The most recent inspection on October 28, 2025, found no deficiencies during a complaint investigation. Earlier inspections showed a mixed history, with some deficiencies related mainly to resident safety and staff reporting, including substantiated complaints about resident-to-resident altercations and failure to follow care plans. Prior reports also noted issues with medication administration, environmental conditions, and staff performance reviews, but enforcement actions such as fines or license suspensions were not listed in the available reports. Most complaint investigations were unsubstantiated except for a few substantiated cases involving resident mistreatment and safety concerns. The facility appears to have addressed many prior deficiencies, as more recent inspections have found no violations, indicating some improvement over time.
Deficiencies (last 5 years)
Deficiencies (over 5 years)3.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
The inspection was a desk audit conducted on January 16, 2025, to review compliance and licensing status of the facility.
Findings
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.
Employees Mentioned
Name
Title
Context
Kahlena Walkins
Director of Nursing
Personnel contacted during the inspection and notified of correction of violations
A desk audit was conducted to review the implementation of the Plan of Correction for a prior violation letter dated 6/17/24.
Findings
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.
An unannounced visit was made to Complete Care at Groton Regency LLC on May 29, 2024, by a representative of the Facility Licensing and Investigations Section to conduct multiple complaint investigations (#33960 and #38728).
Findings
Violations of Connecticut State regulations were identified related to resident-to-resident physical altercations resulting in bruising and inadequate reporting by staff. The facility failed to maintain the safety of Resident #1 during an altercation and failed to report the incident appropriately. The Director of Nursing and nursing staff were involved in the findings and corrective actions.
Complaint Details
Complaints #33960 and #38728 were investigated. The complaints involved allegations of resident-to-resident physical altercation resulting in bruising and failure of staff to report the incident. The investigation included interviews, clinical record reviews, and policy reviews. The complaints were substantiated as violations were identified.
Deficiencies (2)
Description
Failure to maintain the safety of Resident #1 who sustained bruises during a resident-to-resident physical altercation.
Failure of a Nurse Aide to report the physical altercation to licensed staff.
Report Facts
Licensed Bed/Bassinet Capacity: 130Census: 123Plan of Correction Submission Deadline: Jun 27, 2024Random Audit Frequency: 4Random Audit Duration: 3Look Back Period: 72
Employees Mentioned
Name
Title
Context
Jeffrey Turner
Administrator
Named as facility administrator contacted during inspection
Kahlena Watkins
Director of Nursing
Identified as Director of Nursing involved in investigation and responsible for plan of correction
Deborah Smith
RN, NC
Signature on licensing inspection report
Karen Gworek
Supervising Nurse Consultant
Author of the notice letter regarding violations and plan of correction
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.
Findings
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 Details
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.
Deficiencies (1)
Description
Failure to ensure staff followed the resident plan of care for a resident who was continent, including inadequate toileting care and staff response to an alleged abuse incident.
Report Facts
Licensed Bed: 130Census: 124Date of onsite inspection: Mar 20, 2023
Employees Mentioned
Name
Title
Context
Nicole Hollis
ADNS
Personnel contacted during inspection
Jeff Turner
Administrator
Personnel contacted during inspection
Kahlena Watkins
DNS
Personnel contacted during inspection
Nicholas Tomczyk
Nurse Consultant
Author of the licensing inspection narrative report
Unannounced follow-up revisit survey was conducted to verify correction of deficiencies cited in the Plan of Correction Letter dated 01/31/22.
Findings
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.
Report Facts
Licensed Bed Capacity: 130Census: 116
Employees Mentioned
Name
Title
Context
Nicholas Tomczyk
Nurse Consultant
Conducted the inspection and authored the narrative report
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.
Findings
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 Details
Complaint #31562 triggered the investigation. The complaint was substantiated as violations were identified during the inspection.
Deficiencies (4)
Description
Failure to administer an intravenous antibiotic according to physician's order for Resident #1.
Failure to properly secure Resident #2's medications, including improper storage and lack of assessment for self-administration.
Failure to appropriately store and reuse Personal Protective Equipment (PPE), including masks and face shields.
Failure to ensure appropriate protective equipment was worn by unvaccinated staff members.
Report Facts
Licensed Bed/Bassinet Capacity: 130Census: 122Dates of onsite inspection: January 31, 2022 and February 1, 2022.Number of paper bags with PPE: 18Number of N95 masks in bags: 3Number of face shields in bags: 5Number of face shields on separate table: Additional paper storage bag contained multiple face shields.Number of unvaccinated exempt staff: 3Number of unvaccinated exempt contracted staff: 2Number of doses missed by Resident #1: 4
Employees Mentioned
Name
Title
Context
Theodore Vinci
Administrator
Personnel contacted during inspection.
Michele Rose
Director of Nursing Services (DNS)
Interviewed regarding medication administration and PPE storage.
Karen Gworek
Supervising Nurse Consultant
Author of the notice letter regarding violations and plan of correction.
Registered Nurse #1
Registered Nurse
Involved in medication administration for Resident #1.
Advance Practice Registered Nurse #1
APRN
Reviewed clinical record and identified medication administration issues.
Licensed Practical Nurse #1
LPN
Interviewed regarding medication storage and administration for Resident #2.
Staff Development Coordinator
Interviewed regarding medication storage and PPE issues.
The inspection was conducted as a licensing inspection and included review of multiple complaint investigations (CT # 38959, FRI # 30744, 25382, 28170, 27991).
Findings
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.
Complaint Details
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.
Findings
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 Details
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.
Deficiencies (10)
Description
Failure to ensure timely notification to physician and responsible party regarding missing medication for Resident #369.
Facility environment was not clean, comfortable, and free from disrepair including peeling wallpaper, dirty vents, rusted radiators, and cracked tiles.
Failure to provide necessary supervision to prevent mistreatment of Resident #89.
Failure to prevent misappropriation of resident property involving Resident #301 loaning money to a staff member.
Failure to ensure comprehensive care plan review and revision for Resident #55.
Failure to carry out necessary services to maintain good grooming and personal hygiene for Resident #15.
Failure to ensure assessment by registered nurse when change in condition occurred for Resident #369.
Failure to ensure safe transfers resulting in injury to Resident #55 and Resident #302.
Failure to ensure timely weight reweighs and follow-up for Resident #314.
Failure to complete yearly performance reviews for nursing staff.
Staff member involved in misappropriation of resident property.
Social Worker #1
Interviewed regarding Resident #301 cognitive status and incident.
RN #2
Responsible for care plan meetings and scheduling.
SW #1
Social worker involved in Resident #301 incident.
LPN #3
Identified for trimming resident fingernails.
RN #4
Involved in transfer incident and injury to Resident #55.
NA #2
Assisted with Resident #55 transfer and injury.
NA #3
Assisted with Resident #55 transfer and injury.
NA #4
Involved in mechanical lift incident with Resident #302.
COTA #1
Interviewed regarding Resident #55 transfer incident.
HR Manager
Responsible for employee evaluations and education.
Inspection Report Original LicensingDeficiencies: 0Aug 31, 2021
Visit Reason
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.
Findings
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.