Citations in Connecticut
Statistics, citations and compliance trends for long-term care facilities in Connecticut.
Statistics for Connecticut (Last 12 Months)
Financial Impact (Last 12 Months)
Latest citations in Connecticut
A resident with heart and vascular disease was readmitted with orders to stop Clopidogrel and ASA and start Apixaban, but the RN entered the new orders without removing the discontinued meds. The EMR generated interaction alerts for Apixaban with ASA and Clopidogrel, but the RN did not recognize or address them, and the night RN supervisor did not complete the required secondary review of readmission orders. The resident continued receiving Clopidogrel and ASA for several doses, and the MD identified the error as significant.
A resident with a history of heart and vascular disease was readmitted after a hospital stay with orders to stop Clopidogrel and Aspirin and start Apixaban. The readmitting RN entered the new orders but did not remove the discontinued meds or address an EMR alert for drug interactions, and the overnight RN supervisor did not complete the required secondary check. As a result, the resident received Apixaban with Clopidogrel and Aspirin for several doses, then developed dark emesis and rectal bleeding and was sent to the ED.
A resident with dementia, severe cognitive impairment, and wandering behavior left the building after an exit alarm sounded and was later found outside near the solarium. Staff had been aware the resident was wandering overnight and had asked the charge nurse to keep a close eye on the resident, but the resident was last seen in the hallway before being discovered outside. The resident was returned inside with no injuries noted.
A resident with Parkinson's disease did not receive ordered Sinemet after admission because the medication was not transcribed from the hospital W-10 into the EMR and was missed during order verification. Staff later identified the omission after the resident developed worsening stiffness, weakness, and loss of mobility, and the neurologist noted the Parkinson's symptoms had worsened. The DON stated the RN and APRN both missed the order, and the error was not corrected when first identified.
A resident with cardiomyopathy, COPD, DM, and CKD was readmitted after a hospital stay with discharge instructions to start nifedipine ER and stop amlodipine. Instead, both calcium channel blockers were ordered and given together for five days because the W-10 discontinuation order was not followed and the medication reconciliation/order checks were not completed accurately.
Elopement-risk resident exited through unlocked front doors. A resident with schizophrenia, schizoaffective disorder, depression, PTSD, impaired cognition, and a history of removing a wander guard was able to leave when the front doors were opened for a visitor. The receptionist tried to redirect the resident, but the resident became resistive and walked out; staff later found the resident off the property near nearby offices after the resident reported going to a gas station and a church. Interviews and facility documentation indicated the alarm status was unclear and the receptionist did not maintain visual contact with the resident as expected.
Failure to Reconcile Readmission Med Orders and Respond to EMR Interaction Alerts
Penalty
Summary
Licensed nursing staff failed to accurately reconcile and transcribe hospital discharge medication orders for a resident with atherosclerotic heart disease, peripheral vascular disease, anemia, and intact cognition who returned to the facility with a suprapubic catheter and dependence for multiple activities of daily living. The hospital referral report directed discontinuation of Clopidogrel 75 mg and Aspirin 81 mg and initiation of Apixaban 5 mg, but the physician orders entered into the facility record did not include discontinuation orders for Clopidogrel or Aspirin. The resident’s medication administration record showed continued administration of Aspirin for 3 doses and Clopidogrel for 2 doses after those medications should have been stopped. The electronic medication record generated an order note alert identifying drug interaction warnings when Apixaban was added, including interactions with Aspirin and Clopidogrel, but the admitting RN stated she was not aware the system alerted to the potential interaction and did not address it. The Assistant DON stated the facility policy required medication reconciliation by the licensed staff member and a secondary verification of readmission orders by the 11:00 PM to 7:00 AM shift supervisor, but both steps were not followed. The DON stated the readmitting RN was responsible for reconciling the hospital discharge summary with current orders, removing discontinued medications from the active profile, and cross-referencing readmission orders, while the night supervisor was responsible for independently verifying all readmission orders. The newly assigned agency RN supervisor was on only her second shift at the facility and her first 11:00 PM to 7:00 AM shift, and the DON stated the admitting RN was responsible for orienting her to night shift responsibilities, including the required secondary review of readmission orders. The DON further stated there was no formal checklist to ensure shift-specific responsibilities were reviewed, and the required secondary verification was not completed. As a result, the resident continued to receive Clopidogrel and Aspirin after the hospital had discontinued them, and the medical director identified the medication error as significant.
Medication Reconciliation Failure Led to Concurrent Anticoagulant and Antiplatelet Use
Penalty
Summary
The facility failed to ensure a resident’s hospital discharge medication orders were accurately reconciled, transcribed, and verified on readmission. The resident had diagnoses including atherosclerotic heart disease and peripheral vascular disease, and the care plan addressed anemia with directions to give medications as ordered and monitor for side effects and effectiveness. The hospital discharge paperwork directed the facility to discontinue Clopidogrel 75 mg and Aspirin 81 mg and start Apixaban 5 mg twice daily, but the physician orders entered into the facility record included Apixaban without discontinuation orders for Clopidogrel and Aspirin. The medication administration record showed the resident received Aspirin for three doses and Clopidogrel for two doses after those medications should have been discontinued, while also receiving Apixaban as ordered. The electronic medical record generated an order note warning of potential drug interactions between Apixaban and both Aspirin and Clopidogrel, but the alert was not recognized or addressed by the readmitting nurse. The required secondary verification by the night supervisor was also not completed, and the facility’s documentation and interviews confirmed that the readmission orders were not reconciled correctly. During the weekend after readmission, the resident received all three medications concurrently. The nurse’s note documented vomiting dark brown material, active rectal bleeding, small to moderate rectal bleeding with small clots, sleepiness, intermittent nausea, and a blood pressure of 96/54, after which the resident was sent to the ED for evaluation. The medical director identified the event as a significant medication error, and facility leadership confirmed that the discontinued medications had not been removed from the active profile and that the readmission verification process was not followed.
Failure to Supervise a Wandering Resident Who Left the Facility
Penalty
Summary
The facility failed to ensure adequate supervision to prevent a resident with dementia and severe cognitive impairment from leaving the building without staff knowledge. The resident’s admission MDS identified wandering behavior and a significant risk of getting to a potentially dangerous place, and a physician order directed use of a wander guard on the left ankle with checks every shift and function checks every night shift. Therapy documentation also noted the resident required supervision or touching assistance with transfers and ambulation with a walker. On 7/12/2026, the resident was found outside the facility after an exit door alarm sounded. Facility records stated the resident had exited from the dining room/recreation room area, walked approximately 300 feet from the door, and was wearing night clothing and non-skid slippers. The resident was later located standing outside the solarium door and was returned inside with no injuries noted. A reportable event summary stated staff initiated a missing resident search after the alarm, and the resident was found outside the building. Staff statements and interviews showed the resident had been wandering during the overnight shift and had been seen as late as about 3:00 AM in the hallway. NA staff reported asking the charge nurse to keep a close eye on the resident while they cared for other residents, and the charge nurse stated he thought the resident was in bed when the alarm sounded. The administrator stated video review showed staff responding after the alarm and searching for the resident, and the DNS stated the resident had crossed the dining room, opened the outside door, and gone outdoors. The facility’s wandering and elopement policy stated residents with wandering behavior or elopement risk are to receive adequate supervision to prevent accidents or elopements.
Omitted Parkinson's Medication During Admission
Penalty
Summary
Resident #2, who had Parkinson's disease and was admitted for short-term rehabilitation, did not receive Carbidopa-Levodopa (Sinemet) as ordered on the hospital discharge summary and W-10. The discharge paperwork directed two tablets four times daily, and the APRN admission note stated that all medications listed on the hospital W-10 were to be continued. However, no physician order was located showing that the Sinemet was entered into the facility record at admission, and the medication was not administered for 19 days. During the period when the medication was omitted, Resident #2 developed worsening stiffness, tremors, weakness, and functional decline. An APRN note documented a stiff neck that had worsened since admission, and later notes described acute weakness, inability to walk, and significant decline in mobility. Therapy and social service documentation showed the resident progressed from needing limited assistance to requiring two staff for standing and becoming non-ambulatory. The neurologist later identified that the resident had become significantly weaker and that Parkinson's disease had worsened. Facility staff interviews and record review showed the admission medication reconciliation process was not completed as intended. The day shift manager stated she did not complete an additional medication reconciliation against the hospital W-10, and the DON stated the Sinemet was missed by both the RN and APRN who verified the orders. The DON also stated a second medication reconciliation was expected on the next shift, but the medication error was not corrected when it was identified. The resident improved after Sinemet was restarted, and the attending physician stated the omission had a significant impact on the resident's condition and contributed to worsening Parkinson's symptoms.
Medication Reconciliation Error After Hospital Readmission
Penalty
Summary
The facility failed to ensure a medication was discontinued in a timely manner in accordance with physician orders after a resident returned from the hospital. The resident had diagnoses including cardiomyopathy, COPD, diabetes mellitus, and chronic kidney disease, and a care plan identified altered cardiac status with interventions to administer medications as ordered. The resident’s MDS showed moderately impaired cognition and the need for moderate assistance with personal hygiene and transfers. After a hospital transfer for chest pain, the discharge summary and W-10 directed that nifedipine ER 60 mg daily be started and amlodipine 10 mg be stopped. A nursing note documented the resident’s readmission and that all orders were approved by the provider, and a physician order was entered for nifedipine ER 60 mg daily. However, a physician order was also entered the next day for amlodipine besylate 10 mg daily. As a result, the resident received both calcium channel blockers for five days. A facility reportable event later identified the medication error as clinically significant and noted the overlap had occurred with no ill effects. The error was discovered during a chart review after the resident was transferred to the hospital for a separate event. Interviews with nursing staff and the DON identified that the W-10 direction to discontinue amlodipine was not followed on readmission and that the medication reconciliation and subsequent order checks were not completed accurately.
Elopement-risk resident exited through unlocked front doors
Penalty
Summary
The facility failed to ensure that a resident identified as at risk for elopement was prevented from leaving the building when the front doors were unlocked for a visitor. Resident #91 had diagnoses including schizophrenia, anxiety, schizoaffective disorder, depression, and PTSD, was conserved of person and estate, had moderately impaired cognition, was independent with ambulation, and was identified in the record as an elopement risk. The resident also had a history of removing the elopement-prevention bracelet and had been ordered to wear the device on the left ankle with checks each shift and daily functioning checks. On 6/28/26 at about 5:45 PM, Receptionist #1 reported that Resident #91 exited the main elevator with a visitor, asked whether the dining room was open, motioned toward that area, and then ran out the front doors as they were opened for the visitor. The receptionist attempted verbal redirection and told the resident to return, but the resident became resistive, used profanities, and continued walking away. The receptionist then notified nursing staff and an elopement code was initiated. Facility documentation stated the resident was last confirmed to have the wander guard in place at 5:00 PM, but it was unclear whether the alarm activated when the resident left. The resident was not immediately located and was later found by the Administrator walking near the medical offices next to the facility, after having reported going to a gas station and then a church around the corner. Interviews indicated the expectation was for the receptionist to follow or maintain proximity to a high-risk resident attempting to leave until additional staff arrived, and RN #3 stated the receptionist should have followed the resident outside to maintain visual contact. The facility’s wandering and elopement policy required staff to attempt to prevent a resident from leaving, obtain assistance, and ensure notification of the charge nurse when a resident was attempting to leave or had left the premises.
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Compliance trends in Connecticut
Data through Apr 2026Comparisons below measure the most recent period May 2025 – Apr 2026 against the prior period May 2024 – Apr 2025 (two equal 12-month windows). The most recent 3 months are excluded because CMS is still publishing them.
Top tags by month · last 24 months
dashed = still reportingMonthly citation counts for the 5 most-cited tags. The dashed tail is the 3-month reporting lag.
Frequency movers
Biggest change in how often each tag is cited, as a rate per 100 inspections (so it isn't skewed by survey volume): May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025. Only tags with at least 20 citations in both periods are shown.
Severity movers
Tags whose average scope/severity shifted the most: May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025. The number is the average severity on the A–L scale (A=0…L=11); the letter is the band it falls in. A rise means the same tag is being cited at a more serious level — note the average can move enough to rank here while staying within the same letter. Same 20-citation minimum applies.
Care domain movers
Citations grouped into CFR care domains — F-tags by their §483 regulatory section (CMS State Operations Manual, Appendix PP) — measured as a rate per 100 inspections: May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025. Share is the domain's portion of citations this period; avg severity is the mean scope/severity letter and immediate jeopardy the percentage cited at J–L, both over the current period. Domains with at least 20 citations in both periods are shown; the sparkline tracks the last 12 months (left = oldest).
Immediate jeopardies · this period
Citations at the most serious scope/severity — J–L, immediate jeopardy, residents placed at risk of serious harm or death — over May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025. "Surveys with an IJ" counts distinct health inspections that had at least one.
Survey activity · by month
faded/dashed = still reportingCitations each month split into complaint-driven (unscheduled, triggered by grievances) vs standard surveys — bars, left axis — with the number of inspections as a line on the right axis. Rising inspections signal more scrutiny; a rising complaint share means more off-cycle surveys. The most recent 3 months are still being reported.
Deficiency-free survey rate
Share of health surveys that found zero deficiencies — the odds of a clean survey. May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025; the most recent 3 months are still being reported (dashed).
Penalties · by month
faded = still reportingTotal civil money penalty dollars imposed on the state's facilities each month — how hard the state is enforcing. The most recent 3 months are still being reported, and penalties often lag citations by several months.
Emerging tags
Tags that weren't established last period but surged — an early warning, distinct from movers (which track already-common tags). Criteria: fewer than 20 citations in the prior period, but at least 10 this period and 2.5× their prior volume. The sparkline shows monthly counts over the last 12 months (left = oldest).
Trusted data from CMS and state health departments
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