Inspection Reports for
Masonic Healthcare Center

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

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.

The visit was complaint-related, investigating complaints #39816 and #39734. The report does not explicitly state substantiation status.

The inspection identified multiple violations related to failure to notify physicians about ineffective medications, inadequate care plans for urinary incontinence, failure to assess continence after catheter removal, and failure to address and document behaviors properly. Resident #1 was the focus of several findings involving medication management, fall incidents, and care planning.

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.

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

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

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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 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.

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.

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.

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.

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.

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.

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.

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

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 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 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 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.