Inspection Reports for Complete Care at Groton Regency LLC

The inspection visit was conducted as a complaint investigation related to Complaint Investigations #22643521.

No violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection.

Complaint Investigation #22643521 was reviewed and found to have no substantiated violations.

The inspection was a desk audit conducted on January 16, 2025, to review compliance and licensing status of the facility.

No violations of the General Statutes of Connecticut or regulations were identified at the time of this inspection. All previously identified violations were corrected as of January 16, 2025.

A desk audit was conducted to review the implementation of the Plan of Correction for a prior violation letter dated 6/17/24.

Violations #1 and #2 were identified as corrected as of 7/8/24, and the Director of Nursing Services was notified by telephone on 7/15/24 that all violations were corrected.

The inspection visit was conducted as a complaint investigation related to Complaint Investigations #39324.

No violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection.

Complaint Investigation #39324 was conducted and violations were not identified at the time of inspection.

An unannounced visit was made to Complete Care at Groton Regency LLC on May 29, 2024, to conduct multiple complaint investigations (#33960 and #38728) regarding alleged resident-to-resident physical altercations and related issues.

The investigation found that the facility failed to maintain the safety of Resident #1 who sustained bruises during an altercation with another resident. The Nurse Aide who witnessed the altercation failed to report it to licensed staff. The facility was cited for violations related to abuse, neglect, and failure to report incidents. Plans of correction include staff re-education and monitoring.

Complaints #33960 and #38728 involved allegations of resident-to-resident physical altercation resulting in bruising to Resident #1. The Nurse Aide who witnessed the incident did not report it to licensed staff. The Director of Nursing conducted a 72-hour look back to determine the cause of bruising. The facility policy for abuse, neglect, and exploitation was reviewed and staff were re-educated.

The inspection was conducted as a licensing inspection for the purpose of renewal of the facility's license.

No violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection.

An unannounced visit was made to the facility on 03/20/23 for the purpose of conducting a complaint investigation survey related to Complaint Investigation #34142.

Deficiencies were identified during the visit, including failure to ensure staff followed the resident plan of care for a resident who was continent. The investigation involved review of clinical records, interviews, and incident reports related to an alleged staff abuse incident.

Complaint Investigation #34142 was substantiated with identified deficiencies related to abuse allegations involving a male nurse aide and Resident #1. Police and APRN were notified, and the facility took corrective actions including removal of the staff member from schedule and transfer of the resident to the hospital for evaluation.

Unannounced follow-up revisit survey was conducted to verify correction of deficiencies cited in the Plan of Correction Letter dated 01/31/22.

Staffing was reviewed for the period 02/03/22 through 02/24/22 and met the minimum regulatory requirements. The plan of correction, in-services, and audits for multiple cited items were corrected. No deficiencies or violations were identified at this revisit.

Unannounced visits were made on January 31, 2022 and February 1, 2022 for the purpose of conducting a Covid-19 Vaccination Verification and complaint investigation survey related to Complaint #31562.

Violations of Connecticut State regulations were identified including failures in medication administration, medication storage and self-administration, improper storage and reuse of PPE, and failure to ensure appropriate protective equipment was worn by unvaccinated staff. Plans of correction were submitted to address these issues.

Complaint #31562 triggered the investigation. The complaint was substantiated as violations were identified during the inspection.

The inspection was conducted as a licensing inspection and included review of multiple complaint investigations (CT # 38959, FRI # 30744, 25382, 28170, 27991).

The report indicates that violations of the General Statutes of Connecticut and/or regulations were not identified at the time of this inspection. Additional narrative report and certification file were attached.

The inspection was related to multiple complaint investigations referenced by their case numbers; however, no violations were identified during this inspection.

Unannounced visits were made to Groton Regency Center concluding on November 19, 2021, by the Department of Public Health for the purpose of conducting a complaint investigation as well as a certification survey.

The investigation identified multiple violations including failure to timely notify responsible parties of missing medication, environmental disrepair, failure to prevent resident mistreatment, misappropriation of resident property, failure to ensure comprehensive care plan reviews, failure to provide necessary services for ADLs, failure to complete yearly performance reviews for nursing staff, and failure to ensure safe resident transfers.

Complaint investigation was conducted based on multiple complaints (#27991, 28170, 28382, 28959, 30744). The resident to resident incident involving Resident #89 was substantiated as abuse. Other findings included medication errors, environmental issues, mistreatment, misappropriation, and care plan deficiencies.

This document is a Pre-Licensure Consent Order for Complete Care at Groton Regency LLC seeking an initial license to operate a Chronic and Convalescent Nursing Home in Connecticut.

The order outlines conditions and requirements for licensure including contracting with an Independent Nurse Consultant, infection control measures, staffing ratios, quality assurance programs, emergency preparedness, and compliance with state and federal regulations. It establishes oversight mechanisms and reporting requirements to ensure patient safety and regulatory compliance.