Citations in Connecticut
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Connecticut.
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Latest Citations in Connecticut
A resident with osteoarthritis, rheumatoid arthritis, and non-ambulatory status, who required a two-person stand-pivot transfer with a walker per care card and provider order, was transferred by a single NA who did not use a gait belt or walker. The NA assisted the resident to stand from a wheelchair using the bed rail and instructed the resident to pivot toward the bed, during which a pop/grinding sound was heard from the left knee and the resident experienced immediate pain. Initial nursing assessment noted pain with movement but no visible swelling or redness, and the provider was not notified until hours later when swelling and continued pain were reported by an LPN. A STAT X-ray subsequently revealed an acute comminuted fracture of the distal left femoral shaft, and the resident required hospital transfer and surgical repair.
A resident with osteoarthritis and rheumatoid arthritis, who had a PRN order for acetaminophen every six hours for pain, sustained a left distal femur fracture during a transfer and experienced significant pain with movement. Initial PRN acetaminophen given in the late afternoon was documented as effective, but when the resident later yelled out in pain and swelling was observed, an LPN did not administer another PRN dose despite the order parameters. During the night, another LPN observed ongoing discomfort but delayed giving acetaminophen until early morning, assuming it had already been given and not checking the MAR. The early-morning dose was documented as ineffective for 10/10 pain, and although this unrelieved pain was reported to a supervisor, the provider was not notified and no additional pain medication was obtained before the resident was sent to the hospital. The facility’s pain policy requiring frequent reassessment of acute pain, MAR review, and reporting of prolonged unrelieved pain was not followed.
A resident with osteoarthritis, rheumatoid arthritis, and generalized anxiety disorder had a current physician order for bed mobility assist of two and transfer assist of two with a rolling walker, and therapy discharge documentation showed the resident performing stand-pivot transfers with assist of two. Despite this, the resident’s care plan, last reviewed by the IDT and MDS nurse, continued to list the resident as a total lift for transfers and was not revised to reflect the updated mobility status and orders, contrary to the facility’s comprehensive care planning policy requiring ongoing review and revision with condition changes.
The facility did not complete required annual performance evaluations for a nurse aide working the 3–11 PM shift. Review of the aide’s personnel file showed a hire date more than a decade earlier and a last documented evaluation several years ago, with no evidence of subsequent yearly evaluations. The Administrator reported that all employees must receive annual evaluations based on their hire-date anniversary and that HR was responsible for notifying when evaluations were due, routing them to nursing supervisors, and ensuring they were filed. Facility policy specified that evaluations should summarize counseling sessions to identify trends, review job description performance ratings with the employee, and be filed per policy, but this process was not followed for the identified aide.
A resident with severe cognitive impairment, delusions, and a history of physical and verbal aggression was known to wander, resist care, and be difficult to redirect, yet the care plan did not address the risk of entering other residents’ rooms. After this resident slapped another resident in a bathroom, staff documentation continued to show wandering into rooms, agitation, and aggression toward staff and others. Later, the same aggressive resident entered another resident’s room, yelled, demanded compliance, then slapped the resident’s face and grabbed the resident’s arm, resulting in resident-to-resident abuse that was not prevented by effective behavioral interventions or care plan measures.
A dependent resident with hemiplegia, aphasia, and severely impaired cognition, who required staff assistance for bed mobility and transfers, was found by an LPN with multiple unexplained injuries, including a lip laceration, forehead abrasion with swelling, and bruising to the right hand and wrist. Earlier in the shift, the NA assigned to the resident had been upset, stated she should not be working, and left early. Another NA later found the resident incontinent of stool with stool on the floor and confirmed the resident required two-person assistance for care. The DON reported the resident could not get up independently and there were no wandering or aggressive residents on the unit. In a subsequent interview, the resident, using limited verbal communication and gestures, indicated that the NA had struck him, while also acknowledging a fall but without details, leaving the injuries as an injury of unknown origin that met the facility’s criteria for potential abuse.
Two residents experienced accidents due to failures in following orders and implementing fall and incontinence interventions. One resident with hemiplegia and a documented order and care plan for two-person assist with bed mobility was moved in bed by a single NA, who pulled on the resident’s shoulder while boosting in bed, after which the resident reported pain and an x-ray showed an anterior shoulder dislocation. Another resident with dementia, impaired balance, severe cognitive impairment, and progressive urinary and bowel incontinence had multiple unwitnessed falls related to toileting needs, while care plans lacked clear incontinence goals and a toileting schedule, and a required bowel and bladder assessment was not completed on readmission. Despite identified fall risk and orders for gripper socks in bed, staff did not consistently apply or verify gripper socks, and the resident fell from bed while attempting to use a urinal without gripper socks in place.
A resident with severe cognitive impairment and multiple diagnoses was ordered Tramadol oral solution twice daily, while another resident was ordered Lacosamide oral solution twice daily. During a morning medication pass, an LPN poured and administered Lacosamide, prescribed for the other resident, instead of the ordered Tramadol. The DON reported that both medications were controlled substances stored together and had similar-appearing bottles, and that the LPN failed to read and verify the medication label against the Medication Administration Record as required by facility policy, resulting in the administration of the wrong medication.
A resident with dementia, impaired balance, and progressive urinary and bowel incontinence required substantial assistance with toileting and ambulation and used a wheelchair. Despite repeated assessments showing severe cognitive impairment and frequent incontinence, the care plans did not include adequate goals or a specific toileting schedule, and the CNA care card lacked a toileting plan. The care plan required gripper socks while in bed and checks for their placement, but CNAs reported being unaware of this and applied regular socks instead. Over time, the resident sustained multiple unwitnessed falls in the room and bathroom, including a fall from bed while attempting to use a urinal without gripper socks, demonstrating that key fall-prevention and toileting interventions were not implemented as planned.
A resident with dementia, prior cerebral infarction, impaired cognition, wheelchair use, and frequent bowel and bladder incontinence did not receive a required bowel and bladder assessment upon readmission from a hospital stay. Earlier documentation showed bowel continence with the bladder section marked not applicable, while a later MDS indicated frequent incontinence and need for substantial assistance with toileting and personal hygiene. The resident’s care plan did not address continence status, and clinical record review confirmed no bowel and bladder assessment was completed after readmission, despite facility policy requiring a urinary assessment on admission, readmission, and with significant changes in continence, as acknowledged by the DNS.
Improper One-Person Transfer Without Gait Belt Leads to Femur Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident who required two-person assistance for transfers was transferred per protocol, resulting in a preventable accident and an acute comminuted fracture of the left distal femoral shaft. The resident had diagnoses including osteoarthritis of the knee, rheumatoid arthritis, and generalized anxiety disorder, and was non-ambulatory at baseline. An annual MDS showed a BIMS score of 12/15 with some memory deficits, partial assistance needed for bed mobility and transfers, and wheelchair use for mobility. Therapy staff and the DON confirmed that, at the time of the incident, the resident required an assist of two for stand-pivot transfers with a walker per the care card and physician’s order. On the day of the incident, the resident reported feeling very tired and falling asleep in the wheelchair, with left foot discomfort. A nurse aide observed the resident leaning forward in the wheelchair with hands on the side rail and believed the resident was trying to stand. Although the aide knew the resident required two-person assistance and a walker for stand-pivot transfers, she did not call for help, did not use the call bell, did not apply a gait belt, and did not use the walker. Instead, she assisted the resident to stand while the resident held the side rail and instructed the resident to pivot toward the bed. As the resident attempted to pivot on the left leg, both the resident and the aide heard a pop or grinding sound from the left knee, and the resident experienced immediate pain. The aide then maneuvered the resident onto the edge of the bed and into bed without a fall occurring. Following the incident, the resident complained of pain with movement of the left leg and knee. The 3–11 PM RN supervisor assessed the resident around 4:15 PM but did not observe redness or swelling and did not immediately notify the provider. Later that evening, after the charge LPN reported swelling and continued pain, the RN supervisor reassessed the resident and contacted the provider, who ordered a STAT left knee X-ray, ice, and continued PRN Tylenol. The X-ray obtained early the next morning showed an acute comminuted fracture of the distal shaft of the left femur, and the resident was subsequently transferred to the hospital, where surgical intervention with open reduction internal fixation was performed. The incident was documented on the facility’s reportable incident form as occurring during a transfer performed by the 3–11 PM nurse aide, with a pop sound heard and increased left knee pain, and was identified as a preventable accident reflecting a breakdown in supervision and adherence to established protocols.
Failure to Provide Timely and Effective PRN Pain Management After Fracture
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate and timely pain management to a resident following an injury that resulted in a left distal femur fracture. The resident had diagnoses of osteoarthritis, rheumatoid arthritis, and generalized anxiety disorder, and had a standing PRN order for acetaminophen 325 mg, three tablets by mouth every six hours as needed for pain. The care plan identified the resident as having potential for pain related to arthritis, with interventions including administering medications as prescribed and monitoring effectiveness. On the date of the incident, during a transfer by a nurse aide, a popping sound was heard and the resident reported increased left knee pain. The nurse supervisor directed the charge nurse to obtain vital signs and administer acetaminophen around 4:15 PM, which was documented as effective at that time. Later that evening, around 10:40 PM, the charge nurse noted the resident yelled out in pain when the left leg was lifted and observed swelling of the left knee. Despite recognizing the resident’s pain at that time, the charge nurse did not administer another dose of acetaminophen, even though more than six hours had elapsed since the prior dose and the medication was ordered every six hours as needed. The provider was notified and ordered a STAT x-ray, continuation of PRN Tylenol, and application of ice. During the overnight shift, the oncoming LPN was informed that the resident had been in pain at the end of the prior shift and observed that the resident appeared uncomfortable throughout the night. However, this nurse did not administer acetaminophen until 5:12 AM, assuming the prior nurse had already given it and failing to verify the last administration time on the MAR. After the 5:12 AM dose, the resident continued to appear restless and uncomfortable during care, and the acetaminophen was documented as ineffective for a pain level of 10/10. Although the nurse reported the unrelieved pain to the nursing supervisor, there was no documentation that the provider was notified of the ineffective pain control or that any additional or alternative pain medication was obtained prior to the resident’s transfer to the hospital later that morning. The facility’s pain policy required acute pain to be assessed every 30–60 minutes until relief was obtained, review of the MAR to determine PRN use and effectiveness, and reporting of significant changes in pain level and prolonged, unrelieved pain to the practitioner. These steps were not followed, resulting in prolonged unrelieved pain for the resident after the injury and prior to hospital transfer.
Failure to Update Mobility Care Plan to Match Physician Orders
Penalty
Summary
The deficiency involves the facility’s failure to review and revise a resident’s mobility care plan to reflect a current physician’s order. The resident had diagnoses including osteoarthritis of the knee, rheumatoid arthritis, and generalized anxiety disorder, and had a BIMS score of 12/15 indicating some memory recall deficits. A physician’s order dated 3/2/25, and still current, directed that the resident receive bed mobility assistance of two and transfer assistance of two with a rolling walker. The annual MDS identified that the resident required partial assistance with bed mobility and transfers and used a wheelchair for mobility. However, the Resident Care Plan initiated on 1/6/24 and last reviewed on 1/16/26 identified the resident as requiring assistance with mobility due to decreased strength and listed interventions indicating the resident was a total lift for transfers, which did not match the physician’s order. Interviews and record reviews confirmed that the care plan had not been updated despite changes in the resident’s mobility status and existing orders. The PT and OT reported that the resident had been on therapy services until 12/18/25 and was discharged at that time as an assist of two for stand-pivot transfers between bed and wheelchair, consistent with the 3/2/25 activity orders. They stated they would have notified the charge nurse of the resident’s transfer status and that therapy staff do not update care plans, leaving that responsibility to nursing. They acknowledged the mobility care plan last reviewed on 1/16/26 was incorrect and that the resident had not required a total lift for transfers since 3/2025. The DON confirmed that the mobility care plan should have matched the 3/2/25 physician’s order and that both the IDT and the MDS nurse were responsible for reviewing and revising care plans, including during care plan meetings. The facility’s Comprehensive Care Planning policy directed that care plans be revised as residents’ conditions change and be reviewed and updated at significant changes and at least quarterly, but this was not done for this resident’s mobility care plan.
Failure to Complete Annual Performance Evaluation for Nurse Aide
Penalty
Summary
The facility failed to complete required annual performance evaluations for at least one nurse aide. Review of the personnel file for a 3–11 PM nurse aide (NA #1) showed a hire date of 11/26/12 and documented that the last performance evaluation was completed on 12/18/22, with no evidence that yearly evaluations were completed in 2023, 2024, or 2025. The Administrator stated that each employee was required to have an annual performance evaluation based on their hire-date anniversary and explained that, although the facility currently had no Human Resources (HR) staff member, HR had been expected to notify when evaluations were due, distribute them to nursing supervisors for completion, and ensure they were filed in the employee record. Facility policy titled “How to Complete the Performance Evaluation” indicated that the facility reviews and summarizes employee counseling sessions to identify trends and patterns, reviews job description performance ratings with the employee to ensure understanding of performance expectations, and files the performance evaluation per facility policy, but this process was not carried out for NA #1 for multiple consecutive years. No resident medical history or condition was described in relation to this deficiency.
Failure to Prevent Resident-to-Resident Abuse by Aggressive, Wandering Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from abuse by not implementing effective interventions for a resident with known wandering and aggressive behaviors. One resident had diagnoses including Alzheimer’s disease, anxiety disorder, and cognitive communication deficit, with an MDS showing severely impaired cognition, delusions, physical and verbal behaviors directed toward others, and rejection of care. The care plan identified this resident as resistive to care, physically and verbally aggressive, yelling, hitting, and pacing, with instructions to postpone care if combative and to monitor for anxiety, aggression, and delusions. Physician orders directed staff to monitor targeted behaviors of delusions and physical and verbal aggression toward staff and residents. Despite these known behaviors, the resident entered another resident’s bathroom and, after being told to leave, slapped that resident on the left cheek with an open hand. This first resident-vs-resident incident occurred in the context of documented wandering, agitation, and aggression, including notes that the aggressive resident hit staff, threw a cup of juice at staff, was verbally aggressive, refused to use a walker, refused to stop wandering into other residents’ rooms, and was not easily redirected. The care plan developed after the first incident identified that the resident used to work in a prison and was triggered when told “no,” and included interventions such as diversion, removal from the environment, and observation for non-verbal signs of physical aggression. However, the care plan did not address the possibility of this resident wandering into other residents’ rooms. Subsequently, another resident with Alzheimer’s disease, anxiety disorder, bilateral hearing loss, and moderate cognitive impairment, who had a care plan noting potential physical behaviors, lack of personal space boundaries, and yelling, was assaulted when the aggressive resident again entered a resident room. In this second incident, the aggressive resident entered the room, yelled at the other resident, demanded compliance, then slapped the resident on the left side of the face and grabbed the right upper arm. The psychiatric evaluation documented that the aggressive resident had a previous resident-to-resident incident and recent episodes of physical aggression without evidence of infection. The facility’s failure to incorporate the known wandering and room-entry behavior into the care plan and to implement effective interventions to prevent further resident-to-resident contact contributed to this second incident of abuse.
Failure to Protect Dependent Resident From Possible Physical Abuse and Unexplained Injuries
Penalty
Summary
The deficiency involves the facility’s failure to protect a dependent resident from physical abuse and to ensure the resident remained free from injuries of unknown origin. The resident had hemiplegia and hemiparesis affecting the left side, aphasia, depression, and anxiety, with a BIMS score of 3 indicating severely impaired cognition. The care plan documented that the resident was dependent on staff for bed mobility and transfers and required assistance of one staff member for activities of daily living and transfers in and out of bed and chair. The resident was also identified as at risk for falls due to decreased functional mobility and hemiplegia/hemiparesis. On the evening in question, an LPN reported that the NA assigned to the resident approached him in an upset and erratic manner, stating she should not be working because it was her mother’s birthday, and then left the shift early. When the LPN entered the resident’s room to administer medications, he discovered the resident with multiple injuries, including a swollen right lip with a laceration, an abrasion and quarter-sized bump on the forehead, and bruises on the back of the right wrist and thumb area. The resident, who communicated primarily through yes/no responses due to aphasia, initially nodded no when asked if he had fallen or bumped his head and was unable to explain how the injuries occurred. The facility documented this as an injury of unknown origin. Subsequent interviews and observations further highlighted the unexplained nature of the injuries and the possibility of abuse. Another NA who came on after the first NA left reported that the resident was incontinent of stool, required assistance of two staff for personal care, and that stool was found on the floor near the bed when she later provided care and observed the injuries. The DON stated the resident would not have had the ability to get up independently and would likely require two staff to assist if a fall had occurred, and there were no residents on the unit who wandered or had a history of aggression. In a later interview, the resident, with a family member present, verbally identified that the NA who had left the shift early had struck him, and demonstrated this by forming a fist and touching his forehead, while also acknowledging a fall but without being able to provide details. The facility’s own abuse policy required that injuries of unknown origin be investigated as potential abuse when the source is not observed or cannot be explained, or when the injury is suspicious due to its extent, location, or number, conditions that were present in this case.
Failure to Follow Transfer Orders and Implement Fall/Incontinence Interventions Resulting in Resident Injuries
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment and adequate supervision to prevent accidents for two residents. For one resident with hemiplegia and hemiparesis affecting the left, non-dominant side, the physician’s admission assessment documented that the resident was chair bound with no ability to move the left upper or lower extremity, and physician orders, the care plan, and the nurse aide care card all directed an assist of two staff for bed mobility and transfers. Despite these orders, a nurse aide moved the resident in bed alone. The aide reported that he was in a rush, stood at the head of the bed, grasped the transfer sheet with one hand and the resident’s left shoulder with the other, and pulled the resident up in bed, even though he was aware that two-person assistance was required for bed mobility. Following this event, the resident complained of shoulder pain and reported hearing a pop while being moved in bed by the aide. Nursing documentation identified complaints of left shoulder, arm, and hand pain, with intact sensation but no active movement in the left upper extremity at baseline, and noted greenish-yellow ecchymosis on the left hand. An x-ray of the left shoulder showed a normal left humerus with an anterior dislocation of the left shoulder. The facility was unable to provide a transfer policy when requested, and the director of nursing confirmed that the aide had moved the resident in bed without assistance, contrary to the provider’s orders for two-person assistance with bed mobility. The deficiency also involves a second resident with dementia, cerebral infarction, difficulty in walking, severely impaired cognition, impaired balance, and progressive urinary and bowel incontinence who was at high risk for falls. The resident’s care plans over time identified fall risk and directed interventions such as applying gripper socks while in bed, instructing the resident to ask for assistance before ambulating, placing the call bell within reach, and orienting to surroundings. However, the care plans repeatedly lacked clear goals and adequate interventions for incontinence care and did not include a toileting plan or schedule, despite MDS assessments documenting occasional and later frequent incontinence and the resident’s severe cognitive impairment. The bowel and bladder assessment was not completed on readmission after a hospitalization, contrary to facility policy. This resident experienced multiple unwitnessed falls, several associated with toileting needs. Incident reports documented falls in the bathroom and in the room, including one with the wheelchair tipped over and another due to ambulating without assistance. Later documentation showed the resident was frequently incontinent of bowel and bladder, yet the care plan still did not include a toileting schedule. The resident sustained an unwitnessed fall under the bathroom sink with skin tears and rib pain, and after readmission with rib fractures, the care card continued to list the resident as continent and did not provide a toileting plan, instead listing only transfer status. In a subsequent fall from bed while attempting to use a urinal, the resident was not wearing gripper socks, and the assigned nurse aides reported they were unaware that gripper socks were required in bed and did not identify this need from the care card. The director of nursing services acknowledged that the resident should have had a toileting plan/schedule based on severe cognitive impairment and incontinence patterns and that a bowel and bladder assessment should have been performed on readmission, but these were not implemented, and gripper sock interventions were not consistently carried out at the time of the fall.
Medication Error Due to Failure to Verify Medication Label Against Orders
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were administered in accordance with physician orders, resulting in a significant medication error for one resident reviewed in a sample of three. Resident #2, who had diagnoses including Parkinson’s disease, dementia, anxiety, and a history of alcohol and polysubstance abuse, was severely cognitively impaired and dependent on staff for all care. A physician’s order directed that Resident #2 receive Tramadol oral solution 50 mg by mouth twice daily. Another physician’s order directed that Resident #3 receive Lacosamide oral solution 200 mg twice daily. On the morning medication pass, the LPN responsible for administering medications poured and administered Lacosamide, which was prescribed for Resident #3, to Resident #2 instead of the ordered Tramadol. According to facility documentation and interviews, the DON reported that both Tramadol and Lacosamide were controlled substances stored in a locked area and that the medication bottles appeared similar. The DON identified that the LPN did not read the medication label prior to pouring the medication, despite the facility’s Medication Administration policy directing staff to compare the medication label to the resident’s Medication Administration Record. A nurse’s note documented that the incorrect medication was given to Resident #2 at 8:00 AM and that this was recognized and recorded later that day. The incident was also documented on a Facility Reported Incident form, which identified that Resident #2 had been given the incorrect medication.
Failure to Implement Fall-Prevention and Toileting Care Plan for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a complete, measurable care plan addressing fall prevention and incontinence/toileting needs for a cognitively impaired resident at high risk for falls. The resident, admitted in February 2025 with dementia, cerebral infarction, difficulty walking, and severely impaired cognition (BIMS score of 3), required substantial assistance with toileting, hygiene, and ambulation, used a wheelchair, and progressed from occasional to frequent incontinence of bowel and bladder. Despite these documented needs and changes in continence status on multiple MDS assessments, the Resident Care Plans dated 6/12/25, 9/24/25, and 12/9/25 did not include adequate goals and interventions for incontinence care or a specific toileting plan/schedule, even though facility policy required urinary assessments and toileting plans based on continence status. The facility also failed to consistently implement an established fall-prevention intervention requiring gripper (non-skid) socks while the resident was in bed. The care plan identified the resident as at risk for falls due to impaired balance and unsteady gait and directed that gripper socks be applied while in bed, with the 12/9/25 plan further directing staff to check placement of gripper socks at the beginning of the 11 PM–7 AM shift. However, the Certified Nurse’s Aide care card dated 11/20/25 only indicated the resident was continent and included transfer assistance and ensuring non-skid socks were in place, without a toileting schedule. Nursing assistants interviewed reported they were unaware the resident required gripper socks while in bed and described applying regular socks instead. Over the review period, the resident experienced multiple unwitnessed falls, including being found on the bathroom floor with a skin tear to the left elbow, on the room floor with a tipped wheelchair and complaints of pain, next to the bed after ambulating without assistance, and under the bathroom sink with skin tears and reported rib and back pain. A later fall investigation documented that the resident fell out of bed while attempting to use a urinal and was not wearing gripper socks at the time. Interviews with nursing assistants and the DNS confirmed that the resident should have had a toileting plan/schedule due to severe cognitive impairment and incontinence patterns, and that NAs were expected to review care cards for updated care needs, but the care card and care plans did not reflect a specific toileting schedule or fully implemented fall-prevention interventions.
Failure to Complete Bowel and Bladder Assessment on Readmission
Penalty
Summary
The deficiency involves the facility’s failure to complete a required bowel and bladder assessment upon a resident’s readmission, as required by facility policy and professional standards. One resident, admitted in February 2025 with dementia, cerebral infarction, difficulty in walking, and severely impaired cognition (BIMS score of 3), had an earlier Bowel and Bowel assessment that documented bowel continence but listed the bladder section as not applicable. A subsequent quarterly MDS identified that this resident required substantial assistance with toileting hygiene, personal hygiene, and ambulation, used a wheelchair, and was frequently incontinent of both bowel and bladder. The resident’s care plan dated 9/24/25 did not identify the resident’s continence status. After a hospitalization from late November 2025 through 11/27/25, the resident returned to the facility, but review of the clinical record showed no evidence that a Bowel and Bladder Assessment was completed upon readmission. In an interview, the DNS confirmed that, according to the facility’s Urinary Incontinence policy, a urinary assessment should have been completed on admission, readmission, and with any significant change in continence, and acknowledged that such an assessment should have been done following this resident’s readmission. This failure to perform the required assessment upon readmission, despite the resident’s documented incontinence and functional limitations, constituted noncompliance with the facility’s own urinary incontinence policy and professional standards of quality for assessment and care planning.
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