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 Waterbury Center For Nursing & Rehabilitation Llc during CMS and state inspections, most recent first.
Failure to Provide Advance Notice for Room Changes: A facility moved residents from a unit for renovations without giving advance written notice before the room changes were made. Records showed residents received room change notices the same day the moves began, while the initial renovation letter did not state that room changes would occur. The Administrator and DON stated corporate directed the unit closure and rapid resident moves, and the facility policy required residents and families to be informed of the decision and reason for the change.
A resident receiving Methadone for opioid dependence did not receive a scheduled dose after a previous dose was spilled, and staff failed to notify the Methadone Clinic as required by facility policy. Instead, an APRN ordered a one-time dose of Oxycodone. Multiple staff interviews confirmed that the clinic was not contacted, and the facility policy directing immediate notification and no substitution was not followed.
The facility failed to maintain an adequate food supply for the posted menu, leading to frequent substitutions due to budget constraints and vendor issues. Observations revealed limited food items in storage, and interviews confirmed that substitutions occurred regularly, with some not recorded in the substitution log. A resident reported frequent stock shortages, and the Administrator acknowledged the potential to purchase items locally if needed, though this was not routinely done.
The facility failed to ensure proper beard coverings were worn in the kitchen. A dietary aide was observed plating food without a beard covering, despite having a full beard. The dietary manager confirmed the requirement for beard coverings and stated they would instruct the aide to comply. Facility policy mandates beard nets for staff with facial hair at all times in kitchen areas.
The facility failed to implement Enhanced Barrier Precautions (EBP) for two residents, one with a gastrostomy tube and another with a history of VRE, due to lack of signage and communication. Staff were unaware of the need for EBP, leading to care without proper PPE. Additionally, biohazardous waste was improperly stored with clean supplies, risking cross-contamination.
A resident with a PICC line did not have a physician's order for flushing the unused lumen, and the IV medication was not labeled with necessary information. Staff interviews confirmed the absence of an order and labeling, contrary to facility policy, leading to a deficiency in IV therapy management.
A resident with severe cognitive impairment and a history of falls sustained a fracture after a fall. Nursing staff notified the emergency contact instead of the conservator, who was listed as the primary responsible party, due to an incorrect order on the face sheet. This action did not follow facility policy requiring notification of the responsible party after a significant change in condition.
A resident with cognitive impairment and behavioral issues was able to enter another resident's room and physically harm them, resulting in a hematoma. Despite known behavioral risks and interventions in place, staff did not consistently implement measures to prevent such incidents, leading to a failure to protect a resident from abuse.
The facility failed to transmit MDS assessments for six residents to CMS within the required timeframe, resulting in delays ranging from three to twenty-one days. The deficiency was due to staffing limitations, with only one LPN handling MDS coordination, and the absence of a real-time audit trail to verify assessment completion. The facility's policy assigns the responsibility of timely submission to the assessment coordinator or designee.
A facility failed to maintain and ensure the accessibility of advance directives and healthcare proxy documentation for a resident with heart failure and myocardial infarction. Despite having a care plan indicating DNR, DNI, and DNH status, the necessary documentation was missing from the clinical records. Interviews with staff revealed inconsistencies in the documentation process, and the facility's policies on maintaining advance directive forms were not followed.
Failure to Provide Advance Notice for Room Changes
Penalty
Summary
The facility failed to provide residents with written notice before room changes were made due to facility renovations. For fourteen of nineteen residents reviewed for resident rights, the record showed each resident received a Notice of Room Change dated 10/29/2025 that stated a room change was being considered, listed the effective date as the same day the notice was signed, and identified the new room and renovation as the reason for the change. The notices were signed by a facility representative and marked to show the resident, sponsor, new roommate, and sponsor of the new roommate accepted and agreed to the room change. Facility documentation showed all residents on the East 1 Unit received a letter dated 10/30/2025 about an upcoming renovation project, but the letter did not state that room changes would occur. The Administrator stated she was directed by the corporate team to begin moving residents from the East 1 Unit on 10/30/2025, and that the room change notices were given the same day the moving process began. The DON stated corporate directed the unit to close and residents were to be moved quickly within the week, and that all notices were provided on 10/30/2025, the same day the residents were moved. The facility’s room change policy stated residents and families/responsible parties would be informed of the decision and the reason behind it.
Failure to Notify Methadone Clinic and Follow Policy After Spilled and Missing Dose
Penalty
Summary
A deficiency occurred when the facility failed to follow its policy regarding Methadone medication management for a resident with opioid dependence who was on Methadone maintenance treatment. The resident was alert and had no memory recall deficits, and the care plan included interventions for substance abuse and Methadone administration. According to the physician's order, the resident was to self-administer Methadone daily from a lock box after a nurse opened it. The Chain of Custody Record documented that one dose of Methadone was spilled, and later, there was no Methadone available for a scheduled dose. However, the facility did not notify the Methadone Clinic about the spilled or missing doses as required by policy. On the day the Methadone was unavailable, nursing staff notified the APRN, who ordered a one-time dose of Oxycodone instead. Interviews with facility staff, including the RN supervisor, LPN, DON, ADON, and APRN, revealed that none of them contacted the Methadone Clinic regarding the spilled or missing dose. Staff members cited reasons such as the clinic being closed, the resident having a scheduled clinic visit the next day, and lack of awareness of the policy requirements. The Methadone Clinic staff confirmed that they were not informed of the incident and stated that the facility should have contacted them for guidance and possible replacement of the dose. Facility policy specifically directed nursing staff to notify the Methadone Clinic immediately in the event of a missed, held, or spilled dose and not to substitute Methadone with another medication. Despite this, the facility failed to communicate with the clinic and instead administered a different opioid medication. This failure to follow established procedures and policy resulted in a deficiency related to the professional standards of quality for medication management.
Inadequate Food Supply and Menu Substitutions
Penalty
Summary
The facility failed to ensure an adequate food supply for the posted menu, as observed during an initial tour of the kitchen. The walk-in fridge was found to contain no liquid eggs, only a box of hard-boiled eggs, and six individual eggs in a carton. Fresh cabbage was the only fresh vegetable available. The dry food storage had several bare shelves with limited items such as a box of Scooters cereal, eight cans of jelly, several boxes of thickener, six cans of sauerkraut, and condiments. The Dietary Manager (DM) admitted that substitutions were common due to budgetary constraints and that they often ran short on food before deliveries. The DM also noted that substitutions occurred approximately twice per week, but not all were recorded in the substitution log. Interviews with staff and a resident revealed ongoing issues with food supply. A resident reported that items were out of stock several times a week, including milk on the morning of the observation. The Administrator acknowledged vendor issues and stated that if necessary, she could purchase items from a local wholesale club, although this had not been done recently. The Food Supply Manager explained that the facility determined the order quantities based on census, and substitutions were made when items were out of stock. A review of the facility's policy indicated that deviations from posted menus should be recorded, but this was not consistently done, as evidenced by the unrecorded substitution of scrambled eggs on the day of the observation.
Failure to Ensure Proper Beard Coverings in Kitchen
Penalty
Summary
The facility failed to ensure proper beard coverings were worn in the kitchen, as observed during a tray line service. Dietary Aide #1 was seen plating food without a beard or face covering, despite having a full beard. This observation was made at 11:45 AM on 12/18/24. An interview with the Dietary Manager shortly after confirmed that Dietary Aide #1 should have been wearing a beard covering, and the manager stated they would instruct the aide to put one on. The facility's policy on beard and hair coverings mandates that staff with mustaches or beards must fully cover them with a beard net at all times while in kitchen premises, and non-compliance would result in disciplinary action.
Inadequate Infection Control and Biohazard Storage
Penalty
Summary
The facility failed to appropriately implement Enhanced Barrier Precautions (EBP) for two residents, leading to deficiencies in infection control. Resident #370, who had a gastrostomy tube, was not identified on the facility's EBP log, and there was no signage on the resident's room door indicating the need for EBP. Staff members, including nursing assistants and the charge nurse, were unaware of the need for EBP due to the absence of proper signage and communication during shift changes. This oversight resulted in staff providing care without the necessary personal protective equipment (PPE), such as gowns and gloves, during high-contact activities. Similarly, Resident #371, who had a history of vancomycin-resistant Enterococcus (VRE), was not placed on EBP despite the facility's policy indicating that residents with MDROs like VRE should be on EBP. The facility's MDRO tracker identified the resident's history of VRE, but this information was not reflected in the EBP log, and no signage was posted on the resident's room door. Interviews with staff revealed a lack of awareness and understanding of the facility's policy regarding EBP for residents with MDROs, contributing to the failure to implement appropriate precautions. Additionally, the facility failed to ensure the proper storage of biohazardous waste, which was found in the same room as clean supplies. The biohazard storage room contained overflowing bins of medical waste, including sharps containers, placed directly next to clean supplies such as incontinent briefs and PPE. This arrangement posed a risk of cross-contamination, as confirmed by interviews with the central supply staff, the administrator, and the infection preventionist. The facility's policy on medical waste storage was not adhered to, as biohazardous materials were not adequately separated from clean supplies.
Deficiency in IV Therapy Management and Labeling
Penalty
Summary
The facility failed to ensure proper administration and management of intravenous therapy for a resident with a peripherally inserted central catheter (PICC) line. The resident, admitted with conditions including amputation, sepsis, osteomyelitis, and diabetes, was receiving intravenous Vancomycin. However, there was no physician's order for flushing the unused lumen of the PICC line, which is necessary to maintain catheter patency. Observations revealed that the IV medication and administration set were not labeled with the required information such as the administration rate, date, time, and nurse's initials. Interviews with various staff members, including the Assistant Director of Nursing Services (ADNS), Director of Nursing Services (DNS), Infection Preventionist, and Charge Nurses, confirmed the absence of an order for flushing the unused lumen and the lack of proper labeling. The facility's policy requires a prescriber order for vascular access device flushing and mandates labeling of medication or solution containers. The deficiency was attributed to a lack of communication and oversight, as staff members assumed responsibilities were fulfilled by others, leading to the oversight in labeling and flushing protocols.
Failure to Notify Correct Responsible Party After Resident Fall
Penalty
Summary
The facility failed to notify the correct responsible party following a resident's fall with injury. The resident, who had Alzheimer's disease and severe cognitive impairment, experienced a fall resulting in a left distal humerus fracture. The clinical record indicated that the resident's face sheet listed a conservator as the primary responsible party and another individual as the emergency contact. Despite this, after the fall, nursing staff notified the emergency contact rather than the conservator, who was designated as the first contact for emergencies. Interviews and documentation revealed that the nursing staff relied on the contact list as it appeared on the face sheet at the time of the incident, which incorrectly listed the emergency contact first. The social worker confirmed that the conservator should have been contacted first, as updated in April 2024. The facility's policy required notification of the responsible party after a significant change in condition, but this was not followed due to the incorrect order of contacts on the face sheet at the time of the event.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A resident with dementia, syncope, and a history of falls was not protected from abuse when another resident with encephalopathy and Alzheimer's disease entered their room and physically harmed them. The resident who caused the harm had a documented history of pacing, restlessness, and behavioral issues, including previous incidents of entering other residents' rooms and exhibiting agitation. Despite care plans and physician orders to monitor and manage these behaviors, the resident was able to access another resident's room, where they grabbed and twisted the resident's arm, resulting in a hematoma. Observations and interviews confirmed that the resident with behavioral issues continued to pace and attempt to enter other rooms, and that interventions such as a stop sign intended to prevent entry were not consistently implemented. The facility's failure to ensure effective supervision and environmental controls allowed the incident of physical abuse to occur, directly violating the requirement to protect residents from all forms of abuse.
Delayed MDS Assessment Transmissions
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments for six residents were transmitted to the Centers for Medicare & Medicaid Services (CMS) within the required fourteen days of the care plan completion date and/or the MDS completion date. Specifically, the assessments for Residents #17, #18, #66, #67, #99, and #100 were transmitted late, ranging from three to twenty-one days overdue. This delay in transmission resulted in the MDS system registering the assessments as not done, as there was no data entered to confirm their completion. The deficiency was identified through a review of clinical records, facility documentation, and interviews. The Director of Nursing (DNS) acknowledged that LPN #1 was the only MDS Coordinator for the building, and they were in the process of recruiting for a part-time position to assist with MDS responsibilities. Additionally, the DNS indicated that there was no report or audit trail available to verify when the assessments were completed in real time. The facility's MDS policy assigns the responsibility of ensuring timely submission of resident assessments to the assessment coordinator or their designee.
Failure to Maintain Advance Directives Documentation
Penalty
Summary
The facility failed to maintain and ensure the accessibility of advance directives, consents, and healthcare proxy documentation in the clinical records of a resident. The resident, admitted in April 2024 with conditions including heart failure and myocardial infarction, had a care plan indicating a Do Not Resuscitate (DNR), Do Not Intubate (DNI), and Do Not Hospitalize (DNH) status. However, the clinical records did not contain the necessary documentation to support these directives, such as the appointment of a healthcare representative or the advance directive consent form signed upon admission. Interviews with various staff members, including the Director of Nursing Services (DNS), Admission Coordinator, Social Worker, and Medical Records staff, revealed inconsistencies and gaps in the documentation process. The DNS, who was identified as the Power of Attorney (POA) for health care, was unable to provide a copy of the document confirming her appointment until after the surveyor's inquiry. The Admission Coordinator and Social Worker indicated that supporting documents were required before listing responsibilities in the resident's records, yet they were unable to locate such documents in the records. The facility's policies on chart depletion and advance directives were not adhered to, as previous and current advance directive forms were not maintained in the resident's record as required. The Medical Records staff confirmed that all advance directive consent forms should be kept in the resident's record, with the new form on top and previous forms behind it. However, the review and interviews indicated that the advance directive form signed on admission was missing, and the supporting document for the healthcare representative was not found in the records.
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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 Waterbury
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Apple Rehab Watertown | 0.9 mi | ★★★★★ | 14 | 0 |
| Mattatuck Health Care Facility, Inc. | 2.1 mi | — | 0 | 0 |
| Abbott Terrace Health Center | 2.7 mi | — | 0 | 0 |
| Autumn Lake Healthcare At Bucks Hill | 3 mi | ★★★★★ | 0 | 0 |
| Complete Care At Middlebury | 3.3 mi | ★★★★★ | 1 | 0 |
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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.