The October 29 incident involved a resident who had been admitted just days earlier with congestive heart disease, anxiety, and Type 2 diabetes. The person required extensive assistance with personal hygiene, bed mobility, and transfers due to fatigue and confusion following a recent hospitalization.
LPN #1 was administering the resident's morning medications when the resident requested additional applesauce. The nurse took the remaining pills to the medication cart but left a half-filled cup of sodium polystyrene sulfonate mixture positioned in front of the resident on the bedside table.
Sodium polystyrene sulfonate is prescribed to treat dangerously high potassium levels in the blood. The resident's physician had ordered 15 grams of the powder mixed with 60 milliliters of fluid daily.
The medication cart was stationed at the doorway of the resident's room. While the nurse was retrieving applesauce, a loud noise came from behind.
LPN #1 turned to find the resident lying prone on the floor with copious wet marks on the right side of the shirt and right pant leg. When asked what happened, the resident responded: "The nurse gave me liquid that tasted horrible and I started to vomit. Then, you found me."
The incident occurred at 3:05 PM, according to a nurse's note documented that day.
During interviews with federal inspectors on November 13, LPN #1 acknowledged leaving the sodium polystyrene sulfonate mixture on the bedside table while going to get more applesauce. The nurse admitted this violated proper procedure.
"The remaining sodium polystyrene sulfonate mixture should not have been left on Resident #1's bedside table," LPN #1 told inspectors the following day.
The nurse was unsure whether the resident had consumed the remaining medication before falling.
The resident's care plan specifically directed staff to monitor medications for side effects and responses that could contribute to cognitive loss, drug interactions, adverse reactions, or toxicity. The plan noted the resident was alert and oriented but had experienced recent confusion related to hospitalization.
Complete Care at Groton Regency's medication administration policy requires staff to observe residents consuming medications in their entirety before leaving the resident or their room. The policy, dated January 18, 2024, states medications must be administered "in accordance with professional standards of practice."
The Director of Nurses confirmed during a November 14 interview that facility practice required watching residents take all medications completely prior to leaving them unattended.
Federal inspectors cited the facility for failing to ensure services met professional standards of quality, finding minimal harm or potential for actual harm. The violation affected few residents, according to the inspection report.
The resident had been admitted in October 2025 and was described as verbally appropriate but requiring extensive assistance with daily activities including bathing, grooming, dressing, eating, and toileting.
The inspection was conducted following a complaint. Complete Care at Groton Regency is disputing the citation.
The facility's policy explicitly directs medications be administered "in a manner to prevent contamination or infection" and requires staff to "observe resident consumption of medication."
The resident was found with vomit stains covering the right side of clothing after being left alone with the unfinished medication mixture. The loud noise that alerted the nurse suggested the person had fallen while attempting to consume the remaining medication or while experiencing its effects.
The sodium polystyrene sulfonate powder must be mixed with fluid and has an unpleasant taste that can cause nausea and vomiting, particularly in elderly patients with multiple medical conditions.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Complete Care At Groton Regency from 2025-11-14 including all violations, facility responses, and corrective action plans.
Additional Resources
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