Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pomperaug Woods Health Center during CMS and state inspections, most recent first.
Failure to Treat a Resident with Respect and Dignity: A resident with fractures, difficulty walking, and intact cognition reported that an NA was sharp, annoyed, and had a bad attitude while providing overnight toileting care. The resident said this made him/her hesitant to use the call bell afterward, and the DON confirmed the resident felt uneasy about requesting help again because of the aide's demeanor.
A resident with dementia and other medical conditions had an iPad taken from the facility. The missing device was reported by the family, and after an internal search, it was tracked to a location outside the facility. Investigation revealed that a staff member was involved in the misappropriation of the resident's property, violating the facility's policy on protecting residents' belongings.
A resident with chronic pain conditions was prescribed Oxycodone, which was delivered, signed in by two nurses, and stored in the locked narcotic drawer. During a routine audit, the DON discovered that both the medication and its disposition sheet were missing. Despite searching all medication storage areas and interviewing staff, the items could not be located, resulting in a failure to protect the resident from misappropriation of property.
A facility failed to adhere to care plans for three residents, resulting in falls and injuries. One resident, identified as a high fall risk, was not provided with scheduled toileting or gripper socks, leading to a fall with major injuries. Another resident, requiring a two-person assist for transfers, was improperly transferred by a single aide, resulting in a fall. A third resident, also a high fall risk, was not toileted as per the care plan, leading to self-transfer attempts and falls.
The facility failed to maintain accurate temperature logs for kitchen equipment and did not ensure cleanliness of storage containers. Temperature logs were not kept from October 1 to October 10, and when produced, they were postdated. Storage containers for food items were found unclean, and there was no cleaning schedule in place. The facility did not provide policies for temperature maintenance and cleaning.
The facility did not implement appropriate plans of action to correct quality deficiencies identified through its QAPI program. A bed safety program and a mechanical lift sling quality control project were initiated and reported as completed, but facility documentation lacked measurable goals, detailed interventions, or a monitoring process. The DON could not explain the absence of documentation related to these initiatives.
The facility failed to provide PPE gowns to staff handling soiled linens, as observed during an interview with a laundry aide and the Director of Laundry, who was unaware of PPE usage requirements. No PPE gowns were stored in the laundry area, leading to contamination of the aide's clothing while handling soiled and clean linens. Facility policy required gowns and gloves for sorting and washing linen.
A facility failed to maintain a clean and sanitary environment for personal care items in shared bathrooms. Unlabeled items, such as toothbrushes and razors, were found on countertops, leading to confusion among staff and residents. Nursing staff acknowledged the need for labeling and proper storage, as per facility policy.
A resident with type II diabetes and chronic kidney disease, who was cognitively intact, expressed a preference for fresh potatoes over instant ones. Despite this, the resident was repeatedly served instant potatoes, contrary to their documented preference. Staff interviews revealed awareness of the preference but cited oversight as the reason for the error. The facility failed to adhere to the resident's right to self-determination and choice in meal preferences.
A resident with dementia and osteoarthritis, who was cognitively intact, was found with a bruise on the left upper thigh. The DNS did not report the injury to the state agency, believing it did not meet reporting criteria, despite the facility's policy requiring immediate reporting of such injuries.
A resident with a history of falls and cognitive intactness was prescribed Risperdal 0.25 mg every evening for delusions and hallucinations. However, the handwritten order was incorrectly transcribed into the EMAR as every 8 hours, leading to overmedication for 13 days. The error was discovered by an RN who failed to clarify the order, and the prescribing MD confirmed the original order. No adverse effects were reported.
A resident with limited mobility and cognitive impairment was improperly transferred by staff, leading to a fall and femur fracture. The resident required assistance from two staff members for transfers, as per the care plan, but was transferred by one NA alone. The wheelchair was not locked, and the resident was not positioned safely, resulting in the fall. The facility lacked a policy on transferring residents.
A resident with impaired cognition and a history of falls was not transferred according to physician orders, requiring two staff members and a Maximove lift. Instead, a nursing assistant transferred the resident alone, allegedly using rough handling and verbal abuse. The incident led to the assistant's termination after an investigation confirmed the violation of transfer protocols.
A resident with osteoarthritis, dementia, and muscle weakness fell and fractured their femur due to improper transfer procedures and incomplete clinical records. The resident required substantial assistance with transfers, but physician orders for transfer status were unavailable. Two NAs attempted to transfer the resident without locking the wheelchair, and one NA had previously transferred the resident alone, contrary to the care plan.
Failure to Treat a Resident with Respect and Dignity
Penalty
Summary
The facility failed to ensure Resident #8 was treated in a respectful and dignified manner. Resident #8 had diagnoses including major depressive disorder, right femur fracture, difficulty walking, fracture of the first lumbar vertebrae, bilateral sacral fractures, and sacral insufficiency fracture. The care plan identified a functional ADL decline related to fractures and recent surgery, with assistance needed for ADLs and toileting. The quarterly MDS indicated intact cognition with a BIMS score of 15, continence of bowel and bladder, moderate assistance needed for personal hygiene, and touching assistance for toileting and toileting hygiene. Resident #8 reported that while being toileted during the overnight hours, NA #6 was sharp, had a bad attitude, and seemed annoyed while assisting with the bed pan. Resident #8 stated he/she became hesitant to use the call bell afterward because of NA #6's demeanor. The reportable event documentation and interviews reflected that Resident #8 did not describe specific abusive language, but expressed concern about the staff member's attitude and interactions. RN #6 stated he had prior concerns about NA #6's interactions with residents and had previously reported additional allegations involving NA #6, while the DNS confirmed Resident #8 reported feeling hesitant to call for assistance again because of the aide's attitude.
Resident's Personal Property Misappropriated by Staff
Penalty
Summary
A deficiency occurred when a resident's personal property, specifically an iPad with a blue cover, was taken from the facility. The resident, who had diagnoses including dementia, anxiety, generalized muscle weakness, and chronic obstructive pulmonary disease, was identified as having moderately impaired cognition and required substantial assistance with activities of daily living. The missing iPad was reported by the resident's family when they arrived to collect the resident's belongings. Facility staff conducted a search and notified all departments, but the iPad was not found. The family later used the iCloud account to track the device, which was located at a middle school outside the facility. An internal investigation was initiated, and the police were notified. The facility provided the police with a list of staff who had cared for the resident, as well as other relevant information. The police instructed the facility to allow them to handle the investigation as a criminal matter. During the investigation, a staff member was placed on administrative leave, and it was later identified that the iPad was returned to the family and the suspect was a nursing assistant. The facility's policy states that residents have the right to be free from misappropriation of property, but in this instance, the resident's property was not protected from wrongful use.
Failure to Account for Controlled Medication and Documentation
Penalty
Summary
A deficiency occurred when a controlled medication, Oxycodone, and its corresponding controlled substance disposition sheet for a resident with chronic pain conditions were found to be missing from the facility. The resident, who had diagnoses including osteoporosis, spondylosis, cervicalgia, and polyosteoarthritis, was receiving scheduled pain medication and had no memory recall deficits. The medication was delivered by the pharmacy, signed in by two nurses, and placed in the locked narcotic drawer of the medication cart as per facility protocol. However, when the resident required a dose two days later, the medication could not be located in the cart and had to be obtained from the emergency box. A routine bimonthly narcotic audit conducted by the DON revealed that both the blister pack of Oxycodone and the corresponding disposition sheet were unaccounted for. Despite searching all medication storage areas and interviewing staff who worked during the relevant period, the medication and documentation could not be found. Facility policies required proper accounting and documentation of all controlled drugs and defined misappropriation as the wrongful use or misplacement of a resident's belongings or money. The failure to account for the controlled medication and its documentation constituted a failure to protect the resident from misappropriation of property.
Failure to Follow Care Plans Leads to Resident Falls
Penalty
Summary
The facility failed to follow the care plan for Resident #26, who had a history of falls and was identified as a high fall risk. Despite the care plan's directives to apply gripper socks and offer toileting every 2 hours, Resident #26 was found barefoot and had not been toileted according to the schedule. This oversight resulted in a fall with major injuries, including multiple subarachnoid hemorrhages and a nondisplaced occipital bone fracture, requiring a 5-day hospital admission. Resident #2, who required a two-person assist for transfers, was improperly transferred by a single nurse aide, leading to a fall. The care plan and physician orders specified the need for a two-person assist during certain shifts and the use of a Hoyer lift during others. However, the nurse aide attempted to transfer Resident #2 alone, resulting in the resident panicking and being eased to the floor. This incident occurred despite the staff's awareness of the resident's transfer requirements. Resident #10, identified as a high fall risk with a history of falls, was not toileted according to the care plan, which required frequent checks and assistance. The resident was found on the bathroom floor after attempting to self-transfer, having not been toileted as scheduled. The staff failed to adhere to the care plan's directives to offer toileting every hour and to remain with the resident during bathroom visits, contributing to the fall incidents.
Deficiencies in Kitchen Documentation and Cleanliness
Penalty
Summary
The facility failed to maintain proper documentation and cleanliness standards in the kitchen, as observed during a survey. Temperature logs for refrigerators, freezers, and the dishwasher were not maintained from October 1 to October 10, 2024. When questioned, the Culinary Director produced logs that were postdated with temperatures through October 10, 2024, at 5 PM, indicating that the logs were not accurately maintained. Additionally, four 50-pound storage containers used for flour, sugar, oatmeal, and rice were found with a brown sticky substance around the tops, indicating they were not clean. The Culinary Director admitted there was no cleaning schedule or log for these containers. Despite requests, the facility did not provide policies for temperature maintenance and cleaning equipment.
Failure to Document and Monitor QAPI Initiatives
Penalty
Summary
The facility failed to implement appropriate plans of action to correct quality deficiencies identified through its Quality Assurance and Performance Improvement (QAPI) program. The QAPI Committee Minutes from March 2024 indicated the initiation of a bed safety program for entrapment checks before bed changes for residents using bed rails as mobility enablers. By June 2024, the program was reported as completed, with maintenance performing bed checks. However, the facility documentation did not include measurable goals, step-by-step interventions to address the problem, or a method to monitor progress over time. Additionally, the QAPI Meeting Minutes from March 2024 outlined a plan for mechanical lifts and sling quality control to ensure all slings were safe and appropriately sized according to manufacturer guidelines. By July 2024, the project was reported as completed, with all residents having two slings in rotation and inspection as part of daily practice. Despite this, the facility documentation again lacked measurable goals, detailed interventions, or a monitoring process. The Director of Nursing was unable to explain the absence of documentation related to these QAPI initiatives.
Failure to Provide PPE Gowns in Laundry
Penalty
Summary
The facility failed to ensure that staff were provided with Personal Protective Equipment (PPE) gowns while sorting and washing soiled linens. During an observation and interview with a laundry aide, it was identified that PPE gowns had never been used to handle soiled linen. The Director of Laundry, who was new to the position, was unaware of when PPE gowns should be utilized during laundry processing. Further observations revealed that no PPE gowns were stored in the laundry area, and there was contamination of the laundry aide's clothing while handling soiled linens, which was followed by handling clean linens. The facility's policy indicated that employees sorting and washing linen must wear a gown and gloves, and a mask may be worn if aerosolization is expected.
Failure to Maintain Sanitary Storage of Personal Care Items
Penalty
Summary
The facility failed to maintain a clean and sanitary environment for personal care items in shared bathrooms, as observed during a survey. Unlabeled personal care items, including hairbrushes, combs, razors, shampoo bottles, soap dishes, toothbrushes, and denture cups, were found on the countertops in bathrooms shared by residents. These items were not labeled with resident identifiers, leading to confusion among staff about ownership. Nursing assistants interviewed during the survey indicated that they would discard items if they were unsure of ownership, and noted that some residents, who were confused, would use any items available on the countertop. Further observations confirmed that the issue persisted, with unlabeled items remaining on the countertops in shared bathrooms. Interviews with nursing staff, including a registered nurse, revealed that personal care items should be labeled and stored in designated shelving units provided by the facility. The Director of Nursing acknowledged the lack of staff competencies or in-services related to the storage and labeling of personal care items and recognized the need for improvement in this area. The facility's policy emphasizes maintaining a clean, sanitary, and orderly environment, which was not adhered to in this instance.
Failure to Honor Resident's Food Preference
Penalty
Summary
The facility failed to honor a resident's food preference, specifically for fresh potatoes instead of instant potatoes, which was a significant aspect of the resident's self-determination and choice. The resident, who was cognitively intact and independent with eating, had a care plan that emphasized involvement in daily decision-making. Despite this, the resident repeatedly received instant potatoes, contrary to their expressed preference for fresh potatoes. This issue was brought to the attention of the Director of Nursing, who assured the resident it would not happen again. Interviews with staff revealed a lack of adherence to the resident's documented food preferences. A nurse aide confirmed that the resident was initially served instant potatoes and had to replace them with fresh ones. Dietary aides acknowledged awareness of the resident's preference but failed to ensure the correct meal was served due to oversight. The Food Service Director confirmed that staff should have checked meal tickets to ensure the resident received fresh potatoes as per their preference. This oversight indicates a failure in the facility's processes to accommodate the resident's dietary choices as outlined in the Resident Rights policy.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident with dementia and osteoarthritis to the overseeing state agency. The resident was cognitively intact and required a two-person assist for bed mobility, transfers, and toileting. On a specific date, a bruise measuring 6.5cm by 4cm was observed on the resident's left upper thigh during care. Despite the bruise's location, the Director of Nursing (DNS) did not report the injury, as he did not believe it met the criteria for reporting. The facility's Abuse Prevention Policy mandates that all alleged violations of abuse, including injuries of unknown source, must be reported immediately, within two hours of discovery. The policy defines injuries of unknown source as those where the source was not observed or explained by the resident, and the injury is suspicious due to its extent, location, or frequency. The DNS's decision not to report the injury was contrary to this policy, as the injury's source was not observed, and the resident could not explain it.
Medication Transcription Error for Psychotropic Drug
Penalty
Summary
The facility failed to ensure accurate transcription of a physician's order for a newly prescribed psychotropic medication for Resident #16. The resident, who was cognitively intact and had no prior behaviors directed toward others, was admitted with a history of fainting, falls, and a cervical fracture. A psychiatrist prescribed Risperdal 0.25 mg to be administered every evening at 8:00 PM to address delusions, hallucinations, and yelling behaviors. However, the handwritten order was incorrectly transcribed into the electronic medication administration record (EMAR) as Risperdal 0.25 mg every 8 hours, leading to the resident receiving the medication more frequently than prescribed from October 3 to October 15. The error was discovered when RN #2, who was responsible for transcribing the order, noted the discrepancy but did not seek clarification from other staff or the prescribing physician. The Director of Nursing (DNS) was informed of the issue on October 15, and an investigation was initiated. The prescribing physician, MD #2, confirmed the original order and noted potential adverse effects of the incorrect dosage, although no adverse effects were reported for Resident #16. The facility's policy requires verification of handwritten orders by a licensed nurse before entry into the electronic health record, which was not adequately followed in this case.
Failure to Follow Transfer Protocols Results in Resident Injury
Penalty
Summary
The facility failed to ensure that a resident was transferred with the assistance of two staff members as required by the Resident Care Plan. The resident, who had diagnoses including osteoarthritis, dementia, and muscle weakness, required substantial assistance with transfers. On the day of the incident, two nursing assistants (NAs) were preparing to transfer the resident from a wheelchair to a bed. However, the resident was not seated properly in the wheelchair, and when instructed to reposition, the resident slid out of the wheelchair and sustained a femur fracture. The incident report noted that the wheelchair was not locked, and the resident was not positioned safely, leading to the fall. Interviews and record reviews revealed that the resident had an order for assistance of two staff members via a Hoyer lift for transfers, which was not followed. One NA transferred the resident from the toilet to the wheelchair alone, contrary to the care plan, and the resident was not properly positioned in the wheelchair. The Director of Nursing confirmed that the resident required two staff for transfers and acknowledged that the transfer was conducted improperly. The facility did not have a policy on transferring residents, which contributed to the incident.
Failure to Follow Transfer Orders Leads to Deficiency
Penalty
Summary
The facility failed to ensure that a resident was transferred in accordance with physician orders, leading to a deficiency. The resident, who had diagnoses including difficulty in walking and muscle weakness with a history of falls, required partial/moderate assistance with transfers as per the Minimum Data Set. The Resident Care Plan indicated the need for assistance of two staff members during transfers to mitigate fall risk. A physician's order further specified the use of a Maximove lift with two staff members for toileting and transferring. An incident occurred where a nursing assistant (NA) allegedly transferred the resident alone, without the required second staff member, and was reported to have been rough and verbally abusive. The Director of Nursing confirmed that the NA performed the transfer alone, contrary to the physician's orders. The NA was suspended and subsequently terminated following the investigation, which revealed that the resident had a history of directing staff to perform unsafe transfers.
Incomplete Clinical Record and Improper Transfer Lead to Resident Fall
Penalty
Summary
The facility failed to ensure the clinical record for a resident was complete and accurate, specifically regarding transfer status orders. The resident, who had diagnoses including osteoarthritis, dementia, and muscle weakness, required substantial assistance with transfers as per the Minimum Data Set (MDS) and Resident Care Plan (RCP). However, the facility was unable to provide physician orders for the resident's transfer status prior to a fall incident, despite requests for these records. The incident occurred when two nursing assistants (NAs) were preparing to transfer the resident from a wheelchair to bed. The resident was not properly positioned in the wheelchair, and when instructed to move back, the resident leaned forward and fell, resulting in a left femur fracture. The NAs did not lock the wheelchair before attempting to reposition the resident, and one NA had previously transferred the resident from the toilet to the wheelchair without assistance, contrary to the care plan's directive for two-person assistance. The Director of Nursing confirmed the absence of physician orders for the resident's transfer status.
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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 Southbury
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Springs At East Hill, The | 0.8 mi | — | 0 | 0 |
| Lutheran Home Of Southbury Inc | 1.4 mi | ★★★★★ | 5 | 0 |
| River Glen Health Care Center | 2 mi | ★★★★★ | 0 | 0 |
| Complete Care At Middlebury | 6.6 mi | ★★★★★ | 1 | 0 |
| Stone Bridge Center For Health & Rehabilitation | 7.7 mi | ★★★★★ | 2 | 0 |
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