Inspection Report Summary
The most recent inspection on November 10, 2025, identified deficiencies and resulted in a citation related to a complaint investigation. Earlier inspections showed a mixed record, with some renewal inspections finding no violations, such as the one on March 21, 2025, while others, including the December 20, 2024 renewal, noted violations. The main themes of deficiencies involved regulatory compliance issues linked to complaint investigations, though follow-up audits in mid-2024 confirmed correction of prior cited deficiencies. Complaint investigations were mostly unsubstantiated except for the recent case leading to the citation. The inspection history suggests some recurring compliance challenges, but also shows efforts to address and correct identified issues over time.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
7.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
29% worse than Connecticut average
Connecticut average: 5.6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
90% occupied
Based on a November 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy over time
Inspection Report
Deficiencies: 1
Date: Dec 1, 2025
Visit Reason
The inspection was conducted to evaluate compliance with resident rights related to room changes during facility renovations at Waterbury Center for Nursing & Rehabilitation LLC.
Findings
The facility failed to provide residents with a 30-day written notice prior to room changes due to renovations. Notices were given on the same day the moves occurred, contrary to policy and regulatory requirements.
Deficiencies (1)
Failure to provide residents with a 30-day notice of room change due to facility renovations.
Report Facts
Residents reviewed: 14
Residents affected: 15
Date of room change notice: Oct 29, 2025
Date of renovation letter: Oct 30, 2025
Date of amended letter: Nov 7, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed on 11/10/2025 regarding notification and moving process | |
| Director of Nursing (DON) | Interviewed on 11/10/2025 regarding room change notices and corporate directives |
Inspection Report
Monitoring
Census: 108
Capacity: 120
Deficiencies: 0
Date: Nov 10, 2025
Visit Reason
The inspection visit was conducted as a strike monitoring visit related to a complaint investigation #2663729.
Complaint Details
Complaint investigation #2663729 was referenced in relation to this visit.
Findings
Violations of the General Statutes of Connecticut and/or regulations were identified at the time of this inspection, and a citation was issued to the facility. Additional narrative and violation letters are attached but not included in this report.
Report Facts
Licensed Bed Capacity: 120
Census: 108
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maria Serrano | Administrator | Personnel contacted during the inspection |
| Marlene Schaffner | Director of Nursing | Personnel contacted during the inspection |
Inspection Report
Renewal
Census: 110
Capacity: 120
Deficiencies: 0
Date: Mar 21, 2025
Visit Reason
The inspection was conducted as a licensing renewal inspection for the facility.
Findings
No violations of the General Statutes of Connecticut and/or regulations were identified at the time of this inspection. A desk audit was completed on 3/25/2025.
Report Facts
Licensed Bed Capacity: 120
Census: 110
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maria Serrano | Administrator notified of violation correction | |
| Jennifer Green | RN | Report submitted by |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 11, 2025
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to properly manage Methadone medication for Resident #1, specifically related to a dropped/spilled dose and the lack of notification to the Methadone Clinic.
Complaint Details
The complaint investigation found that the facility did not notify the Methadone Clinic of a spilled dose on 1/4/25 or the missing dose on 1/14/25. Staff interviews revealed lack of knowledge of policy and failure to report the incidents. The substitute medication was given to prevent withdrawal symptoms. The facility policy requires immediate notification to the Methadone Clinic for missed or spilled doses.
Findings
The facility failed to follow its policy by not notifying the Methadone Clinic after a dose was spilled and when a dose was missing for Resident #1. Instead, a substitute medication (Oxycodone) was administered without proper notification. Interviews with staff confirmed lack of awareness and failure to report to the clinic as required by policy.
Deficiencies (1)
Failure to implement facility policy regarding Methadone medication management when a dose was dropped/spilled and no Methadone was available for a scheduled dose.
Report Facts
Dose amount: 110
Dose amount: 5
Date of spilled dose: Jan 4, 2025
Date of missing dose: Jan 14, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Nursing Supervisor | Reported the missing Methadone dose to APRN but did not notify Methadone Clinic |
| LPN #1 | Charge Nurse | Notified APRN and supervisor of missing dose but did not notify Methadone Clinic |
| Director of Nursing | Director of Nursing | Acknowledged facility policy and explained normal procedure for missing Methadone doses |
| Assistant Director of Nursing | Assistant Director of Nursing | Did not advise staff to notify Methadone Clinic due to resident's upcoming clinic appointment |
| APRN | Advanced Practice Registered Nurse | Ordered Oxycodone as substitute medication and was not usually involved in Methadone program |
| Person #1 | Licensed Alcohol and Drug Counselor | Methadone Clinic staff who stated the facility should have notified the clinic of the incidents |
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Dec 20, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal and state regulations regarding resident assessments, intravenous therapy, food supply and safety, infection control, medical records, and other care standards at Waterbury Center for Nursing & Rehabilitation LLC.
Findings
The facility was found deficient in timely transmission of MDS assessments to CMS, proper physician orders and labeling for intravenous therapy, adequate food supply and menu substitutions, proper use of beard coverings in the kitchen, maintenance of advance directives and healthcare proxy documentation, implementation of enhanced barrier precautions for residents with MDROs, and appropriate storage of biohazard and clean supplies. Several residents were affected with deficiencies ranging from minimal to potential actual harm.
Deficiencies (7)
Failure to transmit MDS assessments to CMS within required timeframes for multiple residents.
Failure to ensure physician's order for flushing unused lumen on PICC line and failure to label IV medication and administration set appropriately.
Failure to ensure adequate food supply for posted menu resulting in frequent substitutions and shortages.
Failure to ensure proper beard coverings worn by kitchen staff.
Failure to maintain copies of advance directives, consents, and appointed healthcare proxy documentation in resident clinical records.
Failure to appropriately track and place residents with MDRO and feeding tubes on Enhanced Barrier Precautions (EBP) and failure to post required signage and green dot indicators.
Failure to store biohazard waste separately from clean supplies, risking cross contamination.
Report Facts
Days overdue for MDS assessment transmission: 3
Days overdue for MDS assessment transmission: 14
Days overdue for MDS assessment transmission: 13
Days overdue for MDS assessment transmission: 21
Days overdue for MDS assessment transmission: 21
Days overdue for MDS assessment transmission: 5
Number of substitutions in menu: 17
Number of out-of-stock items: 11
Number of out-of-stock items with substitutions: 6
Number of sharp containers overflowing: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | MDS Coordinator | Identified as the only MDS Coordinator and responsible for assessment transmissions. |
| Director of Nursing | DNS | Interviewed regarding MDS transmission, advance directives, and infection control. |
| ADNS | Assistant Director of Nursing | Interviewed regarding IV therapy and Enhanced Barrier Precautions. |
| Dietary Manager | DM | Interviewed regarding food supply and substitutions. |
| Dietary Aide #1 | Dietary Aide | Observed plating food without beard covering. |
| LPN #7 | Infection Preventionist | Interviewed regarding infection control and Enhanced Barrier Precautions. |
| LPN #8 | Charge Nurse | Interviewed regarding IV therapy and Enhanced Barrier Precautions. |
| LPN #9 | Charge Nurse | Interviewed regarding flushing unused PICC lumen. |
| Nursing Supervisor | RN #2 | Interviewed regarding IV therapy and advance directives. |
| Social Worker | SW #2 | Interviewed regarding advance directives documentation. |
| Central Supply Staff | Interviewed regarding biohazard and clean supply storage. | |
| Administrator | Interviewed regarding food supply and biohazard storage. | |
| NA #1 | Nursing Assistant | Observed providing care without proper PPE for resident on EBP. |
| NA #2 | Nursing Assistant | Interviewed regarding knowledge of EBP precautions. |
Inspection Report
Renewal
Census: 109
Capacity: 120
Deficiencies: 0
Date: Dec 20, 2024
Visit Reason
The inspection was conducted as a licensing renewal inspection and included review of complaint investigations numbered 34413, 39996, 40652, and 41620.
Complaint Details
Complaint investigations #34413, #39996, #40652, and #41620 were reviewed during this inspection.
Findings
The report indicates that violations of the General Statutes of Connecticut and/or regulations were identified during the inspection, with attached violation letters referenced but not included in the provided pages.
Report Facts
Licensed Bed Capacity: 120
Census: 109
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maria Serrano | Administrator | Personnel contacted during the inspection. |
| Marlene Schaffner | DWS | Personnel contacted during the inspection. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Dec 20, 2024
Visit Reason
The inspection was conducted due to complaints regarding failure to notify the correct responsible party after a resident's fall with injury and failure to protect a resident from abuse by another resident.
Complaint Details
The complaint investigation found that the nursing staff notified Person #2 instead of Person #1 (the conservator) after Resident #87's fall. For the abuse complaint, Resident #94 physically abused Resident #82 by grabbing and twisting the arm causing a hematoma. The facility added interventions and monitored both residents following the incidents.
Findings
The facility failed to notify the correct responsible party when Resident #87 sustained a fall with injury, notifying the wrong contact first. Additionally, the facility failed to ensure Resident #82 was free from abuse when Resident #94 grabbed and twisted Resident #82's arm causing a hematoma. Interventions and monitoring were added following the incidents.
Deficiencies (2)
Failed to notify the correct responsible party when Resident #87 sustained a fall with injury.
Failed to protect Resident #82 from abuse by Resident #94, resulting in physical injury.
Report Facts
Days Resident #94 exhibited pacing and restlessness: 14
Date of survey completion: Dec 20, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| SW #1 | Social Worker | Interviewed regarding notification responsibilities and emergency contact list |
| LPN #2 | Licensed Practical Nurse | Provided updates to resident's primary responsible party and involved in notification process |
| SW #2 | Social Worker | Responsible for updating contact list and interviewed about conservator status |
| DNS | Director of Nursing Services | Reviewed notification errors and corrected emergency contact listing |
| RN #1 | Registered Nurse | Interviewed about Resident #94's normal behaviors |
Inspection Report
Follow-Up
Census: 112
Capacity: 120
Deficiencies: 0
Date: Aug 21, 2024
Visit Reason
A desk audit was conducted to review the plan of correction related to previous deficiencies cited on 6/17/24 associated with complaints CT00034667 and CT00039263, to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities.
Findings
The deficiencies previously cited have been corrected and no new non-compliance was found during the desk audit.
Report Facts
Licensed Bed Capacity: 120
Census: 112
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marlene Schaffner | Director of Nursing | Personnel contacted during the inspection |
Inspection Report
Follow-Up
Census: 118
Capacity: 120
Deficiencies: 0
Date: Jun 21, 2024
Visit Reason
A desk audit was conducted to review the implementation of the Plan of Correction for a prior violation letter dated 2024-05-30.
Findings
Violations #1 and #2 were identified as corrected as of 2024-06-05. The Administrator was notified via telephone that all violations were corrected.
Report Facts
Licensed Bed/Bassinet Capacity: 120
Census: 118
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maria Serrano | Administrator | Notified of correction of violations during desk audit |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jun 17, 2024
Visit Reason
The inspection was conducted following an allegation of staff to resident verbal abuse involving Resident #1 and a nurse aide during a transfer on 5/18/24.
Complaint Details
The complaint involved an allegation of staff to resident verbal abuse. The verbal abuse was substantiated after investigation. The nurse aide who allegedly committed the abuse resigned and did not provide a written statement. The witness nurse aide failed to report the incident immediately as required by policy.
Findings
The facility substantiated verbal abuse by a nurse aide towards Resident #1 during a verbal altercation. The nurse aide used inappropriate curse words, and the facility failed to ensure timely reporting of the incident by a witness nurse aide. The facility policies on abuse and reporting were reviewed and found to be in place.
Deficiencies (2)
Failed to ensure Resident #1 was free from verbal abuse during an altercation with a nurse aide.
Failed to ensure a nurse aide who witnessed the verbal altercation reported the incident to licensed nurses at the time of occurrence.
Report Facts
Residents sampled: 3
Staff involved: 2
Date of incident: May 18, 2024
Date of report: May 21, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Assistant Director of Nursing | Received report from Resident #1 and initiated investigation |
| Director of Nursing | Director of Nursing | Conducted investigation and substantiated verbal abuse |
| Nurse Aide #1 | Nurse Aide | Witnessed verbal altercation and failed to report incident immediately |
| Nurse Aide #2 | Nurse Aide | Alleged to have verbally abused Resident #1 and resigned during investigation |
Inspection Report
Complaint Investigation
Census: 116
Capacity: 120
Deficiencies: 0
Date: Jun 7, 2024
Visit Reason
The inspection visit was conducted as a complaint investigation related to Complaint Investigation #39417.
Complaint Details
Complaint Investigation #39417 was conducted and found no violations; the complaint was not substantiated.
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 |
|---|---|---|
| Maria Serrano | Administrator | Personnel contacted during the inspection. |
| Marlene Schaffner | Director of Nursing | Personnel contacted during the inspection. |
| Deborah Smith | RN, NC | Report submitted by. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 16, 2024
Visit Reason
The inspection was conducted based on a complaint investigation regarding the facility's failure to ensure a physician's order was in place prior to administering a heat therapy treatment to a resident, which resulted in a burn injury.
Complaint Details
The complaint investigation found that Resident #1 received a moist heat treatment without a physician's order, leading to a 2nd degree burn. The complaint was substantiated based on clinical records, interviews, and facility documentation.
Findings
The facility failed to ensure a physician's order was obtained before administering moist heat treatment to Resident #1, resulting in a 2nd degree burn to the resident's right thigh. The investigation revealed that the heat treatment was applied by an LPN without a physician's order, contrary to facility policy and standards of practice.
Deficiencies (2)
Failure to ensure a physician's order was in place prior to administering a heat therapy treatment, resulting in a burn injury to Resident #1.
Failure to ensure a moist heat treatment was applied per facility protocol.
Report Facts
Residents affected: 1
Burn measurements: 1
Burn depth: 0.1
Heat application duration: 10
Microwave heating time: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Administered moist heat treatment without a physician's order, leading to Resident #1's burn injury |
| Director of Nursing | Director of Nursing | Provided information on facility policy and confirmed that heat treatments require a physician's order and are performed by therapists |
| APRN #1 | Advanced Practice Registered Nurse | Identified the burn on Resident #1's right thigh and noted the heat pack application as the possible cause |
| MD #1 | Medical Doctor | Documented wound progress note evaluating the 2nd degree burn on Resident #1's right thigh |
Inspection Report
Complaint Investigation
Deficiencies: 12
Date: Jun 23, 2022
Visit Reason
The inspection was conducted following a complaint regarding an alleged sexual mistreatment incident between two residents at the facility.
Complaint Details
The complaint investigation was triggered by an alleged sexual mistreatment incident between Resident #47 and Resident #300 on 5/16/22, involving inappropriate sexual contact. The facility's investigation determined the encounter was consensual but failed to report the incident timely to authorities.
Findings
The facility failed to ensure a resident was free from sexual mistreatment by another resident, failed to timely report the alleged sexual abuse to the state agency and local authorities, and failed to ensure timely completion of quarterly assessments and appropriate referrals for PASARR evaluations. Additional deficiencies included medication administration errors, improper pressure ulcer care, unsafe smoking area conditions, failure to schedule timely urology consults, improper medication cart storage, incomplete COVID-19 vaccination education documentation, inadequate infection control contact tracing, and failure to maintain a clean smoking area.
Deficiencies (12)
Failed to ensure a resident was free from sexual mistreatment by another resident.
Failed to timely report alleged sexual abuse to the state agency and local authorities.
Failed to ensure timely completion of quarterly Minimum Data Set (MDS) assessments for multiple residents.
Failed to refer resident for Level II PASARR evaluation following new psychiatric diagnosis.
Failed to administer medications in accordance with physician's orders (Metformin dosage error).
Failed to ensure specialty mattress settings were appropriate and monitored for pressure ulcer care.
Failed to provide a smoking apron in good repair and maintain a clean smoking area.
Failed to schedule timely urology consult for resident with indwelling Foley catheter leakage.
Failed to ensure staff personal beverages were not stored in medication cart containing resident medications.
Failed to initiate contact tracing when staff tested positive for COVID-19 and did not notify state epidemiologists.
Failed to document education and consent regarding COVID-19 vaccination for multiple residents.
Failed to maintain smoking area free of debris and cigarette butts.
Report Facts
Deficiencies cited: 12
Days late for MDS assessments: 28
Weight: 145
Number of residents smoking: 12
Number of cigarette butts observed: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA #5 | Nurse Aide | Discovered sexual mistreatment incident on 5/16/22 |
| LPN #6 | Licensed Practical Nurse | Observed residents during sexual mistreatment incident and conducted body audits |
| RN #3 | Registered Nurse, Nursing Supervisor | Responded to sexual mistreatment incident and notified DNS and Administrator |
| SW #1 | Social Worker | Interviewed residents and involved in investigation of sexual mistreatment |
| Psychiatrist #1 | Psychiatrist | Evaluated residents after sexual mistreatment incident |
| DNS | Director of Nursing Services | Oversaw sexual mistreatment investigation and reporting |
| LPN #5 | Licensed Practical Nurse | Tested positive for COVID-19; involved in infection control review |
| NA #4 | Nurse Aide | Tested positive for COVID-19; involved in infection control review |
| LPN #4 | Infection Preventionist | Responsible for COVID-19 infection tracking and contact tracing |
| LPN #3 | Licensed Practical Nurse | Administered incorrect Metformin dose to Resident #84 |
| APRN #1 | Advanced Practice Registered Nurse | Involved in medication error and urology consult issues |
| DOR | Director of Recreation | Responsible for smoking program and smoking apron oversight |
| DOM | Director of Maintenance | Responsible for cleaning smoking area and patio |
| ADNS | Assistant Director of Nursing Services | Involved in scheduling urology consults |
| Pharmacist #1 | Pharmacist | Provided guidance on medication cart storage |
| Administrator | Facility Administrator | Oversaw facility operations and smoking area maintenance |
Inspection Report
Original Licensing
Deficiencies: 0
Date: Oct 29, 2021
Visit Reason
This document is a Pre-Licensure Consent Order for Waterbury Center for Nursing & Rehabilitation LLC seeking an initial license to operate a Chronic and Convalescent Nursing Home in Connecticut.
Findings
The order outlines extensive requirements and conditions for the facility's initial licensing, including contracting with an Independent Nurse Consultant (INC), staffing ratios, infection preventionist designation, quality assurance programs, environmental consulting firm engagement, and compliance monitoring. It sets forth detailed operational, staffing, and compliance obligations to ensure patient safety and regulatory adherence.
Report Facts
INC consulting hours: 16
INC consulting duration: 6
Nurse aide staffing ratio 1st shift: 10
Nurse aide staffing ratio 2nd shift: 12
Nurse aide staffing ratio 3rd shift: 20
Licensed nurse staffing ratio all shifts: 30
Medical record audits: 5
Quality Assurance Committee meeting frequency: 30
Water management program development timeframe: 28
Emergency preparedness plan development timeframe: 56
In-service Coordinator training hours: 8
Environmental Consulting Firm contract timeframe: 14
Initial onsite review scheduling timeframe: 30
ECF report development timeframe: 30
ECF re-evaluation frequency: 90
ECF re-evaluation report development timeframe: 14
Vendor payment timeframe: 90
Record retention period for nurse supervisor reports: 1825
Record retention period for quality assurance meeting minutes: 1095
Record retention period for daily rounds documentation: 1825
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Menajem Salamon | Member | Member of Waterbury Center for Nursing & Rehabilitation LLC and signatory of the Pre-Licensure Consent Order |
| Donna Ortelle | Section Chief, Healthcare Quality and Safety Branch | Representative of the Connecticut Department of Public Health and signatory of the Pre-Licensure Consent Order |
Inspection Report
Annual Inspection
Deficiencies: 9
Date: Nov 1, 2019
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements and to evaluate the facility environment, safety, and infection control practices.
Findings
The facility failed to maintain a safe, clean, comfortable, and homelike environment, with numerous deficiencies including damaged walls, ceilings, and fixtures, unclean vents, broken equipment, and pest control issues. Additionally, the facility had unsafe boiler room conditions with elevated carbon monoxide levels, unsecured medical records storage, and lapses in infection control practices during wound care.
Deficiencies (9)
Rose bud/blood pressure machine at east nurse station lacked current electrical safety inspection placard.
Bed pump in a resident room lacked current electrical safety inspection placard.
Multiple areas on the second floor Dining Room had missing drywall, peeling paint, wall marring, broken radiator covers, chipped and peeling painted surfaces, stained ceiling tiles, cracked window, and stained ceilings near offices.
Numerous rooms and utility areas throughout the facility had damaged walls, peeling paint, missing tiles, stained ceiling tiles, dirty ceiling vents, broken radiator covers, damaged cabinetry, and missing or broken fixtures.
Boiler room emitted strong fuel odors and elevated carbon monoxide levels; secondary boiler malfunctioned and was red-tagged; primary boiler repaired and returned to service after safety interventions.
Medical records were stored unsecured in unlocked basement storage rooms with water damage and clutter, risking loss or unauthorized access.
Failure to follow infection control practices during wound care for a sampled resident, including lack of hand hygiene between tasks.
Facility environment was not maintained in a safe, clean, comfortable, and homelike manner with widespread damage and uncleanliness throughout resident rooms, common areas, and utility rooms.
Pest control program was ineffective; drain flies observed in shower rooms and hallways; pest control service was not timely or comprehensive.
Report Facts
Carbon monoxide level: 21
Carbon monoxide level: 6
Carbon monoxide level: 2
Number of residents potentially exposed to boiler exhaust fumes: 16
Number of boxes of clinical records: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Failed to perform hand hygiene during wound care for Resident #253 |
| RN #5 | Registered Nurse | Reported environmental issues and re-educated LPN #1 on hand hygiene |
| Director of Physical Plant | Observed facility maintenance issues, boiler room conditions, and reported lack of supplies and maintenance follow-up | |
| Administrator | Aware of repair issues, coordinated redesign assessment, and managed boiler incident response | |
| Director of Maintenance | Reported on clinical records storage and pest control issues | |
| Laundry Staff #2 | Reported strong odors from boiler room during weekend shifts | |
| Housekeeper #1 | Reported housekeeping practices and unawareness of curtain cleaning requirements | |
| Housekeeper #2 | Reported odors making staff sick and windows opened for ventilation | |
| RN #4 | Nursing Supervisor | Reported odors in basement and staff symptoms, communicated with Administrator |
| RN #2 | Corporate Nurse | Indicated facility would purchase a new furnace |
| Medical Record Keeper | Unaware of unsecured clinical records storage |
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