Inspection Reports for
Jewish Senior Services

The investigation was complaint-driven, focusing on allegations of neglect, dignity issues, medication errors, infection control, and safety concerns.

The facility was found deficient in multiple areas including failure to ensure dignified dining, failure to maintain privacy for urinary collection devices, failure to document and investigate grievances and allegations of neglect, failure to notify the State Ombudsman of resident discharge, failure to follow resident care plans, failure to follow physician orders, failure to maintain safe water temperatures, medication errors, unsafe medication storage, and inadequate infection control practices.

The facility failed to ensure the five rights of medication administration were followed, resulting in Resident #1 receiving 40 units of Humalog insulin instead of the prescribed 14 units. The error was attributed to RN #1 feeling flustered during the shift, and education was provided to the nurse regarding proper medication administration protocols.

The investigation was initiated following a complaint about injuries of unknown origin to Resident #1, who had no documented falls or trauma. The complaint was substantiated with findings of a right humerus transverse fracture and a left femur spiral fracture, both attributed by the orthopedic surgeon to trauma.

The facility failed to ensure Resident #1 remained free from significant injuries, including a left femur fracture and a right humerus fracture. Despite a thorough investigation, the facility was unable to determine the cause of the injuries. Interviews with staff and review of clinical records revealed no known falls or accidents prior to the discovery of the injuries.

The complaint investigation found that Resident #1's physician's orders dated 5/27/24 for nectar thick liquids and one-to-one supervision were not transcribed. Interviews with staff confirmed communication failures and lack of documentation. The facility's audit protocol was not performed as required.

The facility failed to transcribe physician's orders for Resident #1 regarding diet modifications and one-to-one feeding supervision, despite documented changes and speech therapy recommendations. The facility's 24-hour chart check audit protocol was not followed, and no policy for transcribing physician's orders was provided.

The complaint investigation found substantiated medication errors involving Resident #1, including transcription errors by RN #1 and administration errors by LPN #1, leading to hypoglycemia and hospitalization. Immediate Jeopardy was identified and later removed after corrective actions.

The facility failed to accurately transcribe readmission medication orders, resulting in Resident #1 receiving incorrect doses of insulin and Cymbalta, leading to a hypoglycemic event requiring hospitalization. Additionally, emergency glucagon (insta-glucose) was not readily accessible on the resident's unit, delaying treatment. The facility implemented corrective actions including staff education and placement of emergency glucose on all units.

The Department found multiple serious deficiencies including failure to accurately transcribe medication orders leading to hypoglycemic events and hospitalizations, inadequate assistance with mobility and protective equipment, failure to prevent falls and pressure ulcers, and ineffective resident elopement prevention measures. Immediate Jeopardy was identified on several occasions, and civil penalties were imposed.

The complaint investigation involved allegations of abuse including physical altercations between residents and mistreatment by staff. The investigation substantiated violations related to failure to notify providers, failure to prevent abuse, failure to revise care plans, and failure to report allegations timely.

The facility was found to have multiple violations related to failure to notify the psychiatric provider of changes in resident behavior, failure to ensure residents were free from physical abuse, failure to revise care plans following incidents, and failure to report suspected mistreatment within required timeframes.

The complaint investigation found that Resident #2 exhibited aggressive behavior, including grabbing Resident #1 by the neck, resulting in a minor abrasion. The facility staff intervened, notified the nursing supervisor, APRN, psychiatry, and responsible parties, and transferred Resident #2 to the emergency department. The facility policy on abuse was reviewed and staff interviews confirmed actions taken.

The facility failed to ensure a resident was free from physical abuse when Resident #2 was observed grabbing Resident #1 around the neck. Staff intervened, and Resident #2 was transferred to the emergency department. The facility implemented 1:1 supervision and notified appropriate parties.

The complaint investigation was substantiated with findings that staff failed to provide assistance with bed mobility and failed to apply elbow pads as ordered, contributing to an acute fracture. The resident was non-verbal and dependent on staff. Staff interviews revealed routine care was provided without required assistance or protective equipment. The APRN noted the resident's osteoporosis increased fracture risk but could not directly link the injury to care failures.

The facility failed to provide appropriate assistance with bed mobility and failed to apply prescribed elbow pads for Resident #1, resulting in an acute fracture of the left olecranon process. Interviews and clinical record reviews confirmed noncompliance with the care plan and physician orders, with minimal harm to the resident.

The investigation was triggered by a complaint regarding Resident #1's fall. The complaint was substantiated as the facility failed to provide required assistance and supervision, contributing to the resident's fall and injury.

The facility failed to ensure the comprehensive care plan included the resident's resistive behaviors and failed to provide adequate supervision and assistance during ambulation, resulting in a fall with significant injury and subsequent death of Resident #1. Staff did not consistently provide the required assist of one during ambulation, and communication failures were noted among staff.

The facility was found deficient in multiple areas including failure to prevent pressure ulcers related to medical devices, inadequate supervision to prevent accidents for a resident at risk of self-harm, medication administration errors including failure to identify residents properly, failure to review pharmacist recommendations, improper medication storage and handling, inadequate infection control practices related to glucometer use, and failure to ensure pneumococcal vaccination was offered and documented.

The visit was complaint-related involving allegations of elopement, abuse (including sexual abuse), failure to report and investigate abuse, failure to activate emergency medical response, failure to ensure physician visits, and failure to provide trauma-informed care. Substantiation status is not explicitly stated.

The facility was found deficient in timely notification of elopement incidents, failure to prevent elopement resulting in immediate jeopardy, failure to ensure residents were free from abuse including sexual abuse, failure to timely report and investigate abuse allegations, failure to activate emergency medical response appropriately, failure to ensure physician visits were conducted as required, failure to provide trauma-informed care, and failure to document abuse incidents properly.

Complaint investigations #30709, 29938, 25799 in 2021 and #00032653, 00032679 in 2022 were conducted. Violations were substantiated as deficiencies were cited.

The facility was found noncompliant with several regulations including failure to assess pressure wounds timely, maintain a safe environment, provide competent staff, secure medication rooms, and ensure staff wore identification badges. Medication administration errors and failure to follow medication administration rights were also noted, resulting in significant resident harm.

The visit was complaint-related based on complaints CT# 00032653 and CT# 00032679. Violations were substantiated as indicated by the findings of medication errors and other deficiencies.

Violations of Connecticut State Agencies regulations were identified, including significant medication errors resulting in hospital admission, failure to ensure newly licensed nurse competency, and incomplete annual employee performance evaluations. Immediate jeopardy findings were noted related to medication administration errors.

Standard-level deficiencies were identified related to supervision of licensed practical nurses and home health aides, and failure to monitor and verify clinical documentation completeness, accuracy, and timely submission. The agency was in compliance with staff vaccination regulatory requirements at the time of the survey.

Complaint investigation involved multiple complaint numbers (#26281, #26419, #28742, #29874, and #30663). The report does not explicitly state substantiation status.

The facility was found to have violations related to failure to complete an admission skin assessment for a resident with an alteration in skin condition. Documentation deficiencies were noted in skin assessments and care plans for the resident. The facility's wound management program and monitoring procedures were reviewed.

The complaint investigation included review and interviews related to pressure ulcer care for Resident #177, accident hazards involving Resident #13, staff competency including observation of an LPN sleeping on duty, and medication administration issues for Resident #182 including undated insulin vials and unsecured medication rooms.

The facility failed to ensure timely and proper assessment and measurement of pressure ulcers, maintain a safe and hazard-free environment to prevent accidents, provide competent staff to ensure resident safety, and properly label and secure medications including insulin vials and medication rooms.

The facility failed to ensure appropriate infection control practices were implemented to prevent and control the spread of infection during the COVID-19 pandemic, including improper hand hygiene and reuse of isolation gowns by staff.

A violation of the Regulations of Connecticut State Agencies and/or General Statutes was noted during the visit related to improper hand hygiene and reuse of isolation gowns by nursing staff. The facility was required to submit a plan of correction addressing these issues.

The facility failed to ensure appropriate infection control practices during the COVID-19 pandemic, specifically related to the reuse of isolation gowns without proper hand hygiene. Observations and interviews revealed that a nurse aide donned an isolation gown with ungloved hands without sanitizing, contrary to facility policy and infection control standards.

The facility failed to provide accurate assessment data for Resident #280, as the discharge MDS incorrectly indicated discharge to an acute care hospital due to a data input error, which was acknowledged and planned to be corrected by the Director of Nurses.

The facility failed to ensure the dignity of Resident #240 was maintained during dining, as the resident's urinary catheter bag was observed uncovered and visible to others. Nursing staff were re-educated on the use of privacy bags for residents with urinary catheters, and audits will be conducted to ensure compliance.

The report identified violations related to failure to ensure resident dignity during dining and inaccurate assessment data for a resident. Specific issues included uncovered urinary catheter bags and data input errors in discharge disposition. Plans of correction were submitted to address these deficiencies.

Violations of Connecticut General Statutes and regulations were identified during the inspection, including uncovered urinary catheter bags and inaccurate assessment data. Plans of correction were submitted to address these issues.

The facility failed to ensure the dignity of Resident #240 by allowing an uncovered urinary catheter bag with visible urine to be exposed in common areas, which was observed during dining and therapy sessions. Nursing staff acknowledged the expectation to cover catheter bags despite no formal policy.

The facility was found to be in substantial compliance with the Public Health Code. Citation #2018-49 was verified as corrected and no new violations were identified during this visit.

The complaint investigation involved multiple residents, focusing on an incident where Resident #1 fell from bed and later expired. The investigation found inadequate supervision and failure to follow the care plan for repositioning and assistance. The complaint was substantiated with citations issued.

Violations of Connecticut State regulations were identified during the inspection, including failure to provide adequate supervision to prevent a resident from falling out of bed, resulting in injury. The facility was cited and issued a violation letter with a plan of correction required.

The facility was found to have multiple violations related to resident care, including failure to provide timely assistance for bowel incontinence, incomplete MDS assessments, failure to ensure resident choices were honored, inadequate pressure ulcer prevention, medication storage issues, and infection control deficiencies. The facility submitted a plan of correction and noted a 5-star rating for staffing from CMS.