Inspection Reports for
The Villa at Stamford

The facility failed to ensure complete and accurate clinical records for one resident, specifically lacking timely documentation of meal intake over multiple dates. Interviews with staff confirmed expectations for accurate meal documentation, but no explanation was provided for the missing records.

The complaint investigation was substantiated. Resident #1 hit Resident #2 first due to dislike, and Resident #2 reacted by hitting Resident #1. The facility's investigation confirmed the resident-to-resident abuse occurred.

The facility failed to ensure that Resident #1 was free from physical abuse by Resident #2 despite a history of verbal and behavioral issues between the two residents. The investigation substantiated that Resident #1 hit Resident #2 first, and Resident #2 reacted by hitting Resident #1 on the cheek. The facility had not addressed the frequent negative behaviors of Resident #1 towards Resident #2 prior to the incident.

The complaint involved an allegation that a nursing assistant slapped Resident #1 on the back on 9/4/2024. The allegation was not substantiated after investigation. The social worker failed to document a follow-up visit after the allegation.

The facility was unable to substantiate the abuse allegation due to lack of witnesses and no injury noted. However, the facility failed to ensure complete and accurate medical records, specifically missing social worker documentation following a follow-up visit after the allegation.

Complaint CT #40889. The allegation involved a nursing assistant slapping Resident #1 on the back on 9/4/2024. The facility was unable to substantiate the allegation after investigation and family notification.

The investigation found a violation related to incomplete and inaccurate medical record documentation following an allegation of abuse involving Resident #1. The facility failed to document social worker follow-up notes after the allegation, and the accused staff member denied the allegation with no witnesses or injuries noted.

The facility was found deficient in multiple areas including failure to notify responsible parties timely after incidents, incomplete care plans following incidents, failure to follow dental and wound care orders, inadequate splint use, failure to prevent resident smoking in rooms, missing annual employee evaluations, and improper implementation of transmission-based precautions for a resident with MRSA infection.

The desk audit found that Violation #1 and corresponding violations were corrected as of 2024-03-13. The DNS was notified by telephone on 2024-04-12 that all violations were corrected.

The complaint investigation involved bruising on Resident #1's left and right arms. Resident #1 reported that two nurse aides were arguing and became rough during care. Protective services and multiple staff interviews were conducted. The Director of Nursing initially did not report the bruising as abuse due to medical explanations but later acknowledged the need to report after surveyor inquiry. The allegation was not substantiated as abuse at the time of the visit.

The facility failed to timely report suspected abuse or neglect related to bruising observed on Resident #1. Interviews and documentation revealed bruises on the resident's arms, conflicting explanations for the bruising, and delayed reporting by staff and administration. The Director of Nursing initially did not report the incident, believing bruising was due to medical causes, but later acknowledged the need to report after surveyor inquiry.

Multiple violations of Connecticut State Agencies regulations were identified during the visits, including failures related to urinary catheter care, abuse prevention, PASARR submissions, pressure ulcer care, oxygen tubing management, dialysis care, medication management, and medication cart cleanliness. Plans of correction were required for each violation with substantial compliance dates set for April 11, 2022.

The facility was found deficient in multiple areas including failure to maintain privacy for residents with urinary catheters, failure to prevent and investigate resident abuse, inadequate implementation of dietary recommendations for pressure ulcer care, improper respiratory care related to oxygen tubing maintenance, insufficient dialysis care for a resident with an arteriovenous fistula, delayed follow-up on pharmacy medication regimen recommendations, and failure to maintain medication carts in a clean and sanitary manner.

Complaint #28575 was the basis for the investigation.

The facility was found noncompliant with regulations related to the care and safety of a resident who sustained a wound and laceration. The investigation identified failures in reviewing and revising the plan of care to ensure interventions for accident prevention and safety were implemented.

The investigation was triggered by a complaint related to Resident #1 who sustained a head injury from a side rail. The facility was unable to validate the exact cause of the injury due to inconsistent reports, but the injury required hospital treatment with staples. The care plan was not properly updated to maintain safety interventions after the injury was resolved.

The facility failed to review and revise the plan of care to ensure interventions for accident prevention and safety were implemented for a resident with a previously identified head injury of unknown origin. Specifically, the care plan was not updated to maintain padded side rails after the injury was resolved, potentially compromising resident safety.

Deficiencies were identified related to failure to use proper hair and beard restraints in the kitchen area and failure to conduct staff COVID-19 testing according to established requirements and guidelines.

The facility failed to properly utilize hair restraints in the kitchen, did not conduct required COVID-19 staff testing, and failed to ensure staff wore picture identification badges as required by policy and law.

The facility failed to ensure staff utilized eye protection on the observation unit as required by policy and protocol, with multiple staff observed not wearing eye protection during resident care.

The facility failed to implement the use of eye protection per standard of care on the observation unit. Staff were observed not wearing proper eye protection despite being aware of the requirement. Education and disciplinary actions were planned to address this issue.

The facility failed to ensure staff utilized proper eye protection on the observation unit where residents' COVID-19 status was unknown. Multiple staff members were observed not wearing eye protection despite being aware of the requirement. The facility did not implement the use of eye protection per standard of care on the observation unit.

The grievance involved Resident #1 whose eyebrows were shaved off and penciled in without explanation. The resident was cognitively impaired and unable to explain the incident. The facility did not document the grievance investigation or provide a written response. The resident's representative reported missing items after discharge with no follow-up. The grievance was not properly handled according to facility policy.

The facility failed to ensure a grievance reported by the resident representative regarding the shaving of a resident's eyebrows was properly documented, investigated, and resolved with a written response. The grievance process was deficient in documentation, follow-up, and corrective action.

The facility was found to have violations of Connecticut State regulations related to grievance documentation and investigation. Specifically, the facility failed to ensure that a concern reported by a resident representative was documented and investigated properly, including missing follow-up and documentation in nursing progress notes and social worker notes.

Complaint investigation CT #27770 was substantiated with findings of noncompliance related to resident safety and care during incontinent care.

Violations of Connecticut State regulations were identified related to a resident fall during incontinent care, where staff failed to ensure resident safety and did not notify nursing when the resident indicated pain, resulting in a fall from bed. The facility was required to submit a plan of correction.

The facility failed to ensure that a resident was kept safe during incontinent care, resulting in a fall from the bed. The investigation identified that nursing staff did not stop care or notify the nurse when the resident was moving away due to pain from pressure sores.

The verbal abuse allegation towards Resident #63 was substantiated by the facility. The complaint investigation revealed that NA #2 verbally abused the resident and was terminated. The medication ordering failure was identified during review of Resident #133's admission and medication administration records.

The facility was found to have substantiated verbal abuse by a nursing assistant towards Resident #63 and failed to immediately remove the staff member from assignment. Additionally, the facility failed to order medications in a timely manner for Resident #133, resulting in missed medications on the day of admission.

Complaint numbers 25727 and 24039 were investigated. The allegation of verbal abuse was substantiated by the facility.

Two main violations were identified: 1) Verbal abuse of Resident #63 by staff member NA #2, which was substantiated and resulted in termination of NA #2's employment; 2) Failure to order medications in a timely manner for Resident #133, a newly admitted resident, resulting in missed medications on the day of admission.