Four residents were observed eating in the hallway on December 18, positioned against the right side wall outside their rooms. One of them, Resident 92, had severe cognitive impairment and required maximum assistance with daily activities, including meal setup.
The 73-year-old resident was admitted in May 2022 with dementia, nutritional deficiency, and dysphagia — difficulty swallowing that can lead to choking or aspiration pneumonia. Her care plan specifically required alternating solids and liquids, sitting upright for 30 minutes after meals, and taking small bites to prevent aspiration.
But the care plan made no mention of hallway dining.
Another resident, number 89, had physician orders directing staff to never leave the patient alone and to keep them in high traffic areas. On December 18, this resident was being fed in the hallway outside their room. The next day, staff had moved the feeding inside the room.
When inspectors asked why residents were eating in hallways, they received conflicting explanations from nursing staff.
RN 6 believed the residents were fall risks and explained that opening the dining room would require pulling an aide from the unit. "There were not enough staff in the morning to have the dining room open," she told inspectors.
But nursing assistant 3 said she was unaware of why residents were eating in the hallway.
The Director of Nursing Services knew some residents ate in hallways but couldn't identify which ones. She suggested fall-risk residents might eat there "so they can be visible to staff."
More revealing was her admission about the dining room: it hadn't reopened for breakfast "for a few years since the beginning of COVID." If it did reopen, nursing staff would be responsible for ensuring residents got there safely.
The DNS couldn't explain why Resident 92 was being fed in the hallway.
Neither could the care plan coordinator, RN 9, who admitted she doesn't write care plans for hallway dining because she was unaware which residents ate meals there. She knew some did, but couldn't say who.
When inspectors requested the facility's dining policy, none was provided.
The practice continued even after inspectors arrived. On December 19, Resident 92 was again observed eating breakfast in the hallway, this time with another resident.
For Resident 92, the hallway setting contradicted multiple safety requirements. Her care plan emphasized the need for proper positioning and careful monitoring during meals due to her swallowing difficulties. The plan specifically noted that family and visitors had been educated about her dietary restrictions.
Federal regulations require nursing homes to provide a homelike environment and ensure residents can eat in areas that promote social interaction and dignity. Hallway dining for residents with complex medical needs raises questions about both safety and quality of life.
The inspection was triggered by a complaint and focused on whether the facility was meeting federal standards for resident care and environment. Inspectors classified the violation as causing minimal harm or potential for actual harm to a few residents.
Resident 92's physician had ordered a soft diet with solid foods for pleasure and prune juice with breakfast. The complexity of managing her nutritional needs while preventing aspiration required careful attention from trained staff in appropriate settings.
The facility's dining room closure, now stretching years beyond the initial COVID-19 emergency, had become a permanent operational decision affecting residents' daily experience and potentially their safety.
Staff shortages appeared to drive the hallway feeding arrangement, with nurses reluctant to assign aides to dining room supervision when they were needed elsewhere on the unit.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Southington Care Center from 2025-12-19 including all violations, facility responses, and corrective action plans.