Inspection Reports for
Northbridge Health Care Center

The complaint investigation substantiated that Resident #1 was improperly restricted from leaving the facility despite being alert and oriented, and that inadequate supervision during 1:1 monitoring led to Resident #1 physically assaulting Resident #3. The facility investigation confirmed the incidents and identified staff failures in supervision and care planning.

The facility failed to honor Resident #1's right to leave the facility at will, as directed by a court-appointed Conservator, resulting in restrictions and agitation. Additionally, the facility failed to ensure adequate supervision during continuous one-to-one monitoring, leading to Resident #1 physically assaulting Resident #3. Deficiencies included failure to update care plans and assessments, inadequate supervision, and failure to prevent resident-to-resident abuse.

The complaint investigation involved allegations of inadequate discharge planning for Resident #2 and resident-to-resident sexual abuse involving Residents #1 and #2. The facility was found to have failed in timely discharge planning, care planning for the residents' relationship, and supervision to prevent inappropriate contact. Both residents had court-appointed Conservators of Person (COP), and multiple staff interviews confirmed awareness of the relationship and incidents.

The facility failed to develop and implement a timely discharge plan for Resident #2, did not create a comprehensive care plan addressing the relationship and abuse allegations between Residents #1 and #2, and failed to provide adequate supervision to prevent a resident-to-resident sexual incident. Multiple interviews and record reviews confirmed these deficiencies with minimal harm and few residents affected.

The facility failed to ensure the RN supervisor was timely notified of a resident's burn injury and that a timely RN assessment was completed. The resident sustained a first degree burn during a shower, and the RN supervisor was only notified via a text message after the fact, with no timely follow-up assessment documented.

Complaint #44004 was investigated. The complaint involved a resident who sustained a first degree burn during a shower on 4/12/2025. The RN supervisor was not notified timely, and the Licensed Practical Nurse failed to notify the RN. The complaint investigation concluded with identification of noncompliance.

The investigation identified a violation related to nursing supervision and resident care, specifically concerning a resident who sustained a first degree burn during a shower and the subsequent failure of timely notification and assessment by nursing staff. The facility submitted a plan of correction addressing these issues.

The complaint was substantiated. Verbal abuse was confirmed through interviews and documentation. NA#1 was terminated on 12/17/2024.

The facility substantiated verbal abuse involving foul language exchanged between NA#1 and Resident #1. The resident was not offended and considered the language playful. NA#1 was terminated following the investigation. The facility policy on abuse, neglect, and exploitation was reviewed.

Complaint investigation #42248 was conducted due to allegations of verbal abuse. The abuse was substantiated and resulted in termination of the involved nursing assistant.

The complaint investigation found substantiated verbal abuse by a nursing assistant (NA#1) towards Resident #1, involving the use of foul language. The NA was terminated, and the facility plans to provide staff education on verbal abuse and conduct audits to ensure respectful resident interaction.

Violation #1 was identified as corrected as of 11/29/24. On 12/3/24, the Assistant Director of Nursing Services (ADNS) was notified via telephone that all violations were corrected.

Violation #1 was identified as corrected as of 2024-11-29. On 2024-12-03, the Assistant Director of Nursing Services was notified that all violations were corrected.

The complaint investigation was substantiated by findings that the facility did not initiate an immediate investigation after receiving information from the hospital social worker that Resident #1 was hit in the face by a nurse. The DNS admitted to not following up on the allegation 16 days after the incident.

The facility failed to investigate an allegation of abuse after Resident #1 experienced an unwitnessed fall resulting in significant right hip pain, facial redness, and possible head injury. The Director of Nursing Services (DNS) acknowledged receiving a report from the hospital social worker about the resident being hit in the face by a nurse but did not follow up or initiate an investigation as required by facility policy.

The complaint investigation substantiated verbal abuse by Resident #1 towards Resident #2 on 10/6/2024. The allegation of staff-to-resident verbal abuse involving NA #1 and Resident #4 on 10/5/2024 was not substantiated due to lack of witness and delayed reporting to administration until 10/9/2024.

The facility failed to ensure residents were free from abuse, with substantiated verbal abuse between residents and a failure to timely report a staff-to-resident verbal abuse allegation. Interventions such as 1:1 observation and safety checks were implemented, and investigations were conducted but one allegation was unsubstantiated due to lack of witness.

The facility was found deficient in multiple areas including failure to assess and monitor residents for self-medication administration, inadequate pain management, failure to prevent verbal abuse, untimely reporting of abuse, incomplete care plans, failure to maintain CPR certification and documentation, inadequate nutritional assessments and interventions, failure to ensure safe dental services, improper oxygen tubing management, failure to implement elopement prevention measures resulting in an Immediate Jeopardy event, inadequate infection control practices during wound care, and lack of staff competency evaluations and training documentation.

The complaint investigation involved allegations of verbal abuse by Licensed Practical Nurse (LPN #6) towards Resident #189, failure to timely report the abuse to outside state agencies, failure to revise care plans for residents at risk for elopement and hospice care, failure to maintain CPR certification and documentation, and failure to prevent elopement of Resident #8 who was found 0.6 miles away from the facility. The verbal abuse allegation was substantiated and LPN #6 was no longer employed. Immediate jeopardy was identified due to the elopement incident and failures in supervision and safety measures.

The facility was found to have multiple deficiencies including verbal abuse by staff towards a resident, failure to timely report abuse to outside agencies, failure to revise care plans timely for residents at risk, failure to maintain CPR certification and documentation for staff, and failure to prevent elopement of a resident at risk resulting in immediate jeopardy.

The facility failed to ensure timely assistance with meals for Resident #1, who required extensive help to eat. Observations showed a 30-minute delay between meal tray delivery and feeding, which did not meet the expectation of feeding within 10 minutes after tray delivery.

The complaint investigation involved Resident #92's fall resulting in a hip fracture, an allegation of mistreatment by staff towards Resident #39 which was unsubstantiated, and concerns about supervision and safety related to Resident #22's possession of smoking materials, intoxication, and elopement. The facility's failure to follow care plans, policies, and proper supervision were central to the complaint findings.

The facility failed to follow standards of care and facility policies related to fall prevention, use of gait belts, proper supervision of residents, and agency staff orientation. Resident #92 sustained a hip fracture after a fall due to improper ambulation assistance. Resident #39's allegation of mistreatment was unsubstantiated but improper transfer techniques were identified. Resident #22 was inadequately supervised, leading to possession of smoking materials, intoxication, and elopement. Additionally, staff failed to comply with dress code policies regarding fingernail hygiene.

Complaint numbers #30833 and #31198 are referenced, indicating the visit was complaint-related.

The report details violations of Connecticut State regulations identified during the visits, including failures in following care plans related to gait belt use, supervision of residents, infection control dress code policies, and staff identification badge compliance. Plans of correction were required to address these deficiencies.

Complaint investigations CT 31198 and 30833 were reviewed during the inspection.

Violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified during the inspection, resulting in a citation #27-02. The report included verification of CMP fund, CRF grant, Shift Coach, and infection prevention and control specialist status.

Complaint #30303 regarding allegations of inappropriate sexual behavior between two residents. The complaint was substantiated based on interviews, clinical record reviews, and facility documentation.

The investigation found that Resident #1 was observed engaging in inappropriate sexual touching of Resident #2, and the facility failed to ensure Resident #2 was free from sexual abuse. Additionally, the facility failed to report the incident of sexual abuse to the Nursing Supervisor and the state agency within the required timeframe, and failed to ensure the physician or APRN were informed of a new medication recommendation.

The facility was found deficient in multiple areas including failure to treat a resident with respect and dignity by not maintaining a homelike environment, failure to accommodate a resident's language preference for a Spanish speaking channel, failure to investigate a resident's missing dentures, failure to provide a resident with physician-ordered nutritional items, and failure to secure medication storage rooms properly.