Inspection Reports for
Advanced Center for Nursing and Rehabilitation

A desk audit confirmed that tags F580, F602, F658, and F684 were brought back into compliance as of 2025-09-19. The facility administrator was notified of these findings on 2025-11-18.

All previously identified violations (1a, 2a, 3a, 5a, 6a, 7a, 8a, 9a, 9b, and 4a) were found to be corrected as of the dates specified, with the administrator notified in person on 2025-10-31 at 1:30 PM that all violations were corrected.

The complaint investigation focused on Resident #2's death related to respiratory distress and failures in oxygen management, Resident #3's care plan deficiencies, medication security, laboratory testing failures for Residents #5 and #11, infection control related to oxygen tubing, and maintenance of oxygen concentrators. The facility disputed the citation related to Resident #2's death.

The facility failed to timely notify providers and assess Resident #2 during respiratory distress, resulting in death. The facility also failed to develop a care plan for Resident #3's oxygen needs, failed to secure medication carts, failed to obtain ordered blood work for Residents #5 and #11, failed to change oxygen tubing weekly for Residents #3, #4, and #5, and failed to ensure annual inspection and cleaning of oxygen concentrators for Residents #6 and #7. These failures resulted in findings ranging from minimal harm to immediate jeopardy.

The facility failed to timely notify physicians/APRNs when medications were not administered or unavailable, failed to ensure proper documentation and control of narcotic medications, and failed to provide medications in accordance with physician orders, resulting in missed doses and unaccounted narcotic medications.

The complaint investigation was substantiated as the facility failed to prevent and respond appropriately to a resident-to-resident physical abuse incident on 5/13/2025 involving Resident #2 and Resident #3. The event was unprovoked and resulted in injuries requiring hospital evaluation. Additionally, failure to monitor vital signs as ordered for Resident #1 was identified.

The facility failed to ensure Resident #2 was free from physical abuse after a resident-to-resident assault involving Resident #3, resulting in injuries and hospital evaluation. Additionally, the facility failed to obtain vital signs as ordered for Resident #1 after discontinuation of a medication, compromising monitoring of the resident's condition.

The desk audit verified that Tag F 686 and the corresponding violation were corrected and back in compliance as of 4/7/25.

The desk audit completed on 6/2/25 verified that the cited violations (Tags F 580 & 755) were corrected and the facility was back in compliance as of 4/7/25.

The facility was found deficient in timely notification of medical providers for significant changes in resident condition, failure to update care plans promptly after falls, incomplete neurological assessments following an unwitnessed fall, and incomplete documentation of medical evaluations by the APRN. These deficiencies were noted for multiple residents and involved failures in communication, documentation, and care planning.

All 25 previously identified violations were corrected as of the follow-up visit on 2025-04-01, and the facility administrator and DNS were notified in person.

The complaint investigation focused on Resident #2's medication administration. It was substantiated that the facility did not notify the physician or APRN when the resident did not receive the medication on 10/5 and 10/6/2024. Interviews with nursing staff and APRN confirmed the lack of notification. The facility was also unable to verify the medication brought in by the family was properly verified and confirmed by a pharmacist.

The facility failed to notify the physician or APRN that Resident #2 did not receive the scheduled medication on 10/5 and 10/6/2024. Additionally, the facility failed to verify that the medication brought in by the family was the correct drug ordered by the physician and failed to ensure the contents of the medication containers were verified by a licensed pharmacist as required by facility policy.

Complaint numbers #39849 and #43282 are referenced. The visit was complaint-driven, but substantiation status is not explicitly stated.

The report details a violation of Connecticut state regulations identified during the visit, including deficient practices related to wound care and pressure ulcer prevention for Resident #1. The resident had a pressure ulcer and treatment delays were noted, leading to transfer to hospital for further evaluation.

The facility failed to ensure that the wound care physician's treatment plans for pressure ulcers were entered into the clinical record and implemented timely. Specifically, specialized equipment and treatments recommended on 2/27/25 were not initiated until 3/4/25, and Resident #1 was transferred to the hospital for wound evaluation and treatment on 3/6/25.

The visit was complaint-related based on Resident #1 reporting that a recreation aide cursed at them during a bingo game on 1/20/25. The complaint was substantiated as the recreation aide admitted to cursing and was terminated.

The facility failed to ensure Resident #1 was treated with dignity and respect when a recreation aide cursed after an incident during a bingo game. The recreation aide admitted to cursing and was terminated from employment. Facility policy requires all residents to be treated with dignity and respect.

The visit was complaint-related, triggered by allegations of disrespectful staff behavior toward Resident #70, abuse allegations involving LPN #6 and Resident #144, and concerns about Resident #1's combative and verbally abusive behavior toward staff and Resident #214. The investigation found substantiated issues including disrespectful staff conduct, failure to remove staff pending investigation, and inadequate monitoring of resident safety.

The facility failed to ensure respectful staff interactions with residents, timely removal of staff pending abuse investigations, adequate monitoring and protection of residents from abuse and threats, and provision of necessary toileting and incontinent care to residents requiring assistance. Several residents were affected by these deficiencies, with minimal harm or potential for actual harm noted.

The facility was found deficient in multiple areas including failure to ensure respectful staff interactions, missing medications, environmental maintenance issues, inadequate abuse prevention policies, delayed psychiatric follow-up, untimely MDS transmissions, incomplete care plans, failure to provide incontinent care, inadequate pain management, missed physician appointments, unsafe smoking environment, infection control lapses, lack of antibiotic stewardship, and deficiencies in medication management especially methadone chain of custody and documentation.

The violation identified as Violation #1a was corrected as of the inspection date. The administrator was notified by telephone and email that all violations were corrected.

The complaint investigation focused on medication administration errors for Resident #1, specifically missed doses of Banzel and failure to notify the APRN. The complaint was substantiated with findings of multiple missed doses and lack of timely notification.

The facility failed to ensure that Resident #1 received the prescribed anti-seizure medication Banzel as ordered, with multiple missed doses in August 2024. The nursing staff did not timely notify the APRN of these missed doses, and the facility lacked documentation of such notifications. The pharmacy delivery schedule and refill system errors contributed to medication delays. No seizure activity was reported as a result of the missed doses.

The facility failed to develop a comprehensive person-centered care plan addressing a resident's wound present on admission, despite having treatment orders and a care plan for potential skin impairment. The facility policy requires measurable objectives and timetables in care plans, but this was not fully implemented for the wound care.

The facility failed to ensure a sanitary environment free of bugs and roaches in five of eleven resident rooms. Observations included live and dead roaches in multiple resident rooms, foul odors, excessive clutter, and ineffective pest control despite ongoing treatments and cleaning efforts.

The complaint involved allegations by Resident #2 and his/her responsible party that a nurse aide was abusive, rough, refused to assist with heating food, and neglected care needs. The facility investigated but found the allegations unsubstantiated. The nurse aide admitted to not heating food but denied abuse. The facility failed to notify the State Agency within the required timeframe.

The facility failed to honor Resident #2's rights by not providing assistance when requested and failed to timely notify the State Agency of an abuse allegation. An investigation found the abuse allegations unsubstantiated, though the nurse aide admitted to not heating Resident #2's food. Additionally, the facility failed to administer medications to Resident #1 as ordered, resulting in missed doses and subsequent hospitalization for a blood clot.

The complaint investigation was triggered by multiple elopement attempts by Resident #1, including an incident on 05/19/23 where the resident left the facility unescorted and was missing for approximately 12 hours. The investigation found failures in elopement risk assessments, monitoring, and security protocols. Immediate Jeopardy was identified and later removed after corrective actions were implemented.

The facility failed to perform elopement risk assessments in accordance with facility policy, resulting in a resident with dementia leaving the building unescorted, causing Immediate Jeopardy. Additionally, the facility failed to ensure effective administrative oversight, including incomplete Medical Director rounds documentation and incomplete clinical record documentation of safety checks.

The complaint involved Resident #1 reporting rude and disrespectful behavior by Nurse Aide #2, including use of profanity and derogatory statements. The complaint was substantiated by witness statements and staff interviews. Resident #1 was assured of safety and the Director of Nursing investigated the incident. Additionally, concerns were raised about contraband possession and related safety issues involving Residents #4 and #5, including an overdose incident.

The facility failed to ensure Resident #1 was treated with dignity and respect during a verbal altercation with staff, resulting in minimal harm. Additionally, the facility failed to document close observation checks and a thorough investigation related to contraband that led to Resident #5's overdose and hospital visit, with Resident #4 implicated in the contraband issue.

Complaint Investigation #32902 was conducted. The complaint involved a resident found unresponsive with fentanyl in their possession, leading to emergency intervention and subsequent visitation restrictions. The complaint was substantiated as violations were identified.

The facility failed to ensure residents' rights to receive visitors at their choosing, resulting in suspension of visitation for all residents except those on hospice or comfort measures following an incident involving a resident's accidental fentanyl overdose. The facility visitation policy was reviewed and visitation restrictions were implemented temporarily.

The visit included complaint investigations for complaints #31843, #31933, #31934, #31993, #32015, #31984, and #31994. Violations were substantiated as noted in the findings and enforcement actions.

Violations of the General Statutes of Connecticut and regulations were identified related to resident care, medication administration, leave of absence policies, contraband control, psychosocial oversight, and documentation. The facility failed to ensure timely physician notification, adequate supervision, and proper care planning for residents with substance abuse and other conditions. Immediate Jeopardy findings were noted in several areas.

The facility failed to complete admission and quarterly MDS assessments timely and accurately. Specific deficiencies included a late admission MDS assessment for Resident #126, an incomplete quarterly MDS assessment for Resident #35, and inaccurate coding of MDS assessments for Residents #33 and #129, including failure to identify a positive PASRR and presence of a Foley catheter.

The facility was found deficient in multiple areas including failure to ensure call bell accessibility for a resident with hemiparesis, failure to timely notify responsible parties of pressure ulcers, inadequate environmental maintenance of shower rooms, failure to monitor intake and output for residents with feeding tubes and catheters, improper wound care procedures, delayed response to significant weight loss, failure to timely change oxygen tubing, inaccurate clinical record keeping for skin checks, improper storage of tracheostomy supplies, lack of infection control tracking, and expired IV supplies in emergency kits.

The facility was found to have multiple violations of Connecticut State Agencies regulations including issues with call bell accessibility, pressure ulcer care, shower room maintenance, timely completion of MDS assessments, wound care, weight loss management, oxygen tubing, infection control, and IV therapy documentation. Plans of correction were submitted for each violation.

Complaint investigations #CT31843, CT31934, CT31933, CT32015, CT31984, and CT31994 were conducted. The findings resulted in immediate jeopardy determinations related to resident care, supervision, and documentation failures.

Violations of the public health code and regulations were identified related to resident care, medication administration, leave of absence policies, contraband control, and psychosocial oversight. The facility failed to ensure adequate supervision, timely physician notification, and proper documentation. Immediate jeopardy findings were noted and plans of correction were required.

Complaint Investigation Survey conducted due to complaints CT #31843, 31933 and #31934. Immediate Jeopardy identified related to drug paraphernalia possession, lack of care plans for substance use disorder, failure to notify providers of elevated blood sugar, failure to transfer residents after Narcan administration, and inadequate psychosocial oversight.

Immediate Jeopardy was identified due to failures in ensuring residents were free from possession of drug paraphernalia, comprehensive care plans for substance use disorder were not developed, timely notification of elevated blood sugar was not made, and residents requiring Narcan administration were not transferred to hospital. Additional deficiencies included failure to ensure adequate psychosocial oversight, medication administration issues, inadequate supervision to prevent access to contraband, incomplete medical records, and lack of effective administrative oversight.

The survey found that Resident #24's room lacked proper signage and a PPE cart to identify transmission mode and proper PPE use. The facility policy for prevention and control of COVID-19 was reviewed, and droplet precautions were implemented immediately after the surveyor's inquiry.

Complaint #26278 was investigated regarding an allegation of mistreatment of Resident #1. The complaint was substantiated by findings that the facility delayed reporting the allegation to the state agency beyond the required timeframe.

The facility was found to have failed to report an allegation of mistreatment of a resident to the state agency in a timely manner, with the report being made ten hours after the incident instead of within two hours as required by policy.

The inspection identified multiple deficiencies including failure to timely report allegations of abuse, late transmission of Minimum Data Set (MDS) assessments, failure to implement care plans for anticoagulant medication, failure to maintain tube feeding protocols, failure to obtain laboratory tests per physician orders, failure to maintain food safety standards including beard guard use and refrigerator temperatures, and incomplete clinical records documentation.

The report details multiple violations of Connecticut State Regulations related to abuse reporting, timely submission of Minimum Data Set (MDS) assessments, care planning for anticoagulant medication, medication reconciliation, enteral feeding, laboratory testing, dietary services, and infection control. Plans of correction are provided for each violation with education, audits, and policy reviews.

The complaint investigation included allegations of verbal abuse by staff towards Resident #19, late submission of MDS assessments, medication errors including anticoagulant management, failure to follow physician orders, feeding tube care deficiencies, laboratory monitoring failures, food safety violations, and incomplete clinical records.

The facility failed to timely report an allegation of verbal abuse, failed to transmit MDS assessments timely, failed to implement care plans for anticoagulant medication, failed to follow physician orders for orthostatic blood pressure monitoring, failed to maintain feeding tube care and documentation, failed to obtain lab work per physician orders, failed to maintain proper food safety practices including beard guard use and refrigerator temperature control, and failed to maintain complete clinical records.

Complaint #25593 triggered the investigation inspection.

The facility was found to have violations related to inaccurate and incomplete clinical documentation, specifically regarding discharge MDS assessments and weight documentation for Resident #1. The facility failed to ensure accurate coding of discharge dates and failed to document weekly weights as required. Plans of correction were submitted addressing these deficiencies.

The report identifies violations related to failure to follow recommendations for obtaining hemoglobin A1c lab tests for a resident with diabetes and failure to ensure respiratory equipment was maintained and stored in a sanitary manner. The facility was required to submit a plan of correction by June 28, 2019.

Complaint investigation was conducted for complaints #24488 and #24386. Violations were substantiated as indicated by the findings and violation letters.

The inspection found multiple deficiencies related to resident care, including failure to provide showers per care plans, failure to honor private room requests, incomplete advanced directive forms, inadequate communication regarding resident condition changes, failure to prevent falls, insufficient assistance with activities of daily living, improper handling of controlled substances, and failure to follow vaccination policies. Plans of correction were submitted for each violation.

Complaint numbers 24488 and 24386 were investigated as part of the unannounced visits. The findings were substantiated with multiple deficiencies identified.

The survey found a pattern of deficiencies constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy, requiring corrections. Deficiencies included failure to honor resident preferences, incomplete advance directives, inadequate documentation and communication regarding hospitalizations, failure to revise fall prevention plans, inadequate assistance with activities of daily living, failure to implement care plans for contractures, improper medication security, failure to follow up on pneumococcal vaccinations, and other regulatory violations.