Deficiencies per Year
12
9
6
3
0
Severe
High
Moderate
Low
Unclassified
Inspection Report
Renewal
Census: 17
Capacity: 17
Deficiencies: 0
Apr 5, 2022
Visit Reason
The inspection was conducted as a renewal licensing inspection of the residential care home facility Tracy Manor, Inc.
Findings
Violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection. An attached violation letter dated April 29, 2022, provides details.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Steven Richheimer | Person-in-Charge | Personnel contacted during the inspection |
| Karen Gworek | RN | Signature of FLIS Staff and report submitter |
| Raymond Kasidas | BFSI | Signature of FLIS Staff |
Inspection Report
Plan of Correction
Deficiencies: 9
Apr 5, 2022
Visit Reason
An unannounced visit was made to Tracy Manor Inc on April 5, 2022 by representatives of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting a licensure inspection.
Findings
Multiple violations of Connecticut State Agencies regulations were identified, including failure to ensure annual continuing education for staff, medication administration errors, expired medications not removed, undated or outdated food in the kitchen, missing thermometer in resident refrigerator, residents' rights violations, and fire safety code deficiencies.
Deficiencies (9)
| Description |
|---|
| Facility failed to ensure annual continuing education was completed by staff. |
| Facility failed to administer medications in accordance with the five rights. |
| Facility failed to document medication administration on pharmacy printed records. |
| Expired medications were found in the medication cart and were not removed or destroyed. |
| Food items in kitchen refrigerator were not dated and outdated foods were not discarded. |
| Facility failed to ensure a thermometer was located in the residents' refrigerator to monitor temperatures. |
| Facility failed to ensure residents' rights were not violated and personal information was kept confidential. |
| Facility failed to ensure fire drills were conducted per state fire safety code and failed to provide documentation of sprinkler system testing, hood cleaning, fire alarm system inspection, generator servicing, and fire alarm maintenance. |
| Rooms #3 and #4 and enclosed smoking area lacked adequate sprinkler coverage as required by NFPA 13. |
Report Facts
Medication administration time error: 43
Expired medication dates: 2
Smoke detectors needing replacement: 16
Sprinkler system inspection last completed: 2017
Hood cleaning frequency: 1
Fire alarm system inspection date: 2021
Generator servicing frequency: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Karen Gworek | Supervising Nurse Consultant | Signed letter regarding plan of correction instructions. |
| Steve Richheimer | Administrator | Named as Person-in-Charge and signed plan of correction. |
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