Southington Care Center

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

dated 10/15/25 identified Resident #89 received a regular, soft diet with puree fruit. In addition, physician orders directed to not to leave the patient alone in the room and keep in high traffic areas. Observation on 12/18/25 at 9:30 AM noted Resident #89 was being fed in the hallway outside of his/her room by the doorway. In addition, 3 other residents (#43, #72 and #92) were eating in the hallway lined up against the right side of the wall in the hallway.Observation on 12/19/25 at 9:00 AM noted Resident #89 was being fed

in his/her room.4. Resident #92 was admitted to the facility in May 2022 with diagnoses that included dementia, nutritional deficiency, and dysphagia (difficulty swallowing). The quarterly Minimum Data Set assessment dated [DATE REDACTED] identified Resident #92 was severely cognitively impaired and required maximum assistance with activities of daily living, set up for meals, and no active signs and symptoms of swallowing disorders. Physician's orders dated 12/4/25 directed a soft diet with solid foods for pleasure and prune juice with breakfast. The Resident Care Plan (RCP) dated 12/19/25 identified Resident #92 was at risk for aspiration/dysphagia with interventions that included ensure receives correct diet and resident's family/visitors were educated on diet. Additionally, the RCP identified to alternate solids and liquids, to sit upright for 30 minutes after meals, and encourage resident to take small bites. The RCP did not reflect Resident #92 ate breakfast in the hallway.Observation on 12/18/25 at 9:30 AM noted Resident #92 was eating in the hallway along with 3 other residents (#43, #89, and #92) lined up against the right side of the wall in the hallway. Observation on 12/19/25 at 9:00 AM noted Resident #92 was eating breakfast in the hallway along with another resident (#43).Interview with RN #6 on 12/19/25 at 9:10AM identified that she believed the residents were eating in the hallway because they were fall risks and that they were not in a dining room with an aide because an aide would need to have to leave the unit and there were not an enough staff in the morning to have the dining room open. Interview with NA #3 on 12/19/25 at 9:15AM stated she was unaware of why the residents were eating in the hallway.Interview with the DNS on 12/19/25 at 10:00 AM identified that she was aware that some residents ate in the hallway but was not able to identify who ate in the hallway. She indicated that if a resident has fallen then they might eat in the hallway so they can be visible to staff. Furthermore, the DNS indicated that the dining room had not reopened for breakfast since for a few years since the beginning of COVID. The DNS indicated that if the dining room was opened then the nursing staff are responsible for ensuring residents are in the dining room. The DNS was unsure why Resident #92 was being fed in the hallway.Interview with the RN #9 (Care Plan Coordinator) on 12/19/25 at 10:00 AM identified that she does not care plan for residents that eat in the hallway because she was unaware of who ate meals in the hallway although she was aware that there were some residents that ate meals in the hallway. Although requested, a policy on dining was not provided.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Southington Care Center

45 Meriden Ave Southington, CT 06489

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

failed to identify 4 Missing Items Reports for residents related to missing personal laundry items.Review of

the QAA Committee Meeting minutes dated July 29, 2025 failed to identify that Missing Items Reports were reviewed with the Grievances during the meeting. The minutes identified there were no Grievances for June. The minutes failed to identify 8 Missing Items Reports for residents related to missing personal laundry items.Minutes were not provided for the August QAA Committee meeting.Review of the QAA Committee Meeting minutes dated September 30, 2025 failed to identify that Missing Items Reports were reviewed with the Grievances during the meeting. The minutes identified there was 1 Grievance for August related to meal service and a motorized wheelchair. The minutes failed to identify 6 Missing Items Reports for residents related to missing personal laundry items.Review of the QAA Committee Meeting minutes dated October 28, 2025 failed to identify that Missing Items Reports were reviewed with the Grievances

during the meeting. The minutes identified there were 2 allegations of abuse/Grievances for September.

The minutes failed to identify 4 Missing Items Reports for residents related to missing personal laundry items.Review of the QAA Committee Meeting minutes dated November 25, 2025 identified the Resident Council was notified that a new linen service would begin in November. The minutes failed to identify that Missing Items Reports were reviewed with the Grievances during the meeting. The minutes identified there were no Grievances for October. The minutes failed to identify 3 Missing Items Reports for residents related to missing personal laundry items.Review of the Quality Assurance Performance Improvement (QAPI) Plan directed, in part, the QAPI program addressed all systems of care. The plan directed the QAPI program identified and prioritized problems and opportunities that reflected the organizational functions and services provided to residents with corrective actions to address gaps in the system. The plan directed that the QAA Committee met at least quarterly and reported on data collected within the areas of input from caregivers, families, and residents, accidents and incidents, performance indicators, and complaints. The plan directed methods for data collection included grievance logs. The plan directed that root cause analysis was used to correct errors and/or system weaknesses. The plan failed to identify if the Missing Items Log was considered and aspect of Grievances.

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