Above average — CMS composite of the measures below.
A standard survey is most likely before around November 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 River Glen Health Care Center during CMS and state inspections, most recent first.
A resident with COPD, chronic respiratory failure, emphysema, and pneumonia had a facility-issued albuterol inhaler left unsecured on the bedside nightstand and was using it independently. The record showed no physician order for self-administration and no completed self-administration assessment, while staff acknowledged the inhaler should have been locked in the med cart between uses and documented for effectiveness.
A resident with Parkinson’s disease, acute respiratory failure with hypercapnia, and CKD had conflicting code status documentation in the chart. The record included a physician-signed DNR form, a hospital discharge summary showing DNR/DNI, and an admission MD order for DNR, but an APRN later entered a Full Code order and documented Full Code/CPR. The care plan also listed Full Code, and the RN supervisor stated the resident’s advance directive orders were confusing and that both DNR and Full Code orders were active at the same time.
A facility failed to keep care plans accurate for a resident with hearing loss, a resident with repeated refusals of care, and a resident with a left-hand ROM limitation. One resident used hearing aids, but the care plan did not reflect that need; another resident repeatedly refused wound care, weights, showers, and boots, yet refusals were not included in the care plan; and a third resident had a left-hand contracture requiring a palm guard, but the care plan and nursing order were inconsistent and did not identify the ROM limitation.
A resident with dementia, anemia, and HTN had a change in code status from full code to DNR with RNP, documented by APRN orders and a signed DNR consent from the responsible party. However, the care plan was not updated and still listed the resident as full code instead of reflecting the current advance directives. Staff interviews showed confusion about who was responsible for updating the care plan after the change.
Incomplete RN Pronouncement Assessment: A resident with CHF, cerebral infarction, and HTN was pronounced dead by an RN after being found not breathing and without a heartbeat. The pronouncement note was incomplete because it did not include BP or pupillary response, and staff interviews confirmed the RNP assessment should have included respirations, pulse/heartbeat, BP, and pupil responsiveness.
A resident with Alzheimer's disease, macular degeneration, and a history of falls required assistance of 1 for toileting and supervision for transfers and ambulation with a RW, but staff allowed the resident to return to the room after requesting a pull-up brief. The resident was later found on the bathroom floor, initially non-responsive and disoriented, with skin tears, a forehead injury, and a hematoma, and was sent to the hospital by ambulance. Staff statements conflicted with the EMR task directions, and the DON stated the resident should have been supervised when returning to the room and during toileting.
Failure to obtain a physician order for a resident's nightly CPAP use. A resident with OSA, acute respiratory failure with hypercapnia, and asthma had a personal CPAP machine at the bedside and reported using it every night, while staff also assisted with mask placement. APRN and MD notes encouraged CPAP use, but the record lacked an order until after surveyor inquiry, and staff acknowledged the order should have been obtained.
Failure to implement EBP for a resident with a Stage 3 pressure ulcer. The resident had dementia, anemia, and HTN, and was severely cognitively impaired with an unhealed pressure injury and substantial to maximal assistance needs. Surveyors observed no EBP signage, no PPE bin, and no laundry bin near the room, and an LPN and APRN performed wound dressing care without wearing gowns, despite policy requiring gown and glove use for wound care.
Inaccurate MDS coding affected several residents. One resident with hearing loss was coded as not using hearing aids despite records and observations showing hearing aids were used. Another resident with dementia had documented contractures, rigidity, and dependence for mobility, but the MDS did not reflect ROM limits or dependent functional status. A third resident had a palm guard order and left-hand contracture, yet the MDS missed the ROM limitation. A fourth resident’s unwitnessed fall with a head hematoma was coded as a fall without injury instead of a minor injury.
Missing Bi-Monthly Narcotic Audits: The facility failed to complete and maintain bi-monthly narcotic audits to monitor for possible drug diversion. The interim DNS could not locate any audit documentation since the prior re-certification survey, and only current yellow narcotic reconciliation sheets were available in a binder. Three sheets showed a July date in the middle of the form, but the interim DNS could not explain what type of audit had been done or provide any complete narcotic audit forms. The Administrator was also unaware of the location of any audit records, and attempts to contact prior DNS staff were unsuccessful.
A resident with severe cognitive impairment and a history of falls was verbally mistreated by an LPN, who expressed frustration and made inappropriate comments about the resident falling. The incident was witnessed and reported by an alert roommate and a nursing assistant, and later substantiated by facility leadership.
A resident with severe cognitive impairment and a history of falls was involuntarily secluded when an LPN placed wheelchairs and a nightstand around the bed, blocking the resident from exiting. Staff observed and confirmed that the resident was confined in this manner, and the LPN acknowledged the actions prevented the resident from getting out of bed, constituting involuntary seclusion.
A resident with severe cognitive impairment was subjected to alleged verbal abuse and improper room arrangement by an LPN, which was witnessed by a nursing assistant. The incident was not reported immediately to supervisory staff or administration, resulting in a delay in notifying the appropriate authorities as required by facility policy.
A resident with severe cognitive impairment was involved in an incident where an LPN was alleged to have been verbally abusive and to have placed items around the resident's bed, restricting movement. Despite the incident being witnessed and later observed by staff, there was no timely documentation in the medical record or evidence that the physician and responsible party were notified, contrary to facility policy.
A resident with MASD and other health conditions reported that an aide was rough and made dismissive remarks during personal care, resulting in a pinpoint abrasion and feelings of disrespect. Nursing assessment confirmed the abrasion and ongoing MASD, and interviews indicated the aide did not provide care in a respectful and dignified manner, contrary to facility policy.
Unsecured inhaler left at bedside without self-administration order or assessment
Penalty
Summary
The facility failed to properly store a resident’s Ventolin HFA inhaler and failed to obtain a physician order and complete a self-administration assessment before allowing the resident to use the medication independently. Resident #118 had diagnoses including COPD, chronic respiratory failure with hypoxia, emphysema, and pneumonia, and was on continuous oxygen therapy. The resident had a physician order for Ventolin HFA 108 mcg/act, 2 puffs inhaled every 4 hours as needed for shortness of breath, but the MAR did not show any documented administrations from 8/1/25 through 8/14/25. The resident was observed with an Albuterol inhaler on the nightstand next to the bed, unsecured and not locked up. The resident stated the inhaler had been given by the facility and was kept at the bedside for self-administration as needed 3-4 times per day, and that nurses were aware of this use. A NA also observed the inhaler at the bedside and stated the resident had used it on a few occasions, while an LPN confirmed the inhaler was from the facility and labeled with the resident’s name and medication. The LPN and RN supervisor both identified that the inhaler should not have been left at the bedside and that the record did not show a physician order for self-administration or a completed self-administration assessment. The clinical record review also showed the resident preferred a metered dose inhaler over nebulizer treatments during episodes of cough, congestion, and wheezing, and Ventolin was listed as a current medication in physician progress notes. After surveyor inquiry, a self-administration assessment was completed, but it was incomplete and did not indicate whether the resident had been interviewed. The facility policy stated self-administered medications must be determined clinically appropriate and safe, documented in the medical record and care plan, and stored in a safe and secure location, with bedside medications turned over to the nurse.
Inconsistent Advance Directive Orders
Penalty
Summary
The facility failed to ensure that Resident #2’s advance directives were consistent. Resident #2 was admitted with diagnoses including Parkinson’s disease, acute respiratory failure with hypercapnia, and chronic kidney disease. The clinical record contained a Connecticut Department of Public Health transfer DNR order form signed by the physician, a hospital discharge summary listing the code status as DNR/DNI, and an admission physician order indicating the resident was DNR. Despite those documents, an APRN order later directed that Resident #2 was Full Code, and an APRN progress note also identified the resident as Full Code/CPR. The quarterly MDS identified the resident as cognitively intact, and the care plan listed an advance directive for Full Code with interventions to honor and re-evaluate advance directives as needed. Review of the record showed both DNR and Full Code orders in place at the same time, and the RN supervisor stated the resident’s advance directive orders were confusing and that she was unsure of the current code status.
Incomplete care plans for hearing needs, refusals of care, and ROM limitation
Penalty
Summary
The facility failed to maintain a comprehensive care plan for a resident with hearing needs. The resident had diagnoses including failure to thrive, heart failure, and osteoarthritis, and a contracted audiology consult from 9/17/24 documented that both hearing aids were cleaned and functioning, with the resident declining new hearing aids at that time. A later nursing re-admission evaluation identified hearing aids for both ears and noted hearing was adequate with the use of hearing aids, but the resident care plan dated 5/22/25 did not include that the resident used hearing aids until an appointment was scheduled with Miracle Ear on 8/14/25. The resident was interviewed on 8/11/25 and stated the right hearing aid was not working and had stopped wearing it a few weeks earlier. The resident indicated the left hearing aid was still being worn and that the hearing aids were normally placed in a recharger case at night. Observations on 8/14/25 and 8/15/25 showed the resident wearing only the left hearing aid. A nurse aide stated she knew the resident was hard of hearing and wore hearing aids, while the RN who completed the MDS and care plan stated she was not aware the resident wore hearing aids. The interim DNS stated the care plan coordinator was responsible for ensuring the care plan was accurate during conference meetings. The facility also failed to include refusal of care in the care plan for a resident with diagnoses including heart failure, diabetes, and chronic kidney disease. Nursing documentation showed repeated refusals, including refusal of a right heel evaluation, refusal to be weighed, refusal of a shower, refusal of wound assessment, and refusal to wear flex boots at night. The resident care plan identified actual skin breakdown to the right heel and a reopened stage 2 ulcer, but did not address the resident's history of refusing care. Staff interviews confirmed the resident often refused care, and the APRN stated the resident had refused wound care and assessments at times and had refused heel evaluation until 6/19/25 despite multiple attempts. The facility also failed to include functional limitation in range of motion in the care plan for a resident with dementia, diabetes, and chronic pulmonary edema. The resident care plan identified a self-care deficit related to physical limitations and use of assistive devices, but did not identify limited range of motion in the left hand or the need for a palm guard splint. Therapy documentation directed a left palm roll at night and a physician order entered by nursing incorrectly identified the right hand instead of the left. The MAR also documented the palm guard being placed on the right hand, while observations showed the resident wearing the splint on the left hand. The OT stated the resident had a progressive contracture with tightness of the 3rd, 4th, and 5th fingers on the left hand and that the palm guard was intended to slow progression of the left hand contracture.
Care Plan Not Updated for DNR Advance Directives
Penalty
Summary
The facility failed to update Resident #15’s resident care plan to reflect current advance directives after the resident’s code status changed from full code to DNR with RNP. Resident #15 had diagnoses including dementia, anemia, and hypertension, and the quarterly MDS identified severe cognitive impairment with substantial to maximal assistance needed for eating, bed mobility, and chair/bed transfers. A DNR consent form was signed by the responsible party after the APRN discussed the change, and an APRN progress note and advance directives order documented DNR and RNP status. Despite those orders, the resident care plan continued to state that advance directives would be honored and reevaluated as needed, but also identified Resident #15 as full code and did not include the DNR, RNP order. Staff interviews showed the MDS RN attended care plan meetings and reviewed advance directives as needed, the LPN stated the RN/supervisor would be responsible for updating the care plan after an advance directive change, and the Nursing Supervisor stated she did not think anyone was responsible for updating the care plan for a change in advance directives. The MDS Coordinator also stated the resident’s care plan should not say full code and should instead reflect physician’s orders.
Incomplete RN Pronouncement Assessment
Penalty
Summary
The facility failed to ensure the Registered Nurse pronouncement of death was comprehensive and included a full assessment for Resident #131. The resident had diagnoses of congestive heart failure, cerebral infarction, and hypertension, and the care plan identified a self-care deficit related to impaired mobility and incontinence. The quarterly MDS showed the resident was cognitively intact and required substantial maximal assistance for toileting, bathing, and transfers, with set-up assistance for eating. A physician’s order directed DNR, RN pronouncement, and comfort measures only. On 6/22/25, nursing notes documented that Resident #131 was observed by RN #5 to not be breathing and without a heartbeat, and the RN pronounced the resident dead at 5:20 AM. The next of kin, funeral home, and the covering APRN were notified. The pronouncement assessment was incomplete because it did not include blood pressure or pupillary reaction. During interviews, RN #2 and RN #8 stated that an RNP assessment needed to include heartbeat, respirations, blood pressure, and pupil response, and that heartbeat should be checked for 1 full minute. RN #5 also stated the note failed to include pupillary responsiveness and blood pressure and that she became busy with something else, leaving the assessment incomplete.
Failure to Supervise Resident During Toileting and Ambulation
Penalty
Summary
The facility failed to provide supervision for a resident who required assistance of 1 with toileting and supervision with ambulation, and the resident fell in the bathroom. Resident #87 had diagnoses including Alzheimer's disease, macular degeneration, and hypertension. The resident's fall risk assessments identified poor recall, judgment, safety awareness, diminished safety awareness, impaired mobility, and a history of falls. The care plan and EMR task section identified the resident needed assistance of 1 staff member for toileting, supervision with transfers using a rolling walker, and supervision with ambulation using a rolling walker. On the night of the event, the resident was observed walking out to the hallway and requesting a pull-up brief. Staff gave the resident the brief and allowed the resident to return to the room. Shortly afterward, a noise was heard coming from the resident's room, and the resident was found lying on the bathroom floor with the head in the doorway. The resident was initially non-responsive to verbal or light tactile stimuli for over a minute, then became responsive but disoriented. Blood was observed on the floor, and the resident had skin tears to both knees and the forehead, a hematoma under the right eye, and was sent to the hospital by ambulance. Facility documentation and witness statements showed discrepancies between the resident's required level of assistance and how staff described the resident's abilities. The reportable event form and staff interviews indicated the resident was described by some staff as independent with walking, transfers, and toileting, while the EMR task section directed staff to provide supervision or assistance. The interim DNS stated staff should have assisted and/or supervised the resident when the resident came into the hallway for a pull-up brief and should not have allowed the resident to return to the room without supervision, because the resident required supervision with transfers and assistance of 1 with toileting. The hospital discharge summary identified the resident had a superficial forehead laceration/facial swelling, mild rhabdomyolysis, mild acute kidney injury, chronic kidney disease, and hypokalemia.
Failure to Obtain Physician Order for CPAP Use
Penalty
Summary
The facility failed to obtain a physician's order for a resident who was using a CPAP machine nightly. The resident had diagnoses including obstructive sleep apnea, acute respiratory failure with hypercapnia, and asthma. A respiratory care evaluation noted the resident had a personal CPAP machine with a nasal mask at the bedside and reported wearing it the prior night. APRN and physician progress notes documented the resident's history of OSA and encouraged continued CPAP use during the SNF stay, but the MDS did not indicate CPAP use and there was no physician's order in place at that time. Observations showed the CPAP machine on the resident's bedside table, and the resident stated it was his/her own machine from home and that it was used every night at the facility. Staff interviews confirmed the machine had been at the bedside and that staff assisted the resident with putting it on at night, but they were unsure why an order had not been obtained. The Nursing Supervisor reviewed the record and stated the resident did not have a physician's order to use the CPAP machine and that it should not have been there without one. After surveyor inquiry, an order was obtained directing CPAP at bedtime with specified settings and assistance with mask placement.
Failure to Implement EBP for Resident with Stage 3 Pressure Ulcer
Penalty
Summary
The facility failed to ensure Resident #15 was placed on Enhanced Barrier Precautions for a Stage 3 pressure ulcer. Resident #15 had diagnoses including dementia, anemia, and hypertension. The resident care plan identified risk for altered skin integrity related to impaired mobility, incontinence, shearing, friction, and cognition, and also identified actual skin breakdown related to a Stage 2 pressure injury on the right buttock. The quarterly MDS showed the resident was severely cognitively impaired, at risk for pressure injuries, had one unhealed Stage 2 pressure injury, and required substantial to maximal assistance with eating, bed mobility, and chair/bed transfers. An APRN wound progress note identified that the right buttock wound advanced to a Stage 3 pressure ulcer. Observation of the resident’s room showed no posted EBP signage, no PPE in proximity to the room, and no laundry bin inside the room. During wound dressing care, an LPN and an APRN entered the room and performed hand hygiene and glove changes, but neither wore a gown while changing the wound dressing. After surveyor inquiry, an EBP sign was later observed at the doorway, but no PPE bin was observed outside the room. The facility policy stated that EBP applies when a resident has a wound or indwelling medical device, that gown and glove use is required for high-contact care activities including wound care, and that signs and PPE should be readily available.
Inaccurate MDS Coding for Hearing Aids, ROM, Mobility, and Falls
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were coded accurately for several residents based on the clinical record, staff interviews, and the RAI manual. For a resident with failure to thrive, heart failure, and osteoarthritis, the 5-day Medicare MDS coded the resident as not using hearing aids even though the record included a nursing readmission evaluation identifying hearing aids for both ears, a prior audiology consult documenting right and left hearing aids, and observations showing the resident wearing a hearing aid in the left ear. The resident stated that both hearing aids had been used routinely until the right hearing aid stopped working a few weeks earlier, and the MDS nurse stated the resident was coded as not having hearing aids because the resident did not have them in at the time. For another resident with dementia, anemia, and hypertension, the quarterly MDS failed to code functional limitations in range of motion for both upper and lower extremities and did not reflect dependence for functional mobility areas. The clinical record included nursing documentation that the resident was very contracted and hard to turn in bed, a dietician note describing delayed swallowing and dependence for eating, and a PT evaluation identifying severe rigidity, extensor tone, and dependence for bed mobility and bed/chair transfers. The MDS coordinator acknowledged that the assessment showing no functional limitation in range of motion was incorrect, and the MDS nurse stated she coded substantial/maximal assistance rather than dependent because she believed all documentation had to match exactly and because some NA documentation reflected substantial/maximal assistance even though other documentation identified dependence. For a resident with dementia, diabetes, and chronic pulmonary edema, the quarterly MDS failed to identify a limitation in range of motion to one upper extremity. The record included a physician order for a palm guard, MAR documentation showing the palm guard was placed on the right hand at bedtime and removed in the morning, and OT documentation stating the resident had a contracture with hand tightness of the 3rd, 4th, and 5th fingers on the left hand and limited range of motion in the left hand. The MDS nurse stated she missed the physician order for the palm guard. For a resident with pneumonia, heart failure, and chronic kidney disease, the admission and reentry MDS assessments did not accurately code a fall with injury. The resident had an unwitnessed fall in which the record documented a large raised area to the left posterior head, pain to the left posterior head, and a hematoma. The reentry MDS instead coded the event as a fall without injury. The MDS nurse stated the fall should have been coded as a fall with a minor injury and identified the omission as an oversight.
Missing Bi-Monthly Narcotic Audits
Penalty
Summary
The facility failed to ensure that bi-monthly narcotic audits were completed to monitor for possible drug diversion. During an interview, the interim DNS stated that she could not locate any facility documentation of bi-monthly narcotic audits conducted since the previous re-certification survey. She reported that she had been employed by the facility since March 2025 as the ADNS and had served as interim DNS since July 2025, but she had not completed any bi-monthly narcotic audits herself and believed any such audits would have been completed by the previous DNS. The interim DNS was able to provide a binder containing the current yellow narcotic reconciliation sheets for residents receiving narcotics, but there were no complete narcotic audit forms. She presented three yellow narcotic reconciliation sheets with a July 2025 date in the middle of the sheet, which she believed indicated some type of partial audit, but she could not identify what type of audit had been conducted and could not provide any additional narcotic audit documentation. The Administrator stated she was not aware of the location of any bi-monthly narcotic audits and, after attempts to contact the previous two DNSs were unsuccessful, no audit forms were produced. The facility policy stated that controlled substance inventory is monitored and reconciled to identify loss or potential diversion, and that the DON documents irreconcilable discrepancies to the Administrator.
Failure to Protect Resident from Verbal Mistreatment by LPN
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of falls was not protected from verbal mistreatment by staff. The resident, who required maximal assistance with transfers and had a care plan addressing cognitive loss and fall risk, became confused and attempted to get out of bed during the night. According to a nursing assistant's written statement and the alert roommate's report, an LPN responded to the situation by expressing frustration and making inappropriate comments, including telling the resident to go ahead and fall and break their hip so they could be sent out. The incident was reported to the RN supervisor later that morning. Facility documentation and interviews confirmed that the roommate, who was alert and oriented, witnessed and reported the LPN's threatening remarks. The resident involved had no recollection of the incident and showed no distress, likely due to their cognitive impairment. Despite the facility's incident summary initially stating the allegation was not substantiated, the Director of Nursing Services later acknowledged that the allegation was substantiated. The facility's abuse prevention policy affirms residents' rights to be free from verbal abuse.
Resident Barricaded in Bed Constitutes Involuntary Seclusion
Penalty
Summary
A resident with severe cognitive impairment, metabolic encephalopathy, and a history of falls was admitted to the facility and required maximal assistance with transfers. The resident's care plan included interventions such as using simple words, reinforcing the need to call for assistance, and providing assistance with activities of daily living. During the early morning hours, the resident became confused, attempted to get out of bed, and was yelling for their spouse. Staff reports and witness statements indicated that an LPN responded to the situation by verbally expressing frustration toward the resident and then physically arranged furniture and wheelchairs around the resident's bed, effectively blocking the resident from exiting the bed. Multiple staff members, including a nursing assistant and an RN supervisor, observed that the LPN had placed two wheelchairs and a nightstand against the sides of the resident's bed, with both quarter side rails raised, creating a physical barrier that confined the resident to the bed. The LPN later acknowledged that these actions prevented the resident from getting out of bed and admitted awareness that such measures could be considered involuntary seclusion or a restraint. The LPN did not attempt alternative interventions, such as getting the resident out of bed or contacting the physician, and believed the situation was being handled appropriately. Facility documentation and staff interviews confirmed that the resident was involuntarily secluded by being barricaded in bed with furniture and wheelchairs. The incident was witnessed by staff and reported to supervisory personnel, who subsequently removed the barriers. The facility's policies explicitly prohibit involuntary seclusion, including confining a resident by blocking exits with furniture, and the incident was substantiated as a violation of these policies.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
Staff failed to report an allegation of abuse in a timely manner for a resident with severe cognitive impairment and a history of falls. The resident, who required maximal assistance with transfers and had interventions in place for cognitive loss, was observed by a nursing assistant (NA) to be verbally abused by an LPN during the night shift. The NA witnessed the LPN expressing frustration toward the resident and placing items such as wheelchairs and a nightstand around the resident's bed, effectively blocking the sides of the bed. The NA did not immediately report the incident to the RN supervisor, and the RN supervisor only became aware of the situation hours later when the resident's roommate requested assistance. The Director of Nursing Services (DNS) and the Administrator were not notified of the allegation until several hours after the incident, at which point the State Agency was informed. Facility policy required immediate notification of administration regarding any abuse allegations, but this protocol was not followed. The delay in reporting was confirmed through staff interviews and review of facility documentation, which did not identify reasons for the failure to report promptly.
Failure to Document Abuse Allegation and Required Notifications
Penalty
Summary
The facility failed to ensure that the medical record for a resident was complete and accurate regarding an allegation of abuse. A resident with severe cognitive impairment and a history of falls was involved in an incident where a staff member was alleged to have been verbally abusive and to have placed items around the resident's bed, restricting egress. Although the incident was witnessed by a nursing assistant and later observed by a registered nurse, there was no documentation of the event in the clinical record prior to a social services note made later that morning. The record also lacked documentation that the physician and responsible party were notified of the incident. Facility documentation and staff interviews confirmed that the registered nurse supervisor was aware of the incident but did not write a nursing note or document the required notifications. The facility's own policy required that events, incidents, or accidents involving residents, as well as family notifications, be documented in the medical record. The deficiency was identified through review of records, facility documentation, and staff interviews, which revealed the absence of timely and complete documentation related to the abuse allegation.
Failure to Ensure Respectful and Dignified Care During Personal Hygiene
Penalty
Summary
A resident with a history of moisture associated skin damage (MASD), anxiety, dysthymic disorder, muscle weakness, difficulty walking, lymphedema, and type 2 diabetes mellitus was admitted with a superficial wound and excoriation to the coccyx, sacral-coccyx, and buttocks. The care plan included interventions for skin breakdown and MASD, requiring staff to administer treatments as ordered and assist with repositioning and hygiene. The resident was noted to be always incontinent of bowel and bladder and required substantial assistance with personal care. On one occasion, the resident reported that a nurse aide was rough during care, specifically stating that the aide forcefully pulled a blanket or draw sheet from under them, causing a painful abrasion on the right buttock. The resident also reported that when they requested gentler care, the aide responded with dismissive or disrespectful remarks such as "suck it up" or "stop being a baby." Assessment by nursing staff confirmed the presence of a pinpoint abrasion and ongoing MASD, but no new significant skin impairments or bruising were observed. The resident described feeling disrespected and mistreated during the encounter. Interviews with staff and the resident confirmed that the aide did not provide care in a respectful and dignified manner, as required by facility policy. The aide acknowledged telling the resident to "work through it" during care and recognized that the resident may have perceived the care as rough due to the existing rash. The facility's policy mandates that all residents be treated with kindness, respect, and dignity, which was not upheld in this instance.
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Illustrative
What surveyors actually found near you
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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.
Illustrative
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Illustrative
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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 | 1.7 mi | — | 0 | 0 |
| Pomperaug Woods Health Center | 2 mi | ★★★★★ | 1 | 0 |
| Lutheran Home Of Southbury Inc | 3.3 mi | ★★★★★ | 5 | 0 |
| Stone Bridge Center For Health & Rehabilitation | 5.7 mi | ★★★★★ | 2 | 0 |
| Complete Care At Middlebury | 8.3 mi | ★★★★★ | 1 | 0 |
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