Inspection Reports for Masonic Healthcare Center
22 Masonic Ave, Wallingford, CT 06492, CT, 06492
Back to Facility ProfileInspection Report Summary
The most recent inspection on January 15, 2025, found no deficiencies and confirmed that all previously identified issues were corrected. Earlier inspections showed a pattern of deficiencies primarily related to resident care, including improper transfer techniques resulting in injury, failure to manage and document behaviors and incontinence properly, and issues with restraint use and social service support. Several complaint investigations substantiated concerns such as neglect, mistreatment, misappropriation of resident property, and infection control lapses, though enforcement actions like staff suspensions and terminations were noted rather than fines or license suspensions. No fines or license enforcement actions were listed in the available reports. The facility’s recent clean inspection suggests improvement following prior citations and corrective actions.
Deficiencies (last 8 years)
Deficiencies (over 8 years)
4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
29% better than Connecticut average
Connecticut average: 5.6 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
87% occupied
Based on a January 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Follow-Up
Census: 227
Capacity: 260
Deficiencies: 0
Date: Jan 15, 2025
Visit Reason
The visit was an on-site follow-up inspection to verify correction of previous deficiencies.
Findings
No violations of the General Statutes of Connecticut or regulations were identified at the time of this inspection. All previously identified violations were corrected as of 12/25/2024.
Report Facts
Licensed Bed Capacity: 260
Census: 227
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Courtney O’Sullivan | Personnel contacted during the inspection | |
| Patricia Evelyn | Personnel contacted during the inspection | |
| Donna Perrin | Director of Nursing | Notified that all violations were corrected |
Inspection Report
Plan of Correction
Census: 227
Capacity: 260
Deficiencies: 0
Date: Jan 15, 2025
Visit Reason
The visit was conducted for the purpose of reviewing the plan of correction to the violation letter dated 12/9/24.
Findings
No violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection. Violation #1 was identified as corrected as of 12/25/24.
Report Facts
Licensed Bed Capacity: 260
Census: 227
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Donna Perrin | Director of Nursing | Notified on 1/15/25 at 2:30 PM that all violations were corrected |
Inspection Report
Renewal
Census: 235
Capacity: 260
Deficiencies: 0
Date: Dec 9, 2024
Visit Reason
The inspection visit was conducted as a renewal licensing inspection and included review of complaint investigations numbered 40798, 41253, and 41343.
Findings
The report form does not explicitly state specific findings or violations; no violations or citations are marked as identified or issued in the provided document.
Report Facts
Licensed Bed Capacity: 260
Census: 235
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Patricia Evelyn | DNS | Personnel contacted during inspection |
| Courtney O'Sullivan | Admin | Personnel contacted during inspection |
| Stella O'Sullivan | Survey Team Leader | Report submitted by |
| Sandra Vermont Hollis | Supervisor | Survey supervisor |
Inspection Report
Complaint Investigation
Census: 231
Capacity: 260
Deficiencies: 0
Date: Nov 13, 2024
Visit Reason
The inspection visit was conducted as a complaint investigation related to Complaint Investigations #41503 and #41753.
Complaint Details
The visit was complaint-related, investigating Complaint Investigations #41503 and #41753. Violations were substantiated as indicated by the attached violation letter.
Findings
Violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection, as referenced in an attached violation letter dated 2024-12-09.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Courtney O'Sullivan | Administrator | Personnel contacted during the inspection. |
| Patricia Evelyn | Director of Nursing | Personnel contacted during the inspection. |
| Deborah Smith | RN, NC | Report submitted by. |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Nov 13, 2024
Visit Reason
An unannounced visit was made to Masonicare Health Center on November 13, 2024, by a representative of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting multiple investigations.
Complaint Details
Complaints #41503 and #41753 triggered the investigation. Substantiation status is not explicitly stated.
Findings
The report details a fall incident involving Resident #1 due to improper transfer technique by staff, resulting in a scalp hematoma and subdural hematoma. The facility identified staff training deficiencies and took corrective actions including remedial education and removal of the responsible staff member.
Deficiencies (1)
Failure to properly transfer a resident resulting in a fall with a laceration to the head and subdural hematoma.
Report Facts
Date of compliance: Dec 25, 2024
Incident date: Oct 16, 2024
Resident BIMS score: 2
Resident care plan date: Aug 3, 2024
Minimum Data Set assessment date: Jul 26, 2024
Staff retraining dates: Mar 15, 2024
Staff retraining dates: Apr 16, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Karen Gworek | Supervising Nurse Consultant | Author of the notice letter regarding violations and plan of correction |
| Courtney O'Sullivan | Administrator | Facility administrator addressed in the notice |
Inspection Report
Complaint Investigation
Census: 228
Capacity: 260
Deficiencies: 4
Date: Jul 8, 2024
Visit Reason
The inspection was conducted as a complaint investigation related to complaint numbers 39816 and 39734, to identify violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies at Masonicare Health Center.
Complaint Details
The visit was complaint-related for complaints #39816 and #39734. Violations were substantiated as multiple deficiencies were identified during the inspection.
Findings
The inspection found multiple violations related to failure to notify physicians about ineffective medications for behaviors, inadequate care plans for urinary incontinence, failure to assess continence after catheter removal, and failure to properly address and document behaviors in residents with dementia. Several residents' clinical records, facility policies, and staff interviews revealed systemic issues in care and documentation.
Deficiencies (4)
Failure to notify a physician when a resident exhibiting behaviors was administered ineffective medication and failure to properly manage and document behaviors.
Failure to ensure a comprehensive care plan was in place for urinary incontinence for a resident.
Failure to complete an assessment for continence after an indwelling catheter was discontinued.
Failure to address and code behaviors on behavior flow sheets for a resident with dementia.
Report Facts
Licensed Bed/Bassinet Capacity: 260
Census: 228
Complaint Numbers: 2
Random Audits Frequency: 4
Random Audits Frequency: 3
Medication Administration Days: 7
Medication Administration Days: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Patricia Evelyn | DNS | Personnel contacted during inspection and identified in findings related to medication ineffectiveness reporting. |
| Courtney O'Sullivan | Administrator | Personnel contacted during inspection and named in findings and correspondence. |
| Margaret McKinney | Supervising Nurse Consultant | Author of the notice letter regarding the inspection findings and plan of correction. |
| Physician #1 | Psychiatric Provider | Interviewed regarding management of Resident #1's behaviors and medication adjustments. |
| NA #1 | Nursing assistant interviewed about Resident #1's behaviors and care. | |
| LPN #1 | Licensed practical nurse interviewed about medication administration and resident behaviors. | |
| RN #1 | Registered nurse interviewed about shift reports and resident fall incident. |
Inspection Report
Complaint Investigation
Census: 222
Capacity: 260
Deficiencies: 0
Date: May 24, 2023
Visit Reason
Multiple complaint investigation surveys were conducted at Masonicare Health Center on 5/24/23 and 5/25/23 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities.
Complaint Details
Multiple complaint investigation surveys CT# 32065, #32716 and #33946 were conducted.
Findings
The investigation included record reviews, interviews, staffing review, observations, and a tour of the facility. As a result, deficiencies were identified.
Report Facts
Complaint Investigation Numbers: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Patricia Evelyn | DNS | Personnel contacted during inspection |
Inspection Report
Follow-Up
Census: 38
Capacity: 43
Deficiencies: 0
Date: Feb 14, 2023
Visit Reason
Revisit to the facility to follow up on previous findings from 12/11/23 and VL 1/4/23, as well as to review complaint investigation #33718.
Complaint Details
Complaint investigation #33718 was reviewed during this visit; no violations were found.
Findings
No violations of the General Statutes of Connecticut or regulations of Connecticut State Agencies were identified at the time of this inspection.
Report Facts
Licensed Bed/Bassinet Capacity: 43
Census: 38
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cora Carbray | DNS | Personnel contacted during inspection |
| Ed Doeling | Administrator | Personnel contacted during inspection |
Inspection Report
Renewal
Census: 35
Capacity: 43
Deficiencies: 1
Date: Dec 6, 2022
Visit Reason
The inspection was conducted as a licensing renewal inspection and included a complaint investigation related to multiple complaint numbers.
Complaint Details
Complaint investigation was conducted for complaint numbers 33146, 337501, 33318, 29955, and 29971. Issues were identified and substantiated as indicated by the violation letter dated 1/4/23.
Findings
Issues were identified during the inspection, including concerns related to restraint utilization and/or seclusion, as noted in the violation letter.
Deficiencies (1)
Issues identified related to restraint utilization and/or seclusion
Report Facts
Licensed Bed Capacity: 43
Census: 35
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ellen Ferrero | RNC | Signature of FLIS staff on inspection report |
| Caron Carbray | DNS | Personnel contacted during inspection |
| Edward Dowling | CH Healthcare Services | Personnel contacted during inspection |
Inspection Report
Follow-Up
Census: 230
Capacity: 260
Deficiencies: 0
Date: Mar 14, 2022
Visit Reason
A desk audit was conducted to review the implementation of the plan of correction from the violation letter dated 12/16/2021.
Findings
The violation(s) identified in the previous inspection have been corrected. The DNS was notified that State Violation(s) #1 was corrected.
Report Facts
Licensed Bed/Bassinet Capacity: 260
Census: 230
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Fran Ferraiolo | RN | Signature of FLIS Staff and report submitter |
| Patricia Evelyn | DNS | Personnel contacted during inspection |
| Alicia Markie | ADNS | Personnel contacted during inspection |
Inspection Report
Complaint Investigation
Census: 244
Capacity: 260
Deficiencies: 1
Date: Dec 8, 2021
Visit Reason
An unannounced visit was made to Masonicare Health Center on December 8, 2021, for the purpose of conducting an investigation related to a complaint (Complaint Investigation #CT 31291).
Complaint Details
Complaint Investigation #CT 31291 was substantiated with violations identified related to failure to document verbal orders in the electronic medical record.
Findings
Violations of the General Statutes of Connecticut and/or regulations were identified during the inspection, specifically related to failure to enter a verbal order given by an APRN into the electronic medical record. The facility failed to document a verbal order for medication administration for one resident.
Deficiencies (1)
Failure to enter into the electronic medical record a verbal order given by an APRN for Resident #1.
Report Facts
Census: 244
Total Capacity: 260
Plan of Correction Deadline: Dec 26, 2021
Plan of Correction Compliance Date: Jan 14, 2022
Random Audits Frequency: 4
Random Audits Frequency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael Blake | DNS | Personnel contacted during inspection |
| Courtney Wood | Administrator | Personnel contacted and recipient of notice |
| Karen Gworek | Supervising Nurse Consultant | Author of the notice letter |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Aug 16, 2021
Visit Reason
An unannounced visit was made to Masonicare Health Center on August 16, 2021, by a representative of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting an infection control survey.
Findings
The facility failed to ensure three of four running fans in the clean linen area were clean, and a laundry worker did not wear appropriate Personal Protective Equipment when transferring dirty laundry. The fans were coated with dust and debris, and the facility lacked a preventative maintenance policy for cleaning fans in the laundry area.
Deficiencies (1)
Facility failed to ensure three of four running fans in the clean linen area were clean.
Report Facts
Fans not clean: 3
Random audits frequency: 4
Random audits frequency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Karen Gworek | Supervising Nurse Consultant | Signed the notice letter regarding the infection control survey and violations. |
| Laundry Worker #1 | Identified as not wearing appropriate Personal Protective Equipment when transferring dirty laundry. | |
| Director of Facility Management | Identified issues with fans in the laundry area and maintenance policies. |
Inspection Report
Complaint Investigation
Census: 244
Capacity: 333
Deficiencies: 2
Date: Jul 28, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey and a Complaint Investigation Survey were conducted to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities.
Complaint Details
The complaint investigation was triggered by an allegation that Resident #1 did not receive incontinent care during the 3rd shift on 6/30/21 to 7/1/21. The allegation was substantiated based on interviews, documentation, and observations. Staff involved were suspended and ultimately terminated. The facility reported the incident to authorities and provided staff education and audits to prevent recurrence.
Findings
The facility was found deficient for neglect related to failure to provide incontinent care to Resident #1 during the 11:00 PM to 7:00 AM shift on 7/1/21, leaving the resident in a urine-saturated bed until care was provided the next day. Additionally, the facility failed to complete an annual performance evaluation for Nurse Aide #3 involved in the complaint.
Deficiencies (2)
Failure to ensure Resident #1 was free from neglect by not providing incontinent care during the entire 11:00 PM to 7:00 AM shift, resulting in the resident being left in a urine-saturated bed.
Failure to complete an annual performance evaluation for Nurse Aide #3.
Report Facts
Total Capacity: 333
Census: 244
Date of survey: Jul 28, 2021
Date of incident: Jul 1, 2021
Date of hire: Mar 9, 2020
Performance evaluation due date: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA #3 | Nurse Aide | Involved in neglect incident and missing annual performance evaluation |
| LPN #1 | Licensed Practical Nurse | Reported neglect incident and directed care provision |
| NA #1 | Nurse Aide | Provided incontinent care after neglect was reported |
| DNS | Director of Nursing Services | Investigated neglect allegation and confirmed findings |
| Administrator | Interviewed regarding performance evaluation process |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jul 28, 2021
Visit Reason
An unannounced visit was made to Masonicare Health Center on July 28, 2021, by a representative of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting an investigation related to complaint CT #30488.
Complaint Details
Complaint CT #30488 triggered the investigation. The complaint alleged neglect of Resident #1 related to incontinent care. The investigation substantiated that Resident #1 did not receive incontinent care during the night shift on 7/1/21, resulting in neglect. Staff involved were suspended and disciplined.
Findings
The facility was found to have failed to ensure a resident was free from neglect related to incontinent care during the night shift on 7/1/21, and failed to complete an annual performance evaluation for a nurse aide. Staff involved were suspended or disciplined, and plans of correction were required.
Deficiencies (2)
Failure to ensure Resident #1 was free from neglect related to incontinent care during the 11:00 PM to 7:00 AM shift on 7/1/21.
Failure to complete an annual performance evaluation for Nurse Aide #3.
Report Facts
Date of inspection visit: Jul 28, 2021
Date of incident: Jul 1, 2021
Hire date of NA #3: Mar 9, 2020
Plan of correction compliance date for violation #1: Oct 14, 2021
Plan of correction compliance date for violation #2: Sep 30, 2021
Random audits frequency weekly: 4
Random audits frequency monthly: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Courtney Wood | Administrator | Named as facility administrator receiving the notice |
| Norma Schuberth | Supervising Nurse Consultant | Author of the notice and contact for questions |
| NA #3 | Nurse Aide | Staff member suspended pending investigation for neglect |
| LPN #1 | Licensed Practical Nurse | Involved in neglect incident and reporting |
| DNS | Director of Nursing Services | Interviewed during investigation and responsible for oversight |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 18, 2021
Visit Reason
An unannounced visit was made to Masonicare Health Center on March 18, 2021, by a representative of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting an investigation related to a complaint.
Complaint Details
The complaint investigation substantiated that Resident #1's debit card and personal property were misappropriated by staff. The police were notified and an investigation was conducted. Staff members matching the description were suspended and one terminated. The police investigation was closed as Resident #1 did not want to press charges.
Findings
The investigation found that Resident #1 was subject to misappropriation and exploitation by facility staff when a nursing assistant took the resident's cell phone without permission and used the resident's debit card for personal use. The facility failed to protect the resident from this exploitation. Staff involved were suspended and the nursing assistant was terminated. The police investigation was closed as the resident did not want to press charges.
Deficiencies (1)
The facility failed to protect Resident #1 from facility staff misappropriation and exploiting Resident #1 when NA #1 took Resident #1's cell phone without permission and used Resident #1's debit card for personal use.
Report Facts
Amount withdrawn: 1400
Amount charged: 316
Date of incident: Mar 5, 2021
Date of report: Mar 6, 2021
Date of investigation summary: Mar 12, 2021
Date of interview: Mar 18, 2021
Number of staff suspended: 2
Random audits frequency weekly: 4
Random audits frequency monthly: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Judy Birtwistle | Supervising Nurse Consultant | Signed the notice letter from Facility Licensing and Investigations Section |
| NA #1 | Staff member who took Resident #1's cell phone and used debit card for personal use; terminated from employment | |
| NA #2 | Staff member matching description provided by Resident #1; suspended pending investigation | |
| Assistant Director of Nursing | ADNS | Interviewed on 3/18/21 regarding the investigation and staff suspensions |
Inspection Report
Abbreviated Survey
Census: 265
Capacity: 357
Deficiencies: 2
Date: Jan 20, 2021
Visit Reason
A COVID-19 Focused Survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including infection prevention and control practices to prevent COVID-19 transmission.
Findings
Deficiencies were cited related to resident rights violations involving privacy during personal care, and infection prevention and control failures including improper social distancing, incorrect use and disposal of PPE, inadequate signage, and improper storage of face shields.
Deficiencies (2)
Facility failed to ensure resident privacy during personal care due to a clear window in the resident's room door without privacy curtains.
Facility failed to implement appropriate infection control practices including residents unmasked and not socially distanced, improper doffing and disposal of isolation gowns, overflowing trash receptacles with used gowns, improper storage of face shields, and lack of signage at unit entrances.
Report Facts
Capacity: 357
Census: 265
Observation time: 11.55
Observation time: 12.1
Observation time: 12.3
Trash receptacles overflowing: 10
Inspection Report
Complaint Investigation
Census: 290
Capacity: 357
Deficiencies: 1
Date: Nov 16, 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 infection prevention and control practices to prevent COVID-19 transmission.
Complaint Details
The investigation was triggered by a complaint regarding failure to notify the responsible party of Resident #1's change in condition. The complaint was substantiated as the facility failed to notify Person #1 despite multiple communications indicating Person #1 was the designated contact for health concerns.
Findings
Deficiencies were identified including failure to notify a responsible party of a change in condition for one sampled resident. The facility did not notify the designated contact of Resident #1's change in condition and new physician orders related to urinary symptoms and fever.
Deficiencies (1)
Failure to notify Person #1 of a change in condition for Resident #1, including new physician orders and clinical changes.
Report Facts
Total Capacity: 357
Census: 290
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Supervisor for the unit where Resident #1 resided; involved in clinical communication and failure to notify family |
| LPN #1 | Licensed Practical Nurse | Identified Resident #1's symptoms and temperature; failed to notify family |
| DNS | Director of Nursing Services | Interviewed regarding notification failure and responsible for plan of correction |
Inspection Report
Routine
Deficiencies: 1
Date: Nov 16, 2020
Visit Reason
An unannounced visit was conducted at Masonicare Health Center to perform a Covid-19 focused infection control survey.
Findings
The facility was found to have violated regulations by failing to notify the designated responsible party of a change in condition for one sampled resident. The facility did not notify Person #1 of Resident #1's change in condition and new physician orders in a timely manner.
Deficiencies (1)
Failure to notify Person #1 of a change in condition for Resident #1 as required by facility policy and state regulations.
Report Facts
Plan of Correction audit frequency: 4
Plan of Correction audit frequency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sandra Vermont-Hollis | Supervising Nurse Consultant | Signed letter regarding inspection and violations |
| Courtney Wood | Administrator | Facility administrator addressed in the report |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Sep 28, 2020
Visit Reason
Unannounced visits were made to Masonicare Health Center concluding on September 28, 2020, for the purpose of conducting an investigation and a COVID-19 Focused Infection Control Survey triggered by complaint #28370.
Complaint Details
Complaint #28370 involved allegations of mistreatment by nursing assistants toward Residents #3 and #4. The complaint was investigated through interviews, clinical record reviews, and observations. Findings substantiated concerns about rough and undignified care, bullying, and failure to provide psychosocial support. The facility failed to adequately address and document follow-up on these allegations.
Findings
The facility was found noncompliant with regulations related to mistreatment allegations involving residents #3 and #4, failure to provide comprehensive social service support, inadequate infection control practices, and failure to ensure staff COVID-19 testing compliance. Multiple interviews, clinical record reviews, and observations documented concerns about resident care, staff behavior, and infection control.
Deficiencies (4)
Failure to ensure care was provided in a dignified manner to Resident #4 amid allegations of mistreatment.
Failure to provide comprehensive social service support to meet residents' psychosocial needs.
Failure to ensure appropriate personal protective equipment (PPE) was donned in resident areas for infection control.
Failure to ensure staff testing for COVID-19 was conducted according to CMS and CDC guidance.
Report Facts
Staff members not tested for COVID-19: 42
Staff members not tested for COVID-19: 68
Percentage of staff tested for COVID-19: 78.6
Percentage of staff tested for COVID-19: 80.5
Resident sample size: 2
Resident sample size: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sandra Vermont-Hollis | Supervising Nurse Consultant | Signed the letter notifying the facility of violations and complaint investigation. |
| Courtney Wood | Administrator | Facility administrator addressed in the notice letter. |
| RN #1 | Director of Infection Control | Interviewed regarding infection control practices and staff COVID-19 testing compliance. |
| RN #2 | Interviewed about Resident #4's care and nursing assistant behavior. | |
| LPN #3 | Licensed Practical Nurse | Identified Resident #4's concerns and interviewed about care and mistreatment allegations. |
| Social Worker #3 | Interviewed residents and involved in psychosocial support and mistreatment allegation follow-up. | |
| LPN #5 | Licensed Practical Nurse | Interviewed about Resident #4 and mistreatment allegations. |
| RN #1 | Interviewed about COVID-19 testing and infection control. | |
| Director of Nurses (DON) | Director of Nurses | Interviewed about staff COVID-19 testing. |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Sep 28, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and a complaint investigation were conducted on 09/24/20, 09/25/20 and 09/28/20 with additional information obtained on 10/05/20 at Masonicare Health Center 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.
Complaint Details
The complaint investigation involved allegations of mistreatment by nursing assistant NA #3 towards Residents #3 and #4, including rough and rude care, intimidation, and failure to provide dignified care. Social Worker #3 failed to provide adequate psychosocial follow-up support after initial visits. Resident #4 reported avoiding call bells and care due to fear of NA #3.
Findings
Deficiencies were identified related to failure to provide care in a dignified manner to Resident #4, failure to provide comprehensive social service support to Residents #3 and #4, failure to ensure appropriate use of personal protective equipment (PPE) in resident areas, and failure to conduct staff COVID-19 testing in accordance with CMS and CDC guidance.
Deficiencies (4)
Failure to ensure care was provided in a dignified manner to Resident #4, including allegations of mistreatment by nursing assistant NA #3.
Failure to provide medically-related social services to Residents #3 and #4 to meet psychosocial needs following allegations of mistreatment.
Failure to ensure appropriate personal protective equipment (PPE) was donned and used properly in resident areas, including improper mask use and uncovered gowns.
Failure to ensure staff COVID-19 testing was conducted weekly for all staff as required, with 42 staff not tested during 9/6/20-9/12/20 and 68 staff not tested during 9/13/20-9/19/20.
Report Facts
Staff not tested for COVID-19: 42
Staff not tested for COVID-19: 68
Staff testing percentage: 78.6
Staff testing percentage: 80.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Worker #3 | Interviewed residents and failed to provide psychosocial follow-up after allegations of mistreatment. | |
| NA #3 | Nursing Assistant | Named in allegations of rough and undignified care to Residents #3 and #4. |
| RN #1 | Director of Infection Control | Provided infection control education and identified PPE and testing deficiencies. |
| LPN #5 | Licensed Practical Nurse | Interviewed Resident #4 and provided education to NA #3 regarding care. |
| RN #2 | Registered Nurse | Interviewed NA #3 and Resident #4 regarding allegations. |
| Administrator | Responsible for ensuring compliance with testing and infection control. | |
| Director of Nurses (DON) | Interviewed regarding staff testing and infection control. |
Inspection Report
Abbreviated Survey
Census: 309
Capacity: 357
Deficiencies: 0
Date: May 9, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted to determine compliance with 42 CFR §483.80 Infection Control regulations for Long Term Care Facilities.
Findings
The facility has implemented the CMS and CDC recommended practices related to COVID-19. No deficiencies were cited as a result of this survey.
Report Facts
Capacity: 357
Census: 309
Inspection Report
Abbreviated Survey
Census: 309
Capacity: 357
Deficiencies: 0
Date: May 9, 2020
Visit Reason
A COVID-19 Focused Survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including proper infection prevention and control practices to prevent the development and transmission of COVID-19.
Findings
No deficiencies were cited as a result of this COVID-19 focused survey.
Inspection Report
Routine
Census: 319
Capacity: 357
Deficiencies: 0
Date: Apr 30, 2020
Visit Reason
A COVID-19 Focused Survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including proper infection prevention and control practices to prevent the development and transmission of COVID-19.
Findings
No deficiencies were cited as a result of this COVID-19 focused survey.
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jun 6, 2019
Visit Reason
An unannounced visit was made to Masonicare Health Center on June 6, 2019, by a representative of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting an investigation related to a complaint of abuse.
Complaint Details
Complaint #25519 was investigated. The allegation of verbal abuse by a nurse aide was substantiated. The nurse aide's employment was terminated on 5/29/19. An attempt to interview the nurse aide was unsuccessful.
Findings
The facility was found to have failed to ensure that Resident #1 was free from verbal abuse and misappropriation of personal property. The investigation identified verbal abuse by a nurse aide and substantiated the allegation of abuse, resulting in termination of the nurse aide's employment.
Deficiencies (2)
Failure to ensure Resident #1 was free from verbal abuse by a nurse aide.
Failure to ensure Resident #1 was free from misappropriation of personal property.
Report Facts
Complaint number: 25519
Dates referenced: Jun 6, 2019
Dates referenced: May 24, 2019
Dates referenced: May 29, 2019
Dates referenced: Jun 22, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Karen Gworek | Supervising Nurse Consultant | Signed letter regarding complaint investigation and plan of correction. |
| Amy Pellerin | Administrator | Facility administrator addressed in the letter. |
Inspection Report
Plan of Correction
Deficiencies: 4
Date: Jan 23, 2019
Visit Reason
Unannounced visits were made to Masonicare Health Center on January 23, 24, 25, 28, and 29, 2019 by representatives of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting multiple investigations and a licensure inspection.
Complaint Details
The visit was complaint-related, involving complaints #23116, 23607, and 23675. Specific substantiation status is not stated.
Findings
The report details multiple violations of Connecticut General Statutes and Regulations related to care and services provided to residents, including failures in therapeutic communication, review of advance directives, pain management interventions, and psychotropic medication orders. Plans of correction are outlined for each violation to address these deficiencies.
Deficiencies (4)
Failure to ensure care and services were provided in a dignified manner, specifically therapeutic communication with residents.
Failure to review advance directives with residents upon readmission to the facility.
Failure to implement interventions for pain relief per the plan of care in a timely manner.
Failure to ensure PRN orders for psychotropic medications were limited to 14 days with appropriate follow-up and documentation.
Report Facts
Inspection visit dates: 5
Complaint numbers: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Named in findings related to therapeutic communication with Resident #163 |
| Director of Nursing Services | Director of Nursing Services | Interviewed regarding staff response to Resident #163 incident and monitoring responsibilities |
| Clinical Nurse Manager | Clinical Nurse Manager | Responsible for auditing communication and advanced directives reviews |
| Social Worker #2 | Social Worker | Interviewed regarding care plan meetings for Resident #215 |
| APRN #2 | Advanced Practice Registered Nurse | Interviewed regarding code status discussions and pain management for Resident #215 |
| LPN #2 | Licensed Practical Nurse | Named in pain management and medication administration events for Resident #692 |
| RN #6 | Registered Nurse | Named in pain management and medication administration events for Resident #692 |
| DNS | Director of Nursing Services | Interviewed regarding pain assessment and psychotropic medication policies |
| APRN #3 | Advanced Practice Registered Nurse | Evaluated Resident #692 and identified suicidal ideation |
| APRN #1 | Advanced Practice Registered Nurse | Interviewed regarding psychiatric medication orders for Resident #300 |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding psychiatric medication orders for Resident #300 |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 30, 2018
Visit Reason
An unannounced visit was made to the facility on November 30, 2018 by a representative of the Facility Licensing & Investigations Section for the purpose of conducting an investigation.
Complaint Details
The investigation was complaint-related, focusing on the accuracy of medical record documentation for one resident who received respiratory treatments. The complaint was substantiated by findings of incomplete documentation and failure to follow facility policy.
Findings
The facility failed to ensure that a resident's medical record was accurate, specifically failing to appropriately document the administration of a PRN nebulizer treatment in the electronic Medication Administration Record (MAR). The resident's symptoms worsened, requiring transfer to the Emergency Department.
Deficiencies (1)
Failure to maintain accurate resident medical records, including incomplete documentation of PRN nebulizer treatment in the electronic MAR.
Report Facts
Date of survey: Nov 30, 2018
Medication administration times: 4
Completion date for corrective action: Dec 24, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Administered nebulizer treatments and failed to document PRN treatment in electronic MAR |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Plan of Correction 113018 Health Survey State
Visit Reason
The document is a plan of correction addressing deficiencies found related to medication administration documentation in the electronic MAR.
Findings
The facility failed to appropriately document the PRN nebulizer in the electronic MAR, placing all residents potentially at risk. Education and monitoring plans are outlined to ensure compliance.
Deficiencies (1)
Failure to appropriately document the PRN nebulizer in the electronic MAR
Report Facts
Number of nurses observed weekly: 5
Deadline for education: Dec 24, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| clinical nurse manager | Responsible for conducting weekly observations of nurses on medication documentation | |
| Quality manager | Responsible for ongoing compliance monitoring | |
| DNS or designee | Responsible to monitor compliance |
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