Inspection Reports for Masonic Healthcare Center

The visit was an on-site follow-up inspection to verify correction of previous deficiencies.

No violations of the General Statutes of Connecticut or regulations were identified at the time of this inspection. All previously identified violations were corrected as of 12/25/2024.

The visit was conducted for the purpose of reviewing the plan of correction to the violation letter dated 12/9/24.

No violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection. Violation #1 was identified as corrected as of 12/25/24.

The inspection visit was conducted as a renewal licensing inspection and included review of complaint investigations numbered 40798, 41253, and 41343.

The report form does not explicitly state specific findings or violations; no violations or citations are marked as identified or issued in the provided document.

The inspection visit was conducted as a complaint investigation related to Complaint Investigations #41503 and #41753.

Violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection, as referenced in an attached violation letter dated 2024-12-09.

The visit was complaint-related, investigating Complaint Investigations #41503 and #41753. Violations were substantiated as indicated by the attached violation letter.

An unannounced visit was made to Masonicare Health Center on November 13, 2024, by a representative of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting multiple investigations.

The report details a fall incident involving Resident #1 due to improper transfer technique by staff, resulting in a scalp hematoma and subdural hematoma. The facility identified staff training deficiencies and took corrective actions including remedial education and removal of the responsible staff member.

Complaints #41503 and #41753 triggered the investigation. Substantiation status is not explicitly stated.

The inspection was conducted as a complaint investigation related to complaint numbers 39816 and 39734, to identify violations of Connecticut State regulations at Masonicare Health Center.

The inspection found multiple violations related to failure to notify physicians about ineffective medications for resident behaviors, inadequate care plans for urinary incontinence, failure to assess continence after catheter removal, and failure to properly address and document resident behaviors. Resident #1 was involved in several findings including medication management, fall with injury, and behavioral issues.

The visit was complaint-related for complaints #39816 and #39734. The complaints were substantiated with findings of noncompliance in multiple areas including medication management, care planning, and behavior management.

Multiple complaint investigation surveys were conducted at Masonicare Health Center on 5/24/23 and 5/25/23 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities.

The investigation included record reviews, interviews, staffing review, observations, and a tour of the facility. As a result, deficiencies were identified.

Multiple complaint investigation surveys CT# 32065, #32716 and #33946 were conducted.

Revisit to the facility to follow up on previous findings from 12/11/23 and VL 1/4/23, as well as to review complaint investigation #33718.

No violations of the General Statutes of Connecticut or regulations of Connecticut State Agencies were identified at the time of this inspection.

Complaint investigation #33718 was reviewed during this visit; no violations were found.

The inspection was conducted as a licensing renewal inspection and included a complaint investigation related to multiple complaint numbers.

Issues were identified during the inspection, including concerns related to restraint utilization and/or seclusion, as noted in the violation letter.

Complaint investigation was conducted for complaint numbers 33146, 337501, 33318, 29955, and 29971. Issues were identified and substantiated as indicated by the violation letter dated 1/4/23.

A desk audit was conducted to review the implementation of the plan of correction from the violation letter dated 12/16/2021.

The violation(s) identified in the previous inspection have been corrected. The DNS was notified that State Violation(s) #1 was corrected.

An unannounced visit was made to Masonicare Health Center on December 8, 2021, for the purpose of conducting an investigation related to a complaint (Complaint Investigation #CT 31291).

Violations of the General Statutes of Connecticut and/or regulations were identified during the inspection, specifically related to failure to enter a verbal order given by an APRN into the electronic medical record. The facility failed to document a verbal order for medication administration for one resident.

Complaint Investigation #CT 31291 was substantiated with violations identified related to failure to document verbal orders in the electronic medical record.

An unannounced visit was made to Masonicare Health Center on August 16, 2021, by a representative of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting an infection control survey.

The facility failed to ensure three of four running fans in the clean linen area were clean, and a laundry worker did not wear appropriate Personal Protective Equipment when transferring dirty laundry. The fans were coated with dust and debris, and the facility lacked a preventative maintenance policy for cleaning fans in the laundry area.

A COVID-19 Focused Infection Control Survey and a Complaint Investigation Survey were conducted to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities.

The facility was found deficient for neglect related to failure to provide incontinent care to Resident #1 during the 11:00 PM to 7:00 AM shift on 7/1/21, leaving the resident in a urine-saturated bed until care was provided the next day. Additionally, the facility failed to complete an annual performance evaluation for Nurse Aide #3 involved in the complaint.

The complaint investigation was triggered by an allegation that Resident #1 did not receive incontinent care during the 3rd shift on 6/30/21 to 7/1/21. The allegation was substantiated based on interviews, documentation, and observations. Staff involved were suspended and ultimately terminated. The facility reported the incident to authorities and provided staff education and audits to prevent recurrence.

An unannounced visit was made to Masonicare Health Center on July 28, 2021, by a representative of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting an investigation related to complaint CT #30488.

The facility was found to have failed to ensure a resident was free from neglect related to incontinent care during the night shift on 7/1/21, and failed to complete an annual performance evaluation for a nurse aide. Staff involved were suspended or disciplined, and plans of correction were required.

Complaint CT #30488 triggered the investigation. The complaint alleged neglect of Resident #1 related to incontinent care. The investigation substantiated that Resident #1 did not receive incontinent care during the night shift on 7/1/21, resulting in neglect. Staff involved were suspended and disciplined.

An unannounced visit was made to Masonicare Health Center on March 18, 2021, by a representative of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting an investigation related to a complaint.

The investigation found that Resident #1 was subject to misappropriation and exploitation by facility staff when a nursing assistant took the resident's cell phone without permission and used the resident's debit card for personal use. The facility failed to protect the resident from this exploitation. Staff involved were suspended and the nursing assistant was terminated. The police investigation was closed as the resident did not want to press charges.

The complaint investigation substantiated that Resident #1's debit card and personal property were misappropriated by staff. The police were notified and an investigation was conducted. Staff members matching the description were suspended and one terminated. The police investigation was closed as Resident #1 did not want to press charges.

A COVID-19 Focused Survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including infection prevention and control practices to prevent COVID-19 transmission.

Deficiencies were cited related to resident rights violations involving privacy during personal care, and infection prevention and control failures including improper social distancing, incorrect use and disposal of PPE, inadequate signage, and improper storage of face shields.

A COVID-19 Focused Infection Control Survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including infection prevention and control practices to prevent COVID-19 transmission.

Deficiencies were identified including failure to notify a responsible party of a change in condition for one sampled resident. The facility did not notify the designated contact of Resident #1's change in condition and new physician orders related to urinary symptoms and fever.

The investigation was triggered by a complaint regarding failure to notify the responsible party of Resident #1's change in condition. The complaint was substantiated as the facility failed to notify Person #1 despite multiple communications indicating Person #1 was the designated contact for health concerns.

An unannounced visit was conducted at Masonicare Health Center to perform a Covid-19 focused infection control survey.

The facility was found to have violated regulations by failing to notify the designated responsible party of a change in condition for one sampled resident. The facility did not notify Person #1 of Resident #1's change in condition and new physician orders in a timely manner.

Unannounced visits were made to Masonicare Health Center concluding on September 28, 2020, for the purpose of conducting an investigation and a COVID-19 Focused Infection Control Survey triggered by complaint #28370.

The facility was found noncompliant with regulations related to mistreatment allegations involving residents #3 and #4, failure to provide comprehensive social service support, inadequate infection control practices, and failure to ensure staff COVID-19 testing compliance. Multiple interviews, clinical record reviews, and observations documented concerns about resident care, staff behavior, and infection control.

Complaint #28370 involved allegations of mistreatment by nursing assistants toward Residents #3 and #4. The complaint was investigated through interviews, clinical record reviews, and observations. Findings substantiated concerns about rough and undignified care, bullying, and failure to provide psychosocial support. The facility failed to adequately address and document follow-up on these allegations.

A COVID-19 Focused Infection Control Survey and a complaint investigation were conducted on 09/24/20, 09/25/20 and 09/28/20 with additional information obtained on 10/05/20 at Masonicare Health Center to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including proper infection prevention and control practices to prevent the transmission of COVID-19.

Deficiencies were identified related to failure to provide care in a dignified manner to Resident #4, failure to provide comprehensive social service support to Residents #3 and #4, failure to ensure appropriate use of personal protective equipment (PPE) in resident areas, and failure to conduct staff COVID-19 testing in accordance with CMS and CDC guidance.

The complaint investigation involved allegations of mistreatment by nursing assistant NA #3 towards Residents #3 and #4, including rough and rude care, intimidation, and failure to provide dignified care. Social Worker #3 failed to provide adequate psychosocial follow-up support after initial visits. Resident #4 reported avoiding call bells and care due to fear of NA #3.

A COVID-19 Focused Infection Control Survey was conducted to determine compliance with 42 CFR §483.80 Infection Control regulations for Long Term Care Facilities.

The facility has implemented the CMS and CDC recommended practices related to COVID-19. No deficiencies were cited as a result of this survey.

A COVID-19 Focused Survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including proper infection prevention and control practices to prevent the development and transmission of COVID-19.

No deficiencies were cited as a result of this COVID-19 focused survey.

A COVID-19 Focused Survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including proper infection prevention and control practices to prevent the development and transmission of COVID-19.

No deficiencies were cited as a result of this COVID-19 focused survey.

An unannounced visit was made to Masonicare Health Center on June 6, 2019, by a representative of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting an investigation related to a complaint of abuse.

The facility was found to have failed to ensure that Resident #1 was free from verbal abuse and misappropriation of personal property. The investigation identified verbal abuse by a nurse aide and substantiated the allegation of abuse, resulting in termination of the nurse aide's employment.

Complaint #25519 was investigated. The allegation of verbal abuse by a nurse aide was substantiated. The nurse aide's employment was terminated on 5/29/19. An attempt to interview the nurse aide was unsuccessful.

Unannounced visits were made to Masonicare Health Center on January 23, 24, 25, 28, and 29, 2019 by representatives of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting multiple investigations and a licensure inspection.

The report details multiple violations of Connecticut General Statutes and Regulations related to care and services provided to residents, including failures in therapeutic communication, review of advance directives, pain management interventions, and psychotropic medication orders. Plans of correction are outlined for each violation to address these deficiencies.

The visit was complaint-related, involving complaints #23116, 23607, and 23675. Specific substantiation status is not stated.

An unannounced visit was made to the facility on November 30, 2018 by a representative of the Facility Licensing & Investigations Section for the purpose of conducting an investigation.

The facility failed to ensure that a resident's medical record was accurate, specifically failing to appropriately document the administration of a PRN nebulizer treatment in the electronic Medication Administration Record (MAR). The resident's symptoms worsened, requiring transfer to the Emergency Department.

The investigation was complaint-related, focusing on the accuracy of medical record documentation for one resident who received respiratory treatments. The complaint was substantiated by findings of incomplete documentation and failure to follow facility policy.

The document is a plan of correction addressing deficiencies found related to medication administration documentation in the electronic MAR.

The facility failed to appropriately document the PRN nebulizer in the electronic MAR, placing all residents potentially at risk. Education and monitoring plans are outlined to ensure compliance.