Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Groton Community Health Care Ctr Res Care Fac during CMS and state inspections, most recent first.
A resident with dementia and severe cognitive impairment had repeated verbal and physical aggression toward other residents, including slapping, striking, yelling, and using derogatory language. The care plan listed general precautions such as keeping the resident away from certain residents and using a stop sign on the doorway, but staff did not document individualized interventions or evidence that the plan was evaluated after each resident-to-resident incident. Surveyors also observed the resident in a common area with another resident, where the resident began yelling and was redirected by the RN unit manager.
Late completion of required MDS assessments: The facility did not complete and transmit quarterly, annual, and significant change MDS assessments within required timeframes for multiple residents. An ADON/MDS coordinator stated the assessments had to be completed within 14 days of the ARD, but the identified assessments were verified after the deadline because sections were not completed by different departments in time.
Meals were not consistently palatable or served at appetizing temperatures. A resident and other residents reported food was cold, did not taste good, and was not visually appealing, and two lunch trays tested by staff showed hot items well below expected serving temperatures, including a hot dog, creamed corn, crab pasta bake, peas, and hot water. Staff interviews confirmed complaints about cold food and noted hall trays were delivered by unit staff after the cart reached the unit.
Dishwasher Water Temperature Not Maintained at Required Level: The main kitchen dishwasher was not maintained at the vendor-recommended temperature for the wash and rinse cycles. The dishwasher manual required 120 degrees Fahrenheit, but the facility’s logs showed temperatures never reached that level, and an observation found the wash cycle peaked at 92 degrees Fahrenheit. Staff gave differing temperature expectations, and leadership reported relying on the outside vendor’s statement that the chemical sanitizing machine could still be effective at lower temperatures.
Failure to Provide Required Medicare Non-Coverage Notice: A resident whose Part A skilled services ended while still staying in the facility did not receive the required SNF ABN when the NOMNC was issued. Records showed the discharge from Part A was facility-initiated before benefit days were exhausted, and staff later documented delayed notification. The DON/SW interview confirmed the notice should have been given with the NOMNC because it affects appeal rights and possible financial liability.
Inaccurate MDS assessments were completed for two residents. One resident with CHF, chronic respiratory failure, and morbid obesity was observed on O2 and later wearing CPAP, but the MDS did not document either therapy. Another resident with MS and schizoaffective disorder was documented as rarely understood and moderately cognitively impaired, even though other assessments and interviews described intact cognition and no care plan evidence of cognitive impairment.
A resident with respiratory failure, COPD, and CHF had physician orders for O2 at 2 L NC and CPAP at bedtime, but the MDS and care plan did not include the resident’s respiratory status or use of these therapies. Staff said the therapies should have been documented on the care plan, while the MAR reflected oxygen monitoring and CPAP use. Surveyors also observed white debris inside the CPAP mask on multiple occasions, and the resident said staff had never cleaned it.
The facility failed to ensure safe water temperatures in resident areas, with measurements exceeding the 110°F standard. Staff lacked awareness of proper temperature standards, and maintenance did not adjust or document corrective actions. This posed a risk of burns to residents, leading to an Immediate Jeopardy finding.
The facility failed to properly install and maintain bed rails, leading to potential entrapment risks for five residents. Observations showed gaps between mattresses and rails exceeding FDA safety guidelines. The facility did not evaluate alternatives, review risks and benefits, or obtain informed consent for bed rail use. Staff interviews revealed a lack of awareness about consent and monitoring procedures, contributing to an Immediate Jeopardy situation.
A resident with dementia and diabetes developed an unstageable pressure wound and cellulitis due to the facility's failure to implement preventative measures when the resident's mobility declined. Observations showed the resident's heels resting on a deflated mattress and inadequate incontinence care. Staff interviews revealed a lack of communication and documentation regarding care needs and interventions, leading to the deficiency.
The facility failed to maintain a safe and comfortable environment due to a lack of hot water from late October to early November. Residents were not immediately informed, and families were not notified at all. Staff used alternative hygiene methods, such as washcloths and a bath in a bag system, which was introduced two weeks after the issue began. Residents expressed dissatisfaction, and financial issues delayed repairs.
The facility was cited for deficiencies related to accident hazards and bedrail safety. Hot water temperatures exceeded safe limits, and the facility lacked hot water for 10 days without notifying the Department of Health or families. Bedrails were not properly maintained, posing entrapment risks. Additionally, required documents were submitted late, and the administration lacked awareness of the deficiencies.
A facility failed to meet food safety standards, with a staff member handling a resident's food without gloves and multiple sanitation issues in the kitchen. A resident with moderate protein-calorie malnutrition was involved, and the kitchen had improperly labeled food, moldy produce, and unsanitary conditions. The dishwasher sanitizer was not maintained at the correct level, and documentation was lacking.
The facility failed to properly label and store medications, with unlocked medication carts and rooms, expired medications administered, and inconsistent refrigerator temperature monitoring. Unlocked carts and rooms were observed on both floors, posing risks to wandering residents. Expired Lispro insulin was administered, and refrigerator logs were incomplete, compromising medication efficacy.
The facility failed to provide effective training for new and existing staff, as evidenced by the lack of documented orientation and required training for four LPNs. The facility's self-assessment identified necessary competencies, but there was no nursing education policy available, and staff education folders lacked documentation of orientation and competency in medication administration and pressure prevention. Interviews revealed inconsistencies in training, with some LPNs receiving minimal orientation and no formal observation. The RN responsible for education acknowledged the lack of a current orientation process and formal competencies, leading to the deficiency.
The facility failed to ensure proper medication management and emergency preparedness. An emergency cart was not checked daily, risking missing supplies during emergencies. A resident received a discontinued cream from an uncertified aide, and another had multiple acetaminophen orders, risking over-administration. Additionally, a resident received Percocet outside prescribed pain parameters due to staff not adhering to orders.
The facility did not provide a private space for Resident Council Meetings, holding them in the dining room with uninvited staff present. Residents were unaware of their right to request privacy, and staff insisted on attending for supervision, violating the facility's policy on resident rights.
The facility failed to provide timely Medicare Non-Coverage notices to three residents, affecting their ability to appeal service terminations. One resident with epilepsy and dementia, and another with dementia and spinal stenosis, did not receive written notices, only verbal acknowledgments. A third resident discharged home also did not receive the required notice. The Director of Social Work misunderstood the requirements for resident-initiated discharges, contributing to the deficiency.
A facility failed to create a comprehensive care plan for a resident with dementia and behavioral symptoms, despite the resident's use of multiple psychotropic medications. The resident exhibited frequent agitation and yelling, but there was no documented care plan addressing these behaviors or non-pharmacological interventions. Staff interviews revealed a lack of specific interventions tailored to the resident's needs, highlighting the facility's oversight in managing the resident's care.
A resident with dementia was not provided with meaningful activities that met their interests and preferences, such as watching TV or listening to music. The resident's room lacked personalization, and there was no evidence of ongoing activity evaluations or invitations to participate in activities. Staff interviews revealed a lack of sufficient activity programming due to staffing shortages, leading to the resident's feelings of loneliness and boredom.
The facility did not ensure a safe and sanitary environment, as evidenced by a strong odor and insect presence in the first-floor shower room and a urine smell in a hallway bathroom. A resident was also observed in a wheelchair with damaged armrests. Staff interviews revealed a lack of awareness and communication regarding these issues.
The facility failed to deliver mail to residents on Saturdays and opened mail without consent, violating residents' rights. Staff interviews revealed that mail delivery was not conducted on weekends, and mail resembling bills was sometimes opened to ensure payment, contrary to facility policy.
The facility did not ensure a proper grievance process for residents, with grievance forms and policies placed in inaccessible areas and no designated grievance officer. Residents were unaware of how to file grievances, and the grievance log showed minimal entries. The Director of Social Work handled grievances but was not officially titled as the grievance officer, and there was no provision for anonymous submissions.
Failure to Protect Residents from Abuse by a Behaviorally Aggressive Resident
Penalty
Summary
The facility failed to ensure residents were free from abuse when Resident #11, a resident with dementia, severely impaired cognition, and behavioral disturbances, had repeated physical and verbal aggression toward other residents. The resident’s care plan identified a potential for physical aggression and later documented a potential to cause harm to others due to impulsiveness, with interventions such as keeping the resident away from certain residents and placing a stop sign across the doorway to prevent others from wandering into the room. However, the care plan did not include documented resident-specific interventions showing how the resident would be kept away from the identified residents, and the stop sign was not consistently observed across the doorway during survey observations. Nursing progress notes and psychologist notes documented multiple aggressive behaviors by Resident #11 over several months, including verbal aggression toward staff and residents, physical aggression toward staff, taking other residents’ food and drinks, wheeling residents who did not want to be wheeled, pushing a peer into a wall, attempting to tip a resident out of a wheelchair, and wandering into other residents’ rooms and taking items. The psychologist documented escalating aggression, including scratching a nurse’s face, putting a footrest through a glass door, hitting residents, and impulsively striking out when corrected. The resident was involved in multiple resident-to-resident incidents in which they slapped or struck other residents, yelled at them, and used derogatory language. There was no documented evidence that after each resident-to-resident incident the facility evaluated whether the care plan interventions were effective or that immediate interventions were provided to assure resident safety and prevent abuse. During interviews, staff described general approaches such as keeping behavioral residents near the nurses’ station, maintaining distance, redirection, frequent checks, and a stop sign across the doorway, but they also acknowledged they were unaware of specific individualized interventions. During an observation, Resident #11 was in the television area with another resident and began yelling and calling that resident a derogatory name before being redirected by the RN unit manager.
Late Completion of Required MDS Assessments
Penalty
Summary
The facility failed to ensure that quarterly and other required MDS assessments were completed and transmitted within the required timeframes for 21 of 21 residents reviewed. Record review showed that Residents #5, #6, #8, #12, #16, #19, #24, #29, #30, #31, #35, #53, #54, #56, #58, #59, #63, #65, #67, #69, and #72 had MDS assessments that were completed later than 14 days after the Assessment Reference Date. The assessments included quarterly, annual, and significant change assessments, and the Section Z entries documented completion verification by the ADON/MDS coordinator after the required timeframe had passed. The facility policy stated that the RN signed the completed MDS assessment and that assessments were submitted electronically per CMS requirements. The CMS MDS 3.0 manual stated that comprehensive assessments must be transmitted within 14 days of the care plan completion date and other MDS assessments within 14 days of the MDS completion date, with no more than 92 days between OBRA assessments. During interview, the ADON stated they were responsible for completing the MDS assessments within 14 days of the ARD and acknowledged that the assessments for the identified residents were not completed timely because sections were not completed by different departments in time.
Meals Served Cold and Unappetizing
Penalty
Summary
Food and drink were not ensured to be palatable, flavorful, visually appealing, and served at an appetizing temperature for two lunch meals reviewed and for residents who reported the food was cold and did not taste good. The facility policy required meals to be palatable and served at correct temperatures, with hot foods held and served at least 135 degrees Fahrenheit. During interviews, Resident #63 stated the food did not taste good, was often served cold, and was not appetizing to look at; the toast was hard and cold and the butter would not melt. Resident #52 also stated the food was always cold and did not taste good, and seven anonymous residents at a resident council meeting said the food did not taste good and was often served cold. During the 02/05/2026 lunch observation, Resident #52's tray was tested in the presence of CNA #22 and a replacement tray was ordered. Measured temperatures included hot dog at 108.5 degrees Fahrenheit, creamed corn at 102.6 degrees Fahrenheit, hot water at 122.7 degrees Fahrenheit, and juice at 54.7 degrees Fahrenheit; the hot dog was described as rubbery and chewy and the creamed corn was not hot. During the 02/06/2026 lunch observation, the food cart arrived on the first floor and was placed near the nurses' station, and Resident #36's tray was tested in the presence of LPN Assistant Unit Manager #23. Temperatures measured were crab pasta bake at 106.7 degrees Fahrenheit, peas at 123 degrees Fahrenheit, and hot water at 110 degrees Fahrenheit. Staff interviews reflected that residents complained about food being cold and not tasting good, and the Food Service Coordinator stated they expected hot foods to be served at 155-165 degrees Fahrenheit while unit staff delivered hall trays to residents.
Dishwasher Water Temperature Not Maintained at Required Level
Penalty
Summary
Food was not stored, prepared, distributed, and served in accordance with professional standards because the main kitchen dishwasher’s water temperature was not maintained at the vendor-recommended level. The installation and operation manual for the ES-2000 and ES-4000 Series dishwasher stated that the minimum water temperature required for the ES4000 wash and rinse cycle was 120 degrees Fahrenheit, but the facility’s January 2026 dishwasher sanitizer level log documented that the water temperatures never reached 120 degrees Fahrenheit for either cycle. During observation, the empty dishwasher was run and the wash cycle temperature reached a high of 92 degrees Fahrenheit. During interviews, the Food Service Worker stated that below 100 degrees Fahrenheit was too low, the Food Service Coordinator stated they had been told both wash and rinse cycles should be 110 degrees Fahrenheit and that they ran the machine three times before it reached that temperature, and the Director of Food Services stated they believed the wash and rinse temperatures should be 110 degrees Fahrenheit. The Director of Food Services also stated they had been told by the outside vendor that because the machine was a chemical sanitizing machine, the water temperature could be as low as 75 degrees Fahrenheit and still be effective. The Director of Maintenance stated they were told by the outside vendor that although the current temperatures were not optimal, it was still sanitizing, and they had not adjusted the temperature.
Failure to Provide Required Medicare Non-Coverage Notice
Penalty
Summary
The facility did not provide the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (CMS-10055) to Resident #33 when Medicare Part A skilled services were discontinued and the resident remained in the facility under custodial care. Record review showed the facility initiated discharge from Medicare Part A before the benefit days were exhausted, and the Notice of Medicare Non-Coverage identified the last covered day of skilled services as 08/26/2025. That notice was signed by the resident’s representative on 08/22/2025, but there was no documented evidence that the SNF ABN was issued at that time. The Skilled Nursing Facility Beneficiary Protection Notification Review process also showed the resident’s Part A skilled services began on 07/18/2025 and ended on 08/26/2025, with the facility/provider initiating discharge when benefit days were not exhausted. The form indicated delayed notification, and a handwritten note stated Social Work issued a delayed SNF ABN for the resident who remained in the facility. A delayed verbal notification was later given to the resident’s representative on 02/02/2026. During interviews, the Director of Social Work stated the SNF ABN should have been provided at the same time as the NOMNC but was not, and the Administrator stated both notices were important because they relate to appeal rights and potential financial liability.
Inaccurate MDS Assessments for Oxygen Use and Cognition
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) assessments for two residents. Resident #5 had diagnoses including congestive heart failure, chronic respiratory failure, and morbid obesity, and the 12/12/2025 MDS documented the resident as cognitively intact, not on oxygen, and without a noninvasive mechanical ventilator. However, the medical record included a provider order for 2 liters of oxygen via nasal cannula to maintain oxygen saturation at 90% and another order for continuous positive airway pressure (CPAP) use at bedtime. During observations, Resident #5 was seen in bed on oxygen at 2 liters via nasal cannula and later wearing a CPAP mask over the nose and mouth. The Assistant Director of Nursing stated the resident was on oxygen and used CPAP, and that these should have been documented on the MDS. Resident #48 had diagnoses including multiple sclerosis and schizoaffective disorder, and the 11/10/2025 MDS documented the resident was rarely understood and had moderate cognitive impairment. The record also showed an earlier MDS assessed the resident as cognitively intact, there was no documented evidence in the care plan of impaired cognition, and a later social service assessment documented intact cognition throughout the interview. The Assistant Director of Nursing stated Social Worker #21 conducted the brief interview for mental status assessments, but the 11/10/2025 MDS did not use that interview and instead documented moderate cognitive impairment. The Assistant Director of Nursing later stated they occasionally signed assessments for other departments, did not complete the assessment, and believed the answers were clicked in error; they stated Resident #48 was not cognitively impaired.
Respiratory Care Not Reflected in Care Plan and CPAP Mask Found Unclean
Penalty
Summary
Resident #5, who had diagnoses including respiratory failure, chronic obstructive pulmonary disease, and congestive heart failure, was found to be receiving respiratory therapies that were not fully reflected in the resident’s care planning and assessment records. The 12/12/2025 MDS documented intact cognition, dependence for most ADLs, and did not indicate use of oxygen therapy or a CPAP machine, even though the resident had physician orders for CPAP at bedtime and oxygen at 2 liters via nasal cannula to maintain oxygen saturations of 90%. The 08/04/2020 comprehensive care plan, updated 09/04/2025, did not include the resident’s respiratory status or use of oxygen or CPAP. Staff interviews indicated that oxygen therapy and CPAP use were expected to be added to the care plan and reflected in the MAR, but multiple staff stated they were unsure why the respiratory interventions were not listed as required. The MAR did document oxygen monitoring, tubing changes, CPAP application at bedtime, and overnight monitoring, but staff also stated there was no place on the MAR to document adding distilled water to the chamber and that they were not sure which shift was responsible for cleaning the CPAP equipment. During observations on multiple days, Resident #5 was seen receiving oxygen at 2 liters via nasal cannula, and the CPAP mask repeatedly had white debris inside it. The resident stated they used the CPAP every night, had never seen staff clean the mask, and wanted it cleaned because they drooled in it while sleeping. Staff interviews confirmed the resident wore oxygen and used CPAP overnight, and one nurse stated the mask was not properly cleaned and that this increased the risk for respiratory infections. The facility policy required sanitary maintenance of CPAP equipment, including cleaning the mask and emptying the water chamber daily, but the observed mask remained unclean during the survey.
Failure to Maintain Safe Water Temperatures
Penalty
Summary
The facility failed to maintain a safe environment for residents by not ensuring that water temperatures in resident sinks and common shower rooms on the First and Second Floors did not exceed the standard of 110 degrees Fahrenheit. Observations and measurements taken during the recertification and extended surveys revealed that water temperatures were significantly higher, with readings as high as 140 degrees Fahrenheit recorded in facility logs. These elevated temperatures were documented over several months, indicating a persistent issue that was not addressed by the facility's maintenance team. Interviews with facility staff, including the Director of Maintenance and the Administrator, revealed a lack of awareness and understanding of the appropriate water temperature standards. The Director of Maintenance was under the impression that water temperatures should be between 122 and 124 degrees Fahrenheit, which is incorrect according to federal and state regulations. Additionally, the maintenance team did not have a protocol for adjusting water temperatures or documenting corrective actions when temperatures were found to be out of range. The facility's policy on water temperature safety was not effectively implemented, as staff relied on subjective methods, such as testing water with their hands, to determine safety. This lack of proper monitoring and adjustment of water temperatures posed a risk of burns and scalds to residents, although no actual harm was reported. The deficiency was identified as Immediate Jeopardy due to the likelihood of serious harm, injury, or death to residents from exposure to excessively hot water.
Removal Plan
- The facility had the vendor on site and the water temperature was reduced.
- The facility completed full house monitoring of temperatures twice per day, logs documented all temperatures were less than 110 degrees Fahrenheit.
- The facility reviewed their policy for hot water and adjusted it to meet the requirement of 110 degrees Fahrenheit.
- The facility provided in-service education to 89.8% of staff, with plans for ongoing education of staff not currently on the schedule, prior to the start of their next shift.
- The survey team interviewed 12 staff from various disciplines, including the two maintenance staff. All staff demonstrated knowledge of education provided regarding water temperatures.
Improper Bed Rail Installation and Maintenance
Penalty
Summary
The facility failed to ensure the correct installation, use, and maintenance of bed rails, leading to potential entrapment risks for five residents. Observations revealed that the bed rails were not properly secured, resulting in gaps between the mattress and the rails that exceeded the safety guidelines established by the FDA. Specifically, Resident #2's bed was against the wall with a bed rail on one side and no bracket to hold the mattress in place, allowing for a gap. Resident #14 had an air mattress with bilateral side rails that were not monitored for changes in air pressure, and Resident #46 had a bed rail on one side with no bracket to secure the mattress. These conditions were found to be out of compliance with Zone 3 entrapment guidelines. The facility also failed to evaluate alternatives to bed rails, review the risks and benefits with the residents or their representatives, and obtain informed consent prior to the installation of bed rails. There was no documented evidence that these steps were taken for the residents involved. Interviews with staff revealed a lack of awareness and understanding regarding the necessity of consent, the risks associated with bed rails, and the procedures for evaluating and monitoring bed rail use. Staff members were unsure about the requirements for physician orders, consent, and ongoing monitoring of entrapment zones. The deficiency was identified during a recertification and extended survey, where it was noted that the facility's policy on bed safety and bed rails was not being followed. The policy required that bed frames, mattresses, and bed rails be checked for compatibility and size to prevent entrapment risks. However, maintenance staff did not routinely inspect the beds, and there was no evidence of inspections being reported to the Administrator or the Quality Assurance and Performance Improvement Committee. The lack of adherence to these protocols resulted in an Immediate Jeopardy situation for all 32 residents with bed rails.
Removal Plan
- The facility removed all bed rails from resident beds, except for three residents who refused to have them removed. They implemented hourly checks for those residents.
- The facility secured two additional beds to ensure the bed and rails met the manufacturers specifications.
- The facility provided in-service education to 87.8% of staff, with plans for ongoing education of staff prior to the start of their next shift for those not currently on the schedule.
Failure to Prevent Pressure Ulcers and Provide Timely Care
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for a resident who experienced a decline in physical mobility. Resident #30, who had diagnoses including unspecified dementia and diabetes, developed an unstageable pressure wound and cellulitis on their heel. The facility did not implement preventative measures to prevent skin breakdown when the resident's mobility declined, and there was no documented evidence that the attending physician was notified of the resident's change in condition. Observations revealed that the resident's heels were resting directly on a deflated mattress, and the resident was not provided with timely incontinence care. The resident's incontinence brief and pad were soaked through, and there was a large, dried, brown ring on the bottom sheet. Additionally, the resident's left heel dressing was missing, and there was no process in place to check wound dressings between changes. Interviews with staff indicated a lack of communication and documentation regarding the resident's care needs and interventions. The facility's policies on pressure ulcer prevention, positioning, and incontinence care were not followed, as evidenced by the lack of interventions to alleviate pressure on the resident's heel and the failure to provide regular repositioning and incontinence care. Staff interviews highlighted the importance of offloading heels and maintaining intact dressings to prevent infection and promote healing, but these measures were not consistently implemented for Resident #30.
Facility Fails to Provide Hot Water for Residents
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for its residents due to a lack of hot water from October 29, 2024, to November 8, 2024. The facility's policy required water temperatures to be maintained between 105 and 120 degrees Fahrenheit to prevent scalding, but temperatures fell significantly below this range, reaching as low as 73 degrees Fahrenheit. Maintenance staff identified the issue on October 29, 2024, and notified the Maintenance Director, but the problem persisted due to delays in obtaining a necessary replacement part for the water pump. During this period, residents were not immediately informed about the lack of hot water, and their families were not notified at all. Staff resorted to using alternative methods for resident hygiene, such as using washcloths from coolers and a bath in a bag system, which was only introduced two weeks after the issue began. Residents expressed dissatisfaction with these measures, preferring to have hot showers, and some were upset about the use of paper plates for meals due to the situation. Interviews with staff revealed a lack of communication and coordination in addressing the issue. The Assistant Director of Nursing and the Director of Nursing were unsure about the notification process for families and the reasons for the delay in repairs. The Administrator acknowledged the inconvenience to residents but did not consider it significant enough to notify the Department of Health, as the facility had not lost water entirely, only hot water. Financial issues, such as a maxed-out credit card, further delayed the repair process.
Deficiencies in Accident Hazards and Bedrail Safety
Penalty
Summary
The facility was found to have several deficiencies during the surveys conducted, which included issues with accident hazards and bedrail safety. Specifically, the facility failed to maintain hot water temperatures within the safe standard of 110 degrees Fahrenheit, posing a risk of serious harm to residents. This issue affected all 70 residents in the facility, as the hot water temperatures in resident sinks and common shower rooms on both the First and Second Floors exceeded the safe limit. Additionally, the facility did not have hot water for a period of 10 days, and the administration failed to notify the Department of Health or the residents' families about this issue. The facility also failed to ensure the correct installation, use, and maintenance of bedrails, which posed a risk of entrapment for residents. Five residents were specifically noted to have bedrails that were not routinely inspected for potential entrapment hazards. The facility did not evaluate alternatives to bedrails, nor did it review the risks and benefits with residents or their representatives, or obtain informed consent prior to installation. This deficiency was identified as an immediate jeopardy situation for all 32 residents using bedrails. Furthermore, the administration did not provide the required documents to surveyors in a timely manner, which impeded the survey process. Documents such as staffing schedules, beneficiary notices, and facility assessments were submitted late, with some being over 11 days late. The administrator was not aware of the extent of the deficiencies and did not have current audits for critical areas such as bedrails, water temperatures, hand hygiene, and care plans. This lack of oversight and failure to adhere to regulatory requirements contributed to the facility's inability to use its resources effectively and efficiently to ensure the highest practicable well-being of its residents.
Food Safety and Sanitation Deficiencies in Facility
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a recertification survey. Specifically, a Certified Nurse Aide handled a resident's food without wearing gloves, which is against the facility's policy prohibiting bare hand contact with food. The resident involved had a diagnosis of moderate protein-calorie malnutrition and required assistance with meal setup. The aide admitted to assisting the resident with their sandwich but could not recall if gloves were worn, despite acknowledging the importance of glove use to prevent cross-contamination and the spread of germs. In the main kitchen, several issues were identified, including improperly labeled and undated food items in the walk-in cooler, such as cheeses, lunch meats, and dressings. Additionally, a box of tomatoes with visible mold was found. The kitchen environment was also found to be unsanitary, with chipped floor tiles, food debris, cobwebs, and mouse traps in storage areas. Equipment such as the microwave and drink cooler had visible food splatters, and the area around the grease trap was soiled. The Food Services Director acknowledged these lapses, noting that cleaning protocols were not being followed as required. Furthermore, the facility's dishwasher sanitizer was not maintained at the recommended level. The Food Services Director was unsure of the correct sanitizer level, which was found to be between 100 and 200 parts per million, contrary to the manual's requirement of a minimum of 50 parts per million. The lack of documentation for sanitizer level checks further compounded the issue, raising concerns about the potential for unsanitized dishes and the risk of bacterial contamination.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored according to professional principles, as observed during a recertification survey. Specifically, medication carts on the First and Second Floors were found unlocked and unattended, posing a risk to residents, especially those who wander. The First Floor 1-2 medication cart was repeatedly observed unlocked at the nurse's station with residents nearby, and the Second Floor 3-4 medication cart was found unlocked in the hall without nursing staff present. Additionally, the Omnicell room on the Second Floor was unlocked, despite containing medications and being accessible to wandering residents. Expired medications were also found in the facility. On the First Floor 1-2 medication cart, Lispro insulin was discovered with an expiration date that had passed, and it was uncertain if it had been administered to residents after expiration. Similarly, the First Floor 3-4 medication cart contained expired Lispro insulin, which was administered to a resident after its expiration date. The failure to check expiration dates before administration was acknowledged by the nursing staff involved. Furthermore, the facility did not consistently monitor refrigerator temperatures in the First Floor medication room, as evidenced by multiple blank spaces in the temperature log. This lack of documentation meant there was no assurance that medications were stored within the required temperature range. An unlabeled multidose vial of flu vaccine was also found in the refrigerator, which should have been labeled with an expiration date. The Assistant Director of Nursing confirmed that medications should be stored securely, and refrigerator temperatures should be monitored every shift to ensure medication efficacy.
Deficiency in Staff Training and Competency Documentation
Penalty
Summary
The facility failed to ensure an effective training program for new and existing staff, as evidenced by the lack of documented evidence of general orientation and required training for four Licensed Practical Nurses (LPNs). The facility's self-assessment identified necessary competencies and care area requirements, including incontinence/toileting programs, dementia care, pressure ulcer prevention and treatment, technical skills, and pain management. However, the facility did not have a nursing education policy available, and the reviewed nursing staff education folders lacked documentation of facility orientation and nursing competency in critical areas such as medication administration and pressure prevention and treatment. Interviews with the LPNs revealed inconsistencies in the training process. LPN #13 mentioned that the Director of Nursing observed them administering medications initially, but subsequent in-service education involved merely signing a paper without clear understanding. LPN #43 did not recall any formal training and learned from an agency nurse. LPN #39 stated they received minimal orientation and were not observed during medication administration or wound care, highlighting the importance of proper education to prevent infections and complications. LPN #16 noted that their orientation included a medication test, but annual competencies were not conducted, and they had not received recent education on pain management or pressure wound prevention. The Registered Nurse responsible for staff education acknowledged the lack of a current orientation process and formal competencies for new hires. They admitted that medication administration observations were not consistently documented, and there were no formal checklists or observation tools unless an issue was identified. The Administrator claimed that nursing competencies were completed before resident care, but it had been a while since the last audit of nursing education. This lack of structured training and documentation led to the deficiency identified during the survey.
Deficiencies in Medication Management and Emergency Preparedness
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. This was evident in the case of three residents and one emergency cart. The emergency cart on the second floor was not checked daily, as required, to ensure that emergency supplies were available. This oversight was confirmed through observations and interviews with staff, who acknowledged that the cart was not consistently checked, which could lead to missing supplies during an emergency. Resident #30, who had a diagnosis of dementia, was administered a discontinued anti-fungal cream by a Certified Nurse Aide who was not certified to apply medicated creams. The resident had a chronic rash, and the application of the wrong cream could have worsened the condition or caused an allergic reaction. Interviews with nursing staff confirmed that the cream was discontinued and should not have been applied, highlighting a lapse in following medication orders and protocols. Resident #16 had multiple orders for acetaminophen, which could lead to confusion and potential over-administration. Despite a recommendation from the pharmacist to consolidate the orders, the duplicate orders remained active, posing a safety concern. Similarly, Resident #17 received Percocet outside of the prescribed pain parameters, with the medication being administered for pain levels lower than those specified in the physician's orders. This was due to the resident's requests and a lack of adherence to the prescribed pain management protocol by the nursing staff.
Lack of Privacy in Resident Council Meetings
Penalty
Summary
The facility failed to ensure a private space for monthly Resident Council Meetings, as required by their own policies and resident rights. During the recertification survey, it was found that the meetings were held in the first floor dining room, where uninvited staff, including the Director of Social Work and the Director of Activities, were present. The residents were informed that they needed supervision during these meetings, which contradicted the facility's policy that allowed residents to conduct meetings in privacy and without uninvited staff. Interviews with five anonymous residents revealed that they were unaware of their right to request a private space for their meetings. The Director of Activities confirmed that the meetings were scheduled monthly in the dining room and that staff presence was mandatory for supervision. The Director of Social Work also stated that they attended the meetings as a second person, and the meetings were run by the Director of Activities, further indicating that the residents' right to privacy during these meetings was not honored.
Failure to Provide Timely Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to provide appropriate liability and appeal notices to Medicare beneficiaries for three residents during a recertification survey. Specifically, the facility did not issue the required Notice of Medicare Non-Coverage (CMS-10123) and Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (CMS-10055) in a timely manner. This deficiency affected three residents who either remained in the facility after the discontinuation of Medicare Part A services or were discharged without receiving the necessary notices. Resident #28, diagnosed with epilepsy and dementia, had a Medicare-covered stay that ended on 7/24/2024. The facility did not provide timely written notice to the resident's representative, who only received verbal acknowledgment a day before the end of services. Similarly, Resident #38, with dementia and spinal stenosis, did not receive timely written notice, and their representative was not informed about the option to appeal the decision. The representative only received verbal acknowledgment two days before the end of services, and there was no evidence of written confirmation. Resident #223, who had a diagnosis of right knee effusion and was discharged home, did not receive the Notice of Medicare Non-Coverage. The Director of Social Work admitted to not sending the required notices via certified mail and misunderstood the requirement for resident-initiated discharges. The facility's failure to provide these notices prevented residents and their representatives from being informed about the termination of services and their right to appeal, as required by regulations.
Failure to Implement Comprehensive Care Plan for Resident with Dementia
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with dementia and behavioral symptoms, including the use of psychotropic medications. The resident, who had diagnoses of dementia, anxiety, depression, and an unspecified mood disorder, was receiving multiple psychotropic medications such as Seroquel, citalopram, Ativan, and Rexulti. Despite the resident's severe cognitive impairment and frequent mood symptoms, there was no documented evidence of a care plan addressing the use of these medications or non-pharmacological interventions to manage the resident's behaviors. Observations and interviews revealed that the resident exhibited frequent yelling, moaning, and agitation, which were not effectively managed or documented in a care plan. Staff interviews indicated a lack of specific interventions tailored to the resident's needs, with some staff members noting the resident's decline and increased behavioral symptoms. The facility's policies required the evaluation and monitoring of psychotropic medication use and the implementation of non-pharmacological interventions, but these were not reflected in the resident's care plan. The deficiency was further highlighted by the absence of a behavior or psychotropic medication care plan, which should have included resident-specific preferences and interventions. Staff members, including CNAs, LPNs, and the Director of Nursing, acknowledged the need for individualized care plans to manage the resident's behaviors and medication use. The lack of a comprehensive care plan for the resident's significant issues, such as dementia and psychotropic medication use, was a clear oversight by the facility.
Failure to Provide Personalized Activities for Resident
Penalty
Summary
The facility failed to provide ongoing programs to support the interests and preferences of Resident #35, who was diagnosed with unspecified dementia and had moderately impaired cognition. The resident's care plan indicated a preference for activities such as watching television, listening to music, and engaging in puzzles, yet their room lacked personalization and activity items like a television or radio. Observations revealed the resident often sat in silence, with no access to preferred activities, and there was no documented evidence of ongoing activity evaluations or invitations to participate in activities after early November. Interviews with staff highlighted a lack of sufficient activity programming, particularly on weekends, due to staffing shortages. Certified Nurse Aides and the Director of Activities noted that Resident #35 preferred 1:1 interactions and was often left without meaningful engagement, leading to feelings of loneliness and boredom. The resident's room was devoid of items that could facilitate their preferred activities, and there was no evidence of recent 1:1 visits, which were deemed important for their psychosocial well-being. The Director of Activities and other staff acknowledged the importance of activities for residents' mental stimulation and social interaction. However, due to limited staffing, the facility struggled to provide adequate activities, especially for residents with cognitive challenges like those on the Second Floor. The lack of personalized activities and social interaction for Resident #35 was a significant oversight, as the resident was not only deprived of their preferred activities but also lacked the necessary social engagement to support their well-being.
Facility Fails to Maintain Sanitary and Comfortable Environment
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and visitors, as observed during a recertification survey. On the first floor, the large shower room was found to have a strong smell of feces and urine, with the presence of small flying insects. Despite cleaning logs indicating daily cleaning, the room's condition suggested otherwise. Additionally, the bathroom in the main hallway by the administrative office had a strong urine smell and visible brown debris on the toilet, indicating inadequate cleaning and maintenance. Resident #30 was observed in a wheelchair that was in disrepair, with both armrests missing plastic and exposing the material underneath. Interviews with staff, including housekeepers, CNAs, and maintenance personnel, revealed a lack of awareness and communication regarding the maintenance of the shower room and the resident's wheelchair. The Director of Housekeeping and the Director of Maintenance both acknowledged the importance of maintaining a clean and dignified environment, yet the deficiencies persisted, impacting the residents' quality of life.
Failure to Deliver and Protect Resident Mail
Penalty
Summary
The facility failed to ensure that residents exercised their rights to receive mail promptly and unopened, as required by their own policies and regulations. During a recertification survey, it was found that mail was not delivered to residents on Saturdays because the activities department, responsible for mail delivery, did not work on weekends. This resulted in residents not receiving their mail until the following Monday, which was confirmed by interviews with residents and staff. Additionally, two residents reported receiving mail that had been opened prior to delivery, which was against the facility's policy that mail should be delivered unopened unless requested otherwise by the resident. Interviews with various staff members, including the Administrative Assistant, Nursing Unit Coordinator, and Director of Activities, revealed a lack of weekend mail delivery and instances of mail being opened if it appeared to be a bill. The Administrator acknowledged awareness of the issue, stating that mail resembling bills was sometimes opened to ensure payment, which violated residents' rights to privacy and timely access to their mail. The facility's failure to deliver mail on Saturdays and the opening of mail without residents' consent were identified as deficiencies in upholding residents' rights.
Inadequate Grievance Process and Lack of Designated Grievance Officer
Penalty
Summary
The facility failed to ensure a proper grievance process was in place for all 70 residents. The grievance policy and forms were not readily accessible, as they were placed in hard-to-reach areas on bulletin boards behind locked doors. Additionally, the facility did not have a designated grievance officer, and the grievance policy contained outdated contact information. During a resident group meeting, all five anonymous residents expressed that they were unaware of how to file a grievance or who the grievance officer was. The grievance log showed only three grievances filed since the last survey, indicating a lack of awareness or accessibility of the grievance process. Interviews with staff revealed that the Director of Social Work handled grievances but was not officially titled as the grievance officer. There was no provision for residents to submit grievances anonymously, as forms had to be handed to staff members. The Administrator acknowledged the importance of having an official grievance officer, but the facility had not implemented this role effectively.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 44 citations issued within 25 miles in the last 12 months — including the 2 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.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Groton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Kendal At Ithaca | 9.3 mi | ★★★★★ | 0 | 0 |
| Northwoods Rehab And Nursing Center At Moravia | 9.4 mi | ★★★★★ | 14 | 0 |
| Guthrie Cortland Medical Center | 9.5 mi | ★★★★★ | 14 | 2 |
| Cortland Park Rehabilitation And Nursing Center | 10.6 mi | ★★★★★ | 0 | 0 |
| Crown Park Rehabilitation And Nursing Center | 10.7 mi | ★★★★★ | 2 | 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.