Waterbury Center for Nursing & Rehabilitation LLC

In the surveyor’s words

From the most serious findings on record at Waterbury Center for Nursing & Rehabilitation LLC, in the surveyor’s own words.

• Immediate jeopardy, isolatedF760Jul 9, 2026

  Based on interviews, review of the clinical record, facility documentation, and facility policy for 3 of 6 residents (Resident #1, Resident #4 and Resident #45) reviewed for hospitalization, upon Resident #1's re-admission from the hospital, insulin orders were held for 2 days per physician orders, the facility failed to follow up with the physician after the 2-day hold, resumed insulin without verifying with the physician , which caused Resident #1 to receive excessive insulin, resulting in severe hypoglycemia, mental status changes and a blood glucose level of 27 milligrams per deciliter (mg/dl) which resulted in a significant medication error. […]

• Actual harm, isolatedF689Jul 9, 2026

  Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 sampled residents (Resident #3) reviewed for falls, the facility failed to ensure staff implemented the required accident prevention interventions, specifically a gait belt and 1 person assistance with ambulation, resulting in Resident #3 falling and sustaining a head injury requiring 2 staples to the back of the head. The findings include: Resident #3s diagnosis included dementia, abnormalities of gait and balance, and convulsions. The Resident Care Plan dated 11/22/25 identified that Resident #3 was at risk of falling with interventions that included to use assistance of 2 for early morning transfers, monitor/assist with toileting needs and keeping personal items within reach. […]

• Actual harm, isolatedF600Jun 23, 2022

  Based on review of the clinical record, facility documentation, facility policy, and interviews for one of two sampled residents (Resident # 300) reviewed for abuse, the facility failed to ensure a resident was free from sexual mistreatment by another resident (Resident #47). The findings include: Resident #47 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #47 was without cognitive impairment, independent with bed mobility and transfers, required limited assist with ambulation while using a walker and to assist with dressing. The care plan dated 3/28/22 identified Resident #47 was at risk for mood changes related to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF803Dec 20, 2024

  Based on observations, review of facility documentation, review of facility policy/procedures and interviews, the facility failed to ensure adequate food supply for the posted menu. The findings included: Initial tour of the kitchen on 12/16/24 at 9:48 AM with the Dietary Manager (DM) identified the walk-in fridge contained no liquid eggs, a box of hard-boiled eggs, and 6 individual eggs in a carton. Fresh cabbage was the only fresh vegetable observed in the walk-in fridge. Observation of dry food storage on 12/16/24 at 10:05 AM with the Dietary Manager identified several bare shelves, 1 box of Scooters cereal, 8 cans of jelly, several boxes of thickener, 6 cans of sauerkraut, and condiments were observed stored on the shelves. […]

• No harm, potential for more than minimal, patternF657Jul 9, 2026

  Based on review of the clinical record, facility policy and interviews for 6 of 6 residents (Resident #3, Resident #52, Resident #87, Resident #91, Resident #106, Resident #114) reviewed for care planning, the facility failed to ensure quarterly Resident Care Plan (RCP) meetings were conducted. The findings include: 1. Resident #3 had diagnoses that included dementia, abnormalities of gait and balance, and convulsions.The Resident Care Plan (RCP) dated 3/22/25 identified Resident #3 was at risk of falling. […]