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 Torrington Center For Nursing & Rehabilitation Llc during CMS and state inspections, most recent first.
Failure to complete a grievance after a resident reported delayed call bell response and toileting care. A resident with intact cognition, bowel/bladder incontinence, and dependence for transfers and toileting said an NA did not respond promptly to repeated call bell requests, leading to incontinence while waiting for assistance. The RN supervisor was aware of the concern, but no grievance was filed and the incident was not reported to administration at the time.
A resident with multiple psychiatric diagnoses exhibited escalating agitation, aggression, and threatening behaviors over two days, including verbal and physical altercations and attempts to hit staff. Despite a physician's order for PRN trazodone and a care plan requiring monitoring and documentation of mood and behavior changes, the resident was not given the medication and the provider was not notified. Interviews confirmed that the expectation was for provider notification in such cases, but this did not occur, violating facility policy.
A resident with a history of psychiatric and behavioral disorders displayed escalating aggression and disruptive behaviors, which were documented by nursing staff but not reported to a provider or managed with as-needed medication. This culminated in the resident physically striking another resident in a common area, an incident witnessed by a speech therapist. The facility's investigation confirmed that physical abuse occurred and that required interventions to prevent such incidents were not implemented.
A resident with multiple psychiatric diagnoses and a history of aggressive and threatening behaviors did not have a comprehensive, individualized care plan to address these behaviors. Despite repeated incidents of verbal and physical aggression, staff interventions were not systematically documented or incorporated into a person-centered care plan, as confirmed by interviews with the MDS Coordinator and DON.
The facility failed to conduct timely interdisciplinary care plan meetings for several residents due to staffing issues, including the absence of a full-time social worker and a permanent MDS Coordinator. This led to delays in developing and updating comprehensive care plans, which should involve residents and their representatives.
The facility did not address the resident council's repeated requests for a social worker from April to July 2024. Despite using response forms to document concerns, no resolution was provided, and the social worker did not attend meetings. The Director of Recreation reported the issue to the Administrator, who failed to act. The part-time social worker was often unavailable, and the facility's policy for resolving issues was not followed.
The facility failed to maintain a homelike, safe, and sanitary environment in two shower rooms and the central unit's carpeted areas. Observations revealed cluttered shower rooms with various items, a black substance on the ceiling, and stained carpets. Staff interviews confirmed the issues, attributing them to limited storage space and informal environmental rounds. Additional maintenance problems included rusty pipes, a cracked light fixture, and ripped shower curtains.
The facility failed to provide adequate social services to residents requiring psychosocial support due to the absence of a full-time social worker. Several residents, including those with cardiac conditions, respiratory failure, and cerebral infarction, had not been evaluated or received necessary follow-up from social services. The lack of social service assessments and progress notes highlighted the facility's inability to meet residents' psychosocial needs.
The facility failed to properly document and complete its antibiotic surveillance tracking form as part of its antibiotic stewardship program. The Infection Preventionist could not produce the necessary documentation, and the Director of Nursing Services acknowledged that meeting minutes did not specify discussions on antibiotic stewardship. The facility's policy required regular reviews of antibiotic utilization and sensitivity patterns, but there was no evidence these were conducted or documented.
The facility failed to allocate appropriate time for the Infection Preventionist (IP) to perform their duties, as RN #2 was primarily scheduled as the RN Supervisor. Despite having completed the necessary training, RN #2 lacked designated hours for infection prevention tasks, often covering for call-outs or short staffing. The previous IP had a more focused schedule, but the current role combines IP, staff development, and RN Supervisor responsibilities without specified minimum hours for infection prevention.
A facility failed to document a resident's life support choices accurately, resulting in a discrepancy between the advance directive indicating DNR/DNI status and physician's orders showing full code. Staff interviews revealed that the inconsistency was not corrected, despite facility policy requiring accurate documentation of resident preferences.
A resident with Alzheimer's and dysphagia was administered crushed medications without a physician's order, including an extended-release medication, by an LPN. The facility's policy requires a provider order for medication administration, which was not followed. Interviews with staff confirmed the need for such orders and the risks of crushing extended-release medications.
A resident admitted with cardiac-related diagnoses did not have a timely discharge plan developed due to the absence of a full-time social worker. Despite the initial care plan identifying the need for discharge planning, no discussions or documentation occurred, and the resident reported no interaction with a social worker. Facility staff confirmed that discharge planning should start upon admission, but this was not done.
A resident with moderate cognitive impairment and health issues expressed dissatisfaction with the lack of weekend activities at the facility. The activities calendar showed only family visits on weekends, and the Director of Activities cited budget constraints as the reason for no weekend programming. The facility's policy requires activities seven days a week, which was not being met.
The facility failed to implement a neurologist's orders for a resident with tremors, continuing Primidone instead of starting Sinemet. Additionally, another resident with cellulitis did not receive proper documentation for a compression glove application, as per physician orders. The facility's policies for care coordination and documentation were not followed, leading to these deficiencies.
A resident with severe cognitive impairment and a history of falls was left unattended in the bathroom by a new nurse aide, resulting in a fall while attempting to transfer to an unlocked wheelchair. The resident's care plan required assistance with toileting, which was not followed, leading to the incident. Facility staff confirmed the resident's need for supervision, indicating a lapse in communication and training.
The facility failed to remove expired medications and improperly stored medications against manufacturer guidelines. An LPN was unsure of the storage requirements for Lorazepam, which was administered past its discard date. Morphine Sulfate was stored in a refrigerator instead of at room temperature, as required. The facility's policy mandates adherence to manufacturer specifications, which was not followed.
The facility failed to ensure proper hand hygiene by staff and did not conduct annual reviews of infection control policies. An LPN did not wash hands after glove removal and another did not perform hand hygiene between resident interactions. The infection control policy was not signed by the Infection Preventionist, and signature pages from previous years were missing.
The facility failed to notify the state Ombudsman's office of resident transfers and discharges, as required. A resident with acute respiratory failure and another with venous hypertension were transferred and discharged without proper notification. The Social Worker responsible for these reports had not sent them since late 2023, and the admissions person was not instructed to do so in their absence. This oversight occurred despite the facility's policy mandating such notifications.
The facility failed to complete timely comprehensive assessments for four residents, with delays ranging from 19 to 85 days. The delay was due to the absence of a full-time MDS coordinator, acknowledged by the LPN responsible for assessments and the DNS. The facility's policy requires adherence to federal and state submission timeframes, which was not met.
The facility failed to complete quarterly MDS assessments on time for 21 residents, with delays up to 72 days. This was due to staffing issues, including the absence of a full-time MDS coordinator and the MDS nurse being on maternity leave. An LPN acknowledged the delays, and the DNS confirmed the situation, leading to the hiring of an outside consultant to assist with the backlog.
A resident with schizoaffective disorder and muscle weakness was involved in two incidents of abuse by another resident with autism and severe cognitive impairment. The first incident involved physical assault, and the second involved pulling the resident's arm, causing a fall. Despite no physical injuries, the facility failed to prevent these incidents, highlighting a deficiency in protecting residents from mistreatment.
Failure to Complete Grievance for Delayed Call Bell Response
Penalty
Summary
The facility failed to ensure a grievance was completed when a resident reported delayed care and call bell response time. The resident had diagnoses including conversion disorder with mixed symptoms, neuralgia, and hypertension. The admission MDS identified intact cognition, frequent bowel and bladder incontinence, substantial assistance needed with personal hygiene, and dependence for transfers and toileting. The care plan identified the resident as frequently incontinent of bowel and bladder and directed staff to provide incontinence care and monitor changes in continence status. The resident reported that during an evening shift, a nurse aide did not respond promptly after the call bell was activated for toileting assistance. The resident stated the aide initially said she was assisting another resident and would return later. When the aide returned, the resident was on a virtual appointment and asked her to come back after it ended, but the resident became incontinent while waiting for assistance. The resident also stated the RN supervisor was made aware that the call bell had been activated multiple times for help with care. Interviews confirmed the resident was upset about the delayed response and that care was eventually provided by another nurse aide after the resident declined care from the original aide and the RN supervisor. The RN supervisor stated she did not file a grievance or report the incident to administration because she changed the resident's assignment and believed that was sufficient. Review of the grievance log showed no grievance was filed for the incident, and facility leadership stated staff should have completed documentation, including a grievance report, and notified the DNS.
Failure to Notify Provider of Resident's Significant Behavioral Changes
Penalty
Summary
A deficiency occurred when the facility failed to notify the physician regarding significant behavioral changes in a resident with multiple psychiatric diagnoses, including paranoid schizophrenia, antisocial personality disorder, conversion disorder with seizures, and severe anxiety. The resident had a physician's order for trazodone as needed for anxiety and a care plan that required monitoring and documentation of mood and behavior changes. Over a two-day period, nursing documentation showed the resident exhibited escalating behaviors such as agitation, anxiety, aggression, verbal and physical altercations, use of vulgar language, threats toward staff, and attempts to hit staff. Despite these documented behaviors, the resident was not administered the prescribed PRN trazodone, and the physician or psychiatric APRN was not notified of the changes. Interviews with the psychiatric APRN and the Director of Nursing confirmed that their expectation was to be notified of such behavioral changes, but this did not occur. The facility's policy required immediate notification of the provider and family when there is a significant change in a resident's physical, mental, or psychosocial status. The failure to notify the provider of the resident's significant behavioral changes and to administer the prescribed PRN medication constituted a violation of facility policy and regulatory requirements.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A resident with diagnoses including paranoid schizophrenia, antisocial personality disorder, conversion disorder, and dementia exhibited ongoing verbal and physical behavioral symptoms, such as aggression, vulgar language, threatening gestures, and attempts to hit staff. Nursing notes documented repeated incidents of disruptive and aggressive behavior over multiple shifts, including throwing staff belongings, using threatening language, and being verbally aggressive toward both staff and other residents. Despite these behaviors, the resident did not receive as-needed medication for anxiety, and there was no documentation that the physician was notified about the escalating behaviors as required by facility policy. On the morning of the incident, the resident attempted to access a closed therapy gym, became agitated, and engaged in a verbal and physical altercation with another resident. The aggressive resident struck the other resident on the shoulder with an open hand while yelling. The incident was witnessed by a speech therapist, who immediately separated the residents and notified nursing staff. The resident who was struck denied pain and had no noted injuries. Facility documentation and interviews confirmed that the aggressive behavior had been escalating prior to the incident, and that appropriate interventions, such as notifying the provider or administering as-needed medication, were not implemented. The facility's investigation substantiated that resident-to-resident physical abuse occurred, and the facility's abuse policy was not followed in preventing the incident.
Failure to Implement Comprehensive Care Plan for Resident with Behavioral Issues
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement a comprehensive care plan with appropriate interventions for a resident exhibiting significant physical and verbal behaviors. The resident had a history of paranoid schizophrenia, antisocial personality disorder, conversion disorder, and unspecified dementia with severe anxiety. Despite multiple documented incidents of aggression, threats, and behavioral disturbances—including threats to staff, physical altercations, and gestures indicating harm—there was no individualized care plan addressing these behaviors. The care plan in place only referenced monitoring and documenting changes in mood and behavior, without specific, personalized interventions to manage the resident's ongoing behavioral issues. Clinical documentation revealed repeated episodes where the resident was verbally and physically aggressive towards staff and other residents, including making threats, using foul language, and engaging in altercations. Staff responses included placing the resident on one-to-one supervision, attempting redirection, and contacting emergency services when behaviors escalated. However, these interventions were not reflected in a comprehensive, person-centered care plan, and there was no evidence of systematic implementation or evaluation of behavioral management strategies tailored to the resident's needs. Interviews with facility staff, including the MDS Coordinator and the Director of Nursing Services, confirmed the absence of a comprehensive care plan for the resident's behaviors. Both acknowledged that such a plan should have been in place and were unable to provide documentation or rationale for its omission. The facility's own policy requires the interdisciplinary team to develop and implement a person-centered care plan with measurable objectives for each resident, which was not followed in this case.
Failure to Conduct Timely Care Plan Meetings
Penalty
Summary
The facility failed to ensure that interdisciplinary team (IDT) care plan meetings were held following comprehensive and quarterly assessments for nine sampled residents. These meetings are crucial for developing comprehensive care plans with the involvement of residents, their families, or responsible parties. The absence of these meetings was attributed to staffing issues, including the lack of a full-time social worker and a permanent MDS Coordinator, which led to a breakdown in scheduling and implementing resident care conferences. For Resident #26, the comprehensive care plan was not developed within the required timeframe due to the absence of a social worker and a newly appointed MDS Coordinator who had not yet organized the necessary meetings. Similarly, Resident #27's care plan did not reflect the resident's or representative's participation, and the care conference was delayed due to staff changes. Resident #32 had not attended a care conference since 2023, and the facility's records confirmed that no meetings were held following the required assessments. Other residents, such as Resident #43, #50, #61, #64, #69, and #376, also experienced similar issues with care plan meetings not being held as required. The facility's policies dictate that care plans should be developed and reviewed with resident participation, but due to the lack of a full-time social worker and consistent MDS Coordinator, these processes were not followed. This resulted in care plans not being updated or revised in a timely manner, impacting the residents' involvement in their care planning.
Failure to Address Resident Council's Request for Social Worker
Penalty
Summary
The facility failed to address the concerns of the resident council regarding the need for a social worker. Over several months, from April to July 2024, the resident council repeatedly expressed their desire to speak with a social worker during their meetings. Despite utilizing designated response forms to document and address resident council requests, there was no resolution or indication that a social worker attended any meetings to address these concerns. Interviews with residents revealed ongoing dissatisfaction due to the absence of a full-time social worker, despite being informed that the facility was attempting to hire someone for the position. The Director of Recreation, responsible for documenting the resident council minutes and distributing response forms, acknowledged the ongoing concern and had brought it to the Administrator's attention. However, the Administrator failed to address the issue effectively, as he could not recall if he had returned the response forms or notified the social worker. The social worker employed during part of this period worked only one day a week and was often at another facility, limiting her ability to address the residents' needs. The facility's policy required tracking and resolving issues through response forms, but this process was not followed, leading to unresolved resident concerns.
Facility Fails to Maintain Homelike and Sanitary Environment
Penalty
Summary
The facility failed to provide a homelike, safe, and sanitary environment in two shower rooms on the central and middle units, as well as in the carpeted areas on the central unit. Observations revealed that two of the three shower rooms in the central shower area were cluttered with various items, including rolling shower chairs, IV poles, a utility cart, and a cardboard box. Additionally, a black substance was noted on the ceiling, and the shower curtain had holes. The third shower room also contained rolling shower chairs. The south wing hallway carpet had several dark brown stains of unknown origin. Interviews with a resident and staff members confirmed the cluttered state of the shower rooms and the presence of stains on the carpet, which were attributed to the lack of basins under shower chairs used by residents. The facility's environmental rounds were conducted informally, using a hot list rather than formal documentation, which led to the shower rooms not being identified as an issue. The Maintenance Director acknowledged that the shower rooms were used for storage due to limited space in the building, and the shower leaks were part of a planned remodel project. The Infection Preventionist did not list the shower room stalls as an issue during environmental rounds, as they had been in the same condition for approximately two years. The Environmental Round Policy of the facility mandates providing a safe, clean, and comfortable environment, but the facility failed to adhere to this policy in the shower rooms and hallway. Further observations of the central and middle unit shower rooms revealed additional issues, such as rusty pipes, a dirty glove on the floor, a cracked light fixture cover, and a burnt-out light bulb. The shower curtains were ripped, and there were numerous areas stained with rust and a brown substance. Interviews with staff confirmed the ongoing use of the shower rooms for storage and the lack of a homelike environment. The Administrator was aware of the maintenance issues and acknowledged the need for repairs, but the facility's limited storage space contributed to the continued use of the shower rooms for storing items.
Inadequate Social Services for Residents
Penalty
Summary
The facility failed to provide adequate social services to residents requiring psychosocial support, as evidenced by the lack of a full-time social worker and insufficient social service assessments and progress notes. Resident #26, admitted with multiple cardiac conditions, had not been seen by a social worker since admission, despite being at risk for psychosocial well-being issues. The facility's social worker, who worked only one day per week, confirmed that she had not evaluated Resident #26, and the clinical record lacked any social service documentation for nearly two months. Resident #35, with diagnoses including acute respiratory failure and morbid obesity, expressed dissatisfaction with the facility's care and follow-up, particularly regarding the Money Follows the Person program. The last social service entry for this resident was in January 2024, and there was no follow-up or documentation of the resident's status in the program, despite the care plan indicating the need for social work intervention for discharge planning. The social worker admitted that discharge planning should start at admission and be documented, but acknowledged the absence of notes for Resident #35 since January. Resident #69, admitted with cerebral infarction and psychosis, reported never having a care plan meeting or seeing a social worker since admission. The facility's records confirmed the lack of social worker evaluation or progress notes for this resident. Similarly, Resident #376, with diabetes and anxiety, had requested to see a social worker upon admission but had not been seen until after surveyor inquiry. The facility's administrator acknowledged the absence of a full-time social worker and the challenges in hiring one, which contributed to the deficiencies in providing necessary social services to the residents.
Deficiency in Antibiotic Stewardship Documentation
Penalty
Summary
The facility failed to ensure the completion and proper documentation of its antibiotic surveillance tracking form as part of its antibiotic stewardship program. During a review, it was found that the Infection Preventionist (IP), who had been in the role since late May or early June 2024, was unable to produce the tracking/surveillance documentation when requested. Although the IP indicated that antibiotic stewardship was tracked monthly using McGeer's criteria, the actual stewardship book was not available for review. Additionally, the IP mentioned that labs were reviewed and checked off in the stewardship book, but these labs were not included in the book itself. Furthermore, the Director of Nursing Services (DNS) acknowledged that while antibiotic stewardship was discussed during Interdisciplinary Team meetings, the meeting minutes did not document the specifics of these discussions. The DNS was unable to locate the necessary antibiotic stewardship paperwork, except for a review from Trident Care covering the period from January 1, 2022, to December 31, 2022. The facility's policy on antibiotic stewardship required regular reviews of antibiotic utilization patterns and sensitivity patterns at committee meetings, but there was no evidence to confirm that these reviews were conducted or documented as required.
Inadequate Time Allocation for Infection Preventionist Duties
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist (IP), RN #2, had appropriate time to fulfill their infection prevention and control duties. The Facility Assessment for 2023 identified RN #2 as holding the dual role of Infection Preventionist and Staff Development, but the facility's monthly schedules from May to September 2024 showed that RN #2 was primarily scheduled as the RN Supervisor. Interviews with the Director of Nursing Services (DNS) and RN #2 revealed that RN #2 did not have designated hours for infection prevention tasks and was often required to cover for call-outs or short staffing, limiting their ability to focus on infection prevention responsibilities. The DNS acknowledged that the previous IP/staff development person worked 32 hours as the IP and 8 hours in staff development, without the additional responsibility of being an RN Supervisor. The current arrangement, as identified by the corporate entities, combined the roles of IP, staff development, and RN Supervisor, with no federal minimum hours specified for the IP role. Despite RN #2 having completed the necessary training for the Infection Preventionist position, the lack of dedicated time for infection prevention duties was a significant issue, as RN #2 was predominantly scheduled as the RN Supervisor.
Failure to Document Resident's Life Support Choices Accurately
Penalty
Summary
The facility failed to accurately document a resident's life support choices, leading to a discrepancy between the resident's advance directive and the physician's orders. The resident, who was admitted with diagnoses including metabolic encephalopathy, dementia, and pneumonia, had an advance directive form signed by their representative and physician indicating a do not resuscitate (DNR) and do not intubate (DNI) status. However, the physician's orders from the time of admission through several months later indicated a full code status, which contradicted the advance directive. Interviews with facility staff revealed that the inconsistency was not identified or corrected in a timely manner. RN #3 acknowledged that the advance directive form and the physician's order were not congruent and indicated that it was the responsibility of the charge nurse or nursing supervisor to update the orders when the advance directive form was completed. The Director of Nursing Services (DNS) also expected that any change in code status should be updated in the resident's clinical record by the charge nurse or RN supervisor. The facility's policy on advance directives emphasized that resident preferences should always be respected and documented accurately in the medical chart and electronic medical record.
Failure to Follow Medication Administration Protocols
Penalty
Summary
The facility failed to ensure that an extended-release medication was not crushed and that a physician's order was in place to administer crushed medications to a resident. Resident #59, who had diagnoses including Alzheimer's disease, dysphagia, and anxiety, was observed during medication administration. The resident's care plan included aspiration precautions, but there was no physician's order to crush medications. During the observation, an LPN crushed several medications, including Metoprolol Succinate, an extended-release medication, and mixed them with pudding for administration. The LPN acknowledged that there was no physician's order to crush the medications and that extended-release medications should not be crushed. Interviews with the RN Supervisor, DNS, and Pharmacist confirmed that medications should be administered whole unless there is a specific order to crush them. The pharmacist highlighted that crushing extended-release medications like Metoprolol Succinate could alter their intended effects. The facility's Medication Administration policy requires a provider order for medication administration, including the right route, which was not followed in this instance. The deficiency was identified through the observation of the medication administration process and subsequent interviews with facility staff.
Failure to Develop Timely Discharge Plan for Resident
Penalty
Summary
The facility failed to develop a timely discharge plan for a resident admitted with multiple cardiac-related diagnoses, including pericardial effusion and hypertensive heart disease with heart failure. The initial care plan identified the need for discharge planning and social service evaluation, but the social service progress notes from admission until late August did not document any discussion of the discharge plan with the resident. The resident, who required extensive assistance for daily activities and had a discharge plan in place according to the admission MDS assessment, reported not having interacted with a social worker or participated in the discharge planning process. Interviews with facility staff revealed that the social worker is responsible for initiating discharge planning upon admission, which should involve meeting with the resident within 72 hours to discuss their discharge plan. However, the covering social worker confirmed that no discharge planning had been documented for the resident. The Director of Nursing Services acknowledged that discharge planning should start upon admission and be documented in the progress notes or care plan, but this was not done due to the absence of a full-time social worker.
Lack of Weekend Recreation Activities for Resident
Penalty
Summary
The facility failed to provide weekend recreation activities for a resident with moderate cognitive impairment and multiple health conditions, including cerebral infarction due to embolism, ischemic cardiomyopathy, and adjustment disorder with depressed mood. The resident expressed dissatisfaction with the lack of activities on weekends, noting that they sometimes prefer in-room activities but also enjoy group activities. The resident reported that weekends were particularly boring due to the absence of recreation staff and lack of visitors. The facility's activities calendar for August showed that the only activities scheduled for weekends were family visits. The Director of Activities confirmed that there was no weekend programming due to budgetary constraints. Before the COVID pandemic, the facility had more recreation staff, but post-pandemic, staffing was reduced, and the Director of Activities had additional responsibilities beyond recreation. Despite discussions with the Administrator and facility owner about the need for more staff and hours, budget limitations prevented any changes. The facility's policy requires activities to be scheduled seven days a week to support residents' physical, mental, and psychosocial well-being, which was not being met.
Failure to Implement Physician Orders and Document Care
Penalty
Summary
The facility failed to implement a neurologist's orders for a resident with chronic obstructive pulmonary disease, Type 2 diabetes mellitus, dementia, and a skin-picking disorder. The neurologist had recommended discontinuing Primidone due to its lack of therapeutic benefit and starting Sinemet for persistent tremors. However, the facility continued administering Primidone and did not initiate Sinemet as ordered. Interviews with the neurology consultant and nursing staff revealed that the responsibility for updating medication orders was not clearly executed, leading to the oversight. Another deficiency involved a resident with pneumonia, dementia, and seborrheic dermatitis, who was prescribed a compression glove for cellulitis and dependent edema. The facility failed to document the application and removal of the compression glove as per the physician's orders. The Medication Administration Records and Treatment Administration Records did not reflect the necessary documentation, and the resident's skin condition was not consistently assessed for signs of infection. The facility's policies for MD consults and skin and wound management were not adhered to, resulting in lapses in care coordination and documentation. The Director of Nursing Services acknowledged the errors in entering orders into the system, which led to the tasks not being prompted for the nursing staff. This lack of documentation and follow-up on physician orders contributed to the deficiencies identified during the survey.
Resident Left Unattended in Bathroom Resulting in Fall
Penalty
Summary
The facility failed to provide adequate supervision for a resident during toileting, resulting in a fall. The resident, who had diagnoses including Alzheimer's disease, schizoaffective disorder, spinal stenosis, and delusional disorder, was identified as being at risk for falls due to a decline in functional mobility. The resident's care plan included interventions such as encouraging the resident to sit at the nurses' station, checking wheelchair brakes, instructing on proper use, and providing assistance with toileting. Despite these interventions, the resident was left unattended in the bathroom by a new nurse aide, leading to an unwitnessed fall while attempting to transfer to an unlocked wheelchair. The resident's fall risk assessment and annual MDS assessment indicated severe cognitive impairment and a need for extensive assistance with toilet transfers and total assistance with toileting hygiene. The incident occurred when the resident was left alone in the bathroom, contrary to the care plan and facility fall prevention policy. Interviews with facility staff, including an LPN, the Rehabilitation Manager, and the Director of Nursing Services, confirmed that the resident required assistance and should not have been left alone. The nurse aide involved was unaware of the resident's need for supervision, highlighting a lapse in communication and training.
Medication Storage and Expiration Deficiencies
Penalty
Summary
The facility failed to ensure that expired medications were not in use and were removed from the medication cart, and also failed to store medications according to the manufacturer's recommendations. During an observation of the South unit's medication cart, an opened bottle of Lorazepam Intensol concentrate was found with an opened date of 7/19/24, which should have been discarded by 8/18/24. However, it was still being administered to a resident nine days past the discard date. The LPN responsible was unsure of the storage requirements for the medication once opened, and the pharmacist confirmed that the medication should be stored at room temperature for no more than 30 days after opening. Additionally, the facility improperly stored Morphine Sulfate Oral Concentrate in a refrigerator, contrary to the manufacturer's instructions to store it at room temperature. The LPN was unaware of the correct storage requirements, and the pharmacist noted that incorrect storage could affect the medication's integrity and potency. The facility's Medication Storage policy requires medications to be stored according to the manufacturer's specifications, which was not adhered to in these instances.
Inadequate Hand Hygiene and Policy Review Lapses
Penalty
Summary
The facility failed to ensure proper hand hygiene practices were followed by staff, as observed in multiple instances. On one occasion, an LPN performed hand hygiene, donned gloves, and obtained a blood glucose level from a resident. However, after removing her gloves, she failed to wash her hands before discarding the used lancet in the corridor, which she held in her ungloved hand. Another LPN was observed not performing hand hygiene after leaving a resident's room and before preparing medications for another resident. This LPN also failed to perform hand hygiene after assisting a resident who had slipped to the floor and before returning to medication preparation. Additionally, the facility's infection prevention and control policies were not reviewed and signed annually as required. The Infection Control Policy Manual was last reviewed and signed by the Administrator, Director of Nursing, and Medical Director in January 2024, but not by the Infection Preventionist, who had not been employed since February 2024. The facility was unable to provide signature pages from 2023 or 2022, indicating a lapse in the annual review process.
Failure to Notify Ombudsman of Resident Transfers and Discharges
Penalty
Summary
The facility failed to provide the required notification of resident transfers and discharges to the state Ombudsman's office for two residents. Resident #35, who had diagnoses including acute respiratory failure, chronic osteomyelitis, and morbid obesity, was hospitalized from May 8 to May 14, 2024, but the facility could not provide the Ombudsman's notice of transfers and/or discharges report for May 2024. The Administrator revealed that the Social Worker, responsible for sending these reports, had not done so since December 2023. The Social Worker, who was shared with another facility and worked limited hours, confirmed she was not making the Ombudsman notifications. Similarly, Resident #73, with diagnoses including venous hypertension, type 2 diabetes, and atrial fibrillation, was discharged home against medical advice on May 24, 2024. The facility's documentation showed that the last report sent to the Ombudsman was in November 2023, despite numerous discharges and transfers occurring in the subsequent months. The Administrator acknowledged the lapse in reporting and noted that the admissions person was not instructed to send the reports in the absence of a full-time Social Worker. The facility's policy requires notification to the Ombudsman for all transfers and discharges, which was not adhered to in these cases.
Failure to Complete Timely Comprehensive Assessments
Penalty
Summary
The facility failed to complete yearly comprehensive assessments for four residents, as required by federal and state regulations. Resident #30's annual Minimum Data Set (MDS) assessment was due by June 3, 2024, but was not completed until August 27, 2024, making it 85 days late. Similarly, Resident #35's assessment was due by August 8, 2024, but was also not completed by August 27, 2024, resulting in a 19-day delay. Resident #47's assessment was due by June 14, 2024, and was 74 days late, while Resident #376's admission MDS assessment was due by July 26, 2024, and was 31 days late. The delay in completing these assessments was attributed to the facility not having a full-time MDS coordinator at the time. The LPN responsible for MDS assessments began her role on July 15, 2024, and acknowledged the lateness of the assessments. The Director of Nursing Services (DNS) was also aware of the delays. The facility's policy mandates that resident assessments be conducted and submitted within the prescribed timeframes, which was not adhered to in these cases.
Delayed MDS Assessments Due to Staffing Issues
Penalty
Summary
The facility failed to ensure that quarterly Minimum Data Set (MDS) assessments were completed in a timely manner for 21 out of 27 sampled residents. The assessments were significantly delayed, with some being overdue by as much as 72 days. This deficiency was identified through clinical record reviews, facility policy reviews, and interviews. The MDS assessments are required to be completed within 14 days of the assessment reference date, as per the Resident Assessment Instrument 3.0 user manual and the facility's MDS policy. The delay in completing the MDS assessments was attributed to staffing issues within the facility. Specifically, the Licensed Practical Nurse (LPN) responsible for MDS coordination acknowledged the delays and cited the absence of a full-time MDS coordinator prior to her taking the position on July 15, 2024. Additionally, the Director of Nursing Services (DNS) confirmed that the MDS nurse was on maternity leave, which contributed to the backlog of assessments. An outside consultant was hired to assist with completing the overdue assessments. The residents affected by the delayed assessments included those with assessments due in June and July 2024. The facility's failure to adhere to the required timelines for MDS assessments indicates a lapse in maintaining compliance with federal and state submission timeframes. This deficiency highlights the importance of having adequate staffing and resources to ensure timely completion of resident assessments, which are crucial for maintaining the quality of care in long-term care facilities.
Resident-to-Resident Abuse Incidents
Penalty
Summary
The facility failed to protect a resident from mistreatment, as evidenced by two incidents of resident-to-resident abuse involving Resident #1 and Resident #2. Resident #1, who was alert and oriented with a history of schizoaffective disorder/bipolar and muscle weakness, was independent for transfers and mobility with a walker. Resident #2, who had autism, Parkinson's disease, schizoaffective disorder/bipolar, depression, and anxiety, was severely cognitively impaired and required assistance for mobility. The first incident occurred when Resident #2 approached Resident #1 and punched them in the stomach, hit their leg, and grabbed their walker. This incident was witnessed by staff, and Resident #2 was placed on one-to-one supervision and sent to the hospital for evaluation. A second incident occurred two days later when Resident #1 alleged that Resident #2 pulled their arm, causing them to fall to the floor. Again, the residents were separated, and Resident #2 was sent to the hospital for evaluation. Interviews with staff and facility documentation revealed that Resident #1 had been calling Resident #2 names prior to the incidents, indicating inappropriate interactions between the two residents. Despite these incidents, Resident #1 did not sustain any physical injuries, and Resident #2 was noted to have increased impulsivity. The facility's policies on resident abuse and resident rights emphasize the importance of ensuring residents are free from abuse. However, the facility's failure to prevent these incidents of resident-to-resident abuse highlights a deficiency in protecting residents from mistreatment. The facility's documentation and interviews with staff indicate that the interactions between the two residents were not adequately managed, leading to the physical altercations.
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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 Torrington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wolcott Hall Nursing Center Inc | 1 mi | ★★★★★ | 1 | 0 |
| Havencare At Litchfield Woods | 1.7 mi | ★★★★★ | 5 | 0 |
| Havencare At Valerie Manor | 1.9 mi | ★★★★★ | 20 | 0 |
| Cherry Brook Health Care Center | 9.8 mi | ★★★★★ | 5 | 0 |
| Cook Willow Health & Rehabilitation Center, Inc. | 10.2 mi | ★★★★★ | 14 | 0 |
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