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
The facility failed to maintain an effective Legionella water management monitoring program after repeated positive water tests. Environmental samples remained positive in multiple bathroom sink locations over several months, while the facility continued monthly testing instead of the HICPAC-recommended biweekly post-remediation interval. The Administrator and DOPOL acknowledged awareness of the guidance, and the facility did not have a specific Legionella policy, although it did maintain a water management plan with Legionella prevention and control measures.
A resident with dementia and a documented assist-of-1 toileting plan was left alone on a toilet commode without a gait belt, stood up before the aide returned, and fell with wrist pain. Another resident with vertigo and syncope was ambulated at night without the required gait belt, lost balance during a bathroom return, fell, and sustained head and arm injuries requiring ER evaluation and stitches.
Failure to Protect a Resident from Physical Assault: A resident with moderate cognitive impairment was punched multiple times in the face and head by another resident with severe cognitive impairment and psychiatric diagnoses while in a lounge area. The assaulted resident sustained a facial injury, oral laceration, loose tooth, and closed head injury requiring hospital evaluation, and staff interviews confirmed the assault occurred before the residents were separated.
An LPN repeatedly left the unit, was later found unresponsive with suspected drug paraphernalia, and multiple residents then had omitted meds, missing assessments, and inaccurate controlled-substance records. The eMAR showed the LPN later signed off meds she could not verify, while residents with conditions such as DM, AFIB, CHF, seizures, chronic pain, and G-tube dependence had missed insulin, anticoagulants, anticonvulsants, pain meds, supplements, and ordered treatments. One resident also missed time-sensitive meds before a fistulogram, and the event was cited as Immediate Jeopardy.
An LPN became unwell during a shift and was later found lethargic with suspected drug paraphernalia, after which multiple residents were identified with omitted meds and treatments. The facility did not notify the provider immediately for numerous residents with conditions such as DM, CHF, seizures, AFIB, chronic pain, dementia, and tube-feeding dependence. Omitted care included insulin, anticoagulants, antihypertensives, anticonvulsants, pain meds, supplements, and blood sugar checks, and provider notes were not documented until the next day.
Missed Resident Care Conferences After MDS Assessments: The facility did not consistently complete RCCs for multiple residents after MDS assessments, including a resident with dementia and severe cognitive impairment, residents with diabetes, CKD on dialysis, Parkinson's disease, spastic hemiplegia, and psychiatric diagnoses. Records showed no documented RCCs after quarterly, annual, admission, or 72-hour assessments for several residents, and interviews noted social services usually scheduled RCCs but the facility had been without a social worker and was behind on MDSs.
Failure to Follow Legionella Monitoring Guidance After Repeated Positive Water Tests
Penalty
Summary
The facility failed to implement an effective Legionella water management monitoring program after repeated positive Legionella test results were identified in environmental water samples. Review of testing records showed monthly environmental testing was performed from December 2025 through June 2026, but January 2026 documentation was unavailable because the sample was reportedly lost in shipping. Positive results were documented in the bathroom sink in one room on 2/24/26, with repeat positives at the same location on 3/18/26 and 4/15/26. On 5/7/26, one bathroom sink tested negative, but another room’s bathroom sink cold water sample tested positive, and on 6/8/26 that same location remained positive with a higher result. Interview with the DOPOL and Administrator on 7/2/26 showed the facility had been managing a Legionella outbreak since June 2025. The Administrator stated the facility had tested every two weeks until negative results began in July 2025, then moved to monthly testing in December 2025, despite acknowledging awareness of HICPAC guidance recommending biweekly post-remediation testing after a positive result. The facility continued monthly testing after repeated positives and, according to the Administrator and DOPOL, replaced affected plumbing fixtures and equipment rather than flushing the water system as part of remediation. The facility did not have a specific Legionella policy, although it maintained an active water management plan that included Legionella prevention and control measures.
Failure to Use Gait Belt and Provide Adequate Supervision During Toileting and Ambulation
Penalty
Summary
The facility failed to ensure safe assistance and supervision during toileting and ambulation for a resident with dementia, impaired cognition, and a documented need for assist of 1 with hand-held ambulation and toileting support. The resident’s care plan directed staff to provide safety support, assist of 1 for transfers, hand-held ambulation, and substantial/maximal assistance with toileting hygiene. The CNA handbook and toileting procedure required use of a transfer belt for standing transfers and for the resident to be assisted with feet flat on the floor while toileting, but the aide who assisted the resident did not use a gait belt and left the resident alone on a toilet commode while retrieving items from the resident’s room. During the toileting episode, the resident stood up from the toilet while the aide was away and fell in the bathroom/shower area, resulting in right wrist pain. The aide stated the resident was left alone on the commode and that the resident’s feet were not able to touch the floor when seated. The bathroom call light had been activated earlier, and the incident report identified that the resident was an assist of 1 for transfers with hand-held ambulation. Staff interviews confirmed the aide did not stay with the resident until the resident was in a safe position and did not use the gait belt. The facility also failed to provide adequate supervision during ambulation for another resident with vertigo, diabetes type II, and syncope who was cognitively intact and used a walker. The resident’s care plan identified fall risk related to vertigo/syncopal episodes and directed independent ambulation with a walker during the day and assist of 1 at night. During a nighttime bathroom trip, the aide walked with the resident back from the bathroom without using a gait belt, despite stating that the resident required one. The aide reported forgetting the gait belt at home and then using an arm hold only when the resident began to fall. The resident fell, struck the head and arm, and later required hospital evaluation, with a CT scan negative and two stitches applied to the forehead.
Failure to Protect a Resident from Physical Assault
Penalty
Summary
The facility failed to protect residents from abuse when one resident physically assaulted another resident in the dining area/lounge. The assaulted resident, who had bipolar disorder, cognitive communication deficit, cirrhosis of the liver, and moderate cognitive impairment, was preparing to play a guitar when the other resident approached and began screaming about the guitar before punching the resident multiple times in the face and head. The assaulted resident was found on the floor with bleeding from the mouth, a loose right-sided tooth, and a headache, and was later evaluated at the hospital for a closed head injury and internal mouth laceration. The resident who committed the assault had dementia, schizoaffective disorder, generalized anxiety disorder, and severe cognitive impairment. The resident was independent with bed mobility, transfers, and ambulation, and the care plan addressed self-care deficits and psychotropic medication use, but the report documents that the resident became physically aggressive toward the other resident and caused injury. Staff separated the residents after the incident, and the aggressive resident was placed on one-to-one observation and transferred for psychiatric evaluation. Staff interviews confirmed the sequence of events and that the assault occurred while one resident was in the lounge area and the other was nearby. The DON stated that, based on the facility abuse policy, the facility failed to keep the assaulted resident free from abuse when another resident struck him/her. The facility abuse policy stated that residents would not be subjected to abuse by anyone.
Widespread Medication Omissions and Inaccurate Controlled-Substance Documentation
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors, with widespread omitted medications, missing assessments, and inaccurate controlled-substance documentation affecting 19 of 29 sampled residents. The report states that on the 3:00 PM to 11:00 PM shift, LPN #1 repeatedly left the unit without notifying supervisory staff, was unavailable to administer scheduled and PRN medications, and was later found lethargic and unresponsive in an employee restroom with suspected drug paraphernalia present. Nursing leadership did not remove the LPN from duty at the time, did not assess residents for possible omissions, did not review the eMAR, and did not notify the provider until the following day. After suspension, the LPN still had remote access to the eMAR and later signed off medications she could not verify as administered. Record review identified numerous omitted medications and missing documentation across multiple residents, including anticoagulants, insulin, anticonvulsants, cardiac medications, psychotropics, pain medications, supplements, and treatments. Examples included omitted baclofen and Creon for a resident with chronic pancreatitis and diabetes; omitted midodrine, tamsulosin, and Ensure for a resident with orthostatic hypotension and weight loss; omitted metoprolol, Eliquis, gabapentin, metronidazole, mirtazapine, oxycodone, and bladder monitoring for a resident with CHF and urinary retention; omitted levetiracetam, Eliquis, and oxycodone for a resident with seizures and DVT; omitted metformin, methocarbamol, omeprazole, pregabalin, tramadol, Symbicort, and calcium carbonate for a resident with spastic hemiplegia and chronic pain; and omitted multiple medications and G-tube care for a resident with gastrostomy status, seizures, and AFIB. The eMAR audit logs showed the LPN later accessed the record and signed off omitted medications while suspended from employment. The report also identified missing required monitoring and documentation, including blank pain assessments, absent blood pressure and heart rate checks before midodrine and metoprolol, missing blood sugar and injection site documentation for insulin, blank treatment records, and incomplete G-tube documentation such as tube feeding, flushing, and placement verification. Controlled-substance handling was inaccurate in several instances, including oxycodone, tramadol, lorazepam, clonazepam, and pregabalin counts or proof-of-use forms that did not match the administration record. For Resident #3, the facility failed to administer multiple time-sensitive medications before a scheduled fistulogram and failed to identify the missed doses or notify the nursing supervisor or provider, which was cited as Immediate Jeopardy.
Failure to Notify Provider After Multiple Medication Omissions
Penalty
Summary
The facility failed to notify the provider immediately after omitted medications and ordered treatments were identified for multiple sampled residents. The report states that during the 3:00 PM to 11:00 PM shift, LPN #1 was off the unit multiple times because she felt unwell, and later was found lethargic in an employee restroom with suspected drug paraphernalia in her possession. EMS responded, LPN #1 was removed from the schedule pending investigation, and twenty-two residents were identified as having omitted medications and/or treatments during that shift. The Medical Director was notified and assessments were completed, with no adverse effects identified at that time. For Resident #3, who had end-stage renal disease, dialysis dependence, type II diabetes, and chronic pain syndrome, the record showed omitted morning medications before a scheduled fistulogram, including sevelamer carbonate and multiple scheduled medications such as allopurinol, amlodipine, bumetanide, losartan, Eliquis, metoprolol tartrate, rosuvastatin, and Voltaren gel. The nurse’s notes did not show that the provider was notified, and the nurse interviewed stated the medications were not transcribed to be given early and that she did not realize they were not administered until after the resident left for transport. Similar failures to notify the provider were documented for other residents with significant medical conditions, including diabetes, CHF, seizure disorders, anticoagulant use, chronic pain, dementia, psychiatric diagnoses, and tube feeding dependence. The omitted medications and orders included insulin, anticoagulants, antihypertensives, anticonvulsants, pain medications, psychiatric medications, supplements, bladder monitoring, and tube-feeding-related care. Several residents had cognitive impairment ranging from intact cognition to severe impairment, and multiple provider notes dated the next day stated the provider was asked to see the resident following medication omissions. The clinical record repeatedly failed to show that the provider was notified on the day the omissions occurred, and in one case the resident reported increased pain and difficulty sleeping after not receiving medications. The report also identified one resident whose blood sugar monitoring was not documented and who reported not receiving medications, including alprazolam and pregabalin, resulting in a panic attack and pain.
Missed Resident Care Conferences After MDS Assessments
Penalty
Summary
The facility failed to ensure Resident Care Conferences (RCCs) were completed at least quarterly and within 7 days of the comprehensive assessment for seven sampled residents. Review of the clinical record showed that RCCs were not scheduled or held after multiple MDS assessments for residents with a range of diagnoses and levels of impairment, including dementia with behavioral disturbances, schizophrenia, repeated falls, chronic kidney disease with dialysis, diabetes, Parkinson's disease, spastic hemiplegia, and psychiatric disorders. In several cases, the record also showed prior RCCs had been held earlier in the year, but no subsequent quarterly conference was documented after later MDS assessments. Resident #6 had severely impaired cognition with a BIMS score of 3 and was dependent for personal hygiene and transfers, yet no RCC was documented after the quarterly MDS or the annual MDS. Resident #11 had intact cognition with a BIMS score of 15 and was dependent for bed mobility and transfers, but no RCC was documented after the quarterly MDS or the annual MDS. Resident #13 had moderately impaired cognition with a BIMS score of 11, was independent with bed mobility, and was dependent on staff for transfers, but no RCC was documented after the annual MDS. Resident #23 had intact cognition with a BIMS score of 13 and required substantial assistance for transfers, but no RCC was documented after the quarterly MDS or after the later period when the next quarterly MDS had not yet been completed. Resident #26 had moderately impaired cognition with a BIMS score of 9 and was dependent on staff for bed mobility and transfers, but no RCC was documented after the quarterly MDS. Resident #29 had moderately impaired cognition with a BIMS score of 9 and required partial assistance for bed mobility and transfers, but no RCC was documented after the quarterly MDS or during the later period when the next quarterly MDS had not yet been completed. Resident #30 was newly admitted with diagnoses including diabetes, long-term insulin use, and lymphedema; no 72-hour RCC was documented after admission, and no RCC was documented after the admission MDS. Interviews confirmed social services typically scheduled RCCs, but the facility lacked a social worker since 5/15/26, the MDS Nurse was behind on assessments, and the DON and Regional Nurse stated they were unaware RCCs were not being held consistently for all residents.
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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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