Inspection Reports for
Ark Healthcare and Rehab Branford Hills

The facility failed to ensure proper notification to the provider for missed insulin administrations, failed to collaborate effectively with the pharmacy to ensure medication delivery, and failed to document missed medication administrations and related interventions accurately in the clinical record.

The complaint investigation focused on medication administration failures for Resident #1, including missed insulin doses and failure to notify the provider or pharmacy. The complaint was substantiated with findings of multiple missed doses and lack of notification.

The facility failed to ensure the provider was notified for each missed administration of Humulin-R insulin for Resident #1, resulting in missed doses over multiple days. Additionally, the facility failed to collaborate effectively with the pharmacy to clarify and deliver the medication, and failed to document missed medication administration and interventions in the clinical record.

The complaint investigation focused on Resident #1's wandering and exit seeking behaviors. The facility failed to notify the family and APRN when a wander guard was applied, failed to update the care plan, and failed to provide adequate supervision, leading to the resident eloping from the facility on 9/8/2024. The investigation found multiple policy and procedural failures contributing to the incident.

The facility failed to notify the resident's family and APRN when a wander guard was applied, failed to develop and implement a comprehensive care plan for wandering behaviors, and failed to provide adequate supervision to prevent elopement. These failures resulted in an incident where the resident eloped from the facility, leading to a finding of Immediate Jeopardy.

The complaint investigation focused on Resident #1's wandering and exit seeking behaviors, failure to notify family and APRN about the wander guard placement, inadequate care planning, and insufficient supervision leading to an elopement incident on 9/8/2024. The complaint was substantiated with findings of Immediate Jeopardy.

The facility failed to notify the resident's family and APRN when a wander guard was applied, did not develop or update a comprehensive care plan addressing wandering behaviors, and failed to ensure adequate supervision to prevent elopement. Resident #1 eloped from the facility despite a wander guard being in place, which was found cut off after the incident. The facility was found to be in Immediate Jeopardy due to these failures.

The complaint investigation found that the facility did not substantiate weekly wound assessment documentation for Resident #1's pressure ulcers. The wound nurse and nursing staff were responsible but failed to complete the required documentation. The ADNS confirmed the documentation should have been done. The DON was unavailable for interview.

The facility failed to document weekly wound tracking and measurements for pressure ulcers on Resident #1, including a Stage 2 coccyx wound and a right calf wound. Interviews revealed that the wound nurse and nursing staff did not complete required documentation, contrary to facility policy.

The facility failed to complete weekly wound assessments for Resident #1's pressure ulcers as required by policy. Documentation was missing for weekly measurements and tracking of wounds, including a Stage 2 coccyx wound and a right calf wound, despite physician orders and wound nurse involvement.

The complaint investigation focused on medication administration errors and failure to obtain ordered laboratory tests for Resident #2. The medication error was substantiated, and the laboratory test omission was confirmed by the DNS and PA #1.

The facility failed to ensure Resident #2 was administered the correct dose of Levothyroxine, resulting in a medication error where the resident received a total dose of 125 MCG instead of the ordered 75 MCG daily. Additionally, the facility failed to obtain the physician-ordered blood work on the scheduled date to assess the resident's thyroid function.

The complaint investigation focused on medication administration errors and laboratory service failures for Resident #2. The medication error involved administration of an incorrect dose of Levothyroxine from 6/12/2024 to 7/11/2024. The laboratory service failure involved not obtaining the ordered blood work on 7/8/2024. Interviews with the Physician Assistant, Director of Nursing Services, and Assistant Director of Nursing Services confirmed these issues.

The facility failed to ensure Resident #2 was administered the correct dose of Levothyroxine, resulting in a medication error where the resident received a total dose of 125 MCG instead of the ordered 75 MCG daily. Additionally, the facility failed to obtain physician-ordered blood work on 7/8/2024 to assess thyroid function as required.

Violation #1 was identified as corrected as of 7/15/24. The Assistant Director of Nursing Services was notified on 7/18/24 that all violations were corrected.

The on-site revisit confirmed that Violation #1 was corrected as of 6/21/24. The DNS, Julie Feder, was notified in person of the correction on 6/25/24 at 2:00 PM.

The facility failed to ensure staff utilized leg rests when moving a wheelchair-dependent resident, resulting in a resident falling and sustaining a nasal fracture. Staff were re-educated on the requirement to keep wheelchair leg and foot rests on when transporting residents.

The complaint investigation found that Resident #2 fell from a wheelchair when leg rests were not used during transport by recreation staff. The fall resulted in a nasal ridge fracture. The complaint was substantiated with evidence from clinical records, facility documentation, and interviews.

The facility failed to ensure staff utilized leg rests when moving a wheelchair-dependent resident, resulting in Resident #2 falling forward and sustaining a nasal ridge fracture. Staff were re-educated on the requirement to keep wheelchair pedals on at all times during transport.

Complaint numbers #30582 and #38818 were investigated. The complaint was substantiated based on the fall incident involving Resident #2 due to staff not using leg rests on the wheelchair during transport.

The facility failed to ensure staff utilized leg rests when moving a wheelchair-dependent resident, resulting in a fall and nasal fracture for Resident #2. Staff education and policy retraining were implemented as corrective actions.

Complaint investigation involved multiple complaint numbers (CT #s 32468, 38575, 38617, 38639).

The facility was found noncompliant with Connecticut State regulations related to resident transfers, specifically failing to provide adequate assistance during a transfer resulting in a fall and injury to Resident #4. The facility submitted a plan of correction addressing staff retraining and audit procedures to prevent recurrence.

The facility failed to utilize required safety measures, including gait belts and rolling walkers, during a two-person stand-pivot transfer of a resident, resulting in a reopened healing skin tear that required hospital treatment. The facility policy mandates gait belt use for all residents needing transfer assistance, but it was not followed during the incident.

The facility failed to utilize required safety measures, including gait belts and rolling walkers, during a two-person stand-pivot transfer of Resident #2, resulting in a reopened healing skin tear and a laceration that required emergency treatment and sutures. Interviews and documentation confirmed noncompliance with facility policy on gait belt use.

The visit was complaint-driven based on complaints #38348 and #38502. The complaint was substantiated as violations were identified during the inspection.

Violations of Connecticut State regulations were identified related to the failure to utilize safety measures during patient transfers, resulting in a resident sustaining a laceration. The facility was found noncompliant with requirements for safe resident handling and transfer protocols.

The facility failed to ensure two caregivers were present during care for a resident with inappropriate sexual behaviors and failed to monitor targeted behaviors related to antipsychotic medication use as required by the care plan and facility protocol.

The facility failed to ensure two caregivers were present when providing care to a resident with inappropriate sexual behaviors, and failed to monitor targeted behaviors related to antipsychotic medication use as required by the care plan and facility policy.

The facility was found deficient in multiple areas including discharge planning, resident rights, abuse prevention, medication administration, pressure ulcer care, nutrition monitoring, respiratory care, infection control, and food safety practices.

The facility was found deficient in multiple areas including failure to ensure resident participation in discharge planning, call bell accessibility, prevention of abuse, timely reporting of abuse allegations, medication administration infection control, appropriate respiratory care, nutrition supplement monitoring, pressure ulcer prevention, audiology services access, feeding tube care, and food safety documentation.

The complaint was substantiated. The facility failed to change the oxygen tubing weekly for Resident #95 as required, which was confirmed by observation, record review, and staff interview.

The facility failed to change the oxygen tubing for Resident #95 in accordance with physician orders and facility policy. The oxygen tubing was not changed weekly as required, and documentation was incomplete.

The complaint investigation found that the facility did not comply with physician orders to change oxygen tubing weekly for Resident #95. The issue was substantiated based on observations, record reviews, and staff interviews.

The facility failed to change the oxygen tubing for Resident #95 in accordance with physician orders and facility policy, despite orders to change it weekly. The medication administration record did not consistently document tubing changes, and staff interviews confirmed the tubing was not changed as required.

The facility failed to develop a baseline care plan for a resident receiving dialysis and failed to apply a physician-ordered positioning/splinting device for another resident. Both deficiencies were identified through clinical record reviews and staff interviews.

The facility failed to develop a baseline care plan for a resident receiving dialysis and failed to apply a physician-ordered positioning/splinting device for another resident, resulting in minimal harm or potential for actual harm to a few residents.