Southington Care Center

Inspectors wroteBased on review of facility documentation, Legionella water testing records, facility policies, and staff interviews reviewed for infection control, the facility failed to implement an effective Legionella water management monitoring program following repeated positive Legionella test results. Specifically, the facility continued monthly environmental testing despite ongoing positive findings from February 2026 through June 2026 and did not follow the post-remediation testing intervals recommended by the Healthcare Infection Control Practices Advisory Committee (HICPAC) guidance.

Inspectors wroteBased on clinical record reviews, facility documentation, and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for missing personal property, the facility failed to protect a resident from misappropriation of property when Resident #1's credit card was removed from the resident's wallet by a staff member and used to make unauthorized purchases.

Inspectors wroteBased on observations, review of the clinical record, facility policy, and interviews for 1 sampled resident (Resident #27) observed on tour, the facility failed to properly store bed pans and for 6 of 6 residents (Resident #30, Resident #68, Resident #77, Resident #111, Resident #118, and Resident #675) reviewed for Infection Prevention, the facility failed to appropriately implement Enhanced Barrier Precautions (EBP) and

Inspectors wroteBased on the interviews, observations, facility policy, and record review for 1 of 1 sampled resident (Resident #27) reviewed for edema, the facility failed to report a weight gain of 3 pounds or more in 24 hours as directed by the physician, and for one (1) of three (3) residents (Resident #626), reviewed for fluid restrictions, the facility failed to ensure the physician was notified when the resident exceeded the daily fluid restriction.

Inspectors wroteBased on the interviews, observations, facility policy, and record review for 1 of 1 sampled resident (Resident #27) reviewed for edema, the facility failed to obtain daily weights as per physician orders.

Inspectors wroteBased on interviews, review of the clinical record, and facility documentation, for 1 of 3 residents (Resident #40) reviewed for Resident Assessments, the facility failed to ensure the comprehensive Minimum Data Set (MDS) assessment was accurately coded for PASRR (Preadmission Screening and Resident Review) Level II. Resident #40 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder, major depressive disorder, and anxiety disorder. The PASRR Level I report dated 8/10/18 indicated that a PASRR Level II evaluation must be conducted. The PASRR Level II report dated 8/10/18 indicated that Resident #40's care needs were appropriate to be serviced in a nursing facility setting, although the resident had diagnoses of schizoaffective disorder, bipolar disorder, major depressive disorder, and anxiety disorder. [...]

Inspectors wroteBased on observations, review of the clinical record, review of facility policy, and interviews for 3 of 3 sampled residents (Resident #57, #91 and #255) reviewed for respiratory care, the facility failed to ensure acceptable infection control practices were implemented regarding care of oxygen tubing, nasal cannulas, and a respiratory mouthpiece.

Inspectors wroteBased on observation, review of the clinical record, facility policy, and interviews for 1 resident reviewed for respiratory care (Resident #8), the facility failed to ensure infection control practices were followed when storing respiratory equipment and/or review of the Infection Control Program, failed to ensure a resident Line List was completed in it's entirety for 2 facility outbreaks

Inspectors wroteBased on observation, clinical record review, review of facility policy and interviews for 1 of 5 sampled residents reviewed for accidents (Resident #112), the facility failed to assess Resident #112 for self-administration of medications.

Inspectors wroteBased on observation, interview, review of the clinical record and facility policies for 2 of 4 sampled residents reviewed for advanced directives (Resident #30 and Resident #51), the facility failed to ensure the advanced directives were comprehensive and addressed in a timely manner and/or with the resident's representative.

Inspectors wroteBased on observation, review of the clinical record and interviews for 1 of 3 sampled residents reviewed for pressure ulcers (Resident #118), the facility failed to follow physician orders for offloading heels.

Inspectors wroteBased on clinical record review and interview for 1 of 4 sampled residents reviewed for accidents (Resident#71), the facility failed to provide supervision to prevent an accident.

Inspectors wroteBased on observation, clinical record review, review of facility policy and interviews for 1 of 4 residents reviewed for accidents (Resident #112), the facility failed store medications in accordance with facility policy: Resident #112 was admitted to the facility on [DATE] with diagnoses that included a fracture of the left arm, muscle weakness and glaucoma. A physician order dated 1/22/19 directed to administer one drop of Cosopt drops to each eye twice a day. The 14-day scheduled minimum data set assessment dated [DATE] identified Resident #112 had no cognitive impairment and required extensive assistance of one person for dressing and personal hygiene. Observation on 4/8/19 at 11:50 AM identified Dorzolamide HCL-Timolol (Cosopt) eye drops on Resident #112's bedside table. [...]

Inspectors wroteBased on observation, review of the clinical record, facility policy, and interviews for 1 of 5 residents reviewed for dining (Resident #4), the facility failed to ensure the physician's diet order was clearly defined for a resident receiving a therapeutic diet.

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for 3 of 5 sampled residents reviewed for Influenza immunization (Resident #3, Resident #8 and Resident #83), the facility failed to ensure that education was provided to the resident and/or resident's representative prior to administering the influenza vaccine.