Inspection Reports for
Arden Care Center

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 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 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 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 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 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 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 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 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 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 substantiated violations concerning resident rights and dignity. Complaints #35470 and #39397 were investigated and violations were found.

Violations of the General Statutes of Connecticut and regulations were identified, including failure to ensure a resident was treated with dignity and respect during a staff conversation. Specific findings involved inappropriate staff-resident interactions and failure to uphold resident rights.

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.

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 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 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 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 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 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 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 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 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 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.