Based on review of the clinical record, facility documentation, facility policy, and staff interviews for one of three residents (Resident #1) reviewed for a change in condition, the facility failed to appropriately respond to an emergency situation in which a resident experienced a medical emergency, and failed to provide interventions when the resident was identified to be unresponsive and had a respiratory rate of three (3) breaths per minute, resulting in a finding of Immediate Jeopardy. The findings include: Resident #1 had a diagnosis of opioid dependence and diabetes. The quarterly Minimum Data Set, dated [DATE] identified Resident #1 had a Brief Interview Mental Status (BIMS) score of 15 indicating intact cognition and was independent with transfers and wheelchair mobility. …
F684 citations in Connecticut
Quality of care · Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Connecticut cites F684 more often than its own record predicts
1.75 times the share F684 takes of citations nationally.
Of every deficiency written in Connecticut in 2025, this is the portion that was F684.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Connecticut surveyors wrote
F684 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/policy, and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for skin impairments, the facility failed to ensure changes in the resident's skin condition were identified, reported, and evaluated in accordance with facility policy. Multiple NAs observed bruising and swelling to the resident's right groin and upper inner thigh beginning on the day of admission and on multiple subsequent dates but failed to report the findings to licensed nursing staff. Additionally, the licensed nurse responsible for the weekly Skin Check on 7/9/26 signed the assessment as complete despite not visualizing the right inner thigh and groin area. …
Based on observations, review of clinical records, review of facility documentation, review of facility policy and interviews for two sampled residents (Residents #117 and #172) reviewed for skin conditions the facility failed to ensure upon identification of as impaired skin integrity that assessments and treatments were implemented timely. The findings include: Resident #172 was admitted to the facility on [DATE] with diagnoses that included dementia, encounter for palliative care, and muscle weakness. The skin and wound evaluation dated 8/18/26 identified that Resident #172 was admitted with skin tears to the left outer forearm, right outer forearm, and left dorsum hand. …
The short window
Recent years
| Year | Share of Connecticut citations | vs expected |
|---|---|---|
| 2023 | 5.78% | 1.60× |
| 2024 | 8.37% | 2.10× |
| 2025 | 7.53% | 1.75× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Connecticut surveyors cite →
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