Inspection Reports for
Whitney Center

200 Leeder Hill Dr, Hamden, CT 06517, CT, 06517

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Deficiencies (last 8 years)

Deficiencies (over 8 years) 8.8 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

57% worse than Connecticut average
Connecticut average: 5.6 deficiencies/year

Deficiencies per year

28 21 14 7 0
2017
2018
2019
2020
2022
2023
2024
2025

Occupancy

Latest occupancy rate 67% occupied

Based on a February 2025 inspection.

This facility has shown a decline in demand based on occupancy rates.

Occupancy rate over time

40% 60% 80% 100% Aug 2017 Nov 2019 Sep 2022 Nov 2023 Feb 2025

Inspection Report

Follow-Up
Census: 20 Capacity: 30 Deficiencies: 0 Date: Feb 21, 2025

Visit Reason
A Desk Audit was completed for Whitney Center to verify the implementation of the Plan of Correction from the re-certification survey conducted on 12/4/24.

Findings
As of 1/15/25, corrections, education, and audits have been verified and no new noncompliance was found.

Report Facts
Licensed Beds: 30 Census: 20

Employees mentioned
NameTitleContext
Michele AckermanDNSPersonnel contacted during the inspection

Inspection Report

Complaint Investigation
Deficiencies: 6 Date: Dec 4, 2024

Visit Reason
The inspection was conducted based on complaints regarding failure to provide appropriate treatment and care according to physician orders and professional standards for multiple residents.

Complaint Details
The complaint investigation was triggered by allegations that the facility failed to provide care according to physician orders and professional standards, including failure to obtain weights, apply compression stockings, conduct neurological checks after falls, perform RN assessments after injuries, and properly transfer residents, resulting in harm or potential harm to residents.
Findings
The facility failed to consistently follow physician orders for weight monitoring, application of compression stockings, neurological checks after falls, RN assessments after injuries, and proper transfer procedures, resulting in minimal harm or potential for actual harm to several residents.

Deficiencies (6)
F0684: The facility failed to ensure weights were obtained every other day as ordered for Resident #20 on Lasix for edema.
F0684: The facility failed to follow the physician's order to apply compression stockings daily for Resident #12.
F0684: The facility failed to complete neurological checks and post fall assessments after multiple unwitnessed falls with head strikes for Resident #3.
F0684: The facility failed to complete an RN assessment after Resident #8 was found with an injury of unknown origin and pain.
F0684: The facility failed to ensure neurological assessments and follow-up assessments were completed following two unwitnessed falls for Resident #124.
F0689: The facility failed to ensure Resident #1 was transferred according to the physician's order using a Sara lift with assistance of 2 staff, resulting in the resident being lowered to the floor and sustaining a nondisplaced fracture.
Report Facts
Weight measurements missed: 3 Falls: 4 Falls: 2 Date of injury: 2023

Employees mentioned
NameTitleContext
RN #4RN SupervisorNamed in findings related to failure to ensure weights were obtained, neurological checks, and transfer incident involving Resident #1.
LPN #2Licensed Practical NurseNamed in findings related to failure to complete RN assessment after Resident #8's wrist injury.
MD #1PhysicianNamed in findings related to physician orders for weights, compression stockings, and transfer procedures.
NA #3Nurse AideNamed in transfer incident where Resident #1 was lowered to the floor resulting in injury.

Inspection Report

Renewal
Census: 23 Capacity: 30 Deficiencies: 0 Date: Dec 4, 2024

Visit Reason
The inspection was conducted as a renewal licensing inspection and included a complaint investigation related to multiple complaint numbers.

Complaint Details
Complaint investigation was conducted for complaint numbers CT 287165, CT 33929 (apt at this facility), CT 35422, CT 36055, CT 29260, and CT 31651.
Findings
The report indicates that violations of the General Statutes of Connecticut and/or regulations were not identified at the time of this inspection. The certification file was reviewed.

Report Facts
Licensed Bed Capacity: 30 Census: 23

Inspection Report

Routine
Deficiencies: 10 Date: Dec 4, 2024

Visit Reason
Routine state inspection of Whitney Center nursing home to assess compliance with regulatory requirements including resident rights, care, safety, and food service.

Findings
The facility was found deficient in multiple areas including failure to support resident council meetings, incomplete advance directive documentation, failure to notify hospice and representatives of resident injury, incomplete neurological assessments after falls, failure to follow physician orders for compression stockings and weights, improper resident transfers resulting in injury, inadequate pain management, and incomplete food temperature monitoring logs.

Deficiencies (10)
F 0565: The facility failed to provide staff support to ensure residents' right to organize and participate in resident council meetings, which had not been held for over a year.
F 0578: The facility failed to ensure code status was reviewed with residents or representatives upon admission and as needed, resulting in missing or delayed documentation for multiple residents.
F 0580: The facility failed to immediately notify the hospice provider and resident representative when Resident #8 complained of new severe wrist pain.
F 0609: The facility failed to timely report Resident #8's wrist injury of unknown origin to the state agency and failed to provide a policy related to such reporting.
F 0610: The facility failed to investigate Resident #8's injury of unknown origin and failed to provide a policy related to RN assessments for such injuries.
F 0644: The facility failed to notify the appropriate state-designated authority of a new diagnosis of psychotic disorder with delusions for Resident #10 and lacked a PASARR policy.
F 0684: The facility failed to ensure residents received treatment and care according to physician orders and professional standards, including failure to obtain weights as ordered, failure to apply compression stockings, failure to complete neurological checks after falls, and failure to assess and manage pain.
F 0689: The facility failed to ensure Resident #1 was transferred according to physician orders using a Sara lift with 2 staff, resulting in a fall and fracture.
F 0697: The facility failed to assess and manage complaints of new severe wrist pain for Resident #8, including failure to document pain assessments and interventions.
F 0812: The facility failed to ensure hot and cold food temperatures were obtained and documented appropriately, and food temperature logs were altered after initial review.
Report Facts
Weight measurements missed: 4 Weight loss: 8.6 Pain medication dosage: 325 Fracture date: 2023

Employees mentioned
NameTitleContext
RN #4RN SupervisorNamed in findings related to failure to complete neurological assessments and supervision of transfers.
LPN #2Licensed Practical NurseNamed in findings related to failure to assess and document Resident #8's wrist injury and pain.
NA #3Nursing AssistantNamed in findings related to improper transfer of Resident #1 resulting in fall and injury.
Dietary Director #1Dietary DirectorNamed in findings related to failure to ensure food temperature logs were properly completed.
Dietary Director #2Chef ManagerNamed in findings related to altered food temperature logs and lack of policy awareness.

Inspection Report

Complaint Investigation
Deficiencies: 12 Date: Dec 2, 2024

Visit Reason
The inspection was conducted based on complaints and allegations regarding failure to provide staff support for resident council meetings, failure to review and honor residents' code status and advance directives, failure to notify hospice providers and resident representatives about new severe pain complaints, failure to investigate injuries of unknown origin, failure to assess and manage residents' conditions properly, and failure to maintain proper food temperature logs.

Complaint Details
The visit was complaint-related, investigating allegations of failure to support resident council meetings, failure to review and honor code status and advance directives, failure to notify hospice and representatives about pain complaints, failure to investigate injuries of unknown origin, failure to follow physician orders, and failure to maintain food safety standards. Substantiation status is not explicitly stated.
Findings
The facility was found deficient in multiple areas including lack of resident council meetings, inadequate review and documentation of residents' code status and advance directives, failure to notify appropriate parties about resident pain and injuries, incomplete investigations of injuries, failure to follow physician orders, inadequate neurological assessments after falls, and failure to maintain proper food temperature records. Several residents' rights and care standards were not met, and multiple violations of Connecticut State Agencies regulations were identified.

Deficiencies (12)
Facility failed to provide staff support to ensure residents' right to organize and participate in resident council meetings.
Facility failed to ensure code status was reviewed with residents or representatives upon admission and as needed.
Facility failed to immediately notify hospice provider and resident representative when resident complained of new severe wrist pain.
Facility failed to notify the state agency of injuries of unknown origin and failed to investigate such injuries properly.
Facility failed to assess and manage residents' conditions in accordance with professional standards and physician orders.
Facility failed to ensure neurological checks and post-fall assessments were completed after residents sustained falls with head strikes.
Facility failed to ensure residents received treatment in accordance with professional standards and MD orders.
Facility failed to ensure resident transfers were performed according to physician's orders.
Facility failed to ensure residents were free from accident hazards and received adequate supervision and assistive devices to prevent accidents.
Facility failed to ensure hot and cold food temperatures for meals were obtained and documented appropriately.
Facility failed to maintain clear discharge instructions and complete discharge paperwork for residents.
Facility failed to adhere to minimum staffing requirements for a social worker over a 6-month period.
Report Facts
Residents reviewed for code status: 5 Residents reviewed for unnecessary medications: 5 Residents reviewed for accidents: 5 Residents reviewed for Preadmission Screening and Resident Review (PASARR): 1 Residents reviewed for discharge: 1 Residents reviewed for transfers: 1 Residents reviewed for falls: 1 Residents reviewed for pain management: 1 Residents reviewed for injury of unknown origin: 1 Residents reviewed for food temperature logs: Facility-wide food service logs reviewed

Employees mentioned
NameTitleContext
Margaret JoyceAdministratorNamed in relation to oversight and plan of correction responsibilities
RN #4RN SupervisorIdentified in findings related to injury assessments and nursing supervision
LPN #2Identified in findings related to injury assessments and documentation
MD #1PhysicianReferenced in multiple findings related to orders and assessments
MD #2PhysicianReferenced in findings related to code status and orders
Dietary Director #1Referenced in findings related to food temperature logs
Dietary Director #2Chef ManagerReferenced in findings related to food temperature logs
SW #1Social WorkerReferenced in findings related to PASARR and social worker staffing
RN #5Referenced in findings related to resident discharge
NA #3Nursing AssistantReferenced in findings related to resident transfers and falls

Inspection Report

Complaint Investigation
Census: 137 Capacity: 150 Deficiencies: 2 Date: Nov 22, 2023

Visit Reason
An unannounced visit was made to Whitney Rehabilitation Care Center on November 22, 2023, for the purpose of conducting a complaint investigation (#36433).

Complaint Details
Complaint investigation #36433 was substantiated with violations identified regarding a resident who wandered off the facility property unattended on 8/5/23, failure to report the incident timely, and failure to notify the physician or APRN. The resident was found safe and returned by a family member. Interviews and record reviews confirmed these findings.
Findings
Violations of the General Statutes of Connecticut and/or regulations were identified related to a resident who eloped from the facility without staff awareness and failure to thoroughly investigate the incident or notify the state agency timely. The facility failed to document notification to the physician or APRN when the resident eloped.

Deficiencies (2)
Failure to thoroughly investigate and report a resident elopement incident to the state agency at the time it occurred.
Failure to document notification to the physician or APRN when the resident eloped.
Report Facts
Licensed Bed Capacity: 150 Census: 137 Compliance Date: Jan 3, 2024 Exit Doors: 7 Distance Resident Found: 3 Random Audits Frequency: 4

Employees mentioned
NameTitleContext
Lauren KuzmaDirector of Nursing (DON)Named as personnel contacted and involved in the investigation.
Michael FioreAdministratorNamed as personnel contacted and involved in the investigation.
Karen GworekSupervising Nurse ConsultantAuthor of the notice letter regarding violations and plan of correction.

Inspection Report

Complaint Investigation
Census: 31 Capacity: 59 Deficiencies: 1 Date: Nov 17, 2022

Visit Reason
An unannounced visit was made to the facility on 11/17/2022 for the purpose of conducting a complaint investigation. The visit was triggered by Complaint #33276.

Complaint Details
Complaint investigation #33276 was substantiated with violations identified during the visit. The complaint involved failure to transcribe medication orders leading to resident harm.
Findings
Violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified during the inspection. The facility failed to transcribe a medication order from the hospital discharge summary into the Electronic Medication Administration Record (EMAR) for a new admission, resulting in missed doses and a change in condition for the resident.

Deficiencies (1)
Failure to transcribe a medication order from the hospital discharge summary into the EMAR, resulting in missed doses of Enoxaparin and subsequent pulmonary embolism for Resident #1.
Report Facts
Licensed Bed Capacity: 59 Census: 31 Missed doses: 5 Citation Number: 2022

Employees mentioned
NameTitleContext
Michele AckermanDirector of Nursing (DNS)Personnel contacted during inspection
Nicholas TomczykNurse ConsultantConducted the complaint investigation and authored the narrative report
Karen GworekSupervising Nurse ConsultantIssued the notice letter regarding violations and plan of correction

Inspection Report

Annual Inspection
Deficiencies: 8 Date: Sep 7, 2022

Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements and evaluate the facility's care and safety practices.

Findings
The facility was found deficient in multiple areas including failure to implement comprehensive care plans to prevent falls, inadequate coordination of care for pressure ulcers, lack of nursing competencies for IV skills, improper food handling and sanitation practices, and failure to follow infection prevention protocols including PPE use and COVID-19 staff screening.

Deficiencies (8)
F 0656: The facility failed to implement a comprehensive care plan for a resident at high risk for falls, resulting in an unwitnessed fall with minor injury.
F 0684: The facility failed to communicate and coordinate care with hospice services for a resident with a newly identified skin condition.
F 0684: The facility failed to notify and ensure RN assessment for a newly identified pressure ulcer on a resident's finger.
F 0686: The facility failed to ensure an RN assessment was completed for a new pressure ulcer identified on a resident's finger.
F 0689: The facility failed to implement the care plan to prevent a fall for a resident at high risk, including proper shoe storage and supervision.
F 0726: The facility failed to ensure nursing staff completed annual IV competencies for 2021 and 2022.
F 0812: Kitchen staff failed to perform hand hygiene after touching trash and the ice machine was not cleaned regularly, posing contamination risks.
F 0880: The facility failed to use PPE appropriately for a resident on contact precautions and failed to ensure two staff completed COVID-19 symptom screening prior to shift start.
Report Facts
Deficiencies cited: 8 Skin tear size: 5 Skin tear size: 6 Skin tear size: 0.125 Pressure ulcer size: 1.5 Pressure ulcer size: 2 Pressure ulcer size: 0.125

Employees mentioned
NameTitleContext
LPN #1Licensed Practical NurseAssigned nurse on the day Resident #15 had a fall and involved in shoe placement and fall observation
DNSDirector of Nursing ServicesProvided interviews regarding care plan adherence, staff competencies, and infection control expectations
RN #6Registered NurseAssigned nurse for Resident #20 when new skin condition was identified
LPN #3Licensed Practical NurseNotified of new skin integrity issue and involved in coordinating care with physician
RN #3Staff Development NurseInterviewed regarding nursing competencies and training
Dietary Aide #1Dietary AideObserved failing to perform hand hygiene after touching trash bin
Food Service DirectorFood Service DirectorInterviewed regarding ice machine cleaning and staff hand hygiene
RN #4Registered NurseObserved not using PPE properly in resident room with MRSA contact precautions
LPN #2Licensed Practical NurseFailed to complete COVID-19 screening prior to shift start
NA #1Nursing AssistantFailed to complete COVID-19 screening prior to shift start
AdministratorFacility AdministratorInterviewed regarding staff COVID-19 screening expectations

Inspection Report

Renewal
Census: 28 Capacity: 59 Deficiencies: 0 Date: Sep 7, 2022

Visit Reason
The inspection visit was conducted for the purpose of license renewal at the Whitney Center facility.

Findings
No violations or citations were identified during the inspection. Certification files and required verifications including CMP fund, CRF grant, Shift Coach, and Full Time Infection Prevention and Control Specialist were reviewed and confirmed.

Report Facts
Licensed Bed/Bassinet Capacity: 59 Census: 28 Inspection Dates: 4

Employees mentioned
NameTitleContext
Marie MathewFLIS StaffSignature on inspection report and report submitter
Debra O'NeillBFSISignature on inspection report
Evelyn BlancoRNSignature on inspection report
James KuoSignature on inspection report
Donna SchubaSupervisorApproval for issuance of license granted

Inspection Report

Abbreviated Survey
Census: 46 Capacity: 59 Deficiencies: 1 Date: Sep 8, 2020

Visit Reason
An unannounced visit was made to Whitney Center on September 8, 2020, by a representative of the Facility Licensing and Investigations Section of the Department of Public Health to conduct a COVID-19 focused infection control survey.

Findings
The facility failed to ensure proper use of Personal Protective Equipment (PPE) and maintenance of droplet and contact precautions for Resident #1, including failures in hand hygiene and donning/doffing of gowns, gloves, and face shields as required by infection control standards.

Deficiencies (1)
Failure to ensure proper Personal Protective Equipment (PPE) was donned and doffed in accordance with infection control standards for Resident #1 on droplet and contact precautions.
Report Facts
Total Capacity: 59 Census: 46 Audit Date: Nov 26, 2020 Audit Census: 45 Audit Capacity: 59

Employees mentioned
NameTitleContext
Sandra Vermont-HollisSupervising Nurse ConsultantAuthor of the letter regarding the plan of correction
Janet A. RosatoRegistered NurseSurveyor who signed the follow-up survey on 11/27/2020

Inspection Report

Plan of Correction
Census: 46 Capacity: 59 Deficiencies: 2 Date: Sep 8, 2020

Visit Reason
An unannounced visit was conducted at Whitney Center on September 8, 2020, for the purpose of conducting a COVID-19 focused infection control survey.

Findings
The facility failed to ensure that droplet and contact precautions were maintained for a resident on modified precautions, and staff did not consistently perform proper hand hygiene or use of PPE according to infection control standards. Deficiencies were identified related to infection prevention and control practices.

Deficiencies (2)
Failure to ensure droplet and contact precautions were maintained for Resident #1.
Staff did not perform proper hand hygiene or use PPE correctly when providing care to Resident #1.
Report Facts
Total Capacity: 59 Census: 46 Census: 45

Employees mentioned
NameTitleContext
Sandra Vermont-HollisSupervising Nurse ConsultantAuthor of the notice letter regarding the inspection
Janet A. RosatoRegistered NurseState surveyor who signed the survey report on 11/27/2020

Inspection Report

Abbreviated Survey
Census: 46 Capacity: 59 Deficiencies: 1 Date: Sep 8, 2020

Visit Reason
A COVID-19 Focused Infection Control 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 transmission of COVID-19.

Findings
The facility failed to ensure proper use of Personal Protective Equipment (PPE) in accordance with infection control standards for a resident on droplet and modified contact precautions. Observations and staff interviews revealed multiple instances of staff not performing hand hygiene or donning required PPE when providing care, leading to a failure to maintain droplet and contact precautions.

Deficiencies (1)
Failure to ensure proper Personal Protective Equipment (PPE) was donned and doffed in accordance with infection control standards for Resident #1 on droplet and modified contact precautions.
Report Facts
Total Capacity: 59 Census: 46 Completion date for plan of correction: Oct 13, 2020

Inspection Report

Follow-Up
Census: 46 Capacity: 59 Deficiencies: 0 Date: Nov 6, 2019

Visit Reason
The visit was conducted for the purpose of reviewing the implementation of the Plan of Correction (POC) for the violation letter dated 10/3/19.

Findings
Staffing was reviewed for the period 10/23/19 through 11/8/19 and met the minimum requirements of the regulations of Connecticut State Agencies. No violations were issued as a result of this visit.

Employees mentioned
NameTitleContext
LaShaun PriceDONPersonnel contacted during the inspection
Siobhan O’NeillNurse ConsultantReport submitted by and signed as Nurse Consultant

Inspection Report

Complaint Investigation
Deficiencies: 13 Date: Sep 19, 2019

Visit Reason
Investigation of multiple complaints including resident privacy violation, abuse allegations, failure to report abuse, inadequate investigation of abuse, untimely Minimum Data Set (MDS) submissions, improper transfer assistance, failure to revise care plans after falls, inadequate nutrition monitoring, failure to monitor orthostatic blood pressures with antipsychotic use, medication storage issues, outdated food storage, and failure to timely offer pneumococcal vaccination.

Complaint Details
The investigation was complaint-driven, focusing on allegations of privacy violations, abuse, failure to report abuse, inadequate investigations, and other regulatory compliance issues.
Findings
The facility failed to protect resident privacy by allowing unauthorized photographs, failed to prevent mental abuse, failed to report and investigate abuse allegations properly, failed to submit MDS assessments timely, failed to ensure proper staff assistance during mechanical lifts, failed to revise care plans after falls, failed to monitor resident weight and notify appropriate staff, failed to monitor orthostatic blood pressures as ordered for residents on antipsychotics, failed to secure medication carts, stored outdated food in the kitchen, and failed to offer pneumococcal vaccination in a timely manner.

Deficiencies (13)
F 0583: The facility failed to ensure resident privacy and confidentiality when a nursing assistant took a photo of Resident #18 in a Hoyer lift without written consent, causing distress.
F 0600: The facility failed to protect Resident #18 from mental abuse related to unauthorized photography and subsequent distress.
F 0609: The facility failed to timely report an allegation of abuse involving Resident #4 being kissed without consent.
F 0610: The facility failed to document a thorough investigation following an abuse allegation involving Resident #4.
F 0640: The facility failed to submit Minimum Data Set (MDS) assessments timely for eighteen residents, exceeding the 14-day submission requirement.
F 0659: The facility failed to ensure two staff assisted during a Hoyer lift transfer of Resident #18, violating the care plan and safety protocols.
F 0689: The facility failed to review and revise the care plan for Resident #247 after a fall resulting in a hip fracture, lacking new interventions to prevent further falls.
F 0692: The facility failed to obtain baseline and weekly weights as per policy for Resident #45, and failed to notify physician and dietician of significant weight loss.
F 0756: The facility failed to ensure the pharmacist identified and reported irregularities regarding missing orthostatic blood pressure monitoring for Resident #198 on antipsychotic medication.
F 0758: The facility failed to monitor orthostatic blood pressures as ordered for Residents #3 and #198 receiving antipsychotic medications.
F 0761: The facility failed to ensure medication and treatment carts were locked when unattended on the East Rock unit.
F 0812: The facility failed to discard outdated meat stored in the walk-in refrigerator, violating food safety standards.
F 0883: The facility failed to offer pneumococcal vaccination in a timely manner to Resident #3 and failed to track vaccination status properly.
Report Facts
Days late for MDS submission: 69 Days late for MDS submission: 30 Weight loss in pounds: 11.7 Number of residents with late MDS submissions: 18 Date of survey completion: Sep 19, 2019

Employees mentioned
NameTitleContext
NA #1Nursing AssistantTook unauthorized photo of Resident #18 and was terminated for violating abuse policy.
LPN #1Licensed Practical NurseReported incident of unauthorized photo and assisted Resident #18.
RN #2Registered NurseIdentified late MDS submissions and failure to document orthostatic blood pressures.
RN #3Registered NurseAcknowledged orthostatic blood pressures were ordered but not done for Resident #3.
RN #4Registered NurseObserved unlocked medication and treatment carts.
Director of NursingDirector of NursingReviewed abuse investigation and confirmed termination of NA #1.
AdministratorFacility AdministratorConducted investigation of privacy violation and abuse allegations.
Consulting PharmacistPharmacistFailed to identify and report missing orthostatic blood pressure monitoring.

Inspection Report

Follow-Up
Census: 48 Capacity: 59 Deficiencies: 0 Date: Aug 23, 2018

Visit Reason
The visit was a follow-up to review the Plan of Correction and Violation Letter dated July 9, 2018, to verify correction of previous deficiencies.

Findings
No violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection. A narrative report and additional information were attached.

Report Facts
Licensed Bed Capacity: 59 Census: 48

Employees mentioned
NameTitleContext
Margaret JoyceAdministratorPersonnel contacted during the inspection.
LaShawn PriceRN, DNSPersonnel contacted during the inspection.
P. Henrietta SimmonsNCReport submitted by.

Inspection Report

Complaint Investigation
Census: 134 Capacity: 150 Deficiencies: 14 Date: Aug 21, 2017

Visit Reason
Unannounced visits were made to Whitney Rehabilitation Care Center on August 21, 22, 23 and 24, 2017 for the purpose of conducting multiple complaint investigations related to complaints #CT21254, CT21852, CT21857, and CT21950.

Complaint Details
Complaints #21254, #21852, and #21950 were investigated. Violations were identified and substantiated as noted in the report and attached violation letter dated 9-19-17.
Findings
Multiple violations of the Regulations of Connecticut State Agencies and General Statutes were identified during the visits, including failures in documentation, resident care, grievance resolution, dining dignity, accident prevention, medication storage, and life safety compliance. A citation #2017-54 was issued as a result of this inspection.

Deficiencies (14)
Failed to document notification of change to resident's responsible party regarding significant weight loss.
Failed to ensure prompt and satisfactory resolution of grievances.
Failed to provide dignified dining experience and treat residents with dignity and respect.
Failed to develop comprehensive care plan to address wandering.
Failed to revise plan of care to accurately reflect resident's bed mobility.
Staff failed to perform within scope of practice related to CPAP mask removal.
Failed to ensure residents' nails were kept clean and trimmed.
Failed to maintain carpet in a safe and hazard free manner.
Failed to ensure medical supplies were stored in a clean and sanitary manner.
Failed to assess and document resident following a fall with injury.
Failed to ensure medication storage room was locked and secured.
Failed to handle dishware in a sanitary manner in the kitchen.
Failed to ensure fire alarm system was installed, tested, and maintained in accordance with NFPA codes.
Failed to ensure automatic sprinkler system was installed to provide complete coverage.
Report Facts
Licensed Bed Capacity: 150 Census: 134 Citation Number: 2017 Inspection Dates: 4

Employees mentioned
NameTitleContext
Albert MislowAdministratorPersonnel contacted during inspection
Rosella A. CrowleySupervising Nurse ConsultantSigned complaint investigation letter
Richard HoweRNCReport submitted by

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