Inspection Reports for
Arden Care Center

The facility was found deficient in informing residents about their health status and treatment options, documenting and administering controlled substances properly, and ensuring medication administration followed provider orders. Deficiencies involved failure to inform a resident of a new diagnosis, improper documentation of controlled substance removal and administration, and medication errors including incorrect dosing and administration timing.

The complaint investigation focused on medication administration and resident care for Resident #4, including failure to inform the resident of a new diagnosis, failure to document controlled substance handling, and medication administration errors. The complaint was substantiated with findings of minimal harm or potential for harm.

The facility failed to inform Resident #4 of a new diagnosis and treatment options, failed to document controlled substance removal and administration properly, and administered medications incorrectly, including incorrect doses and administration prior to receiving provider orders. Deficiencies involved failure to support informed decision-making, medication documentation errors, and medication administration errors.

The complaint investigation was substantiated. An agency nurse, LPN #1, was alleged and found to have taken oxycodone 5 mg tablets for personal use. The facility and police were notified, and the nurse was terminated from the staffing agency. Multiple interviews and video surveillance confirmed the misappropriation and documentation irregularities.

The facility failed to prevent the wrongful removal and personal use of narcotic medication by a licensed practical nurse, failed to ensure narcotic medications were administered and documented accurately per physician orders, and failed to conduct proper narcotic shift counts and maintain accurate controlled substance documentation.

The complaint investigation was substantiated with findings that an agency nurse (LPN #1) was alleged and found to have taken oxycodone 5 mg tablets from the medication cart for personal use. The investigation included review of surveillance footage, medication administration records, controlled substance logs, and staff interviews. LPN #1 was terminated from the staffing agency. Documentation discrepancies and failure to follow narcotic count policies were also identified.

The facility failed to prevent the wrongful use of a resident's narcotic medication by a staff member, failed to ensure narcotic medication was administered per physician's orders and documented accurately, and failed to conduct proper narcotic shift counts and maintain accurate controlled substance documentation.

Violations #1 through #3 were identified as corrected during the desk audit. The facility administrator and ADNS were notified of the corrections on the same day.

The complaint investigation involved Resident #3 who had a history of wandering and resided on a secured unit. The resident was able to exit the unit through an unlatched door and was found outside the building. Staff maintained line-of-sight and redirected the resident back inside without incident. The door was left slightly ajar by a staff member who failed to ensure it was locked.

The facility failed to ensure the entrance door to a secured unit was completely latched, allowing Resident #3, who had a history of wandering and cognitive impairment, to exit the unit unsupervised. Staff maintained line-of-sight and promptly redirected the resident back inside without incident.

The complaint investigation found that Resident #3, who had dementia and a history of wandering, was able to exit the secured unit through an unlatched door. The resident was observed outside the building but was promptly redirected back inside without incident. The investigation identified a staff member failed to ensure the door was locked after entering or exiting the unit. The complaint was substantiated with findings of inadequate supervision and door security.

The facility failed to ensure the entrance door to the secured unit was completely latched, allowing Resident #3 to exit the unit unsupervised. Staff maintained line-of-sight and promptly redirected the resident, but the door was left slightly ajar by a staff member, violating safety protocols.

Violation #1 was identified as corrected as of August 1, 2025, and the Director of Nursing was notified of the correction on September 17, 2025.

The complaint involved Resident #1 who had multiple wounds and was cognitively intact. The facility was found to have failed in notifying the physician about missed wound treatments, neglected wound care resulting in soiled dressings, and failed to investigate an abuse allegation where Resident #1 was left naked and crying in bed. The investigation was delayed and not properly communicated by staff.

The facility failed to notify the physician when wound treatments were refused or not administered, failed to protect Resident #1 from neglect related to missed wound care, and failed to initiate an investigation into an abuse allegation where Resident #1 was found naked and crying in bed. Multiple staff members did not follow proper notification and reporting protocols.

The complaint investigation involved Resident #1 who had multiple wounds and required wound care. The facility failed to notify the physician when wound treatments were refused or not administered on 8/2/2025 and 8/3/2025. Resident #1 was found naked, crying, and left unattended in bed on 8/4/2025, and the facility failed to initiate an investigation immediately upon receiving this allegation. Multiple interviews with staff and family members confirmed these failures.

The facility failed to notify the physician when wound treatments were refused or not administered, failed to protect a resident from neglect when wound treatments were missed, and failed to initiate an investigation into an abuse allegation where a resident was left naked and crying in bed. Multiple staff members did not follow proper notification and reporting protocols.

The investigation substantiated the misappropriation of Resident #2's rings by Nursing Assistant #1. The DON confirmed the incident and the nursing assistant was terminated. A warrant was issued for the nursing assistant's arrest.

The facility failed to ensure staff did not remove Resident #2's jewelry, resulting in misappropriation. An investigation confirmed the incident, leading to termination of the involved nursing assistant and a warrant for arrest.

The facility failed to ensure that the wanderguard bracelet function was monitored for a resident identified at risk for elopement. Documentation and staff interviews confirmed that the wanderguard bracelet function was not checked daily as required by facility policy and physician orders.

The complaint investigation found that Resident #1's wanderguard bracelet function was not checked daily as required, despite physician orders and facility policy. The Regional Clinical Director was unable to provide documentation verifying daily checks. Resident #1 eloped from the facility and was placed on one-to-one observation with the wanderguard bracelet discontinued.

The facility failed to verify the functionality of the wanderguard bracelet for Resident #1, who was at risk for elopement, from 6/19 through 7/7/2025. The Regional Clinical Director confirmed that the wanderguard bracelet function should have been checked daily but documentation was not provided. The facility policy requires placement checks every shift and daily function inspections.

The facility was found to have multiple deficiencies including failure to maintain resident dignity, incomplete care planning with lack of resident involvement, inadequate security of resident funds, poor dining experience, inappropriate use of physical restraints, incomplete care plan revisions, failure to follow pain management orders, inadequate pressure ulcer care, unsecured hazardous areas, nutritional assessment deficiencies, expired medications in stock, missing dentures without proper follow-up, unsanitary kitchen conditions, improper food labeling and storage, inappropriate linen storage, incomplete vaccination education and consent, and unsafe bed placement without required clearance.

The facility was found deficient in multiple areas including failure to maintain resident dignity with catheter care, inadequate resident participation in care planning, insufficient surety bond coverage for resident funds, poor dining experience, inappropriate use of physical restraints, incomplete care plan updates, inconsistent pressure ulcer prevention and care, expired medications in stock, missing dentures without emergency dental care, unsanitary kitchen conditions with improper food labeling and temperature monitoring, improper linen storage, incomplete influenza vaccination education and consent, and unsafe bed clearance in resident rooms.

The facility failed to ensure care plans were reviewed and revised timely to include placement on a secured unit for six residents. Additionally, the facility failed to assess clinical criteria and obtain consent prior to placement on the secured unit for these residents. Documentation of clinical criteria and resident/representative involvement was missing prior to 12/26/2024.

The complaint investigation focused on whether the facility properly reviewed and revised care plans to reflect secured unit placement and whether assessments and consents were obtained prior to placement. The complaint was substantiated with findings of noncompliance.

The facility failed to ensure care plans were timely reviewed and revised to include placement on the secured unit for six residents. Additionally, the facility did not complete assessments or obtain consent prior to placing residents on the secured unit. Documentation of clinical criteria for placement and resident/representative involvement was also lacking.

The complaint investigation was substantiated by video evidence and staff interviews, confirming that LPN #3 removed controlled medication from this facility and two other facilities. The facility reported incident and subsequent investigation included review of medication counts, video surveillance, and staff interviews.

The facility failed to ensure that a controlled medication and its disposition sheet were not removed from the facility by a licensed nurse. The investigation revealed that a Licensed Practical Nurse (LPN #3) took nineteen tablets of Oxycodone belonging to Resident #2, and shift-to-shift counts of controlled medications were not properly conducted by two licensed nurses as required.

The complaint investigation was substantiated. A licensed practical nurse (LPN #3) confessed to removing controlled medication from this facility and two other facilities. Video surveillance and staff interviews confirmed the misappropriation and failure to conduct proper medication counts.

The facility failed to prevent the removal of controlled medication and the corresponding disposition sheet by a licensed nurse. Additionally, the facility failed to ensure shift-to-shift counts of controlled medications were conducted by two licensed nurses as required.

The visit was complaint-related, investigating complaints #41420, #41500, and #41353. The investigation substantiated violations involving misappropriation of controlled medication and failure to follow controlled substance management policies.

Violations of Connecticut State regulations were identified, including misappropriation of controlled medication (Oxycodone) and failure to ensure proper controlled substance counts and documentation. Video surveillance and staff interviews confirmed removal of controlled medication by a licensed practical nurse.

The complaint was related to an allegation of abuse by Licensed Practical Nurse (LPN) #2 during a dressing change on 9/24/24. The allegation was not substantiated due to no witnesses, but LPN #2 was terminated based on prior job performance and customer service trends.

The facility failed to ensure Resident #1 was free from physical and verbal abuse by a staff member during a dressing change. The investigation concluded abuse could not be substantiated due to lack of witnesses, but the involved nurse was terminated based on past performance and customer service issues.

The complaint was related to an allegation of abuse by LPN #2 towards Resident #1 during a dressing change on 9/24/24. The abuse was not substantiated due to lack of witnesses, but LPN #2 was terminated based on employee file and past performance.

The facility failed to ensure Resident #1 was free from physical and verbal abuse by a staff member. The investigation found that LPN #2 was aggressive during wound care, did not follow physician orders for wound treatment, and was terminated based on past performance and customer service trends despite lack of witnesses to substantiate abuse.

The complaint involved Resident #1 reporting that the charge nurse played loud music and responded to a request to turn it off with a racially charged statement. The complaint was substantiated based on staff statements and documentation.

The facility failed to ensure Resident #1 was treated with dignity and respect by a staff member who played loud music and made racially inappropriate remarks. The investigation included review of clinical records, staff statements, and facility policies on resident rights.

The complaint involved Resident #1 reporting that the charge nurse playing loud music refused to turn it off and made a racially insensitive remark stating 'I am brown, and you are white.' The complaint was substantiated based on clinical record reviews, facility documentation, and interviews.

The facility failed to ensure Resident #1 was treated with dignity and respect when a charge nurse playing loud music responded inappropriately to the resident's request to turn off the music, including making a racially insensitive comment. The facility policy on resident rights was reviewed, and interviews with involved staff were attempted but not obtained.

The visit was complaint-related involving allegations of disrespectful treatment and racial remarks by staff toward Resident #1. The complaint investigations #35470 and #39397 were substantiated with violations found.

Violations of Connecticut State regulations were identified related to resident rights and dignity during staff interactions. The facility failed to ensure Resident #1 was treated with dignity and respect during a conversation with staff.

The document outlines the terms and conditions for licensing, including requirements for contracting with an Independent Nurse Consultant, appointment of nurse supervisors, quality assurance programs, emergency preparedness, and compliance with life safety and facility maintenance standards. It includes a plan of correction with timelines for repairs and compliance.

The complaint investigation found that Resident #2's room was changed without the required thirty-day notice and without Resident #2's consent. The complaint was substantiated based on interviews with the Director of Nursing, Director of Social Services, and review of facility policies and clinical records.

The facility failed to notify Resident #2 and provide the required written notice prior to changing the resident's room after hospital discharge. Interviews and documentation review confirmed the room change was made without Resident #2's knowledge or consent, violating resident rights and facility policies.

Complaint investigation regarding failure to provide required written notice of room change to Resident #2. The complaint was substantiated based on clinical record reviews, interviews, and facility documentation.

The facility failed to notify Resident #2 and provide the required written notice prior to changing the resident's room following hospitalization. Interviews with staff confirmed the room change was made without Resident #2's prior knowledge or consent, and documentation of notification was not provided. Facility policies require notification and resident consent for room changes, which were not followed in this case.

The complaint investigation was substantiated based on witness statements confirming NA #3 yelled at Resident #2. The administration facilitated termination of NA #3's employment.

The investigation substantiated that NA #3 yelled at Resident #2, constituting verbal abuse. NA #3 was directed to leave the facility and subsequently terminated. Resident #2 was assessed and found to have no injuries and reported feeling safe.

The complaint investigation was substantiated based on witness statements and facility investigation. NA #3 was found to have yelled at Resident #2 on 2/23/2024, leading to suspension and termination of NA #3's employment.

The facility substantiated that NA #3 verbally abused Resident #2 by yelling and screaming at the resident while providing care. The resident was found to have no injuries and reported feeling safe. NA #3 was suspended and subsequently terminated for the abuse.

The complaint investigation included allegations of medication errors involving missed doses of anti-seizure medications for Resident #1, and allegations of resident-to-resident sexual abuse involving Residents #2 and #3. The sexual abuse allegations were substantiated with findings of inappropriate sexual behavior and failure to prevent access to the victim's room. The medication errors resulted in immediate jeopardy due to a resident's hospital admission for seizures.

The facility failed to timely notify the APRN of medication omissions, resulting in missed doses and a resident's hospital admission due to seizures. The facility also failed to prevent resident-to-resident sexual abuse and did not implement adequate interventions to protect residents. Additionally, the facility experienced multiple medication administration errors due to lack of emergency medication supply and improper medication storage temperatures.

The complaint investigation included medication errors involving Resident #1, allegations of resident-to-resident sexual abuse involving Residents #2 and #3, and medication storage concerns. The investigation found substantiated failures in medication administration, notification, abuse prevention, and medication storage.

The facility failed to timely notify the APRN of medication omissions, failed to prevent resident-to-resident sexual abuse, failed to implement interventions to prevent repeated abuse incidents, failed to ensure medications were administered according to physician orders resulting in a significant medication error and hospital admission, and failed to maintain proper medication storage temperatures.

The complaint investigation involved Resident #1's respiratory care and failure to notify the physician or APRN of changes, and Resident #4's neglect allegation involving refusal of care and failure to report the incident timely. The complaint was substantiated with findings of minimal harm or potential for actual harm.

The facility failed to notify the physician or APRN immediately when Resident #1 required suctioning and Albuterol inhaler use for respiratory distress, resulting in delayed evaluation. The facility also failed to reapproach Resident #4 after refusal of care and did not report the neglect allegation timely to the Administrator or Director of Nursing. Interviews and record reviews confirmed these failures, with minimal harm or potential for actual harm noted.

The complaint investigation involved Resident #1's respiratory care and failure to notify medical staff of condition changes, and Resident #4's neglect allegations including refusal of care not properly addressed or reported. The neglect allegation resulted in termination of Nurse Aide #1.

The facility failed to notify the physician or APRN of Resident #1's respiratory status changes requiring suctioning and Albuterol administration. Resident #1 was not evaluated timely by medical staff. The facility also failed to reapproach Resident #4 after care refusal and did not report neglect allegations properly, resulting in termination of a nurse aide.

The facility was found deficient in honoring resident rights related to Leave of Absence (LOA) privileges, ensuring adequate supervision to prevent resident-to-resident abuse, conducting timely discharge planning, performing timely RN assessments after falls, providing adequate supervision to prevent accidents, and maintaining complete and accurate clinical records including documentation of LOAs, falls, and medical appointments.

The investigation was complaint-driven, focusing on allegations of resident rights violations, abuse, inadequate discharge planning, fall management, and incomplete clinical documentation. Substantiation status is not explicitly stated.

The facility failed to honor a resident's rights regarding Leave of Absence (LOA), ensure adequate supervision to prevent resident-to-resident abuse, conduct timely RN assessments after falls, provide adequate discharge planning, and maintain complete and accurate clinical records including documentation of resident leaves, falls, and medical appointments.

The complaint investigation found that Resident #1 eloped from the facility on 10/2/2023, was missing for over two hours, and was found approximately six miles away. The facility failed to complete required elopement risk assessments and implement appropriate interventions despite Resident #1's known verbal exit-seeking behavior. Immediate jeopardy to resident health or safety was identified.

The facility failed to ensure adequate supervision and timely elopement risk assessments for Resident #1, who eloped from the facility and was found approximately six miles away after over two hours. Immediate Jeopardy was identified due to these failures, and subsequent corrective actions including staff education and updated assessments were implemented.

The complaint investigation was triggered by Resident #1 eloping from the facility on 10/2/2023. The resident was missing for approximately 2 hours and 17 minutes and was found about six miles away. The investigation found the facility did not complete required elopement risk assessments and failed to implement interventions despite Resident #1's known behaviors and verbalizations of wanting to leave.

The facility failed to ensure adequate supervision and did not conduct required elopement risk assessments or implement appropriate interventions for Resident #1, who eloped from the facility and was found approximately six miles away. Immediate Jeopardy was identified due to these failures.

The complaint involved an allegation of sexual abuse of Resident #1 reported by hospital personnel. The allegation was substantiated by hospital findings and bruising patterns suspicious for sexual abuse. The facility delayed reporting and investigation. The hospital social worker reported elder abuse to the State on admission. The facility investigation was initiated seven days after notification.

The facility failed to timely report the allegation of sexual abuse to the State Agency and failed to initiate an investigation at the time the allegation was reported. Resident #1 sustained multiple injuries including fractures and bruising suspicious for abuse. The facility's investigation was delayed by seven days after notification by the hospital social worker. Interviews revealed communication and procedural failures in reporting and investigating the abuse allegation.

The complaint involved an allegation of sexual abuse reported by hospital personnel concerning Resident #1. The facility failed to report the allegation to the State Agency promptly and delayed investigation. The allegation was substantiated by hospital findings and social worker reports.

The facility failed to report the allegation of sexual abuse to the State Agency at the time it was reported and failed to initiate an investigation within 24 hours as required. Resident #1 sustained multiple injuries including fractures suspected to be caused by abuse. The facility's investigation was delayed by seven days after notification by the hospital social worker.

The investigation was triggered by complaints alleging staff to resident abuse, misappropriation of funds, inadequate care planning, accident hazards, and medication cart security issues. Substantiation is implied by the findings but not explicitly stated.

The facility was found to have failed in ensuring residents were treated with dignity, protecting residents from misappropriation of funds, developing comprehensive care plans to prevent choking risks, providing adequate supervision to prevent accidents, and securing medication carts when unattended. Several incidents involving residents #1, #2, and #3 were investigated, including verbal and physical altercations, financial misappropriation, a choking episode with immediate jeopardy, and unsecured medication carts.

The investigation was triggered by complaints alleging staff to resident abuse, misappropriation of resident funds, inadequate care planning for choking risk, and medication cart security issues. Some allegations were substantiated, including staff abuse and misappropriation of funds. Immediate jeopardy was identified related to a choking incident.

The facility failed to ensure residents were treated with dignity, protect residents from misappropriation of personal funds, develop comprehensive care plans to prevent choking episodes, provide adequate supervision to prevent accidents, and secure medication carts when unattended. Immediate jeopardy was identified related to a choking incident involving a resident with dysphagia.

The facility failed to ensure quarterly care plan meetings including residents or their representatives, timely review and revision of care plans by the interdisciplinary team, proper monitoring and replacement of wander guard devices, and timely completion of elopement risk assessments. Additionally, the facility failed to secure the generator room door and adequately supervise a resident who eloped, resulting in Immediate Jeopardy to resident health and safety.

The complaint investigation focused on Resident #4's wandering and elopement risk. The facility was found non-compliant for failing to hold care plan meetings, review care plans timely, check and replace wander guard devices properly, and complete elopement risk assessments. Resident #4 eloped from the facility on 4/25/2023 and was found 0.3 miles away after staff were unaware for over two hours. Immediate Jeopardy was cited but was resolved by 4/29/2023 with corrective actions.

The facility failed to hold quarterly care plan meetings including the resident or responsible party, failed to timely review and revise the care plan by the interdisciplinary team, failed to ensure proper placement and function checks of the wander guard device, and failed to complete timely elopement risk assessments. These failures resulted in Resident #4 eloping from the facility and being found 0.3 miles away, leading to an Immediate Jeopardy finding.

The facility was found deficient in multiple areas including failure to ensure privacy for a resident's urinary device, incomplete RN assessments after skin condition changes, inadequate pressure ulcer care, failure to assess a resident after a fall before moving, failure to monitor resident weight as ordered, serving food to a resident with known allergies causing allergic reactions, and improper food storage practices.

The visit was complaint-related, investigating multiple complaints including dignity/privacy concerns, skin care, pressure ulcer management, fall supervision, nutrition monitoring, food allergy incidents, and food storage sanitation. The complaints were substantiated with findings of deficiencies in all these areas.

The facility was found deficient in multiple areas including failure to ensure privacy for a resident's urinary device, incomplete RN assessments after skin condition changes, inadequate pressure ulcer care, failure to assess a resident after a fall by an RN, failure to monitor resident weight as ordered, failure to prevent serving food to a resident with allergies causing allergic reactions, and failure to store food in sanitary conditions.

The complaint investigation involved allegations of environmental deficiencies, failure to report and investigate abuse, inadequate resident care including bathing and splint application, and dietary service issues including food temperature and special diet accommodations. The abuse allegation involving Resident #39 was substantiated as the facility failed to report and investigate properly.

The facility failed to maintain a clean and homelike environment, failed to report and investigate an abuse allegation timely and thoroughly, failed to provide care according to residents' care plans including bathing and splint application, and failed to serve food at appropriate temperatures and according to resident dietary preferences.

The facility was found deficient in maintaining a clean and safe environment, timely reporting and investigating abuse allegations, providing care according to resident plans including bathing and range of motion, monitoring resident weights as ordered, serving food at appropriate temperatures, accommodating resident dietary preferences, and ensuring food service staff compliance with hygiene and safety policies.