Inspection Reports for
Complete Care at Groton Regency LLC
1145 Poquonnock Road, Groton, CT 06340, Groton, CT
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
6.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
20% worse than Connecticut average
Connecticut average: 5.6 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
94% occupied
Based on a October 2025 inspection.
Occupancy over time
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Nov 14, 2025
Visit Reason
The inspection was conducted based on complaints regarding resident rights violations and medication administration practices involving Resident #1 at Complete Care at Groton Regency.
Complaint Details
The complaint involved Resident #1 alleging unprofessional conduct by RN #1, who used inappropriate language during medication administration. The facility also failed to prevent the resident from being left unattended with medication, resulting in a fall. The nursing home is disputing the citation related to medication administration.
Findings
The facility failed to ensure Resident #1 was treated with respect during medication administration, including unprofessional language by RN #1. Additionally, the facility failed to ensure the resident was not left unattended with administered medications, resulting in a fall and potential harm.
Deficiencies (2)
Failure to honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights, including unprofessional language used by RN #1 during medication administration.
Failure to ensure the resident was not left unattended with administered medications, leading to a fall and potential harm.
Report Facts
Medication dosage: 15
Medication fluid volume: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Named in unprofessional conduct and inappropriate language during medication administration |
| LPN #1 | Licensed Practical Nurse | Named in medication administration and leaving medication unattended leading to resident fall |
| Director of Nursing Services | Director of Nursing | Provided interview regarding professionalism standards and facility practices |
Inspection Report
Complaint Investigation
Census: 122
Capacity: 130
Deficiencies: 0
Date: Oct 28, 2025
Visit Reason
The inspection visit was conducted as a complaint investigation related to Complaint Investigations #22643521.
Complaint Details
Complaint Investigation #22643521 was reviewed and found to have no substantiated violations.
Findings
No violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey Turner | Administrator | Personnel contacted during the inspection. |
| Kahlena Watkins | DON | Personnel contacted during the inspection. |
Inspection Report
Census: 125
Capacity: 130
Deficiencies: 0
Date: Jan 16, 2025
Visit Reason
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 |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Nov 7, 2024
Visit Reason
The inspection was conducted following a complaint investigation related to Resident #1's traumatic fall and failure to transport the resident to an orthopedic appointment as ordered by the physician, as well as failure to complete a timely fall risk assessment after the fall.
Complaint Details
The complaint investigation was triggered by a report that Resident #1 had a traumatic fall resulting in a fractured shoulder and that the facility failed to arrange transportation for the resident's orthopedic appointment on 7/11/24. The complaint was substantiated based on review of clinical records, interviews, and facility documentation.
Findings
The facility failed to transport Resident #1 to an orthopedic appointment per physician's order and did not complete a fall risk assessment until 23 days after the fall. Additionally, the facility failed to adequately supervise Resident #1, who required assistance with ambulation, resulting in multiple falls and injuries including fractures to the right humerus and right femur. The facility attempted interventions but supervision was insufficient to prevent repeated falls.
Deficiencies (3)
Failed to transport Resident #1 to an orthopedic appointment per physician's order.
Failed to complete a fall risk assessment after Resident #1's fall until 23 days later.
Failed to follow the plan of care to adequately supervise Resident #1, resulting in multiple falls and injuries.
Report Facts
Falls: 4
Days delay: 23
Appointment reschedule time: 15
Assist level: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #2 | Registered Nurse | Documented missed orthopedic appointment and assessed Resident #1 after falls. |
| DNS | Director of Nursing Services | Interviewed regarding transportation arrangements and supervision policies. |
| LPN #1 | Licensed Practical Nurse | Provided one-to-one supervision and reported on Resident #1's falls and supervision challenges. |
| RN #1 | Registered Nurse | Assessed Resident #1 after falls and reported on supervision limitations. |
| RN #3 | Registered Nurse | Documented x-ray results and hospital transfer for fracture evaluation. |
| APRN #1 | Advanced Practice Registered Nurse | Interviewed regarding fracture cause and resident risk factors. |
Inspection Report
Follow-Up
Census: 126
Capacity: 130
Deficiencies: 0
Date: Jul 15, 2024
Visit Reason
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.
Report Facts
Licensed Bed Capacity: 130
Census: 126
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey Turner | Administrator | Personnel contacted during inspection |
| Stephanie Schumann | Report submitted by | |
| Karen Gworek | Supervisor | Supervisor signature on report |
Inspection Report
Complaint Investigation
Census: 121
Capacity: 130
Deficiencies: 0
Date: Jun 20, 2024
Visit Reason
The inspection was conducted as a complaint investigation related to Complaint Investigations #39324.
Complaint Details
Complaint Investigation #39324 was conducted and violations were not identified at the time of inspection.
Findings
No violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection.
Report Facts
Licensed Bed/Bassinet Capacity: 130
Census: 121
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey Turner | Administrator | Personnel contacted during inspection |
| Kahlena Watkins | Director of Nursing | Personnel contacted during inspection |
| Deborah Smith | RN, NC | Report submitted by |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 29, 2024
Visit Reason
The inspection was conducted due to an allegation of resident-to-resident physical altercation involving Resident #1 and Resident #2, including concerns about bruising and possible abuse.
Complaint Details
The complaint investigation was substantiated with findings that Resident #1 sustained bruising during a physical altercation with a roommate. The Nurse Aide who witnessed the incident did not report it immediately due to fear. The Director of Nursing confirmed the failure to report and initiated a 72-hour look back to determine the cause of bruising.
Findings
The facility failed to maintain the safety of Resident #1 who sustained bruises during an altercation with a roommate. The Nurse Aide who witnessed the incident failed to report it to licensed staff. Investigations revealed the bruising was not caused by prior bloodwork as initially thought. The Nurse Aide was scared and did not report the incident timely, violating facility policy on abuse reporting.
Deficiencies (2)
Failure to protect Resident #1 from physical abuse during a resident-to-resident altercation resulting in bruising.
Failure of Nurse Aide to timely report suspected abuse to licensed staff.
Report Facts
Days blood thinner held: 3
Date of incident: May 2, 2024
Date of survey completion: May 29, 2024
Look back period: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Aide #1 | Nurse Aide | Witnessed the altercation, attempted to intervene, but failed to report the incident to licensed staff. |
| RN #1 | Registered Nurse | 3-11PM Nursing Supervisor who was approached about the bruise but was initially unaware. |
| Director of Nursing | Director of Nursing | Investigated the incident, initiated 72-hour look back, and confirmed failure to report by Nurse Aide. |
| Advanced Practice Registered Nurse | APRN | Assessed Resident #1's bruising and directed holding blood thinner medication. |
Inspection Report
Complaint Investigation
Census: 123
Capacity: 130
Deficiencies: 2
Date: May 29, 2024
Visit Reason
An unannounced visit was made on May 29, 2024, to conduct multiple complaint investigations (#33960 and #38728) related to alleged resident-to-resident physical altercations and other violations of Connecticut State regulations.
Complaint Details
Complaints #33960 and #38728 involved allegations of resident-to-resident physical altercation with bruising and failure of staff to report the incident. The complaint was substantiated with findings of bruising and inadequate reporting by staff.
Findings
The facility failed to maintain the safety of Resident #1 who sustained bruises during an altercation, and the Nurse Aide who witnessed the incident failed to report it to licensed staff. The Director of Nursing initiated a 72-hour look back to determine the cause of bruising and the facility implemented plans of correction including staff re-education and audits.
Deficiencies (2)
Failure to maintain safety of Resident #1 during resident-to-resident physical altercation resulting in bruises.
Nurse Aide failed to report the physical altercation to licensed staff.
Report Facts
Licensed Bed/Bassinet Capacity: 130
Census: 123
Plan of Correction Submission Deadline: Jun 27, 2024
Look back period: 72
Random audits frequency: 4
Plan of correction review period: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey Turner | Administrator | Contacted personnel and recipient of the notice letter |
| Kahlena Watkins | Director of Nursing (DON) | Interviewed regarding bruising and investigation; responsible for plan of correction |
| Karen Gworek | Supervising Nurse Consultant | Author of the notice letter regarding violations and plan of correction |
Inspection Report
Routine
Census: 122
Deficiencies: 5
Date: Mar 27, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, clinical assessments, staffing, food safety, and medical record maintenance at Complete Care at Groton Regency.
Findings
The facility was found to have multiple deficiencies including failure to consistently open the main dining room on weekends due to staffing issues, failure to complete a significant change MDS assessment for a resident admitted to hospice, failure to ensure adequate nursing staff to transport residents on weekends, failure to remove expired food from the refrigerator, and failure to maintain accurate advanced directive documentation in resident records.
Deficiencies (5)
Failed to ensure the main dining room was open and utilized for resident dining consistently on weekends.
Failed to complete a Significant Change in Status MDS assessment when a resident was admitted to hospice.
Failed to ensure enough nursing staff was available to transport residents to the dining room on weekends.
Failed to ensure expired food was dated and removed from the refrigerator.
Failed to ensure clinical record contained accurate documentation pertaining to advanced directives.
Report Facts
Resident census: 122
Licensed nurses on 7-3 shift: 6
Nursing assistants on 7-3 shift: 10
Nursing assistants on 7-3 shift: 9
Date of observation of residents dining: 30
Date of expired ham: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | MDS Coordinator | Identified responsibility for scheduling and completion of MDS assessments and noted failure to complete significant change MDS assessment. |
| LPN #1 | Charge Nurse | Identified dining room closure on weekends due to staffing shortage. |
| Food Service Director (FSD) | Identified dining room closure on weekends and use of tray service; collaborated on decision to close dining room weekends. | |
| NA #1 | Nursing Assistant | Reported no transport of residents to dining room on 3/24/24 due to closure. |
| RN #2 | Unit Manager | Noted assistance provided to transport residents during weekdays but not weekends. |
| Scheduler | Responsible for scheduling staff and noted staffing levels based on census. | |
| Administrator | Acknowledged staffing limitations on weekends affecting resident transport to dining room. | |
| FSD #2 | Food Service Director | Identified expired food in refrigerator during dietary tour. |
| RN #3 | Unit Manager | Identified misfiling of advanced directive forms in resident records. |
| Unit Coordinator | Responsible for filing and scanning records; noted lack of name verification when filing. | |
| DNS | Director of Nursing Services; provided clarifications on staffing, QAPI, and record filing responsibilities. |
Inspection Report
Renewal
Census: 123
Capacity: 130
Deficiencies: 0
Date: Mar 20, 2024
Visit Reason
The inspection was conducted as a licensing inspection for the purpose of renewal of the facility's license.
Findings
No violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 20, 2023
Visit Reason
The inspection was conducted following a complaint alleging that a male nurse aide put his hands down a resident's pants, prompting investigation of potential abuse.
Complaint Details
The complaint was substantiated as the nurse aide did not follow the resident's care plan, but no criminal act was found. The resident was agitated and verbally aggressive during the investigation and hospital transfer.
Findings
The facility failed to ensure staff followed the resident's plan of care regarding continence and toileting. The investigation found that a new male nurse aide checked a sleeping resident for incontinence without waking him, which led to the resident's agitation and allegations of assault. The nurse aide did not touch the resident below the waistline or genital area, and no crime was determined. The facility re-educated the nurse aide and implemented a plan to avoid male caregivers for this resident.
Deficiencies (1)
Failed to ensure staff followed the resident plan of care for a resident that was continent.
Report Facts
Date of survey completion: Mar 20, 2023
Date of incident: Mar 3, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA #1 | Nurse Aide | New staff member involved in the incident and investigation |
| DON | Director of Nursing | Interviewed regarding the incident and staff re-education |
| PO #1 | Police Officer | Responded to the incident and interviewed involved parties |
Inspection Report
Complaint Investigation
Census: 124
Capacity: 130
Deficiencies: 1
Date: Mar 20, 2023
Visit Reason
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.
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.
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.
Deficiencies (1)
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: 130
Census: 124
Date 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 |
Inspection Report
Follow-Up
Census: 116
Capacity: 130
Deficiencies: 0
Date: Feb 17, 2022
Visit Reason
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: 130
Census: 116
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nicholas Tomczyk | Nurse Consultant | Conducted the inspection and authored the narrative report |
| Anne Audette | Interim DNS | Personnel contacted during inspection |
| Ted Vinci | Administrator | Personnel contacted during inspection |
Inspection Report
Complaint Investigation
Census: 122
Capacity: 130
Deficiencies: 4
Date: Jan 31, 2022
Visit Reason
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.
Complaint Details
Complaint #31562 triggered the investigation. The complaint was substantiated as violations were identified during the inspection.
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.
Deficiencies (4)
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: 130
Census: 122
Dates of onsite inspection: January 31, 2022 and February 1, 2022.
Number of paper bags with PPE: 18
Number of N95 masks in bags: 3
Number of face shields in bags: 5
Number of face shields on separate table: Additional paper storage bag contained multiple face shields.
Number of unvaccinated exempt staff: 3
Number of unvaccinated exempt contracted staff: 2
Number 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. | |
| Physical Therapy Assistant #1 | PTA | Observed not wearing appropriate PPE mask. |
Inspection Report
Deficiencies: 4
Date: Nov 19, 2021
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to the safety, cleanliness, care planning, activities of daily living, and nutritional care of residents at Complete Care at Groton Regency.
Findings
The facility was found deficient in maintaining a safe, clean, and comfortable environment, ensuring comprehensive care plan development and revision with resident representative involvement, providing adequate assistance with activities of daily living including grooming, and ensuring proper nutritional monitoring including obtaining reweights after significant weight loss as per physician orders.
Deficiencies (4)
Facility failed to ensure the environment was clean, comfortable and free from disrepair, including peeled wallpaper, dusty bathroom vents, cracked tiles, rusted radiators, and detached wall trim.
Facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team and resident representative was given opportunity to participate.
Facility failed to provide necessary assistance to maintain good grooming and personal hygiene, including failure to trim resident's fingernails as required.
Facility failed to ensure reweights were obtained after significant weight loss and failed to follow physician's orders related to weights.
Report Facts
Deficiencies cited: 4
Weight loss percentage: 6.71
Weight loss percentage: 8.59
Weight loss in pounds: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #2 | Registered Nurse | Responsible for setting up care plan meetings in the EMR |
| SW #1 | Social Worker | Responsible for setting up care plan meetings and calling residents' representatives |
| DNS | Director of Nursing Services | Provided information on maintenance rounds, care plan meeting responsibilities, and weight monitoring |
| LPN #3 | Licensed Practical Nurse | Provided information on responsibility for trimming residents' fingernails |
| Former Dietitian | Dietitian | Provided information on weight monitoring and reweight procedures |
| Director of Maintenance | Provided information on maintenance rounds and environmental observations |
Inspection Report
Complaint Investigation
Census: 119
Capacity: 102
Deficiencies: 0
Date: Nov 19, 2021
Visit Reason
The inspection was conducted as a licensing inspection and included review of multiple complaint investigations (CT # 38959, FRI # 30744, 25382, 28170, 27991).
Complaint Details
The inspection was related to multiple complaint investigations referenced by their case numbers; however, no violations were identified during this inspection.
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.
Report Facts
Licensed Bed/Bassinet Capacity: 102
Census: 119
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ted Vinci | Administrator | Personnel contacted during inspection |
| Joanne Antico | Director of Nursing Services | Personnel contacted during inspection |
| Nicole Hollis | ADNS | Personnel contacted during inspection |
Inspection Report
Complaint Investigation
Deficiencies: 10
Date: Nov 19, 2021
Visit Reason
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.
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.
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.
Deficiencies (10)
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.
Report Facts
Missing medication pills: 17
Resident sample size: 3
Resident sample size: 1
Resident sample size: 1
Resident sample size: 2
Resident sample size: 1
Resident sample size: 4
Weight loss percentage: 6.71
Weight loss percentage: 8.59
Missing pills: 17
Plan of correction completion date: 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sandra Vermont-Hollis | Supervising Nurse Consultant | Author of the notice letter and overseeing complaint investigation. |
| Patrick Townsend | Administrator | Facility administrator named in the report. |
| LPN #1 | Identified missing medication and reported observations related to Resident #369. | |
| RN #1 | Nursing supervisor involved in medication incident for Resident #369. | |
| MD #1 | Physician involved in medication and resident incident for Resident #369. | |
| Director of Nursing | Responsible for plans of correction and nursing supervision. | |
| Director of Maintenance | Interviewed regarding environmental disrepair and maintenance rounds. | |
| NA #1 | Witnessed resident mistreatment incident involving Resident #89. | |
| DA #1 | 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 Licensing
Deficiencies: 0
Date: Aug 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.
Report Facts
Duration of Order: 1
Independent Nurse Consultant hours: 8
Infection Control Nurse hours: 32
Nurse aide staffing ratios: 10
Nurse aide staffing ratios: 12
Nurse aide staffing ratios: 20
Licensed nurse staffing ratios: 30
Medical record audits: 5
Quality Assurance Committee meetings: 30
Water management program documentation retention: 3
Quality Assurance meeting documentation retention: 3
Nurse Supervisor record retention: 5
Daily rounds documentation retention: 5
Fine amount: 1000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jacob R. Klugman | Authorized Agent | Signed the Pre-Licensure Consent Order on behalf of Complete Care at Groton Regency LLC |
| Donna Ortelle | Section Chief, Healthcare Quality and Safety Branch | Signed the Pre-Licensure Consent Order on behalf of the Connecticut Department of Public Health |
Inspection Report
Deficiencies: 6
Date: May 31, 2019
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, safety, abuse reporting, re-admission policies, social services, and therapeutic diet adherence at Complete Care at Groton Regency.
Findings
The facility was found deficient in multiple areas including failure to ensure dignified care for a resident, failure to maintain a safe and homelike environment, failure to timely report suspected abuse to the state agency, failure to re-admit a resident after hospitalization in accordance with policy, failure to ensure social service follow-up after an abuse allegation, and failure to provide thickened liquids as prescribed by physician orders.
Deficiencies (6)
Failed to ensure resident received care in a dignified manner related to verbal abuse allegations involving Nurse Aide #1.
Failed to maintain table cloth linens and ceiling tiles in a safe, clean, homelike environment; observed torn table cloths and stained ceiling tiles.
Failed to timely notify the state agency of an allegation of verbal abuse within required 2 hours.
Failed to re-admit a resident after hospitalization and therapeutic leave exceeding bed-hold policy.
Failed to ensure social service follow-up after an allegation of abuse.
Failed to provide thickened liquids as prescribed by physician orders for a resident with swallowing difficulties.
Report Facts
Residents Affected: 3
Date of survey completion: May 31, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA #1 | Nurse Aide | Named in verbal abuse allegation and investigation |
| NA #2 | Nurse Aide | Observed serving incorrect liquids to Resident #114 |
| NA #3 | Nurse Aide | Alleged by Resident #275 to have caused bruising; suspended pending investigation |
| Administrator | Conducted abuse investigation and provided statements on denial of re-admission | |
| Housekeeping Supervisor | Interviewed regarding table cloth maintenance | |
| Director of Maintenance | Interviewed regarding stained ceiling tiles | |
| Infection Control RN | Registered Nurse | Conducted environmental rounds and commented on ceiling tile conditions |
| Social Worker #2 | Social Worker | Unable to provide documentation of follow-up after abuse allegation |
| Regional Nurse (RN #1) | Registered Nurse | Discussed re-admission process and denial of Resident #269 |
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