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Citation history
Health deficiencies cited at Summit At Plantsville Center For Health & Rehabili during CMS and state inspections, most recent first.
The facility failed to revise and implement a behavior-focused care plan and care card after multiple physical altercations between two cognitively impaired residents on a secured unit. One resident with dementia, anxiety, and violent behavior had known triggers related to fear of theft and unfamiliar people, while another resident with dementia and wandering behavior was newly admitted. Despite documented verbal and physical altercations, including incidents where one resident struck and pushed the other causing injury, the written care plan and care card were not updated to include specific behavioral triggers, de-escalation strategies, or clear directions to keep the two residents separated. Instead, staff relied on temporary 1:1 monitoring, periodic checks, and verbal communication in huddles, leaving some staff, including an NA unfamiliar with the residents, without written guidance on maintaining safe distance or managing interactions, which preceded another physical altercation in one resident’s room.
A resident with dementia, anxiety, and a history of violent behavior had a care plan noting potential physical aggression and general interventions such as reassurance and monitoring, but the plan and care card were not updated with specific, measurable strategies after the resident pushed another cognitively impaired resident, causing a fall and head injury. Despite this initial altercation and temporary one-to-one monitoring, the written interventions remained unchanged, and staff continued to rely on existing generic directions. Later, when the same two residents encountered each other again in one resident’s room, another physical altercation occurred. A NA on duty reported not receiving specific instructions about keeping the two residents apart or how to manage them when in close proximity, while the DON reported relying on verbal staff huddles rather than revising the written care plan and care card.
A resident with dementia and a history of falls was observed by a nurse aide and an LPN sleeping in the dining room, contrary to the care plan directive to encourage sleeping in the resident's own bedroom. Staff did not intervene, and the resident later fell while attempting to walk, sustaining multiple pelvic fractures. Facility policy required implementation of person-centered care plans, which was not followed in this instance.
A resident with dementia and multiple comorbidities suffered a fall and reported severe pain, but did not receive as-needed acetaminophen for pain relief during the hour before hospital transfer. Both the LPN and RN present observed the resident's distress but did not administer pain medication, despite facility policy and an active PRN order. Hospital evaluation later revealed multiple pelvic fractures.
A resident with dementia and mobility deficits, care planned for two-person assist during transfers, was transferred by a single nurse aide. During the transfer, the resident became combative and sustained a laceration to the left shin after hitting the wheelchair, requiring sutures. Facility records and interviews confirmed the care plan was not followed.
A medication cup containing multiple pre-poured medications for a resident was left unsecured on top of a medication cart in the hallway when an LPN walked away to assist another resident, leaving the cart unattended and out of sight. The ADON confirmed that this action was against facility policy, which requires medications to be secured or under visible control at all times.
A resident with multiple medical conditions sustained a head injury when a Hoyer lift tipped during a transfer to a shower chair. The incident occurred because staff were unable to fully open the lift's legs for stabilization due to space constraints and obstacles in the room, resulting in the lift striking the resident's forehead. Staff interviews confirmed that environmental limitations prevented proper use of the lift, and the facility's policy requiring full stabilization was not followed.
A resident with Alzheimer's and hemiparesis was injured when a nursing assistant failed to respect the resident's request to slow down while pushing their wheelchair. The resident's hand was caught between the wheelchair and doorframe, resulting in redness and an x-ray. The facility's investigation confirmed the NA's failure to adhere to the resident's request and the need for caution, violating the resident's right to dignity and respect.
Failure to Update Behavior Care Plan After Repeated Resident Altercations
Penalty
Summary
The deficiency involves the facility’s failure to revise and implement a resident-specific care plan and care card with clear behavioral interventions after repeated resident-to-resident physical altercations on a secured unit. One resident (Resident #1), admitted in April 2025 with dementia, anxiety disorder, and violent behavior, was identified as severely cognitively impaired and having the potential to be physically aggressive related to progressive cognitive impairment. The care plan noted that this resident expressed fear that others might steal personal belongings, especially the remote control, and that behavior escalated when unfamiliar individuals were present. Interventions included proactively introducing new staff and residents and monitoring for danger to self and others, while the care card only directed staff to assist with hand hygiene and monitor for agitation and restlessness. Another resident (Resident #2), admitted in March 2026 with dementia, cognitive communication deficit, and post-traumatic stress disorder, was also severely cognitively impaired and had wandering behavior. Shortly after admission, nursing notes documented arguments between the two residents, with staff separating them several times. On 3/22/26, a reportable event documented that a verbal altercation between the two residents turned physical when Resident #1 struck Resident #2 on the left cheek, causing bruising, swelling, and a small laceration. A one-to-one monitor was initiated for Resident #1 and Resident #2’s room was changed. The care plan for Resident #1 was updated to include one-to-one monitoring and psychiatric consultation, but the care card remained unchanged and did not include specific triggers, de-escalation strategies, or instructions to keep the two residents apart. On 3/28/26, another reportable event documented that yelling was heard in the hallway and a nurse witnessed the two residents standing in close proximity, yelling at each other. Resident #1 struck Resident #2, Resident #2 struck back, and Resident #1 then pushed Resident #2, who fell and struck the head on the floor, sustaining a small laceration. A one-to-one monitor was again assigned to Resident #1, but the care plan still did not identify additional interventions to prevent further altercations with other residents, and the care card continued to list only hand hygiene and monitoring for agitation and restlessness. The one-to-one monitor was discontinued the next day, and 15-minute checks were implemented for Resident #1, but no changes were made to the care card through 4/9/26. On 4/10/26, another reportable event documented that Resident #2 entered Resident #1’s room. A nursing assistant, who had only worked with Resident #1 twice before and was unfamiliar with Resident #2, followed Resident #2 into the room to redirect and locate a walker. Resident #1 yelled at Resident #2 to get out of the room, and when Resident #2 touched Resident #1’s walker, Resident #1 punched Resident #2 in the face. Resident #2 punched back, and the two residents continued to exchange punches until another nursing assistant intervened and redirected Resident #2 out of the room. The nursing assistant reported that, although a shift report was received, there were no specific instructions that these two residents needed to be kept at a safe distance or how to manage them when in close proximity, and the assistant was unaware of their prior altercations. The Director of Nursing Services stated that staff huddles and direct reports were used to communicate issues between the residents and acknowledged that the care plan and care card for Resident #1 were not updated with specific interventions, while relying on huddles and medication adjustments instead.
Failure to Update Care Plan After Resident-to-Resident Altercations
Penalty
Summary
The deficiency involves the facility’s failure to update a cognitively impaired resident’s comprehensive care plan with specific, measurable interventions after a physical altercation, despite known aggressive behaviors. Resident #1, admitted in April 2025 with dementia, anxiety disorder, and violent behavior, was identified on a quarterly MDS as severely cognitively impaired, needing partial assistance with bathing and hygiene, and able to ambulate with supervision. The resident’s care plan dated 3/25/26 already noted potential for physical aggression related to progressive cognitive impairment and included general interventions such as reassuring the resident about personal belongings, proactively introducing new staff and residents, and monitoring and reporting signs of danger to self and others. The resident care card from 3/22/26 through 3/27/26 listed only assistance with hand hygiene and monitoring for agitation and restlessness. On 3/28/26, an LPN heard yelling and witnessed Resident #1 push another cognitively impaired resident (Resident #2), causing a fall and head strike that resulted in a small laceration and transfer to the hospital. Although a one-to-one monitor was assigned to Resident #1 and later discontinued, the resident’s care plan and care card were not updated with additional, specific interventions to deter or prevent further altercations with other residents. From 3/28/26 through 4/9/26, the care card interventions remained unchanged from those in place before the first altercation. On 4/10/26, Resident #2 entered Resident #1’s room, and Resident #1 yelled at and punched Resident #2, who then hit Resident #1 back. A nursing assistant working that shift reported having worked with Resident #1 only twice before, being unfamiliar with Resident #2, and not receiving specific instructions about keeping the two residents apart or managing them in close proximity, and the DNS acknowledged relying on staff huddles rather than updating the resident’s care plan and care card with specific interventions after the initial incident.
Failure to Implement Care Plan Intervention for Fall Risk Resident
Penalty
Summary
The facility failed to implement a care plan intervention for a resident identified as a potential fall risk. The resident, who had diagnoses including dementia, muscle weakness, anxiety, and major depressive disorder, was noted in the care plan to have a behavior of sleeping in the dining room at bedtime. The care plan directed staff to encourage the resident to sleep in their own bedroom. However, on the night of the incident, both a nurse aide and an LPN observed the resident sleeping in the dining room with the lights off but did not wake the resident or encourage them to return to their room as required by the care plan. Subsequently, the resident attempted to walk and fell, resulting in multiple minimally displaced pelvic fractures. Documentation confirmed that the resident was found on the floor in front of a chair, reported significant pain, and was transferred to the hospital for evaluation and treatment. Interviews with staff and facility leadership confirmed that the care plan intervention was not followed, and the facility's policy required that person-centered care plans be implemented by qualified staff.
Failure to Provide Timely Pain Management After Resident Fall
Penalty
Summary
A resident with a history of dementia, muscle weakness, anxiety, and major depressive disorder experienced a fall in the dining room during the night. The resident was found on the floor, complaining of severe pain (rated 8 out of 10) in the right thigh, and exhibited limited range of motion due to pain. Despite having an active order for acetaminophen as needed for pain, the clinical record and Medication Administration Record (MAR) showed no documentation that pain medication was administered during the hour the resident waited to be transferred to the hospital. Both the charge nurse (LPN) and the Nursing Supervisor (RN) were present, observed the resident's pain, and acknowledged in interviews that the resident was in significant distress, but neither provided pain relief prior to transfer. Hospital imaging later confirmed the resident had sustained multiple minimally displaced pelvic fractures. Interviews with facility staff, including the APRN and Assistant Director of Nursing, confirmed that pain management should have been provided according to facility policy, which directs staff to evaluate and medicate for new or acute pain. The failure to administer pain medication was not in accordance with the facility's pain management policy and resulted in the resident remaining in severe pain for an extended period.
Failure to Follow Two-Person Transfer Protocol Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident, who had diagnoses including dementia with agitation, Alzheimer's Disease, anxiety, and weakness, and was dependent on staff for transfers, was not assisted by two staff members during a transfer as required by the care plan. The care plan specified that the resident needed a two-person assist for transfers due to functional mobility deficits and a history of being resistive to care. Despite these directives, a nurse aide attempted to transfer the resident alone, without the assistance of a second staff member. During the solo transfer attempt, the resident became agitated and combative, which resulted in the resident hitting their left lower leg on the wheelchair and sustaining a laceration. The injury required medical attention, including transfer to the emergency department and the placement of sixteen sutures. Facility documentation and interviews confirmed that the care plan was not followed, and the transfer was conducted by only one staff member, contrary to established protocols.
Unattended Pre-Poured Medications Left on Medication Cart
Penalty
Summary
A medication cup containing pre-poured medications for one resident was left unsecured on top of a medication cart in the hallway when the charge nurse, an LPN, walked away to assist another resident with putting on shoes. The medication cart was left unattended and not within the nurse's line of sight, while several residents were observed sitting nearby in the hallway. The incident was observed during a facility tour with the Assistant Director of Nursing (ADON), who acknowledged the presence of the unattended medication cup on the cart. Review of the medication administration record confirmed that the cup contained multiple medications, including citalopram, empaglifozin, folic acid, loratadine, Norvasc, risperidone, apixaban, Entresto, metformin, Senokot S, and vitamin B12, all intended for a specific resident. Both the LPN and the ADON confirmed in interviews that medications should not be left unattended or unsecured, and facility policy requires medications to be kept secured in a locked area or under visible control at all times.
Resident Head Injury Due to Improper Hoyer Lift Transfer
Penalty
Summary
A deficiency occurred when staff failed to ensure a safe mechanical lift (Hoyer lift) transfer for a resident with multiple medical conditions, including atrial fibrillation, neuropathy, muscle wasting, and a right hand contracture. The resident required substantial assistance with bed mobility and was dependent on staff for transfers. During a transfer to a shower chair, the Hoyer lift tipped and struck the resident on the forehead, resulting in a bump, bruising, and subsequent headaches. The incident was witnessed by two nursing assistants, and the resident was later evaluated for a head contusion and worsening ecchymosis around the eyes. The transfer was complicated by environmental constraints in the resident's room. The large shower chair could not fit next to the bed, requiring staff to position it in the doorway. Staff had to maneuver the Hoyer lift past the resident's roommate and other obstacles, such as a bedside table that could not be moved due to the roommate's objections. As a result, the Hoyer lift legs could not be fully opened for stabilization, contrary to the facility's mechanical lift policy and manufacturer guidelines. This lack of proper stabilization led to the lift tipping during the transfer process. Interviews with staff involved in the incident confirmed that space limitations and the inability to fully open the Hoyer lift legs contributed to the accident. The Director of Nursing Services was unaware of the environmental challenges staff faced during transfers in this room. The facility's policy required the Hoyer lift legs to be locked in the maximum open position for stability and resident safety, which was not possible in this situation due to the room's layout and obstacles.
Failure to Respect Resident's Request Leads to Injury
Penalty
Summary
The facility failed to ensure that a resident was treated with respect and dignity, as evidenced by an incident involving a nursing assistant (NA) and a resident with Alzheimer's and left-sided hemiparesis. The resident, who had moderate cognitive impairment and was dependent on assistance for activities of daily living (ADLs) and transfers, was being pushed in a wheelchair by NA #1. Despite the resident's request for the NA to slow down, the NA continued to push the wheelchair quickly, resulting in the resident's hand getting caught between the wheelchair wheel and the doorframe, causing redness and necessitating an x-ray. The facility's investigation confirmed that the NA did not heed the resident's request to slow down and was not careful when maneuvering through the doorway, leading to the resident's injury. The Director of Nursing Services (DNS) acknowledged that the NA should have slowed down and been more cautious. The facility's Residents' Rights policy emphasizes the right of residents to be treated with consideration, respect, and full recognition of their dignity and individuality, which was not upheld in this incident.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Plantsville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Southington Care Center | 0.9 mi | — | 3 | 0 |
| Livewell Connecticut | 1.4 mi | — | 1 | 0 |
| Civita Care Center At Cheshire | 5.1 mi | — | 2 | 0 |
| Cheshire House Health Care Facility & Rehab Center | 5.5 mi | — | 2 | 0 |
| Bradley Home Infirmary/pavilion | 5.9 mi | — | 3 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.