Below average — CMS composite of the measures below.
The next survey window likely opens 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 Summit At Plantsville Center For Health & Rehabili during CMS and state inspections, most recent first.
The facility failed to revise and implement a behavior-focused care plan and care card after multiple physical altercations between two cognitively impaired residents on a secured unit. One resident with dementia, anxiety, and violent behavior had known triggers related to fear of theft and unfamiliar people, while another resident with dementia and wandering behavior was newly admitted. Despite documented verbal and physical altercations, including incidents where one resident struck and pushed the other causing injury, the written care plan and care card were not updated to include specific behavioral triggers, de-escalation strategies, or clear directions to keep the two residents separated. Instead, staff relied on temporary 1:1 monitoring, periodic checks, and verbal communication in huddles, leaving some staff, including an NA unfamiliar with the residents, without written guidance on maintaining safe distance or managing interactions, which preceded another physical altercation in one resident’s room.
A resident with dementia, anxiety, and a history of violent behavior had a care plan noting potential physical aggression and general interventions such as reassurance and monitoring, but the plan and care card were not updated with specific, measurable strategies after the resident pushed another cognitively impaired resident, causing a fall and head injury. Despite this initial altercation and temporary one-to-one monitoring, the written interventions remained unchanged, and staff continued to rely on existing generic directions. Later, when the same two residents encountered each other again in one resident’s room, another physical altercation occurred. A NA on duty reported not receiving specific instructions about keeping the two residents apart or how to manage them when in close proximity, while the DON reported relying on verbal staff huddles rather than revising the written care plan and care card.
The facility failed to complete required monthly environmental rounds for several months, and its infection surveillance process did not include all infections because the IP tracked only residents treated with antibiotics. During a period of increased respiratory illness, multiple residents met McGeer criteria for pneumonia, URI, lower respiratory infection, or COVID-19, but the increase was not identified as an outbreak and no line list was started. In the dining room, an LPN and an NA handled residents’ food with bare hands while assisting with meals.
Expired medications and unlabeled multi-use vials were found on medication carts. An LPN observed a bottle with no expiration date, another bottle opened after its expiration date, four Lidocaine 1% vials without opened dates, and an expired resident-specific Meclizine bubble pack with tablets remaining. Staff interviews confirmed that nurses were responsible for checking expiration dates, labeling opened vials, and removing expired or no-longer-prescribed medications from circulation.
Failure to Assess and Document Pneumococcal Vaccinations A facility failed to ensure pneumococcal vaccination status was assessed, offered, and documented for multiple residents. Several residents with significant medical conditions and impaired cognition had consents on file, but the record did not show the vaccine was administered, refused, contraindicated, or otherwise tracked. An LPN/IP and the DON/ADNS acknowledged problems with admission paperwork, missing vaccine forms, and no tracking system for vaccination status.
Advance directive and code status orders did not match. A resident with Alzheimer's disease and impaired cognition had an advance directive signed by the responsible party directing DNR/DNI and other limits on treatment, but the physician's orders, care plan, APRN notes, and EHR repeatedly listed the resident as full code. The DNS and an LPN both verified the resident was still documented as full code, despite the signed directive and facility policy requiring a written order to reflect the resuscitation choice.
MDS assessments failed to accurately reflect a resident’s positive PASRR level II status. The resident had diagnoses including bipolar disorder, anxiety, and insomnia, and the care plan addressed behavior problems related to extreme fear and bipolar disorder. The SW stated she completed the PASSR section of the MDS and acknowledged the assessments should have been coded to show the positive level II status.
A resident receiving Xarelto for DVT did not have an active care plan addressing anticoagulant therapy, including monitoring for bleeding and related side effects. Staff identified that the anticoagulant care plan had been resolved even though the resident remained on the medication, and acknowledged the care plan should have reflected ongoing anticoagulant use and bleeding monitoring.
Alternating Pressure Mattress Not In Place or Set Correctly: A resident with a right heel DTI, impaired mobility, and pressure injury risk was ordered an alternating pressure mattress set to the resident’s weight. Surveyors observed the resident on a regular mattress without the ordered surface, and later observed the alternating mattress set at 325 pounds instead of the ordered setting. Although staff documented checks on the MAR/TAR, an LPN stated she signed off without physically verifying the mattress, and other staff described mattress changes between a regular mattress and the alternating surface.
Missed Quarterly Nutritional Assessment for Resident With Weight Loss: A resident with Alzheimer’s disease, dysphagia, HTN, and GERD had documented 15% weight loss and was on a mechanically altered diet, but the dietician did not complete or produce a quarterly nutritional assessment after the last note identifying weight loss. The resident’s care plan and MDS reflected severe cognitive impairment, limited assist with eating, and unplanned weight loss, while the physician ordered a minced and moist diet with thin liquids and upright positioning for meals.
Failure to Offer COVID-19 Booster on Admission: A resident with severe cognitive impairment and multiple diagnoses was not documented as having been offered the COVID-19 booster on admission, and the record did not show prior vaccination, acceptance, or refusal. The IP/LPN reported missing vaccine paperwork in admission packets and no tracking system for vaccination status, and the DNS confirmed no consent form could be located.
A resident with dementia and a history of falls was observed by a nurse aide and an LPN sleeping in the dining room, contrary to the care plan directive to encourage sleeping in the resident's own bedroom. Staff did not intervene, and the resident later fell while attempting to walk, sustaining multiple pelvic fractures. Facility policy required implementation of person-centered care plans, which was not followed in this instance.
A resident with dementia and multiple comorbidities suffered a fall and reported severe pain, but did not receive as-needed acetaminophen for pain relief during the hour before hospital transfer. Both the LPN and RN present observed the resident's distress but did not administer pain medication, despite facility policy and an active PRN order. Hospital evaluation later revealed multiple pelvic fractures.
A resident with dementia and mobility deficits, care planned for two-person assist during transfers, was transferred by a single nurse aide. During the transfer, the resident became combative and sustained a laceration to the left shin after hitting the wheelchair, requiring sutures. Facility records and interviews confirmed the care plan was not followed.
A medication cup containing multiple pre-poured medications for a resident was left unsecured on top of a medication cart in the hallway when an LPN walked away to assist another resident, leaving the cart unattended and out of sight. The ADON confirmed that this action was against facility policy, which requires medications to be secured or under visible control at all times.
A resident with multiple medical conditions sustained a head injury when a Hoyer lift tipped during a transfer to a shower chair. The incident occurred because staff were unable to fully open the lift's legs for stabilization due to space constraints and obstacles in the room, resulting in the lift striking the resident's forehead. Staff interviews confirmed that environmental limitations prevented proper use of the lift, and the facility's policy requiring full stabilization was not followed.
A resident with Alzheimer's and hemiparesis was injured when a nursing assistant failed to respect the resident's request to slow down while pushing their wheelchair. The resident's hand was caught between the wheelchair and doorframe, resulting in redness and an x-ray. The facility's investigation confirmed the NA's failure to adhere to the resident's request and the need for caution, violating the resident's right to dignity and respect.
Failure to Update Behavior Care Plan After Repeated Resident Altercations
Penalty
Summary
The deficiency involves the facility’s failure to revise and implement a resident-specific care plan and care card with clear behavioral interventions after repeated resident-to-resident physical altercations on a secured unit. One resident (Resident #1), admitted in April 2025 with dementia, anxiety disorder, and violent behavior, was identified as severely cognitively impaired and having the potential to be physically aggressive related to progressive cognitive impairment. The care plan noted that this resident expressed fear that others might steal personal belongings, especially the remote control, and that behavior escalated when unfamiliar individuals were present. Interventions included proactively introducing new staff and residents and monitoring for danger to self and others, while the care card only directed staff to assist with hand hygiene and monitor for agitation and restlessness. Another resident (Resident #2), admitted in March 2026 with dementia, cognitive communication deficit, and post-traumatic stress disorder, was also severely cognitively impaired and had wandering behavior. Shortly after admission, nursing notes documented arguments between the two residents, with staff separating them several times. On 3/22/26, a reportable event documented that a verbal altercation between the two residents turned physical when Resident #1 struck Resident #2 on the left cheek, causing bruising, swelling, and a small laceration. A one-to-one monitor was initiated for Resident #1 and Resident #2’s room was changed. The care plan for Resident #1 was updated to include one-to-one monitoring and psychiatric consultation, but the care card remained unchanged and did not include specific triggers, de-escalation strategies, or instructions to keep the two residents apart. On 3/28/26, another reportable event documented that yelling was heard in the hallway and a nurse witnessed the two residents standing in close proximity, yelling at each other. Resident #1 struck Resident #2, Resident #2 struck back, and Resident #1 then pushed Resident #2, who fell and struck the head on the floor, sustaining a small laceration. A one-to-one monitor was again assigned to Resident #1, but the care plan still did not identify additional interventions to prevent further altercations with other residents, and the care card continued to list only hand hygiene and monitoring for agitation and restlessness. The one-to-one monitor was discontinued the next day, and 15-minute checks were implemented for Resident #1, but no changes were made to the care card through 4/9/26. On 4/10/26, another reportable event documented that Resident #2 entered Resident #1’s room. A nursing assistant, who had only worked with Resident #1 twice before and was unfamiliar with Resident #2, followed Resident #2 into the room to redirect and locate a walker. Resident #1 yelled at Resident #2 to get out of the room, and when Resident #2 touched Resident #1’s walker, Resident #1 punched Resident #2 in the face. Resident #2 punched back, and the two residents continued to exchange punches until another nursing assistant intervened and redirected Resident #2 out of the room. The nursing assistant reported that, although a shift report was received, there were no specific instructions that these two residents needed to be kept at a safe distance or how to manage them when in close proximity, and the assistant was unaware of their prior altercations. The Director of Nursing Services stated that staff huddles and direct reports were used to communicate issues between the residents and acknowledged that the care plan and care card for Resident #1 were not updated with specific interventions, while relying on huddles and medication adjustments instead.
Failure to Update Care Plan After Resident-to-Resident Altercations
Penalty
Summary
The deficiency involves the facility’s failure to update a cognitively impaired resident’s comprehensive care plan with specific, measurable interventions after a physical altercation, despite known aggressive behaviors. Resident #1, admitted in April 2025 with dementia, anxiety disorder, and violent behavior, was identified on a quarterly MDS as severely cognitively impaired, needing partial assistance with bathing and hygiene, and able to ambulate with supervision. The resident’s care plan dated 3/25/26 already noted potential for physical aggression related to progressive cognitive impairment and included general interventions such as reassuring the resident about personal belongings, proactively introducing new staff and residents, and monitoring and reporting signs of danger to self and others. The resident care card from 3/22/26 through 3/27/26 listed only assistance with hand hygiene and monitoring for agitation and restlessness. On 3/28/26, an LPN heard yelling and witnessed Resident #1 push another cognitively impaired resident (Resident #2), causing a fall and head strike that resulted in a small laceration and transfer to the hospital. Although a one-to-one monitor was assigned to Resident #1 and later discontinued, the resident’s care plan and care card were not updated with additional, specific interventions to deter or prevent further altercations with other residents. From 3/28/26 through 4/9/26, the care card interventions remained unchanged from those in place before the first altercation. On 4/10/26, Resident #2 entered Resident #1’s room, and Resident #1 yelled at and punched Resident #2, who then hit Resident #1 back. A nursing assistant working that shift reported having worked with Resident #1 only twice before, being unfamiliar with Resident #2, and not receiving specific instructions about keeping the two residents apart or managing them in close proximity, and the DNS acknowledged relying on staff huddles rather than updating the resident’s care plan and care card with specific interventions after the initial incident.
Infection control program deficiencies in surveillance, outbreak recognition, environmental rounds, and dining practices
Penalty
Summary
The facility failed to complete monthly infection control environmental rounds for January, February, and March 2024. Review of the environmental rounds documentation for January 2024 through August 2025 did not identify completed rounds for those three months. The Infection Preventionist stated the missing months could not be located in the binder and explained that environmental rounds are conducted monthly with department heads, but she had only started in the IP role in April 2024. The facility also failed to ensure that monthly infection surveillance reports included all infections identified within the facility. The Infection Preventionist stated she tracked only residents treated with antibiotics and did not track residents with symptoms of infection if they were not treated with antibiotics. Review of the surveillance records for November 2024 through August 2025 showed that infections not treated with antibiotics were not included. During review of the July 2025 respiratory infection data, multiple residents met McGeer criteria for pneumonia, lower respiratory tract infection, upper respiratory infection, or COVID-19, and one resident's chart documented worsening cough, wheezing, shortness of breath, productive green sputum, and orders for chest x-ray, labs, and a viral respiratory panel. The facility failed to identify a possible communicable disease/outbreak among residents during an increase in facility-acquired respiratory infections. July 2025 infection reports showed 16 cases of facility-acquired respiratory tract infections, with increases in pneumonia and lower respiratory tract/bronchitis rates compared with June 2025. Staff interviews showed that the Infection Preventionist and DNS did not initiate a line list, did not recall contacting corporate IP staff for guidance, and did not identify the increase as an outbreak at the time. The outbreak policy defined an outbreak as multiple facility-acquired infections in the same area within a set period or two or more nosocomial pneumonia cases within 10 days, and it also referenced considering Legionnaires testing for non-aspiration pneumonia cases. For dining room infection control, three residents were observed during lunch service while staff handled food with bare hands. An LPN cut a resident's chicken sandwich while placing a bare hand on the sandwich, and an NA buttered bread for two residents using her bare hands. Both staff members acknowledged during interview that they should not have touched residents' food with bare hands and that hand hygiene should have been performed before assisting with food.
Expired and Unlabeled Medications Found on Medication Carts
Penalty
Summary
The facility failed to ensure expired medications were removed from medication carts and failed to ensure multi-use vials were labeled when opened. On the secured unit medication cart, an LPN observed a bottle of aspirin 81 mg with no expiration date, a bottle of calcium 600 plus D5 mcg with an expiration date of 7/2025 and an opened date of 8/31/25 written on it after the expiration date, and four multi-use vials of Lidocaine 1% that were not marked with an opened date. During interview, the LPN stated the vials should be marked with the date opened and noted that night shift staff were delegated to check expiration dates, although the nurse managing the medication cart was responsible for checking them. On the 1st floor medication cart, an LPN observed an expired resident-specific bubble pack of Meclizine 25 mg tablets with an expiration date of 6/18/25 and 7 tablets remaining. The LPN stated all nurses are responsible for removing expired medications from the medication cart and that expired medications should be given to the supervisor. The Nursing Supervisor stated that medications without an expiration date should not be put into circulation and that multi-use vials should be labeled when opened and discarded 30 days from the opened date. The ADNS and DNS stated that all staff are required to check expiration dates and discard medications if needed, and that medications no longer prescribed should be removed from the medication cart. The facility policy stated that medications shall expire on the manufacturer-specified date unless otherwise indicated and, once expired, should be removed from circulation.
Failure to Assess, Offer, and Document Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that pneumococcal vaccination status was assessed, offered, and administered or documented as requested for multiple residents on admission or during their stay. Review of clinical records, facility policy, and staff interviews showed that for five of ten sampled residents reviewed for immunizations, the pneumococcal vaccine was not documented as offered, administered, refused, contraindicated, or previously received in a way that matched the facility’s stated process. Resident #3 was admitted in May 2025 with diagnoses including cerebral infarction, anemia, and respiratory failure, and the quarterly MDS identified severely impaired cognition. The MDS also indicated the pneumococcal vaccine had not been received because it was not offered. The record did not contain a consent, declination, or documentation of a vaccine being given. The Infection Preventionist (LPN #2) reviewed the record and could not identify that the vaccine had been offered or received before admission. She stated that vaccine consent is obtained on admission, but also reported problems with admission packets missing vaccine paperwork and that she did not have a tracking system to monitor vaccination status. The ADNS and LPN #2 later stated there had been problems with residents’ vaccination status and that a whole-house audit had been done because there was a break in the facility’s process, but no audit documentation or timeline was provided. Resident #20 was admitted in July 2025 with Alzheimer’s disease, type 2 diabetes mellitus, and interstitial pulmonary disease, and the admission MDS identified severely impaired cognition. The record showed the responsible party signed consent on 8/4/2025 for the facility to administer or complete the pneumococcal series according to CDC guidelines and the physician’s direction. However, the clinical record did not show that the resident received the pneumococcal vaccine at the facility, and there was no documentation of refusal. The Infection Preventionist confirmed the resident had received Pneumovax 23 outside the facility in 2019, but she could not identify any pneumococcal vaccine given at the facility to complete the series. The DNS stated that once consent is obtained, the vaccine is expected to be administered as soon as possible. Resident #151 had diagnoses including type 2 diabetes mellitus, COPD, and acute respiratory distress, and the significant change MDS identified severely impaired cognition. The record showed consent was signed on 6/2/2025 to administer or complete the pneumococcal series, but no pneumococcal vaccine was documented as given, and there was no refusal, contraindication, or historical vaccine documentation in the record. The Infection Preventionist and ADNS reviewed the record and could not identify any pneumococcal vaccine administered at the facility. The Infection Preventionist stated the resident was unable to receive the vaccine because he or she was ill, but no documentation supporting that reason was found in the clinical record. Resident #153 was admitted in March 2025 with diagnoses including COPD, pneumonia, and muscle weakness, and the quarterly MDS identified severely impaired cognition, an active cardiorespiratory condition, and that the pneumococcal vaccine had not been received because it was not offered. The record did not contain consent, declination, or documentation of a vaccine being administered. The documented cause of death on the death certificate was pneumonia. The Infection Preventionist could not identify that the vaccine had been offered or received prior to admission and stated she did not have a tracking system to monitor vaccination status. Resident #154 had diagnoses including hypertension, asthma, and diastolic congestive heart failure, and the annual MDS identified the resident as cognitively intact. The assessment indicated the pneumococcal vaccine had not been received because it was not offered. Consent was signed on 7/19/2025 to administer or complete the pneumococcal series, but the record did not show that the vaccine was given, refused, or otherwise documented. The Infection Preventionist confirmed prior Pneumovax 23 outside the facility in 2019 but could not identify any facility-administered pneumococcal vaccine to complete the series.
Advance directive and code status orders did not match
Penalty
Summary
The facility failed to ensure the physician's orders accurately reflected Resident #20's code status as do not resuscitate. Resident #20 was admitted with diagnoses including Alzheimer's disease and type 2 diabetes mellitus with hyperglycemia. The hospital discharge summary identified the resident as full code, and the physician's orders did not direct a code status. The care plan also identified the resident as having an advanced directive of CPR with interventions to honor the advanced directives as directed by the resident/responsible party for guidance. APRN progress notes repeatedly identified the resident's code status as full code, and the admission MDS showed severely impaired cognition and use of a walker for mobility. The clinical record also contained an advanced directive form signed by the resident's responsible party that directed DNR, artificial respiration, artificial nutrition, IV hydration, and hospitalization. The care plan meeting notes identified the resident as full code. The responsible party stated the directive choice was DNR/DNI. The DNS stated she witnessed the advance directive and that the paperwork was to be given to nursing supervisors to enter into the care plan and place an order, but the resident was still listed in the computer as full code. LPN #4 also verified in the computer that the resident's code status was full code. Facility policy required a written physician's order to reflect the choice to resuscitate or not to resuscitate.
MDS Did Not Reflect Positive PASRR Status
Penalty
Summary
The facility failed to ensure an accurate assessment for a resident with diagnoses of bipolar disorder, anxiety, and insomnia. The resident’s PASRR level II screening dated 8/5/2015 identified a positive level II PASRR, but the annual MDS assessments dated 4/27/24 and 4/8/25 did not reflect that status and instead identified intact cognition, no behaviors, dependence on staff for dressing, personal hygiene, and transfers, and active psychiatric mood disorders of anxiety and bipolar disorder. The resident’s care plan dated 3/16/25 identified a behavior problem related to extreme fear and bipolar disorder, with interventions to administer medications as ordered, anticipate and meet needs, assess behavior episodes and determine underlying causes, and explain procedures before starting them. The Social Worker stated she was responsible for completing the PASSR section of the MDS and that positive level II status should be entered on the assessment, and after review she acknowledged the annual MDS assessments should have been coded to reflect the positive level II status.
Care Plan Missing Anticoagulant Monitoring
Penalty
Summary
The facility failed to ensure Resident #110’s care plan included interventions for the possible side effects and monitoring associated with anticoagulant therapy. Resident #110 had diagnoses including major depressive disorder, anxiety disorder, hypertensive heart disease, and spastic diplegic cerebral palsy, and the quarterly MDS dated 7/14/25 identified intact cognition and the need for supervision or touching assistance with eating. The physician’s July 2025 orders included Xarelto 20 mg by mouth at bedtime for DVT. During interview and record review on 9/8/25, the MDS Coordinator Director identified that Resident #110 was taking an anticoagulant medication but the current care plan did not address anticoagulant use. She stated the anticoagulant care plan had been resolved on 7/22/25 when the care plan was reviewed and revised, even though the resident remained on the medication. The Care Plan Coordinator stated she was responsible for updating and revising care plans and had not resolved the anticoagulant care plan because the resident was still taking the medication; she also identified that the care plan should have reflected anticoagulant use and monitoring for bleeding. The facility policy stated the interdisciplinary team uses the comprehensive person-centered care plan to address resident strengths, needs, and problems, and that the care plan is periodically reviewed and revised based on changes in status.
Alternating Pressure Mattress Not In Place or Set Correctly
Penalty
Summary
The facility failed to ensure that an alternating pressure relief mattress was in place as ordered and set to the resident’s ordered weight for a resident with a deep tissue injury to the right heel. The resident had diagnoses including major depressive disorder, anxiety disorder, hypertensive heart disease, and spastic diplegic cerebral palsy, and the quarterly MDS identified intact cognition, dependence on staff for transfers, personal hygiene, and toileting hygiene, non-ambulatory status, wheelchair use, and risk for pressure ulcers/injury. The care plan identified a potential for skin breakdown related to impaired mobility and later added interventions for the right heel DTI, including an air mattress set at alternating 200 per current weight and heel lift boots. The physician ordered the staff to check the function and setting of the air mattress and set it at 200 every shift. The resident’s weight was documented as 181 pounds. The wound physician noted the right medial heel DTI remained not healed, with persistent non-blanchable deep red, maroon, or purple discoloration and measurements of 1.7 cm by 2.1 cm with no measurable depth and no drainage or odor. The note also included orders for off-loading and the facility pressure injury prevention protocol. Observation showed the resident in bed on a regular mattress without the alternating air pressure mattress in place, and a later observation showed the alternating pressure mattress in place but set at 325 pounds. The air mattress audit documented the setting at 200 pounds, while the MAR/TAR showed nursing staff signed off that the mattress setting had been checked on multiple shifts. During interview, the charge nurse stated she signed off that the mattress had been checked but had not physically checked it. The wound nurse stated the resident was placed on the alternating pressure mattress when the DTI was identified and that a setting of 325 pounds would be too hard and could potentially cause skin issues. Housekeeping staff stated the mattress had been changed between a regular mattress and the alternating mattress, and nursing staff stated the resident had a regular mattress before the alternating mattress was put back in place.
Missed Quarterly Nutritional Assessment for Resident With Weight Loss
Penalty
Summary
The facility failed to ensure that the dietician completed a quarterly assessment for Resident #95, a resident with diagnoses including Alzheimer's disease, dysphagia, hypertension, and GERD. The resident's dietician progress note dated 3/12/25 identified a 15 percent weight loss and a current weight of 148 pounds. The resident's care plan dated 3/14/25 identified the resident as at risk for malnutrition related to Alzheimer's disease, dysphagia, and a mechanically altered diet, with interventions to allow sufficient time to eat, provide the prescribed diet, encourage and monitor intake throughout the day, and provide feeding assistance as needed. The quarterly MDS assessment identified the resident as having severe cognitive impairment, requiring limited assistance with eating, having unplanned weight loss, and being on a mechanically altered diet. A physician's order dated 5/7/25 directed a regular diet with minced and moist texture, thin liquids, no rice, and upright positioning during and after meals. Review of dietician progress notes and/or nutritional evaluations from 3/13/25 to 6/14/25 did not identify a quarterly nutritional assessment after the last assessment that noted weight loss, and the dietician could not produce quarterly nutritional assessment documentation for that period. During interview, the dietician stated she is responsible for assessing nutritional status on admission, quarterly, and/or with significant change, and that her evaluation includes diagnoses, diet, preferences, meal intake, and medications.
Failure to Offer COVID-19 Booster on Admission
Penalty
Summary
The facility failed to ensure that the COVID-19 booster vaccine was offered to a resident on admission. Resident #3 was admitted in May 2025 with diagnoses including cerebral infarction, anemia, and respiratory failure, and the quarterly MDS identified severely impaired cognition and that the resident was not up to date with COVID-19 vaccination. Review of the clinical record on 9/9/25 did not identify documentation that the resident received the 2024-2025 COVID-19 booster historically or that the vaccine had been offered, accepted, or refused at the facility. During interview, the IP/LPN stated that vaccine consent is obtained on admission by the admitting nurse or by her when she is in the facility, and that she was responsible for reviewing vaccine consent. She identified an issue with admission packets not including the vaccine paperwork and stated she did not have a tracking system in place to check resident vaccination status. Review of the immunization consents and records with the DNS also failed to identify a consent form for the COVID-19 booster, and the DNS stated that if it was not there, then it was not offered, which should have been done on admission. The facility policy stated that residents are to be educated and offered the COVID-19 vaccine as recommended by ACIP/CDC.
Failure to Implement Care Plan Intervention for Fall Risk Resident
Penalty
Summary
The facility failed to implement a care plan intervention for a resident identified as a potential fall risk. The resident, who had diagnoses including dementia, muscle weakness, anxiety, and major depressive disorder, was noted in the care plan to have a behavior of sleeping in the dining room at bedtime. The care plan directed staff to encourage the resident to sleep in their own bedroom. However, on the night of the incident, both a nurse aide and an LPN observed the resident sleeping in the dining room with the lights off but did not wake the resident or encourage them to return to their room as required by the care plan. Subsequently, the resident attempted to walk and fell, resulting in multiple minimally displaced pelvic fractures. Documentation confirmed that the resident was found on the floor in front of a chair, reported significant pain, and was transferred to the hospital for evaluation and treatment. Interviews with staff and facility leadership confirmed that the care plan intervention was not followed, and the facility's policy required that person-centered care plans be implemented by qualified staff.
Failure to Provide Timely Pain Management After Resident Fall
Penalty
Summary
A resident with a history of dementia, muscle weakness, anxiety, and major depressive disorder experienced a fall in the dining room during the night. The resident was found on the floor, complaining of severe pain (rated 8 out of 10) in the right thigh, and exhibited limited range of motion due to pain. Despite having an active order for acetaminophen as needed for pain, the clinical record and Medication Administration Record (MAR) showed no documentation that pain medication was administered during the hour the resident waited to be transferred to the hospital. Both the charge nurse (LPN) and the Nursing Supervisor (RN) were present, observed the resident's pain, and acknowledged in interviews that the resident was in significant distress, but neither provided pain relief prior to transfer. Hospital imaging later confirmed the resident had sustained multiple minimally displaced pelvic fractures. Interviews with facility staff, including the APRN and Assistant Director of Nursing, confirmed that pain management should have been provided according to facility policy, which directs staff to evaluate and medicate for new or acute pain. The failure to administer pain medication was not in accordance with the facility's pain management policy and resulted in the resident remaining in severe pain for an extended period.
Failure to Follow Two-Person Transfer Protocol Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident, who had diagnoses including dementia with agitation, Alzheimer's Disease, anxiety, and weakness, and was dependent on staff for transfers, was not assisted by two staff members during a transfer as required by the care plan. The care plan specified that the resident needed a two-person assist for transfers due to functional mobility deficits and a history of being resistive to care. Despite these directives, a nurse aide attempted to transfer the resident alone, without the assistance of a second staff member. During the solo transfer attempt, the resident became agitated and combative, which resulted in the resident hitting their left lower leg on the wheelchair and sustaining a laceration. The injury required medical attention, including transfer to the emergency department and the placement of sixteen sutures. Facility documentation and interviews confirmed that the care plan was not followed, and the transfer was conducted by only one staff member, contrary to established protocols.
Unattended Pre-Poured Medications Left on Medication Cart
Penalty
Summary
A medication cup containing pre-poured medications for one resident was left unsecured on top of a medication cart in the hallway when the charge nurse, an LPN, walked away to assist another resident with putting on shoes. The medication cart was left unattended and not within the nurse's line of sight, while several residents were observed sitting nearby in the hallway. The incident was observed during a facility tour with the Assistant Director of Nursing (ADON), who acknowledged the presence of the unattended medication cup on the cart. Review of the medication administration record confirmed that the cup contained multiple medications, including citalopram, empaglifozin, folic acid, loratadine, Norvasc, risperidone, apixaban, Entresto, metformin, Senokot S, and vitamin B12, all intended for a specific resident. Both the LPN and the ADON confirmed in interviews that medications should not be left unattended or unsecured, and facility policy requires medications to be kept secured in a locked area or under visible control at all times.
Resident Head Injury Due to Improper Hoyer Lift Transfer
Penalty
Summary
A deficiency occurred when staff failed to ensure a safe mechanical lift (Hoyer lift) transfer for a resident with multiple medical conditions, including atrial fibrillation, neuropathy, muscle wasting, and a right hand contracture. The resident required substantial assistance with bed mobility and was dependent on staff for transfers. During a transfer to a shower chair, the Hoyer lift tipped and struck the resident on the forehead, resulting in a bump, bruising, and subsequent headaches. The incident was witnessed by two nursing assistants, and the resident was later evaluated for a head contusion and worsening ecchymosis around the eyes. The transfer was complicated by environmental constraints in the resident's room. The large shower chair could not fit next to the bed, requiring staff to position it in the doorway. Staff had to maneuver the Hoyer lift past the resident's roommate and other obstacles, such as a bedside table that could not be moved due to the roommate's objections. As a result, the Hoyer lift legs could not be fully opened for stabilization, contrary to the facility's mechanical lift policy and manufacturer guidelines. This lack of proper stabilization led to the lift tipping during the transfer process. Interviews with staff involved in the incident confirmed that space limitations and the inability to fully open the Hoyer lift legs contributed to the accident. The Director of Nursing Services was unaware of the environmental challenges staff faced during transfers in this room. The facility's policy required the Hoyer lift legs to be locked in the maximum open position for stability and resident safety, which was not possible in this situation due to the room's layout and obstacles.
Failure to Respect Resident's Request Leads to Injury
Penalty
Summary
The facility failed to ensure that a resident was treated with respect and dignity, as evidenced by an incident involving a nursing assistant (NA) and a resident with Alzheimer's and left-sided hemiparesis. The resident, who had moderate cognitive impairment and was dependent on assistance for activities of daily living (ADLs) and transfers, was being pushed in a wheelchair by NA #1. Despite the resident's request for the NA to slow down, the NA continued to push the wheelchair quickly, resulting in the resident's hand getting caught between the wheelchair wheel and the doorframe, causing redness and necessitating an x-ray. The facility's investigation confirmed that the NA did not heed the resident's request to slow down and was not careful when maneuvering through the doorway, leading to the resident's injury. The Director of Nursing Services (DNS) acknowledged that the NA should have slowed down and been more cautious. The facility's Residents' Rights policy emphasizes the right of residents to be treated with consideration, respect, and full recognition of their dignity and individuality, which was not upheld in this incident.
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Illustrative
What surveyors actually found near you
We read the 863 citations issued within 25 miles in the last 12 months — including the 9 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 Plantsville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Southington Care Center | 0.9 mi | ★★★★★ | 3 | 0 |
| Livewell Connecticut | 1.4 mi | ★★★★★ | 1 | 0 |
| Civita Care Center At Cheshire | 5.1 mi | ★★★★★ | 2 | 0 |
| Cheshire House Health Care Facility & Rehab Center | 5.5 mi | ★★★★★ | 2 | 0 |
| Bradley Home Infirmary/pavilion | 5.9 mi | ★★★★★ | 3 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.