The facility further failed to maintain appropriate infection control practices for a resident with urinary retention, UTI, and a sacral pressure ulcer who had a urinary collection device. Observation showed the drainage bag was hung low under the wheelchair with the front bottom half resting on the floor. The LPN and nurse aide stated the bag should not have been on the floor and instructed the aide to reposition it so it would not contact the floor. The DON confirmed the drainage bag should not have been resting on the floor and that it was the aide’s responsibility to ensure the urinary collection device was positioned off the floor.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to provide the required notification of discharge/transfer to the State Ombudsman’s Office for the only sampled resident reviewed for hospitalization. The resident was admitted with diagnoses including multiple fractures, diabetes, and small cell lung cancer. The admission care plan identified hyperglycemia related to diabetes with interventions to monitor and record food intake, monitor blood glucose per physician orders, and monitor for signs of hypoglycemia. The 5-day MDS identified the resident as cognitively intact and requiring substantial to maximal assistance for bathing and toileting, and partial to moderate assistance for transfers. On 8/10/25, the resident was observed with intermittent body tremors, non-verbal, eyes open, and unable to follow commands; the blood sugar was 32 and glucagon was given intramuscularly. The APRN was notified and directed that the resident be sent to the ER for evaluation, and the next of kin was notified. The resident was admitted to the hospital the next day. A social worker note documented that the family was educated on the bed hold policy and declined it, and the family member planned to retrieve the resident’s belongings. During interview, Social Worker #2 stated the ombudsman was not notified of the transfer to the hospital and said the facility’s notification policy did not include residents on the short-term rehabilitation unit; the facility did not provide a policy for ombudsman notification.
Insulin Overdose Due to Medication Administration Error
Penalty
Summary
A medication administration error occurred when a nurse administered 40 units of Humalog insulin to a resident with type 2 diabetes, heart failure, and hypertension, instead of the physician-ordered 14 units before breakfast. The resident's blood sugar was recorded as 322 prior to the administration, and the nurse reported reviewing and verifying the physician's orders before giving the insulin. However, the nurse inadvertently drew up and administered the incorrect dose, realizing the mistake only after the injection was nearly complete. The nurse attributed the error to feeling flustered due to earlier difficulties with computer access and a fire alarm during the shift. The resident was cognitively intact, independent with activities of daily living, and had a care plan in place for diabetes management, including blood glucose monitoring and insulin administration as ordered. The facility's documentation and interviews confirmed that the five rights of medication administration were not followed, specifically the right dose, resulting in the resident receiving an excess of 26 units of insulin. The incident was identified and reported by the nurse, and the supervisor and family were notified.
Failure to Prevent and Identify Injuries of Unknown Origin in Dependent Resident
Penalty
Summary
A resident with Alzheimer's disease, severe cognitive impairment, and generalized muscle weakness, who was non-ambulatory and dependent on staff for all mobility and transfers, was found to have sustained significant injuries of unknown origin, including a left femur fracture and a right humerus fracture. The resident's care plan required the use of a Tilt in Space wheelchair with specific supports and mandated two-person assistance with a Hoyer lift for all transfers. Despite these interventions, the resident was discovered with bruising, swelling, and pain in the right upper arm, which upon X-ray revealed a transverse fracture. Further hospital evaluation identified an additional displaced fracture of the left femur. Facility documentation and staff interviews indicated that there were no reported falls, accidents, or incidents involving the resident in the days leading up to the discovery of the injuries. Multiple staff members who provided care in the 72 hours prior to the incident did not observe any abnormalities, bruising, or changes in the resident's condition. The facility's investigation, including review of shift reports and staff statements, failed to determine the cause of the injuries, and there was no documentation of any event that could have resulted in such trauma. Medical assessment by the treating orthopedic surgeon concluded that the types of fractures sustained—a transverse humerus fracture and a spiral femur fracture—were consistent with trauma, such as a fall, and not likely to result from routine handling or movement, even in the presence of severe osteoporosis. The facility's safe handling policy was reviewed, but the investigation was unable to identify any deviation from policy or specific incident that led to the resident's injuries.
Failure to Provide Adequate Supervision and Assistance with Ambulation
Penalty
Summary
The facility failed to ensure adequate supervision and assistance for a resident with neurocognitive disorder with Lewy body dementia, atrial fibrillation, and congestive heart failure, who required assistance with ambulation. Despite the resident's care plan and physician's orders directing assistance of one with a rolling walker, the resident was observed ambulating independently multiple times during the night. The nurse aide on duty did not report the resident's non-compliance and independent ambulation to the nurse, and the nurse did not intervene, believing it was the resident's baseline functional level. On the night of the incident, the resident was last assisted with toileting at 3:00 AM and then returned to bed. Shortly after, the resident's bed alarm went off, and the nurse aide observed the resident standing by the bed and later ambulating independently. The nurse aide was attending to other residents' bed alarms and did not observe the resident return to the room. A thumping sound was heard, and the resident was found on the floor next to the bed with the walker nearby, complaining of pain and a headache. The resident was transferred to the emergency room, where a CT scan revealed an acute/hyperacute left posterior parietal hematoma. The resident was not a candidate for surgical intervention and was transitioned to comfort measures, subsequently expiring at the hospital. Interviews with staff indicated that the resident had poor safety awareness and was difficult to redirect, and staff should have been providing assistance with ambulation as ordered.
Failure to Address Resistive Behaviors in Care Plan
Penalty
Summary
The facility failed to ensure the comprehensive care plan for a resident with neurocognitive disorder with Lewy bodies included the resident's resistive behaviors. The resident, who had moderate cognitive impairment and a history of falls, required supervision with bed mobility, transfers, and ambulation with a walker. Despite this, the care plan did not address the resident's known resistive behaviors, which were identified by the Director of Nursing as a necessary inclusion. On the night of the incident, the resident was found on the floor after a fall, having been last seen in the common area. The resident was agitated, weepy, and in pain, and was subsequently transferred to a hospital where a CT scan revealed a significant hematoma. The resident later expired at the hospital. Interviews with staff revealed that the resident was known to be resistive to care and often ambulated independently without staff assistance, despite requiring assistance. The care plan's failure to address these behaviors contributed to the incident.
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 486 citations issued within 25 miles in the last 12 months — including the 6 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 Bridgeport
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ludlowe Center For Health & Rehabilitation | 1 mi | ★★★★★ | 11 | 0 |
| Springs At 3030 Park, The | 1.2 mi | ★★★★★ | 3 | 0 |
| Cambridge Health And Rehabilitation Center | 1.3 mi | ★★★★★ | 2 | 0 |
| Civita Care Northbridge | 1.7 mi | ★★★★★ | 22 | 0 |
| Maefair Center For Health & Rehabilitation | 2.6 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Mozaic Senior Life.
100% money-back within 48 hours.
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.