Based on observations, review of the clinical records, facility documentation, facility policy, and interviews for 22 of 40 residents (Resident #3, Resident #9, Resident #12, Resident #18, Resident #27, Resident #31, Resident #33, Resident #42, Resident #45, Resident #49, Resident #56, Resident #59, Resident #61, Resident #63, Resident #67, Resident #68, Resident #69, Resident #72, Resident # 74, Resident #78, Resident #81, Resident #92) reviewed during a tour of the secured memory unit, the facility failed to ensure the 5 Rights of medication administration, and professional standards of practice, were adhered to during the administration of medications. These failures resulted in the finding of Immediate Jeopardy. The findings include: 1. …
F658 citations in Connecticut
Professional standards of care · Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Connecticut cites F658 more often than its own record predicts
2.79 times the share F658 takes of citations nationally.
Of every deficiency written in Connecticut in 2025, this is the portion that was F658.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Connecticut surveyors wrote
F658 findings written in Connecticut, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 4 sampled residents (Resident # 23) reviewed for accidents, the facility failed to utilize a gait belt for transfers, failed to conduct a Registered Nurse (RN) assessment following a fall and prior to further movement, once transferred failed to conduct a thorough assessment, and failed to contact the physician representing a failure to maintain professional standards of practice. The findings include: Resident #23's diagnoses included dementia, malignant neoplasm of the anal canal, morbid obesity, and was actively receiving chemotherapy. …
Based on review of the clinical records, review of facility policy and procedures, review of facility documentation, and interviews one of twelve sampled residents (Resident #5) reviewed for facility-acquired pressure injuries, and for one of five sampled residents (Resident #56) reviewed for infection control, the facility failed to ensure that medication and treatments were administered in accordance with professional standards of practice. The findings include: Resident #56's diagnoses included malignant melanoma, autonomic neuropathy, and history of transient ischemic attack and cerebral infarction. …
The short window
Recent years
| Year | Share of Connecticut citations | vs expected |
|---|---|---|
| 2023 | 2.85% | 1.78× |
| 2024 | 2.70% | 1.65× |
| 2025 | 4.98% | 2.79× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Connecticut surveyors cite →
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