Inspection Reports for
Shady Knoll Center for Health and Rehabilitation
41 Skokorat St, Seymour, CT 06483, CT, 06483
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
27.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
388% worse than Connecticut average
Connecticut average: 5.6 deficiencies/year
Deficiencies per year
40
30
20
10
0
Occupancy
Latest occupancy rate
95% occupied
Based on a September 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Plan of Correction
Census: 121
Capacity: 128
Deficiencies: 2
Date: Sep 17, 2025
Visit Reason
A desk audit was conducted to review the implementation of the Plan of Correction for the Violation letter dated July 24, 2025.
Findings
Violations #1 and #2 were identified as corrected as of August 3, 2025, and the Administrator was notified of the corrections on September 17, 2025.
Deficiencies (2)
Violation #1
Violation #2
Report Facts
Licensed Bed Capacity: 128
Census: 121
Inspection Report
Monitoring
Capacity: 128
Deficiencies: 0
Date: Sep 4, 2025
Visit Reason
A desk audit was conducted to review the implementation of the Plan of Correction for a prior violation letter dated 2025-08-11.
Findings
Violations numbered 1 through 13 were identified as corrected during the desk audit. The facility administrator was notified of the corrections on the same day.
Report Facts
Violations corrected: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elza Augustin | Administrator | Notified via telephone that the violations were corrected. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jul 21, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding medication errors at the facility.
Complaint Details
The complaint investigation was substantiated. The facility was found to have administered the wrong dose of Methotrexate to Resident #1 on two occasions due to pharmacy mislabeling and staff failure to verify medication labels. The resident experienced no adverse effects, and corrective education was provided to staff during the survey.
Findings
The facility failed to ensure medication was administered according to physician orders and failed to ensure staff read the manufacturer label prior to administration, resulting in a medication error where a resident received double the prescribed dose of Methotrexate. The pharmacy mislabeled the medication vial, and staff did not verify the discrepancy between the pharmacy and manufacturer labels, leading to administration errors on two occasions.
Deficiencies (2)
F 0684: The facility failed to provide appropriate treatment and care according to orders, resident’s preferences, and goals, resulting in a medication error where a resident received 50 mg of Methotrexate instead of the prescribed 25 mg due to mislabeled medication vials and staff not verifying labels.
F 0761: The facility failed to ensure drugs and biologicals were labeled in accordance with professional principles, resulting in a medication error due to pharmacy mislabeling of Methotrexate vials and staff not checking both pharmacy and manufacturer labels.
Report Facts
Medication dose: 50
Medication dose: 25
Date of medication error: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| APRN #1 | Advanced Practice Registered Nurse | Provided follow-up care and monitoring for Resident #1 after medication error |
| LPN #1 | Licensed Practical Nurse | Administered incorrect Methotrexate dose on 6/17/2025 |
| LPN #2 | Licensed Practical Nurse | Administered incorrect Methotrexate dose on 6/10/2025 |
| Pharmacy Manager | Notified facility of pharmacy labeling error leading to medication error | |
| Director of Nursing | Director of Nursing | Identified medication errors and provided staff education |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jul 21, 2025
Visit Reason
The inspection was conducted due to a complaint investigation related to medication errors involving the administration of Methotrexate to a resident.
Complaint Details
The complaint investigation found that Resident #1 received the wrong dose of Methotrexate (50 mg instead of 25 mg) on 6/10/2025 and 6/17/2025 due to incorrect pharmacy labeling and staff not verifying manufacturer labels. The resident had no adverse effects, and corrective education was provided to staff.
Findings
The facility failed to ensure medication was administered according to physician orders and failed to ensure staff read the manufacturer label prior to administration, resulting in a medication error where a resident received double the prescribed dose of Methotrexate. The error was due to incorrect labeling by the pharmacy and staff not verifying manufacturer labels against pharmacy labels. Education was provided to staff during the survey to prevent recurrence.
Deficiencies (2)
Failed to ensure medication was administered in accordance with physician orders and failed to ensure staff read the manufacturer label prior to administering medication, resulting in a medication error.
Failed to ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked compartments for controlled drugs.
Report Facts
Medication dose: 50
Medication dose: 25
Dates of incorrect administration: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| APRN #1 | Advanced Practice Registered Nurse | Notified of medication error, provided follow-up care and monitoring for Resident #1 |
| LPN #1 | Licensed Practical Nurse | Administered wrong dose of Methotrexate on 6/17/2025 |
| LPN #2 | Licensed Practical Nurse | Administered wrong dose of Methotrexate on 6/10/2025 |
| Pharmacy Manager | Notified facility of pharmacy labeling error | |
| Director of Nursing | Director of Nursing | Identified medication error and staff education needs |
Inspection Report
Annual Inspection
Deficiencies: 13
Date: Jun 30, 2025
Visit Reason
The inspection was conducted as part of an annual recertification survey to assess compliance with regulatory requirements and evaluate the facility's care and services.
Findings
The facility was found to have multiple deficiencies including failure to thoroughly investigate an allegation of mistreatment, incomplete PASRR Level II assessments, incomplete care plans for residents with smoking/vaping history, failure to support resident oral care preferences, untimely weight monitoring, delayed wound care treatment, failure to ensure resident safety with mobility equipment, failure to provide meals according to resident preferences and timely manner, serving meals at inappropriate temperatures, improper food storage and labeling, failure to refer residents to therapy after decline, failure to submit complete staffing data, and failure to respond timely to pharmacy recommendations.
Deficiencies (13)
Failed to ensure an allegation of rushed and rough care causing a bruise was thoroughly investigated.
Failed to ensure PASRR Level II assessment was completed following exempted short term approval.
Failed to develop a comprehensive care plan for a resident with history of smoking/vaping and smoking contraband.
Failed to support a resident's choice related to assistance with oral care.
Failed to ensure weekly weight monitoring was completed timely for a resident with heart failure.
Failed to follow physician orders timely and initiate treatment orders for a newly identified pressure ulcer wound.
Failed to ensure adequate supervision and safety related to use of motorized mobility equipment after removal.
Failed to ensure a meal was provided according to resident preference and served in a timely manner.
Failed to ensure meals were served at appropriate temperatures.
Failed to ensure opened food items were labeled and dated and expired food was discarded.
Failed to refer resident to physical and occupational therapy after identifying decline in activities of daily living.
Failed to submit complete and accurate Payroll Based Journal staffing data for the first quarter.
Failed to review and respond to pharmacy recommendations in a timely manner regarding medication dosage.
Report Facts
Weight gain: 8.8
Weight gain: 33.8
Pressure ulcer size: 0.27
Medication dosage: 40
Medication dosage: 20
Food temperature: 128
Food temperature: 129
Expired food date: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| APRN #1 | Advanced Practice Registered Nurse | Completed investigation for abuse allegation and involved in medication order changes |
| DNS | Director of Nursing | Interviewed regarding abuse investigation, PASRR referrals, medication reviews, and vape device incidents |
| NA #6 | Nurse Aide | Interviewed regarding abuse allegation involving Resident #33 |
| NA #7 | Nurse Aide | Interviewed regarding abuse allegation involving Resident #33 |
| NA #1 | Nurse Aide | Interviewed regarding oral care assistance for Resident #103 |
| RN #1 | Registered Nurse | Interviewed regarding oral care assistance and NA care cards |
| RN #2 | Infection Prevention Registered Nurse | Interviewed regarding wound care tracking and assessments |
| RN #4 | Registered Nurse | Identified new wound and notified APRN |
| OT #1 | Occupational Therapist | Assessed Resident #44 for safe use of motorized chair |
| FSD | Food Service Director | Interviewed regarding meal tray serving and food temperature issues |
| Administrator | Interviewed regarding meal service, PBJ submission, and vape device incidents | |
| Pharmacist | Interviewed regarding delayed response to medication recommendations | |
| MDS Coordinator RN #5 | Registered Nurse | Interviewed regarding failure to refer Resident #102 to therapy after decline |
| Director of Rehabilitation | Interviewed regarding therapy referrals and motorized chair use |
Inspection Report
Complaint Investigation
Deficiencies: 13
Date: Jun 30, 2025
Visit Reason
Complaint investigation triggered by allegations of mistreatment, failure to complete PASRR assessments, care planning deficiencies, and other regulatory compliance concerns.
Complaint Details
The complaint investigation was triggered by allegations of mistreatment, failure to complete required assessments and care plans, medication management issues, and other regulatory compliance concerns. The facility was unable to substantiate mistreatment but was found deficient in multiple areas of care and compliance.
Findings
The facility was found deficient in multiple areas including failure to thoroughly investigate abuse allegations, incomplete PASRR Level II assessments, inadequate care planning for residents with smoking/vaping history, failure to provide assistance with oral care as preferred, untimely weight monitoring, lack of re-evaluation for mobility equipment use, delayed wound care initiation, failure to ensure smoking policy compliance, delayed pharmacist response to medication recommendations, failure to serve meals according to resident preferences and at proper temperatures, improper food storage and labeling, failure to refer residents to therapy after decline, and failure to submit required staffing data.
Deficiencies (13)
F0610: The facility failed to thoroughly investigate an allegation of rushed and rough care causing a bruise to Resident #33's left hand, missing key staff and witness interviews.
F0645: The facility failed to complete a PASRR Level II assessment for Resident #44 following an exempted short term approval and readmission.
F0656: The facility failed to develop a comprehensive care plan addressing Resident #44's history of smoking and vaping after admission and readmission.
F0677: The facility failed to support Resident #103's preference for assistance with oral care, including setup of supplies twice daily.
F0684: The facility failed to ensure weekly weight monitoring was completed timely for Resident #35 and failed to re-evaluate mobility equipment use for Resident #44 after removal of a motorized chair.
F0686: The facility failed to initiate timely treatment orders and wound care for a new right heel pressure ulcer for Resident #31, delaying wound care by 39 days.
F0689: The facility failed to ensure Resident #44 was free of smoking materials and failed to assess and intervene appropriately regarding smoking/vaping devices brought in by visitors.
F0756: The facility failed to timely review and respond to pharmacist recommendations to reduce Resident #93's Celexa dosage from 40 mg to 20 mg over a 5-month period.
F0803: The facility failed to provide Resident #67 a meal according to preference and served the wrong meal without timely correction.
F0804: The facility failed to serve meals at appropriate hot temperatures, with test tray items served at 128-130 degrees instead of the required 135 degrees.
F0812: The facility failed to label and date opened food items and failed to discard expired food, including orange juice 21 days past expiration.
F0825: The facility failed to refer Resident #102 to physical and occupational therapy after identifying a decline in activities of daily living.
F0851: The facility failed to submit the 1st quarter Payroll Based Journal staffing data for nursing hours from 10/1/24 through 10/10/24.
Report Facts
Weight gain: 33.8
Weight gain percentage: 9.25
Pressure ulcer size: 0.27
Expired orange juice days: 21
PBJ missing days: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| APRN #1 | Advanced Practice Registered Nurse | Involved in investigation of abuse allegation and medication order management |
| DNS | Director of Nursing | Interviewed regarding abuse investigation, PASRR assessments, medication management, and smoking policy |
| NA #1 | Nurse Aide | Named in oral care assistance deficiency for Resident #103 |
| NA #6 | Nurse Aide | Interviewed in abuse allegation investigation |
| NA #7 | Nurse Aide | Interviewed in abuse allegation investigation |
| NA #8 | Nurse Aide | Named in meal service deficiency for Resident #67 |
| RN #1 | Registered Nurse | Interviewed regarding oral care assistance and care card documentation |
| RN #2 | Infection Prevention Registered Nurse | Interviewed regarding wound care tracking and assessments |
| RN #4 | Registered Nurse | Identified wound and notified APRN for Resident #31 |
| RN #5 | Registered Nurse | MDS Coordinator interviewed regarding therapy referral process |
| OT #1 | Occupational Therapist | Interviewed regarding motorized chair re-evaluation for Resident #44 |
| Director of Rehabilitation | Interviewed regarding therapy referrals and motorized chair use | |
| Pharmacist | Interviewed regarding medication review and recommendations for Resident #93 | |
| Administrator | Interviewed regarding PBJ submission and meal service | |
| Dietary Director | Interviewed and observed regarding meal service and food storage |
Inspection Report
Follow-Up
Census: 107
Capacity: 128
Deficiencies: 0
Date: Oct 16, 2024
Visit Reason
A desk audit was conducted to review the implementation of the plan of correction for violations cited in a previous letter dated 7/30/24.
Findings
The desk audit found that all violations (#1, #2, #3, and #4) were corrected as of 10/16/24, confirmed by notification to the Administrator Elza Augustin.
Report Facts
Violations reviewed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Diane Azeez | Director Of Nursing | Personnel contacted during the inspection |
| Elza Augustin | Administrator | Notified via telephone that all violations were corrected |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jun 17, 2024
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to ensure timely physician notification of missed dialysis treatments, failure to schedule transportation for dialysis treatments, failure to maintain a dialysis communication book, and incomplete clinical record documentation of oral care.
Complaint Details
The investigation was complaint-driven, focusing on missed dialysis treatments and communication failures. The complaint was substantiated based on clinical record reviews, interviews, and documentation showing failures in notification, transportation scheduling, and record keeping.
Findings
The facility failed to notify the physician/APRN timely after missed dialysis treatments for Resident #2, failed to schedule transportation for dialysis resulting in multiple missed treatments, failed to maintain a dialysis communication book, and failed to ensure complete and accurate clinical records for oral care provided or refused for Resident #1.
Deficiencies (3)
F 0580: The facility failed to ensure the physician was notified timely of Resident #2's missed dialysis treatment on 12/28/2022. Documentation and interviews confirmed no notification was made to the physician/APRN after missed treatments on 12/28 and 12/29/2022.
F 0698: The facility failed to schedule transportation timely for Resident #2's dialysis treatments, resulting in missed treatments on 12/28, 12/29, and 12/30/2022. The facility also failed to maintain a dialysis communication book as required.
F 0842: The facility failed to ensure clinical records were complete and accurate for Resident #1's oral care, with multiple days lacking documentation of oral hygiene provided or refused. Staff interviews confirmed refusals were not documented properly.
Report Facts
Missed dialysis treatments: 4
Dates with undocumented oral care: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| APRN #1 | Advanced Practice Registered Nurse | Named in relation to missed notification of Resident #2's dialysis treatments. |
| DNS | Director of Nursing Services | Interviewed regarding missed dialysis notifications, transportation scheduling failures, and oral care documentation issues. |
| NA #1 | Nursing Assistant | Interviewed about providing oral care to Resident #1 and documentation practices. |
| NA #2 | Nursing Assistant | Interviewed about offering oral care to Resident #1 and inability to document refusals. |
| Dialysis Provider #1 | Interviewed confirming missed dialysis treatments for Resident #2. |
Inspection Report
Plan of Correction
Census: 117
Deficiencies: 4
Date: Jun 17, 2024
Visit Reason
An unannounced visit was conducted at Shady Knoll on June 17, 2024, by the Department of Public Health for the purpose of conducting multiple investigations related to regulatory compliance.
Complaint Details
The visit was triggered by complaints #33780 and #39237. The report does not explicitly state substantiation status.
Findings
The report identifies multiple violations including failure to notify physicians/APRN of missed dialysis treatments, failure to maintain a dialysis communication book, incomplete and inaccurate clinical records especially related to oral care, and failure to meet staffing levels according to Connecticut Public Health Code. Corrective measures and plans to monitor compliance are outlined for each violation.
Deficiencies (4)
Failure to notify physician/APRN timely of missed dialysis treatments for Resident #2.
Failure to ensure timely transportation and maintain dialysis communication book for Resident #2.
Failure to ensure clinical records were complete and accurate including documentation of oral care and refusals for Residents #1 and #2.
Failure to meet staffing levels in accordance with Connecticut Public Health Code on sampled days.
Report Facts
Census: 117
Staffing hours required: 253.89
Staffing hours provided: 222.25
Staffing hours deficit: 31.64
Census: 110
Staffing hours required: 238.7
Staffing hours provided: 229
Staffing hours deficit: 9.7
Staffing hours provided: 237.75
Staffing hours deficit: 13.97
Missed dialysis treatments: 2
Dialysis frequency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maureen Golas Markure | Supervising Nurse Consultant | Author of the notice letter regarding the inspection and plan of correction |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Jun 17, 2024
Visit Reason
The inspection was conducted due to complaints regarding the facility's failure to ensure timely physician notification of missed dialysis treatments, failure to schedule transportation timely for dialysis, failure to maintain a dialysis communication book, and incomplete clinical record documentation for oral care.
Complaint Details
The complaint investigation found that Resident #2 missed dialysis treatments on 12/28/2022 and 12/29/2022 due to transportation issues and the facility failed to notify the physician/APRN timely. The facility also failed to maintain a dialysis communication log. Additionally, for Resident #1, the facility failed to document oral care provided or refused accurately in the clinical record.
Findings
The facility failed to notify the physician/APRN timely after missed dialysis treatments for Resident #2, failed to schedule transportation timely resulting in multiple missed dialysis sessions, failed to maintain a dialysis communication log, and failed to ensure complete and accurate clinical records for oral care provided or refused for Resident #1.
Deficiencies (4)
Failed to ensure the physician was notified timely of a missed dialysis treatment for Resident #2.
Failed to ensure transportation was scheduled timely for Resident #2 requiring dialysis and failed to maintain a dialysis communication book.
Failed to maintain a dialysis communication book for Resident #2 requiring dialysis treatments.
Failed to ensure clinical record was complete and accurate to include oral care provided and/or refused for Resident #1.
Report Facts
Missed dialysis treatments: 3
Oral care documentation missing: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| APRN #1 | Advanced Practice Registered Nurse | Notified that Resident #2 missed dialysis treatments but was not informed timely; documentation note on 12/29/2022 did not mention missed dialysis. |
| DNS | Director of Nursing Services | Interviewed regarding missed dialysis treatments, failure to notify physician/APRN, and missing dialysis communication log. |
| Dialysis Provider #1 | Confirmed missed dialysis treatments for Resident #2 and rescheduling attempts. | |
| NA #1 | Nursing Assistant | Provided oral care to Resident #1 on some dates but failed to document on 5/3 and 5/10/2024. |
| NA #2 | Nursing Assistant | Assigned to Resident #1 on several dates; stated oral care was offered but refused and could not document refusals in the system. |
Inspection Report
Original Licensing
Capacity: 64
Deficiencies: 0
Date: Jun 3, 2024
Visit Reason
The document is a Change of Ownership Pre-Licensure Consent Order for Shady Knoll Center for Health & Rehabilitation seeking an initial license to operate a Nursing Home. It outlines the terms and conditions for licensing and regulatory compliance prior to the issuance of the license.
Findings
The document details the requirements for compliance including contracting an Infection Control Nurse (INC), quality assurance programs, emergency preparedness, staffing requirements, and facility maintenance. It incorporates a Plan of Correction approved on August 7, 2024, with penalties for noncompliance. The document also includes a detailed plan of correction addressing structural, electrical, fire safety, and other regulatory compliance issues to be completed within specified timeframes.
Report Facts
Plan of Correction submission date: Aug 7, 2024
Penalty amount: 1000
Days to cure noncompliance: 14
INC consulting hours per week: 16
INC contract execution timeframe: 14
Initial onsite review timeframe: 30
Re-evaluation frequency: 3
Retention period for records: 5
Retention period for QA meeting minutes: 3
Days for emergency preparedness plan revision: 28
Escrow amount: 772315.74
Inspection date: Jun 3, 2024
Plan of Correction approval date: Aug 5, 2024
Facility capacity: 64
Inspection completion timeframe for electrical systems: 60
Inspection completion timeframe for life safety repairs: 90
Inspection completion timeframe for HVAC inspection: 180
Inspection completion timeframe for fire alarm system: 60
Inspection completion timeframe for nurse-call system: 180
Inspection completion timeframe for kitchen suppression system: 60
Inspection completion timeframe for dietary grease trap system: 120
Inspection completion timeframe for exterior building surfaces: 90
Inspection completion timeframe for exterior lighting: 120
Inspection completion timeframe for interior finishes: 180
Inspection completion timeframe for doors: 180
Inspection completion timeframe for windows and screens: 180
Inspection completion timeframe for plumbing lines: 180
Inspection completion timeframe for fire safety system: 60
Inspection completion timeframe for fire alarm system repairs: 120
Inspection completion timeframe for fire stopping repairs: 90
Inspection completion timeframe for nurse-call system repairs: 365
Inspection completion timeframe for elevator system: 120
Inspection completion timeframe for gas and vacuum systems: 120
Inspection completion timeframe for water management plan: 30
Inspection completion timeframe for laundry department evaluation: 180
Inspection completion timeframe for dietary department evaluation: 180
Inspection completion timeframe for housekeeping department evaluation: 180
Inspection completion timeframe for cabinetry and countertops evaluation: 180
Inspection completion timeframe for kitchen suppression system: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marvin Ostreicher | Member of the LLC | Member of the LLC executing the Pre-Licensure Consent Order |
| Lorraine Cullen | Branch Chief, Healthcare Quality and Safety Branch, Department of Public Health | Signed the Pre-Licensure Consent Order on behalf of the Department of Public Health |
| Keith Edwards | Director of Engineering & Planning | Approved the Plan of Correction on August 5, 2024 |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Apr 16, 2024
Visit Reason
The inspection was conducted as a routine annual survey to assess compliance with regulatory requirements related to resident care, documentation, and facility safety systems.
Findings
The facility failed to notify the physician of a resident's decline in oral intake, failed to ensure meal intake was properly documented, and had a non-audible call bell system on the third floor nursing unit. These deficiencies posed minimal to potential for actual harm to residents.
Deficiencies (3)
F 0580: The facility failed to notify the physician of a decline in Resident #1's oral intake and condition, despite documented reduced food and fluid consumption and clinical signs of illness.
F 0842: The facility failed to ensure meal intake was documented for Resident #1, with missing entries on intake logs and no policy provided for meal intake documentation.
F 0919: The facility failed to ensure the call bell system was audible at the nurse's station and throughout the third floor nursing unit, compromising resident safety.
Report Facts
Serum sodium level: 162
Fluid need range (ml): 1975
Fluid need range (ml): 2370
Resident #1 meal intake percentage: 25
Resident #1 meal intake percentage: 0
Resident #1 meal intake percentage: 50
Resident #1 meal intake percentage: 25
Blood pressure: 149
Blood pressure: 55
Heart rate: 174
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Advanced Practicing Registered Nurse (APRN) | Evaluated Resident #1 on 3/12/24 and ordered tests and emergency room transport | |
| Director of Nurses (DNS) | Interviewed regarding intake and output monitoring and meal intake documentation responsibilities | |
| Administrator | Interviewed regarding call bell system issues and replacement plans | |
| Assistant Maintenance Director | Interviewed about call bell system malfunction and vendor contact | |
| Maintenance Director | Interviewed about monthly call bell system checks and bid for replacement | |
| Call System Vendor | Interviewed about call bell system and planned enunciator installation |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Apr 16, 2024
Visit Reason
The inspection was conducted as part of a regulatory annual survey to assess compliance with healthcare facility standards, focusing on resident care, documentation, and safety systems.
Findings
The facility was found deficient in notifying the physician of a resident's decline in oral intake, documenting meal intake properly, and maintaining a fully functional call bell system on the third floor. These deficiencies posed minimal to potential minimal harm to residents.
Deficiencies (3)
Failed to notify the physician of a decline in a resident's oral intake and condition change.
Failed to ensure meal intake was documented properly, with missing entries on intake logs.
Call bell system on the third floor was not audible at the nurse's station and throughout the unit.
Report Facts
Serum sodium level: 162
Fluid need range (ml): 1975
Fluid need range (ml): 2370
Heart rate: 174
Blood pressure: 149
Blood pressure: 55
Temperature (F): 100.9
Date of last call light system check: Feb 29, 2024
Time of call system vendor interview: 1400
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Advanced Practicing Registered Nurse | APRN | Evaluated Resident #1 on 3/12/24 and ordered tests and emergency room transport |
| Director of Nurses | DNS | Interviewed on 4/16/24 regarding intake monitoring and meal documentation responsibilities |
| Administrator | Interviewed on 4/16/24 regarding call bell system issues and awareness | |
| Assistant Maintenance Director | Interviewed on 4/16/24 about call bell system volume issues | |
| Maintenance Director | Interviewed on 4/16/24 about call light system checks and replacement bid | |
| Call System Vendor | Interviewed on 4/16/24 regarding call bell system repairs |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Oct 18, 2023
Visit Reason
The inspection was conducted to investigate complaints related to medication management, pressure ulcer care, accident hazards, supervision adequacy, and discharge procedures at Shady Knoll Center for Health & Rehabilitation.
Complaint Details
The investigation was complaint-driven, focusing on medication errors, pressure ulcer care deficiencies, inadequate supervision, and safety hazards. The complaint was substantiated with findings of minimal harm and few residents affected.
Findings
The facility failed to ensure proper medication reconciliation at discharge, failed to implement pressure relieving devices timely for residents with pressure ulcers, did not provide adequate supervision for residents requiring 1:1 observation, and failed to maintain a safe environment free from accident hazards. Additionally, the facility did not document fall care plans appropriately and allowed discontinued medications to be sent home with a resident.
Deficiencies (4)
F0661: The facility failed to ensure discharge information included a resident's fall and hospital evaluation, and discontinued medications were sent home with the resident.
F0686: The facility failed to implement pressure relieving devices upon admission for residents with multiple pressure ulcers, delaying appropriate care.
F0689: The facility failed to maintain a safe environment free from accident hazards and did not provide adequate supervision for residents requiring 1:1 observation, resulting in falls and unsafe conditions.
F0761: The facility failed to remove discontinued medications from the medication cart, resulting in discontinued drugs being sent home with a resident at discharge.
Report Facts
Discontinued medications sent home: 2
Non-clinical staff shifts providing 1:1 observation: 230
Resident weight: 86
Pressure ulcer measurements: 2
Pressure ulcer measurements: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Reviewed discharge packet with resident representative but failed to compare medication blister packages, resulting in discontinued medications being sent home. |
| DNS | Director of Nursing Services | Interviewed regarding medication reconciliation failures and lack of awareness about discontinued medications sent home. |
| LPN #2 | Licensed Practical Nurse | Nurse on duty during Resident #222 fall; unable to recall incident. |
| RN #5 | Nursing Supervisor | Reported loose pill incident found on floor in Resident #8's room. |
| Ambassador #1 | Non-clinical staff | Assigned to provide 1:1 constant observation for Resident #55 without clinical training. |
| RN #7 | Corporate Director of Clinical Services | Provided policy on safety monitoring by non-clinical staff and discussed staffing practices. |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Oct 18, 2023
Visit Reason
The inspection was conducted to investigate complaints related to discharge medication errors, pressure ulcer care, accident hazards, supervision adequacy, and fall prevention at Shady Knoll Center for Health & Rehabilitation.
Complaint Details
The complaint investigation focused on medication errors at discharge, pressure ulcer care deficiencies, accident hazards, inadequate supervision for a resident requiring 1:1 observation, and fall prevention failures. Substantiation status is not explicitly stated.
Findings
The facility failed to ensure discontinued medications were removed and not sent home with a resident upon discharge, failed to implement pressure relieving devices timely for residents with pressure ulcers, failed to maintain a safe environment free of accident hazards, failed to provide adequate supervision for a resident requiring 1:1 observation by trained staff, and failed to prevent a resident from falling out of bed during pain patch application.
Deficiencies (6)
Failed to ensure necessary information was communicated to the resident and receiving healthcare provider at discharge, including failure to remove discontinued medications sent home with resident #222.
Failed to provide appropriate pressure ulcer care and prevent new ulcers by not implementing pressure relieving devices upon admission for residents #117 and #222.
Failed to ensure the nursing home area was free from accident hazards and provide adequate supervision to prevent accidents for residents #8, #55, and #222.
Failed to provide adequate 1:1 constant observation by trained staff for Resident #55, utilizing non-clinical staff without proper training or certification.
Failed to develop and document a fall care plan prior to Resident #222 falling out of bed and sustaining minor head injury.
Failed to remove discontinued medications from the medication cart, resulting in Resident #222 being discharged with discontinued Ativan and Trazadone medications.
Report Facts
Discontinued medications sent home: 2
Non-clinical staff providing 1:1 observation: 21
Shifts covered by non-clinical staff: 230
Weight of Resident #222: 86
Pressure ulcer measurements: 2
Pressure ulcer measurements: 3
Medication doses sent home: 12
Medication doses sent home: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Reviewed discharge packet with Resident #222's representative but failed to compare medication blister packages and discharge medication list; took all medications from medication cart and gave to resident representative including discontinued medications. |
| DNS | Director of Nursing Services | Interviewed regarding discharge medication errors and pressure ulcer care; unaware of discontinued medications sent home with Resident #222; indicated expectation for nurse to review discharge medications. |
| LPN #2 | Licensed Practical Nurse | Nurse on duty at time of Resident #222's fall out of bed; did not recall incident. |
| RN #5 | Nursing Supervisor | Reported loose pill found on floor in Resident #8's room; unable to identify medication. |
| Ambassador #1 | Non-clinical staff | Assigned to provide 1:1 constant observation for Resident #55; no clinical background or training; did not know facility policy on 1:1 observation. |
| RN #7 | Corporate Director of Clinical Services | Interviewed regarding use of non-clinical staff for 1:1 observation of Resident #55 and related policies. |
Inspection Report
Complaint Investigation
Deficiencies: 14
Date: Oct 18, 2023
Visit Reason
Complaint investigation triggered by allegations related to resident care, medication management, environment, supervision, and documentation.
Complaint Details
The investigation was complaint-driven, focusing on allegations of delayed resident assistance, medication management errors, environmental hazards, inadequate supervision, and documentation deficiencies.
Findings
The facility was found deficient in multiple areas including failure to ensure timely assistance to residents, inadequate diabetes management and notification, poor environmental maintenance, failure to notify ombudsman of hospital transfers, incomplete PASARR re-screening, improper use of non-clinical staff for 1:1 observation, failure to provide scheduled showers, expired CPR certifications, failure to monitor vital signs as ordered, inaccurate nurse staffing postings, medication reconciliation errors at discharge, unsanitary kitchen equipment, improper sanitizing solution concentration, expired emergency food supplies, and incomplete or inaccurate medical record documentation.
Deficiencies (14)
F 0561: The facility failed to ensure resident choices were accommodated when Resident #117 requested to go to bed, resulting in a delay of 2 hours and 30 minutes for assistance.
F 0580: The facility failed to notify the physician and resident's representative when blood glucose levels were outside ordered parameters for Residents #59 and #119.
F 0584: The facility failed to maintain the environment in good repair and homelike manner, with multiple units having damaged walls, ceilings, radiators, and doors.
F 0623: The facility failed to notify the Office of the State Long-Term Care Ombudsman of hospital transfers for Residents #105 and #112.
F 0645: The facility failed to complete PASARR re-screening following a new mental health diagnosis for Resident #55.
F 0659: The facility failed to ensure qualified staff provided targeted 1:1 constant observation for Resident #55, utilizing non-clinical staff without proper training or documentation.
F 0677: The facility failed to provide scheduled showers to Resident #95 on multiple dates in September and October 2023.
F 0678: The facility failed to ensure licensed staff maintained current CPR certification; 6 licensed personnel had expired certifications.
F 0684: The facility failed to follow physician orders for diabetes management, failed to monitor vital signs as ordered for multiple residents, and failed to document neurological assessments following falls.
F 0689: The facility failed to ensure a safe environment for Residents #8, #55, and #222, including medication safety, adequate supervision for 1:1 observation, and proper positioning during care, resulting in falls and medication errors.
F 0732: The facility failed to post accurate nurse staffing information for multiple shifts in October 2023.
F 0761: The facility failed to remove discontinued medications from the medication cart and discharged Resident #222 with discontinued medications.
F 0812: The facility failed to maintain kitchen equipment in a clean and sanitary condition, failed to maintain chemical sanitizing solution at proper concentration, and failed to ensure emergency food supplies were within use-by dates.
F 0842: The facility failed to maintain complete and accurate medical records, including failure to document continuous 1:1 behavior monitoring for Resident #55, failure to document neurological assessments post falls, failure to document vital signs as ordered, and failure to document showers provided to Resident #95.
Report Facts
Discontinued medications sent home: 2
Non-clinical staff shifts providing 1:1 observation: 230
Expired CPR certifications: 6
Out of date emergency food items: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Reviewed discharge medications with resident representative but failed to compare medication blister packages and allowed discontinued medications to be sent home with resident. |
| RN #8 | Registered Nurse | Administered insulin for elevated blood glucose but failed to notify physician/APRN or document recheck. |
| NA #5 | Nurse Aide | Failed to provide scheduled showers to Resident #95 on multiple dates and failed to document showers given. |
| Dietary Director | Acknowledged unsanitary kitchen equipment and improper sanitizing solution concentration. | |
| DNS | Director of Nursing Services | Provided multiple interviews regarding deficiencies in notification, documentation, supervision, and staff training. |
| Administrator | Acknowledged issues with staffing postings, supervision, and shower provision. |
Inspection Report
Routine
Deficiencies: 16
Date: Oct 18, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, medication management, environment, staffing, and other facility operations.
Findings
The facility was found to have multiple deficiencies including failure to ensure timely staff response to resident call lights, inadequate diabetes management and notification of abnormal blood glucose levels, environmental maintenance issues, failure to notify the Ombudsman of hospital transfers, incomplete PASARR re-screening, inadequate 1:1 observation by qualified staff, failure to provide scheduled showers, expired CPR certifications, incomplete vital sign monitoring, unsafe medication management at discharge, unsanitary kitchen equipment and improper sanitizing solution concentrations, inaccurate nurse staffing postings, and incomplete documentation of 1:1 behavior monitoring.
Deficiencies (16)
Failure to ensure resident choices were accommodated when Resident #117 requested to go to bed, with staff taking over 2 hours to assist.
Failure to notify physician and resident representative of abnormal blood glucose levels for Resident #59 and #119.
Facility environment not maintained in good repair; multiple rooms had damaged walls, ceilings, and radiators.
Failure to notify Ombudsman of hospital transfers for Residents #105 and #112.
Failure to complete PASARR re-screening following new mental health diagnosis for Resident #55.
Non-clinical staff without training provided 1:1 constant observation for Resident #55 with inappropriate behaviors.
Failure to provide scheduled showers to Resident #95 on multiple dates.
Licensed staff had expired CPR certifications.
Failure to follow physician orders for diabetes management and vital sign monitoring for multiple residents.
Failure to ensure safe environment and adequate supervision for residents, including medication administration and fall prevention.
Resident #222 fell out of bed during application of pain patch; facility unable to substantiate how fall occurred.
Failure to remove discontinued medications from medication cart; discontinued medications sent home with Resident #222 at discharge.
Oxygen nasal cannula not stored in sanitary manner; found detached and on floor.
Inaccurate posting of nurse staffing information for multiple shifts.
Kitchen equipment unclean with debris and grease; sanitizing solution below recommended concentration; emergency food supply items out of date.
Failure to maintain complete and accurate medical records including 1:1 behavior monitoring documentation, vital sign monitoring, neurological assessments post falls, and shower documentation.
Report Facts
Discontinued medications sent home: 2
Expired CPR certifications: 6
1:1 observation shifts by non-clinical staff: 230
Out of date peanut butter containers: 6
Out of date oat containers: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #4 | Registered Nurse | Answered Resident #117's call light and explained delay due to emergency shower |
| NA #1 | Nurse Aide | Assigned to Resident #117, delayed assistance for over 2 hours due to emergency shower |
| DNS | Director of Nursing Services | Provided multiple interviews regarding deficiencies and corrective actions |
| Administrator | Provided interviews regarding deficiencies and corrective actions | |
| RN #8 | Registered Nurse | Provided care to Resident #59 with elevated BG and failed to notify physician |
| LPN #1 | Licensed Practical Nurse | Reviewed discharge medications for Resident #222 but failed to compare blister packs |
| NA #5 | Nurse Aide | Failed to provide scheduled showers to Resident #95 on multiple dates |
| RN #7 | Corporate Director of Clinical Services | Discussed use of non-clinical staff for 1:1 observation for Resident #55 |
| Dietary Director | Provided interviews regarding kitchen sanitation and emergency food supply |
Inspection Report
Complaint Investigation
Deficiencies: 10
Date: Jul 28, 2021
Visit Reason
The inspection was conducted following complaints and allegations of mistreatment, injury of unknown origin, verbal mistreatment, and concerns about resident care and safety.
Complaint Details
The investigation was triggered by complaints of mistreatment, injury of unknown origin, verbal mistreatment, and concerns about resident care and safety. The allegations involved multiple residents and staff members, including nurse aides and licensed nurses. Some allegations were substantiated with findings of failure to provide dignified care, failure to report and investigate abuse, and failure to follow care protocols.
Findings
The facility was found to have multiple deficiencies including failure to provide dignified care, failure to timely notify responsible parties of injuries, failure to maintain equipment in good repair, failure to timely report and investigate suspected abuse and mistreatment, failure to ensure safe resident transfers, failure to obtain timely physician orders for oxygen, incomplete and inaccurate clinical records, and failure to follow infection control protocols.
Deficiencies (10)
F 0550: The facility failed to ensure care was provided in a dignified manner to Resident #49, including an incident of verbal mistreatment by a nurse aide.
F 0580: The facility failed to timely notify the resident's physician and responsible party of an injury of unknown origin (bruise) to Resident #38 and failed to assess and document the bruise properly.
F 0584: The facility failed to ensure equipment was in good repair and safe for usage, including a detached dresser drawer handle, holes in privacy curtains, and inappropriate use of a plastic bag to lengthen an overbed light pull cord.
F 0609: The facility failed to timely report suspected abuse, neglect, or verbal mistreatment to the Director of Nursing Services, Administrator, and State Survey Agency for Residents #38 and #355.
F 0610: The facility failed to immediately initiate investigations and protect residents from further mistreatment related to a bruise of unknown origin and verbal mistreatment allegations for Residents #38 and #355.
F 0684: The facility failed to ensure Resident #38's bruise was assessed and documented per accepted nursing standards.
F 0689: The facility failed to ensure Resident #605 was transferred with the assistance of two staff as ordered, and failed to use a gait belt during transfer.
F 0695: The facility failed to obtain a physician's order for oxygen treatment for Resident #81 in a timely manner.
F 0842: The facility failed to maintain complete and accurate clinical records for Resident #53, including incorrect diagnoses, incomplete intake and output documentation, and failure to document follow-up with a specialist.
F 0880: The facility failed to ensure infection control practices were followed for Resident #358 by not wearing required eye protection when providing care.
Report Facts
Deficiencies cited: 10
ADL documentation incomplete shifts: 10
ADL documentation incomplete shifts: 22
ADL documentation incomplete shifts: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Spoke with Resident #355 about verbal mistreatment and failed to report the incident. |
| RN #5 | Registered Nurse | Failed to report and assess bruise on Resident #38. |
| LPN #3 | Licensed Practical Nurse | Alleged to have verbally mistreated Resident #355 and delayed pain medication. |
| NA #5 | Nurse Aide | Made negative statement to Resident #49 and was removed from care assignment. |
| DNS | Director of Nursing Services | Interviewed regarding multiple deficiencies and expectations for reporting and care. |
| RN #6 | Registered Nurse | Relieved RN #5 and did not receive report of bruise discovery. |
| RN #2 | Registered Nurse | Entered incorrect diagnoses into Resident #53's clinical record. |
| RN #4 | Registered Nurse | Commented on incorrect diagnoses entry for Resident #53. |
| APRN #1 | Advanced Practice Registered Nurse | Provided admission progress note for Resident #53 and commented on clinical record completeness. |
| APRN #2 | Advanced Practice Registered Nurse | Interviewed regarding hospital discharge instructions for Resident #53. |
Inspection Report
Complaint Investigation
Deficiencies: 10
Date: Jul 28, 2021
Visit Reason
The inspection was conducted based on allegations of mistreatment, injury of unknown origin, verbal mistreatment, and concerns related to resident care and safety.
Complaint Details
The complaint investigation included allegations of mistreatment, injury of unknown origin, verbal mistreatment, failure to notify responsible parties, failure to report abuse timely, failure to investigate allegations, and failure to maintain accurate clinical records.
Findings
The facility failed to ensure dignified care, timely notification of injuries, proper equipment maintenance, timely reporting and investigation of abuse allegations, accurate clinical documentation, safe resident transfers, timely physician orders for oxygen, and adherence to infection control protocols.
Deficiencies (10)
Failed to ensure care was provided in a dignified manner to Resident #49.
Failed to notify physician and responsible party timely of an injury of unknown origin for Resident #38.
Failed to ensure equipment was in good repair and safe for usage in resident rooms.
Failed to timely report suspected abuse, neglect, or verbal mistreatment and report investigation results to proper authorities.
Failed to respond appropriately to alleged violations by not immediately initiating investigations for bruises and verbal mistreatment.
Failed to provide appropriate treatment and care by not assessing and documenting a bruise of unknown origin per standards of care.
Failed to ensure resident was transferred with assistance of two staff as ordered.
Failed to obtain a physician's order for oxygen treatment in a timely manner for Resident #81.
Failed to maintain complete and accurate clinical records including diagnoses, intake/output documentation, and follow-up appointment recommendations for Resident #53.
Failed to ensure infection control practices were followed, specifically the required use of eye protection when providing care to Resident #358 on transmission based precautions.
Report Facts
Deficiencies cited: 10
ADL documentation incomplete shifts: 10
ADL documentation incomplete shifts: 22
ADL documentation incomplete shifts: 19
Oxygen liters per minute: 2
Dates of incident reports and interviews: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA#5 | Nurse Aide | Named in mistreatment allegation involving Resident #49 and removed from care assignment. |
| DSS | Director of Social Service | Interviewed regarding mistreatment allegations and resident cognitive status. |
| DNS | Director of Nursing Services | Interviewed multiple times regarding notification failures, investigations, and policy expectations. |
| RN #5 | Registered Nurse | Failed to report and assess bruise on Resident #38; unresponsive to interview requests. |
| RN #6 | Registered Nurse | Interviewed regarding bruise reporting and shift handover. |
| Person #1 | Resident's Responsible Party | Reported not being notified of resident's bruise. |
| Person #2 | Family Member | Discovered bruise on Resident #38 and reported to nursing staff. |
| LPN #3 | Licensed Practical Nurse | Alleged verbal mistreatment of Resident #355 and delayed pain medication administration. |
| RN #1 | Registered Nurse | Spoke with Resident #355 about mistreatment but failed to report incident. |
| NA #3 | Nurse Aide | Observed transferring Resident #605 alone without gait belt despite orders. |
| LPN #1 | Licensed Practical Nurse | Interviewed about Resident #605 transfer requirements. |
| LPN #1 | Licensed Practical Nurse | Identified missing physician order for oxygen for Resident #81. |
| APRN #2 | Advanced Practice Registered Nurse | Provided progress notes and interviewed regarding Resident #53 and oxygen order for Resident #81. |
| RN #2 | Registered Nurse | Entered incorrect diagnoses in Resident #53's clinical record. |
| RN #4 | Registered Nurse | Commented on incorrect diagnoses entry for Resident #53. |
| NA #2 | Nurse Aide | Failed to wear eye protection when providing care to Resident #358 on transmission based precautions. |
Inspection Report
Renewal
Census: 119
Capacity: 120
Deficiencies: 0
Date: Inspection Report Shady Knoll Center for Health Rehab LIR 7 1 25
Visit Reason
The inspection was conducted as a licensing inspection for renewal purposes and included review of a complaint investigation #44619.
Findings
The report indicates that violations of the General Statutes of Connecticut and/or regulations were not identified at the time of this inspection.
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