Inspection Reports for
Regency House Of Wallingford I
181 E Main Street, Wallingford, CT 06492, CT, 06492
Back to Facility ProfileDeficiencies (last 7 years)
Deficiencies (over 7 years)
6.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
18% worse than Connecticut average
Connecticut average: 5.6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
94% occupied
Based on a September 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Plan of Correction
Census: 122
Capacity: 130
Deficiencies: 5
Date: Sep 24, 2025
Visit Reason
A desk audit was conducted to review the implementation of the Plan of Correction for a prior Violation letter dated August 14, 2025.
Findings
Violations #1 through #5 were identified as corrected as of August 39, 2025. The Director of Nursing was notified of the corrections on September 24, 2025.
Deficiencies (5)
Violation #1
Violation #2
Violation #3
Violation #4
Violation #5
Report Facts
Violations corrected: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kathy Lopez | Director of Nursing | Notified of correction of violations #1-#5 on September 24, 2025 |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Aug 1, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding an alleged resident-to-resident physical abuse incident involving Resident #92 and Resident #134.
Complaint Details
The complaint investigation involved an alleged physical abuse incident between Resident #92 and Resident #134 on 6/29/24. The allegation was substantiated as the incident was witnessed by a charge nurse. The facility delayed notifying the social work department until 7/8/24, seven days after the incident. The social worker was unable to recall details but confirmed Resident #92 is usually not aggressive. The facility took corrective actions including re-education and audits.
Findings
The facility failed to ensure Resident #92 was free from physical abuse and failed to notify the social work department timely about the resident-to-resident altercation. The incident was witnessed by a charge nurse, and although no injury was observed, the facility delayed notifying social work by 7 days. The facility re-educated staff and implemented corrective actions to prevent recurrence.
Deficiencies (2)
Failed to protect Resident #92 from physical abuse by another resident.
Failed to notify the social work department timely of a resident-to-resident altercation to ensure follow-up.
Report Facts
Residents reviewed for abuse: 3
Days delay in social work notification: 7
Date of incident: Jun 29, 2024
Date of report: Aug 1, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing Services | Director of Nursing Services (DNS) | Notified all parties of the abuse incident and involved in investigation |
| Social Worker #2 | Social Worker | Followed up on resident altercation and provided interview information |
| Social Worker #1 | Social Worker | Identified late notification of resident-to-resident altercation and oversaw timely reporting |
| Registered Nurse #1 | Registered Nurse | Interviewed regarding the incident and facility corrective actions |
| Licensed Practical Nurse charge nurse | Licensed Practical Nurse | Witnessed the physical altercation between residents |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Aug 1, 2025
Visit Reason
The inspection was conducted following a complaint regarding resident-to-resident abuse and failure to properly notify social work and ensure timely follow-up, as well as concerns about medication administration and staffing reporting accuracy.
Complaint Details
The complaint involved allegations of resident-to-resident physical abuse and failure to notify social work timely for follow-up. The abuse incident was substantiated with witness statements and documentation. The social work department was notified 7 days late. The facility re-educated staff and implemented corrective actions.
Findings
The facility failed to protect a resident from physical abuse by another resident, delayed notification to social work for follow-up on the altercation, improperly administered medication by giving the wrong formulation, failed to document medication administration accurately, and inaccurately reported weekend staffing data to the Payroll Based Journal.
Deficiencies (5)
Failed to ensure Resident #92 was free from physical abuse by another resident.
Failed to notify social work department timely of a resident-to-resident altercation for follow-up.
Failed to ensure licensed staff used the correct medication formulation as per physician orders for Resident #85.
Failed to document administration of as-needed medications in the medical record for Residents #7 and #85.
Failed to accurately report weekend staffing data to the Payroll Based Journal for quarters 3 and 4 of 2024.
Report Facts
Medication administration dates: 3
Controlled substance removal dates: 9
PBJ quarters with inaccurate staffing data: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #7 | Licensed Practical Nurse | Administered lorazepam tablets after order changed to liquid and failed to document administration |
| DNS | Director of Nursing Services | Notified parties of abuse incident, discussed resident altercation, and identified lack of social work notification |
| SW #2 | Social Worker | Followed up on resident altercation late and unable to recall incident details |
| RN #1 | Regional Nurse | Indicated LPN #7 should have notified DNS about medication administration error and reviewed medication documentation policies |
| APRN #1 | Advanced Practice Registered Nurse | Evaluated Resident #85 for medication renewal and explained medication formulation change |
| LPN #4 | Licensed Practical Nurse | Administered hydromorphone and admitted to inconsistent documentation in MAR |
| Administrator | Facility Administrator | Discussed PBJ staffing reporting issues and corrective actions |
| Corporate Director #1 | Corporate Director | Reported that staff were misclassified in PBJ reporting causing inaccurate weekend staffing data |
Inspection Report
Complaint Investigation
Census: 127
Capacity: 130
Deficiencies: 0
Date: Aug 1, 2025
Visit Reason
The inspection was conducted as a licensing inspection and to investigate complaints identified by complaint investigation numbers 124427 CT, 124416, and CT 2573687.
Complaint Details
Complaint investigation numbers 124427 CT, 124416, and CT 2573687 were referenced in relation to this inspection.
Findings
The report indicates that violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection, with an attached violation letter referenced.
Report Facts
Licensed Bed Capacity: 130
Census: 127
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Bond | Administrator | Personnel contacted during the inspection. |
| Katherine Lopez | DNS | Personnel contacted during the inspection. |
Inspection Report
Complaint Investigation
Census: 129
Capacity: 130
Deficiencies: 0
Date: Jan 3, 2025
Visit Reason
The inspection was conducted as a complaint investigation related to complaint numbers #42277 and #42362.
Complaint Details
Complaint investigation related to complaint numbers #42277 and #42362; no violations were found.
Findings
No violations of the General Statutes of Connecticut and/or the regulations of Connecticut State Agencies were identified at the time of this inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Bond | Administrator | Personnel contacted during the inspection. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jul 24, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely notify a provider of a resident's change in condition and to conduct a full investigation related to an injury of unknown origin.
Complaint Details
The complaint investigation focused on Resident #1, who had a left tibial fracture of unknown origin. The facility was not aware of a recent fall and failed to timely notify the provider of the resident's change in condition. The investigation was incomplete with only 42% of staff statements obtained. The resident was found unattended on the toilet despite requiring assistance.
Findings
The facility failed to notify the provider timely of a change in condition for Resident #1, failed to obtain a STAT venous doppler ultrasound as ordered, and failed to supervise the resident while on the toilet. The resident was found to have a left tibial fracture of unknown origin, and the facility's investigation was incomplete with only partial staff statements obtained.
Deficiencies (3)
Failed to notify a provider timely of a change in condition for Resident #1.
Failed to ensure a full investigation was conducted related to an injury of unknown origin (left tibial fracture).
Failed to follow a physician's order related to a STAT venous doppler ultrasound and failed to supervise a resident while on the toilet.
Report Facts
Staff statements obtained: 5
Date of survey completion: Jul 24, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Identified unusual behavior of Resident #1 and left resident unattended on the toilet. | |
| LPN #2 | Received report of Resident #1's unusual behavior and fed the resident lunch. | |
| LPN #3 | Notified RN #8 about redness and swelling to Resident #1's left lower extremity. | |
| RN #8 | Registered Nurse | Obtained the order for venous doppler ultrasound and aware the order was STAT. |
| RN #1 | Unit Manager | Called diagnostic company regarding venous doppler ultrasound scheduling. |
| DNS | Director of Nursing Services | Reported incident to state agency and conducted investigation. |
| APRN #1 | Advanced Practice Registered Nurse | Assessed Resident #1 and ordered STAT venous doppler ultrasound. |
| NA #1 | Nursing Assistant | Reported Resident #1's unusual behavior and assisted with feeding. |
| NA #5 | Nursing Assistant | Assisted LPN #1 in getting Resident #1 off the toilet. |
| NA #7 | Nursing Assistant | Found Resident #1 unattended on the toilet and unable to get resident off without assistance. |
| PTA #1 | Rehab Director | Reported Resident #1 should not have been left unattended on the toilet. |
Inspection Report
Routine
Deficiencies: 3
Date: Oct 10, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to residents' rights, care planning, and food safety in the nursing home.
Findings
The facility was found deficient in ensuring a physician's order for cardiopulmonary code status was in place, developing and implementing comprehensive care plans reflecting boundary restrictions between residents, and properly dating opened food items in the dietary department.
Deficiencies (3)
Failed to ensure there was a physician's order directing cardiopulmonary code status elected by the resident.
Failed to develop and implement a comprehensive care plan to ensure nursing staff were aware of boundary restrictions between residents.
Failed to ensure food items were appropriately dated to reflect the opening date and/or the use-by date.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| APRN #1 | Advanced Practice Registered Nurse | Wrote the physician's order addressing Resident #50's code status and evaluated residents for psychiatric concerns. |
| LPN #4 | Licensed Practical Nurse | Interviewed regarding procedures for reviewing Resident #50's code status. |
| DNS | Director of Nursing Services | Interviewed about the delay in entering the DNR order and awareness of resident relationship restrictions. |
| SW #1 | Social Worker | Provided education and guidance to Resident #45 and developed boundary restrictions between residents. |
| NA #3 | Nursing Assistant | Interviewed about awareness of resident relationships and boundary restrictions. |
| LPN #3 | Licensed Practical Nurse | Interviewed about awareness of resident relationships and boundary restrictions. |
| NA #2 | Nursing Assistant | Interviewed about awareness of resident relationships and boundary restrictions. |
| Food Service Director | Food Service Director | Interviewed regarding food dating practices and staff in-service. |
Inspection Report
Renewal
Census: 123
Capacity: 130
Deficiencies: 0
Date: Oct 2, 2023
Visit Reason
The inspection was conducted as a renewal licensing inspection of the Regency House Nursing Center.
Findings
Violations of the General Statutes of Connecticut and/or regulations were identified at the time of this inspection. Additional narrative or violation details are referenced but not included in the provided pages.
Report Facts
Licensed Bed/Bassinet Capacity: 130
Census: 123
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Boyle | Personnel contacted during inspection | |
| Kathleen Lopez | Personnel contacted during inspection |
Inspection Report
Follow-Up
Census: 125
Capacity: 130
Deficiencies: 0
Date: Apr 5, 2023
Visit Reason
A desk audit was completed on 4/5/23 to review the implementation of the Plan of Correction for the Violation Letter dated 1/31/23.
Findings
Violation #1 was corrected as of 2/9/23 and the Administrator was notified via telephone on 4/5/23.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Bond | Administrator | Personnel contacted during the inspection |
| Judy Birtwistle | SNC | Report submitted by and signature on inspection report |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Jul 27, 2021
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with regulatory requirements related to resident care, safety, medication management, and infection control at Regency House Nursing and Rehabilitation Center.
Findings
The facility was found deficient in multiple areas including failure to timely address physician recommendations for a resident with exit-seeking behavior, inadequate RN assessment after a resident fall before moving the resident, failure to date oxygen tubing and medication supplies properly, improper storage of cleaning and personal supplies in medication rooms, and failure to properly disinfect the glucometer according to facility policy.
Deficiencies (5)
Failed to ensure staff addressed a physician recommendation timely for a resident with exit seeking behavior.
Failed to ensure an RN assessment was completed timely after a resident fall before the resident was moved.
Failed to ensure oxygen tubing was dated to identify the date it was last changed.
Failed to ensure cleaning supplies and personal supplies were stored appropriately, failed to ensure multidose medications were dated when opened, and failed to ensure expired medications were removed from the medication cart.
Failed to disinfect the facility glucometer after resident use in accordance with facility policy.
Report Facts
Residents affected: 5
Date of survey completion: Jul 27, 2021
Expiration date of vinegar: 202102
Date tubing was due to be changed: Jul 18, 2021
Number of times glucometer wiped: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| APRN #1 | Psychiatric Advanced Practice Registered Nurse | Recommended Wander Guard device for Resident #89 and involved in fall assessment for Resident #13 |
| RN #1 | Nursing Supervisor | Failed to follow through with APRN #1's recommendations for Resident #89 |
| RN #2 | Corporate Nurse | Identified RN #1 should have followed APRN #1's recommendations |
| RN #3 | Registered Nurse | Could not remember oxygen tubing change schedule; replaced undated tubing |
| RN #6 | Registered Nurse Supervisor | Assessed Resident #13 after fall and expressed concern about premature resident transfer |
| LPN #2 | Licensed Practical Nurse | Observed medication cart storage issues and removed undated medications |
| LPN #3 | Licensed Practical Nurse | Observed personal items in medication room and removed expired medications |
| LPN #5 | Licensed Practical Nurse | Notified RN #6 of Resident #13 fall and involved in post-fall events |
| NA #5 | Nursing Assistant | Witnessed Resident #13 fall and transferred resident before RN assessment |
| LPN #1 | Licensed Practical Nurse | Failed to properly disinfect glucometer using two wipes as per policy |
Inspection Report
Renewal
Census: 121
Capacity: 130
Deficiencies: 0
Date: Jul 27, 2021
Visit Reason
The inspection was conducted as a renewal licensing inspection for Regency House Nursing Home.
Findings
The facility was found to be in compliance with visitation policies and no violations of the General Statutes or regulations were identified during this inspection. The facility did not apply for CMP funds but did apply for a CRF grant.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cynthia Hayde | RN | Report submitted by |
| David Bond | Admin | Personnel contacted |
| Rosalyn Morano | Admin | Personnel contacted |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Jul 27, 2021
Visit Reason
An unannounced visit was made to Regency House Nursing And Rehabilitation Center by the Department of Public Health for the purpose of conducting an annual survey.
Findings
The report details multiple violations of Connecticut State regulations identified during the visit, including issues with resident care, nursing assessments, medication storage, infection control, and oxygen therapy management. Plans of correction were submitted addressing each violation with measures to prevent recurrence and ensure compliance.
Deficiencies (5)
Failure to ensure timely RN assessment after a resident fall before transfer.
Failure to ensure oxygen tubing was dated to identify last change.
Failure to ensure cleaning supplies and personal supplies were stored appropriately and multidose medications were dated when opened; failure to remove expired medications from medication cart.
Failure to disinfect the facility glucometer after resident use in accordance with facility policy.
Failure to properly disinfect glucometers according to facility policy.
Report Facts
Plan of correction submission deadline: Aug 21, 2021
Dates of observations and incidents: Jul 7, 2021
Dates of observations and incidents: Jul 20, 2021
Dates of observations and incidents: Jul 26, 2021
Dates of observations and incidents: Jul 27, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maureen Golas Markure | Supervising Nurse Consultant | Signed the notice letter and responsible for overseeing the inspection |
| APRN #1 | Named in findings related to resident care and elopement risk assessment | |
| RN #1 | Interviewed regarding resident care and elopement risk | |
| RN #3 | Interviewed regarding oxygen tubing schedule | |
| RN #6 | Supervisor involved in resident fall incident | |
| LPN #2 | Interviewed regarding medication room observations | |
| LPN #3 | Interviewed regarding medication room observations | |
| LPN #5 | Witnessed resident fall and involved in incident | |
| NA #5 | Witnessed resident fall and involved in incident |
Inspection Report
Renewal
Census: 121
Capacity: 130
Deficiencies: 0
Date: Jul 20, 2021
Visit Reason
The inspection was conducted as a renewal licensing inspection for the facility.
Findings
The facility was found to be in compliance with visitation policies and did not apply for CMP funds. The report indicates no violations were identified at the time of inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tricia Calderone | Personnel contacted during the inspection |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: May 11, 2020
Visit Reason
Unannounced visits were made to Regency House Nursing And Rehabilitation Center to conduct an investigation and a COVID-19 focused infection control survey.
Complaint Details
The visit was complaint-related, focusing on falls and infection control practices. The facility was found noncompliant in multiple areas related to resident care and infection control.
Findings
The facility was found to have multiple violations including failure to notify the physician when a resident continued to complain of pain after a fall, failure to address abnormal diagnostic X-ray findings timely, failure to ensure post-fall monitoring was completed per policy, failure to address complaints of pain adequately, and failure to implement appropriate infection control practices to prevent spread of infection.
Deficiencies (4)
Failed to contact the physician as directed when pain continued after a fall for Resident #1.
Failed to ensure appropriate care and treatment for Resident #1 who was non-ambulatory, including failure to address abnormal diagnostic X-ray findings timely and failure to ensure post-fall monitoring was completed according to policy.
Failed to ensure complaints of pain were addressed after a fall for Resident #1.
Failed to ensure appropriate infection control practices were implemented to prevent and control the spread of infection, including improper use of isolation gowns by staff.
Report Facts
Date of fall event: Apr 26, 2020
Date of X-ray: Apr 27, 2020
Plan of correction submission deadline: Jun 5, 2020
Audit frequency: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Susan Newton | Supervising Nurse Consultant | Author of the inspection report letter |
| David O. Bond | Administrator | Facility administrator addressed in the report |
| LPN #7 | Licensed Practical Nurse | Did not inform supervisor of resident's continued pain after fall |
| RN #4 | Registered Nurse | Supervisor who was to be notified of resident's continued pain |
| APRN #2 | Advanced Practice Registered Nurse | Directed staff to notify if resident continued to complain of pain |
| LPN #1 | Licensed Practical Nurse | Observed resident's bed elevated at time of fall |
| NA #1 | Nurse Aide | Observed bed elevated and resident's habit of playing with bed controls |
| RN #3 | Registered Nurse | Helped X-ray technician and reported X-rays taken |
| LPN #4 | Licensed Practical Nurse | Charge nurse on shift unaware of X-ray results and resident's pain complaints |
| RN #1 | Registered Nurse | Nursing supervisor who did not receive X-ray results report |
| RN #2 | Unit Manager | Called APRN and sent resident to emergency department after discovering X-ray results |
| LPN #6 | Licensed Practical Nurse | Did not medicate resident with as needed Tylenol after pain complaints |
| NA #3 | Nurse Aide | Reported resident's pain complaints during repositioning |
| NA #4 | Nurse Aide | Reported resident's pain complaints during repositioning |
| Administrator | Interviewed about PPE gown shortages and isolation gown usage |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: May 11, 2020
Visit Reason
A Covid-19 focused survey was conducted to determine compliance with 42 CFR Part 483 requirements for LTC facilities including infection control and prevention, and an investigation for complaint CT #27447 was completed.
Complaint Details
Investigation related to complaint CT #27447 regarding failure to notify physician and inadequate care after resident fall with pain complaints.
Findings
The facility failed to notify the physician timely after a resident's fall with continued pain, failed to provide appropriate care and treatment including timely response to abnormal X-ray findings, failed to monitor post-fall resident properly, and failed to manage pain adequately. Infection control practices were also found deficient related to improper use of isolation gowns.
Deficiencies (4)
Failed to notify physician promptly when pain continued after a fall.
Failed to ensure appropriate care and treatment after fall including timely response to abnormal X-ray findings and post-fall monitoring.
Failed to ensure complaints of pain were addressed after a fall.
Failed to implement appropriate infection control practices to prevent spread of infection, including improper use of isolation gowns.
Report Facts
Deficiencies cited: 4
Fall date: Apr 26, 2020
X-ray order time: 1100
X-ray taken time: 2210
X-ray results received time: 2239
Pain monitoring shifts prior to fall: 75
Pain complaints shifts prior to fall: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #7 | Licensed Practical Nurse | Named in failure to notify physician of continued pain after fall |
| RN #4 | Registered Nurse | Supervised on day of fall, failed to ensure notification to APRN of continued pain |
| APRN #2 | Advanced Practice Registered Nurse | Directed to be notified if resident continued to complain of pain after fall |
| LPN #1 | Licensed Practical Nurse | Witnessed resident fall from elevated bed |
| NA #1 | Nurse Aide | Reported resident habit of elevating bed and found resident on floor |
| NA #2 | Nurse Aide | Reported resident needed assistance and found resident on floor |
| LPN #4 | Licensed Practical Nurse | Charge nurse on shift after fall, unaware of X-ray results and pain complaints |
| RN #1 | Registered Nurse | Nursing supervisor on shift after fall, did not receive report of pending X-ray results |
| RN #2 | Unit Manager | Discovered X-ray results and arranged transfer to hospital |
| LPN #6 | Licensed Practical Nurse | Failed to medicate resident with as needed pain medication after complaints |
| NA #3 | Nurse Aide | Reported resident pain during repositioning not communicated to nurse |
| NA #4 | Nurse Aide | Reported resident pain during repositioning not communicated to nurse |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: May 9, 2020
Visit Reason
An unannounced visit was made to Regency House Nursing and Rehabilitation Center on May 9, 2020 for the purpose of conducting a COVID-19 Focused survey.
Complaint Details
Complaint #27385 triggered the visit. No substantiation status was stated.
Findings
The facility failed to update policies and improperly reused disposable gowns contrary to CDC recommendations during the COVID-19 pandemic, risking staff and resident safety. Observations and interviews confirmed gowns were reused throughout shifts without proper guidelines on discarding or extended use.
Deficiencies (1)
Facility failed to update policies and failed to utilize personal protective equipment according to CDC recommendations by reusing disposable gowns instead of extending their use, risking infection control.
Report Facts
Disposable gowns available: 600
Facility units with COVID-19 residents: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Karen Gworek | Supervising Nurse Consultant | Signed the notice letter and directed questions regarding violations |
| David Bond | Administrator | Named in relation to the facility and plan of correction |
| Director of Nursing | Interviewed regarding PPE policies and COVID-19 resident cohorting | |
| Licensed Practical Nurse #1 | Charge Nurse | Interviewed about gown use practices during COVID-19 care |
| Licensed Practical Nurse #2 | Interviewed about gown use and safety concerns during COVID-19 care |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: May 9, 2020
Visit Reason
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.
Findings
The facility failed to update policies and failed to utilize personal protective equipment according to CDC recommendations during the COVID-19 pandemic by extending the use of disposable gowns instead of reusing them, putting staff and residents at risk of infection. Observations and interviews confirmed gowns were reused throughout shifts and hung outside resident rooms, contrary to proper infection control practices.
Deficiencies (1)
Failure to update policies and failure to utilize personal protective equipment according to CDC recommendations during the COVID-19 pandemic by extending the use of disposable gowns instead of reusing disposable gowns.
Report Facts
Disposable gowns available: 600
Units with COVID-19 positive residents: 4
Audit frequency: 3
Audit frequency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Charge Nurse | Interviewed regarding PPE gown use and reuse practices |
| Licensed Practical Nurse #2 | Interviewed regarding PPE gown use and reuse practices and safety concerns | |
| Director of Nursing | Director of Nursing | Interviewed regarding PPE policies and unable to provide CDC documentation |
Inspection Report
Routine
Deficiencies: 1
Date: May 9, 2020
Visit Reason
An unannounced visit was made to Regency House Nursing and Rehabilitation Center on May 9, 2020 by a representative of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting a COVID-19 focused survey.
Findings
The facility had 600 disposable gowns available, but staff were reusing disposable gowns throughout shifts when caring for COVID-19 positive residents, contrary to CDC guidelines. The Director of Nursing was unable to provide documentation of CDC recommendations on extended use versus reuse of PPE. The facility's cohort guidelines lacked clarity on when gowns should be discarded. The policy allowed staff to reuse gowns for entire shifts, which was a concern for infection control.
Deficiencies (1)
Staff were not following proper procedure for PPE usage, specifically reusing disposable gowns throughout shifts when caring for COVID-19 positive residents.
Report Facts
Disposable gowns available: 600
Units with COVID-19 positive residents: 4
Audit frequency: 3
Audit frequency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Karen Gworek | Supervising Nurse Consultant | Signed the notice letter |
| Director of Nursing (DON) | Interviewed regarding PPE usage and facility policies | |
| Licensed Practical Nurse (LPN) #1 | Interviewed about gown usage practices | |
| Licensed Practical Nurse (LPN) #2 | Interviewed about gown usage practices and concerns |
Inspection Report
Monitoring
Census: 94
Capacity: 130
Deficiencies: 1
Date: May 9, 2020
Visit Reason
The visit was conducted for monitoring COVID-19 infection control and included a complaint investigation (Complaint #27385).
Complaint Details
Complaint investigation #27385 was conducted as part of the visit. The complaint was related to infection control practices concerning COVID-19.
Findings
The inspection identified violations related to the extended use and reuse of disposable gowns for COVID-19 positive residents, with concerns about staff safety and adherence to CDC guidelines. A plan of correction was required to address these issues.
Deficiencies (1)
Improper reuse of disposable gowns for COVID-19 positive residents, contrary to CDC guidelines.
Report Facts
Licensed Bed Capacity: 130
Census: 94
Disposable Gowns: 600
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Donna Dwyer | Director of Nursing | Interviewed regarding COVID-19 cohorting and gown usage policies. |
| Karen Gworek | Supervising Nurse Consultant | Signed the complaint investigation letter. |
| LPN #1 | Licensed Practical Nurse | Interviewed about gown usage when caring for COVID-19 positive residents. |
| LPN #2 | Licensed Practical Nurse | Interviewed about gown usage and safety concerns during COVID-19 care. |
Inspection Report
Routine
Census: 109
Capacity: 130
Deficiencies: 0
Date: Apr 28, 2020
Visit Reason
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.
Findings
No deficiencies were cited as a result of this COVID-19 focused survey.
Inspection Report
Complaint Investigation
Census: 120
Capacity: 130
Deficiencies: 1
Date: Apr 11, 2019
Visit Reason
The inspection was conducted as a complaint investigation related to multiple complaint numbers (CT00023992, CT0023782, CT00024018, CT00024140) and to assess violations of Connecticut State regulations.
Complaint Details
The visit was complaint-related, investigating complaints #23992, #23782, #24018, and #24140. Violations were substantiated as indicated by the issuance of citation #19-23.
Findings
Violations of Connecticut General Statutes and regulations were identified during the inspection, resulting in a citation (19-23). A desk audit conducted later found that violations 1-4 were corrected. The facility was required to submit a plan of correction by May 6, 2019.
Deficiencies (1)
Violations of the General Statutes of Connecticut and/or regulations were identified during the complaint investigation.
Report Facts
Licensed Bed Capacity: 130
Census: 120
Citation Number: 19
Citation Number: 23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Bond | Administrator | Named as personnel contacted during the inspection and in relation to findings. |
| Donna Dwyer | RN | Named as personnel contacted during the inspection. |
| Siobhan O'Neill | Nurse Consultant | Conducted desk audit and provided findings on correction of violations. |
Inspection Report
Plan of Correction
Deficiencies: 5
Date: Apr 11, 2019
Visit Reason
Unannounced visits were made to Regency House Nursing And Rehabilitation Center to conduct multiple investigations and a certification survey.
Findings
The report details violations related to resident care, including issues with advanced directives, medication administration, skin integrity, hospice notification, and documentation. Plans of correction were submitted addressing these deficiencies with education, audits, and monitoring.
Deficiencies (5)
Failure to ensure resident code status was correctly identified and honored.
Failure to notify responsible party of medication changes or changes in condition.
Failure to ensure skin integrity impairment was addressed and documented.
Failure to notify hospice service of changes in resident condition.
Medication error involving methotrexate administration and failure to follow physician orders.
Report Facts
Complaints referenced: 4
Dates of plan of correction completion: Completed 5/2/19, 5/21/19, and 8/8/18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cher Michael | Supervising Nurse Consultant | Signed the amended violation letter |
| RN #1 | Registered Nurse | Witnessed consent form, involved in medication error and skin integrity findings |
| Person #2 | Responsible party for Resident #128, involved in notification findings | |
| Physician (MD) #3 | Physician | Interviewed regarding medication sensitivities |
| Director of Nurses | Interviewed regarding skin integrity audit and findings | |
| Licensed Practical Nurse (LPN) #1 | Licensed Practical Nurse | Performed weekly skin integrity checks |
| RN #3 | Registered Nurse | Interviewed regarding hospice notification |
| Hospice nurse | Interviewed regarding hospice assessments | |
| Corporate nurse | Interviewed regarding hospice service notification | |
| RN #1 | Registered Nurse | Involved in medication administration error and disciplinary action |
| Licensed Practical Nurse (LPN) #4 | Licensed Practical Nurse | Interviewed regarding medication order verification |
| Licensed Practical Nurse (LPN) #5 | Licensed Practical Nurse | Interviewed regarding medication pass and error notification |
| APRN #2 | Advanced Practice Registered Nurse | Consulted on medication error and treatment |
| Physician (MD) #1 | Physician | Interviewed regarding methotrexate administration and toxicity |
| Pharmacist #1 | Pharmacist | Interviewed regarding methotrexate dosing and medication alerts |
Inspection Report
Renewal
Census: 125
Capacity: 130
Deficiencies: 0
Date: Feb 26, 2018
Visit Reason
The inspection was conducted as a renewal licensing inspection and included review of complaint investigations CT# 21847 and CT# 22556.
Complaint Details
The inspection included review of complaint investigations CT# 21847 and CT# 22556.
Findings
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 2018-03-19.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Bind | Administrator | Personnel contacted during the inspection |
| Donna Dwyer | DNS | Personnel contacted during the inspection |
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