Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ark Healthcare & Rehabilitation At Branford Hills during CMS and state inspections, most recent first.
Failure to Protect Cognitively Impaired Resident from Sexual Abuse: A non-verbal resident with severe cognitive impairment and dependence for ADLs was found with blood in the brief after another resident was observed exiting the room wearing only underwear. Staff documented that the other resident could not explain being in the room, and later police forensic testing confirmed that resident's DNA on the victim's oral and genital swabs.
A resident with Alzheimer’s disease, onychomycosis, and toe pain did not receive timely podiatry follow-up after returning from a hospital stay. Surveyors observed the resident barefoot with extremely lengthy, thick toenails, and records showed the facility failed to notify the contracted podiatry provider that the resident had returned, delaying the resident’s foot care.
Dietary staff failed to date opened frozen, refrigerated, and dry food items, and several products were expired or lacked expiration dates. Surveyors also found an unidentified raw meat item, an uncovered onion, and a Clorox cleaner bottle stored in a cooler used for resident food. The FSD stated staff had been instructed to date items when opened and believed he had left the chemical in the cooler.
A resident on droplet/contact precautions for an undiagnosed respiratory illness was observed out of the room and in common areas without a mask, and the resident said he/she had not been told why precautions were needed. An RN performing g-tube care for a resident on EBP wore gloves but no gown during residual checks, flushing, and tube feeding. During a dressing change for a resident with two stage 3 pressure ulcers, an RN treated one wound and then the other without hand hygiene or changing gloves between wounds.
Incomplete ADL Care Plans for Shaving and Nail Care: Two residents with severe cognitive impairment and significant ADL needs had care plans that did not include their refusals or preferences related to shaving and fingernail trimming. One resident was repeatedly observed unshaven with an electric razor left at the bedside, and an NA reported frequent refusals and occasional combativeness. The other resident was repeatedly observed with extremely long, sharp fingernails, while the care plan did not reflect refusal of nail trimming or a preference for long nails.
A nurse was observed still completing the morning med pass late in the day, and two residents’ ordered meds were signed off several hours after the scheduled times. One resident with dementia, a pelvis fracture, and anxiety had multiple 8:00 AM and 9:00 AM meds documented around noon, including some doses given too close together, while another resident with dementia, HF, and anxiety had 8:00 AM meds documented at about 12:17 PM to 12:18 PM. The DNS and another RN were unaware the morning pass was still unfinished, and the nurse said the pass was heavy with meds for over 30 residents.
Failure to Provide Meal Cueing and Assistance: A resident with dementia and a recent pelvic fracture was repeatedly observed with meals placed in front of him/her but without timely cueing or effective feeding assistance. Staff often left the resident with untouched or nearly untouched trays, and the resident consumed little food during multiple dining observations. Records later documented poor PO intake and significant weight loss, while staff stated they had not been aware earlier that the resident was not eating well or might need feeding help.
Two residents had air mattresses that were not set according to MD orders, with LPNs documenting the pumps as correct even though survey observations showed the firmness and/or alternating settings did not match the orders. In another case, a resident with dementia and COPD had an APRN order for VS every shift for 3 days after a new abdominal/flank skin finding, but the VS log showed they were obtained only 3 of 9 shifts and an RN acknowledged the order was not completed as directed.
A resident at risk for pressure ulcers developed a coccyx skin issue that was documented on a weekly skin assessment, but the area was not staged and no treatment order was obtained when first identified. Two days later, an LPN found an open coccyx area with drainage and redness, and a treatment order was then placed. The RN said she normally documents skin issues after weekly checks or when staff identify them during care, and the wound MD stated treatment should have been ordered when the area was first noted.
A resident with COPD, bipolar disorder, and anxiety was found with an unsecured Albuterol inhaler at the bedside without an order for self-administration, and multiple residents were observed with bed wheels unlocked, partially locked, or broken so the beds could move freely. One resident with a fall risk care plan reported that an unlocked bed moved during an independent transfer and caused a large skin tear on the forearm. Other residents stated they often noticed their beds were unlocked and had nearly fallen when the beds moved.
Delayed Re-Weight and Weight Loss Recognition A resident with dementia, a pelvis fracture, and severe cognitive impairment had ordered weight monitoring, but staff did not obtain or document a timely re-weight after repeated refusals and a questionable low weight. An LPN struck out one weight, forgot to enter another re-weight, and did not document the significant weight loss or related notifications. The APRN and RN were not aware of the weight loss until the record was reviewed, and staff relied on aides to report poor intake.
A resident with a feeding tube, severe cognitive impairment, diabetes, dementia, and CHF had ordered enteral nutrition and flushes, but the RN did not start the tube feeding at the ordered time and later left it running beyond the scheduled stop time to reach the volume goal. The RN also failed to verify g-tube length before giving the feeding and flushes, and an additional ordered water flush was missed at the scheduled time.
A resident with a double lumen PICC line and IV antibiotics had no documented weekly arm circumference or external catheter length measurements to monitor the line. Staff interviews and record review showed the required orders were not obtained or implemented, and when the PICC was later removed, the APRN did not document that the line was fully intact.
A resident with COPD, respiratory failure, emphysema, and pneumonia was ordered continuous O2 at 2 L/min via nasal cannula, but surveyors observed the oxygen concentrator set at 3 L/min on two occasions. The concentrator was out of the resident’s reach, and an RN later confirmed the setting was incorrect and adjusted it. The charge nurse stated she signed the TAR without checking the setting and assumed it was correct from the prior shift.
Improper Storage and Labeling of Controlled Medications: The facility failed to store controlled substances under double lock and failed to keep medications properly labeled and secured. Multiple controlled meds were found in the DNS office under only one lock, and the office door was open while unattended; the Administrator stated others had keys to the office. An LPN was also observed discarding medication cups from a med cart, and surveyors found an unlabeled cup of meds plus a recapped syringe containing an unidentified substance in the top drawer. The LPN could not identify the syringe contents or the refusal procedure, while an RN stated meds should not be pre-poured or kept in the top drawer.
A resident with dementia, tremors, and poor coordination did not receive ordered red foam built-up utensils at meals. Staff observed the resident using regular utensils with difficulty, and an NA admitted forgetting to provide the adaptive equipment even though it was labeled and available on the unit. Interviews confirmed nursing staff were responsible for giving the utensils at mealtime.
Resident Council concerns about nursing staff using cell phones and ear buds during work were repeatedly raised by residents, but meeting minutes often did not show any discussion of what the facility did in response. Residents stated they did not know whether concerns brought to council were addressed and believed the issue kept happening without noticeable change. The Administrator and Interim Rec Director could not clearly identify why the follow-up and documentation were not consistently included in the council process.
Unclean and Poorly Maintained Shower Room: The second floor Ledgewood 2 shower room had chipped and cracked ceiling paint, a black/brown substance on the floors and walls, and a used wet washcloth on the shower floor. An LPN stated environmental rounds were done every other week and that the shower was not clean, and the Maintenance Director also confirmed the room was not clean. Environmental Rounds logs did not identify concerns for any of the 6 showers over the past 6 months.
Staff did not promptly inform a resident, the resident's doctor, and a family member about important events such as injury, decline, or room changes that affected the resident.
A resident with diabetes and other complex conditions missed four days of prescribed insulin after the facility failed to coordinate with the pharmacy to clarify and deliver the correct medication. The pharmacy did not fill the updated order, and nursing staff did not consistently notify supervisors or the pharmacy about the missed doses, resulting in a lapse in medication administration.
A resident with diabetes and other complex conditions did not receive prescribed Humulin-R insulin on multiple occasions due to the medication being unavailable. Documentation failed to show that the nursing supervisor, provider, or pharmacy were notified of the missed doses, as required by facility policy. Nursing notes only reflected notification and follow-up for one missed dose, with no documentation for other missed administrations.
A resident with dementia and known exit-seeking behaviors managed to elope from the facility, despite having a wander guard in place. The facility failed to conduct an elopement assessment, notify the family or APRN, and ensure regular checks of the wander guard's placement and function. Staff interviews revealed a lack of communication and understanding regarding the resident's elopement risk, leading to the resident being found 0.3 miles away from the facility. This resulted in a finding of Immediate Jeopardy.
A facility failed to notify a resident's family and APRN of a significant change in condition when a wander guard was applied due to exit-seeking behavior. Despite the resident's history of dementia and a hip fracture, staff did not follow the facility's policy to inform the necessary parties. Interviews revealed a lack of communication and adherence to notification procedures.
A resident with dementia and a history of hip fracture exhibited increased exit-seeking behavior, but the facility failed to update the care plan to reflect these changes or the application of a wander guard. The resident was later found 0.3 miles away from the facility, highlighting a deficiency in addressing the elopement risk. Staff interviews confirmed the care plan was not updated as required by the facility's policy.
Failure to Protect Cognitively Impaired Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a cognitively impaired, non-verbal resident from sexual abuse by another resident. Resident #3 had diagnoses including dementia, aphasia, intellectual developmental disability, autistic disorder, dysphagia, and speech disturbance, and the annual MDS identified severe cognitive impairment, dependence on staff for all ADLs, and need for supervision with ambulation. The care plan identified the resident needed staff assistance with ADLs related to dementia, aphasia, and autism, had decreased communication skills, and required an assist of one and no male caregivers. Resident #2 had diagnoses including Parkinson's disease and dementia without behavioral disturbances, but the quarterly MDS identified intact cognition with a BIMS score of 15 and no behaviors or wandering. During the overnight hours, staff observed Resident #2 exiting Resident #3's room wearing only underwear. Staff also found Resident #3 awake in bed with one leg out of the pajama pants and blood noted in the brief and on the edges of the underwear. The resident was non-verbal and unable to provide information about what occurred. The nursing notes and staff interviews documented that the incident was reported after the observation of Resident #2 leaving the room and the blood found on Resident #3's brief. Resident #2 could not explain why he/she was in the room, and staff noted no blood on Resident #2's clothing, hands, or genital area. Resident #3 was sent to the ED for a SANE exam, where no visible trauma, lacerations, or abrasions were identified. Police and forensic testing later confirmed Resident #2's DNA on Resident #3's oral and genital swabs, and the police report stated an arrest warrant was sought for Resident #2 for sexual assault.
Delayed Podiatry Services and Overgrown Toenails
Penalty
Summary
The facility failed to ensure timely podiatry services for a resident with Alzheimer’s disease, onychomycosis, and bilateral toe pain. The resident had agreed to facility-contracted podiatry services, and a prior podiatry consult documented painful, moderately aching toenails that were relieved by cutting the nails, with follow-up recommended in 2 to 3 months. The resident’s care plan identified a self-care deficit and included assistance with ADLs, nail care, and obtaining podiatry consults as needed for health and comfort. During observation, the resident was seated barefoot with extremely lengthy and thick toenails on both feet. The clinical record and interviews showed the resident had last been seen by podiatry on 3/20/25, and after returning to the facility from a hospitalization on 7/25/25, the resident did not receive another podiatry visit despite the podiatrist coming to the facility on a regular basis. The DNS stated nursing staff should have assessed the resident’s feet and placed the resident back on the podiatry list, and also identified that the facility failed to notify the consulting podiatry company that the resident had returned, which contributed to the delay in care.
Dietary Storage and Labeling Deficiencies
Penalty
Summary
The dietary department failed to ensure food was stored, dated, and discarded in accordance with facility policy and professional standards. During a tour of the department, surveyors observed multiple opened frozen food items in the walk-in freezer that were undated when opened, including riblets, onion rings, pork chops, hamburger patties, fish cakes, meatballs, stuffed shells, and French toast sticks. In Reach in Cooler #3, surveyors found opened refrigerated items that were not dated, including sour cream, cottage cheese, butter, and mayonnaise, along with a 96-ounce container of sour cream that had expired on 12/22/25 and dressing containers with no expiration date. Surveyors also observed additional storage and labeling problems in the same cooler and other food storage areas. Reach in Cooler #3 contained an unidentified portion of pink raw meat wrapped in aluminum foil and an uncovered cut onion. In the dry goods storage area, opened packages of egg noodles, elbow pasta, and spaghetti were resealed but not dated. In the kitchen food prep area, several opened seasonings and other food items were either undated, expired, or lacked expiration dates, including lemon extract, cream of tartar, dill weed, poultry seasoning, bay leaves, black pepper, balsamic glaze, celery salt, ground cumin, granulated garlic, mashed potatoes, whole celery seed, imitation vanilla, powdered sugar, and Old Bay seasoning. A 32-ounce spray bottle of Clorox Clean-Up Cleaner with Bleach was also stored on a shelf in Reach in Cooler #3, and the Food Service Director stated he had instructed staff to date items when opened and believed he had left the cleaning chemical in the cooler.
Infection control failures during isolation, g-tube care, and wound dressing changes
Penalty
Summary
Resident #3 was placed on contact/droplet precautions for an undiagnosed viral respiratory illness after being seen for new onset cough, congestion, fatigue, and feeling generally unwell. The resident’s assessment noted nasal congestion, decreased breath sounds bilaterally, and an upper respiratory infection with cough and congestion. A physician order directed droplet/contact precautions for suspected viral illness for 7 days, and the facility policy stated that residents on contact/droplet precautions should be strongly encouraged to stay in their room and, if unable, wear a surgical mask. The resident was observed outside the room, in the hallway, on an elevator, in a lounge, and in a recreation room without a mask, and a visitor was also observed without a mask. The resident stated he/she was not aware of being on isolation precautions and had not been directed by staff to wear a mask when outside the room. Review of the clinical record and interviews with nursing staff and the Infection Preventionist failed to identify documentation that the resident had been informed of the reason and need for the precautions. Staff also acknowledged that the resident should have been educated and should not have been out of the room without a mask, but the resident was observed moving through common areas and another unit without one. Resident #124 had diabetes, dementia, congestive heart failure, and a feeding tube, and was on Enhanced Barrier Precautions related to the indwelling medical device. During observed g-tube care, the RN performed hand hygiene, entered the room with supplies, and donned gloves, but did not wear a gown while checking residual, returning residual, flushing the tube, and starting the tube feeding. The RN stated he had forgotten to put on the gown before entering the room, and the DNS confirmed that gown and gloves should have been worn for the feeding tube care under EBP. Resident #144 had stage 3 pressure ulcers to the coccyx and right buttock with physician-ordered wound treatments for each wound. During an observed dressing change, the RN treated the coccyx wound and then proceeded to treat the right buttock wound without performing hand hygiene or changing gloves between the two wounds. The RN acknowledged the error and stated the wounds should have been treated individually with hand hygiene and glove changes between them. The wound physician also stated that each wound needed to be treated individually to prevent contamination.
Incomplete ADL Care Plans for Shaving and Nail Care
Penalty
Summary
The facility failed to ensure the care plan was comprehensive for two residents with ADL needs. Resident #41 was admitted with diagnoses including Parkinson's disease, dementia, and anxiety, and was assessed as severely cognitively impaired and needing moderate assistance with personal hygiene. The resident care plan addressed general ADL assistance, toileting, transfers, meals, and fluctuating ability due to cognitive status, but it did not reflect the resident's refusals for shaving. Observations on multiple days showed the resident unshaven with about 1/2 inch of hair growth on the chin and cheeks, and an electric razor was seen on the bedside dresser during those observations. Resident #41's care flowsheet showed shower days scheduled weekly, and no refusals were documented for showers during the month reviewed. The DNS stated residents were shaved with ADL care and as needed, and refusals were to be documented by NAs. During review of the care plan, the corporate MDS Director confirmed that Resident #41 did not have a care plan for refusing shaving and stated the care plan should reflect refusals if the resident did not allow staff to shave him/her. A later interview with an NA indicated the resident often refused shaving and could become combative at times, and that the resident's electric razor was no longer functioning. Resident #58 was admitted with diagnoses including dementia, adjustment disorder, and generalized muscle weakness, and was assessed as severely cognitively impaired and requiring maximum assistance with ADLs. The resident care plan addressed toileting, incontinent care, oral hygiene, bed mobility, glasses, therapy, and transfers, but did not reflect the resident's refusal to have fingernails trimmed or the desire to have long fingernails. Observations on multiple days showed the resident's fingernails were extremely long, sharp, and pointed. The DNS stated fingernails were trimmed on shower days and as needed, and the corporate MDS Director confirmed the care plan did not include the resident's refusal or preference regarding fingernail trimming until after surveyor inquiry.
Late Medication Administration for Two Residents
Penalty
Summary
The facility failed to ensure medications were administered within the ordered time frame for two residents. For one resident with diagnoses including dementia, pelvis fracture, and anxiety, the care plan identified risk for malnutrition and the physician ordered multiple morning medications, including allopurinol, amlodipine, cranberry, ferrous sulfate, losartan, naloxegol, omeprazole, vitamin D, polyethylene glycol, acetaminophen, Seroquel, tramadol, and trazodone. On observation, the resident was sitting upright in bed while the medication administration record showed the 8:00 AM and 9:00 AM medications were not signed off until between 12:23 PM and 12:47 PM, several hours late. Some doses were also documented close to, before, or after other scheduled doses, including duplicate or closely spaced administrations of acetaminophen, Seroquel, tramadol, and trazodone. For the second resident, who had diagnoses including dementia, heart failure, and anxiety, the care plan identified risk for alteration in cardiopulmonary function and the physician ordered morning medications including acetaminophen, trazodone, vitamin B-12, vitamin D3, and artificial tears. The resident was observed sitting out of bed in a chair, and the medication administration record showed the 8:00 AM medications were not signed off until 12:17 PM to 12:18 PM. These medications were documented more than four hours late, including acetaminophen, trazodone, vitamin B-12, vitamin D3, and artificial tears. During observation, RN #3 was seen moving from room to room with the medication cart and looking at the computer attached to the cart before placing medications into cups and taking them into rooms. The same procedure had been observed during an earlier medication pass. At 12:20 PM, the DNS observed RN #3 still completing the morning medication pass and was unable to identify why the nurse was still passing morning medications at that time of day. RN #7 stated he believed RN #3 was passing 12:00 PM medications and was not aware the morning pass had not been completed. RN #3 stated the pass was late because it was heavy with medications for over 30 residents and that he had previously told the unit manager the pass took too long, but no change had occurred. The facility policy required medications to be administered within 1 hour before or after the ordered time.
Failure to Provide Meal Cueing and Assistance
Penalty
Summary
The facility failed to provide cueing and assistance with meals for a resident who was severely cognitively impaired, had dementia, and had a recent left pelvic fracture. The resident’s care plan identified risk for malnutrition, variable food intake, and the need to document meal consumption, notify the nurse if meals were refused, and offer alternative foods. Records also showed the resident had been receiving a regular diet with thin liquids and oral nutritional supplements, and later developed a significant weight loss from 123.4 lbs. to 108.6 lbs. During dining observations, the resident was repeatedly left with meals in front of him/her without effective cueing or assistance. On one occasion, the resident had a bowl of soup and a covered plate placed in front of him/her, picked up a spoon but did not bring food to the mouth, and was later only given one bite of chicken before staff walked away to assist another resident. The resident was then offered ice cream but did not eat it and was transported out of the dining room after consuming only one bite of food. On other observations, the resident was found in bed with breakfast or lunch trays untouched or nearly untouched, with no visible prompting to eat and no attempts by the resident to self-feed. Additional observations showed the resident sitting with food in front of him/her for extended periods, including stuffed shells, mixed vegetables, a cupcake, scrambled eggs, oatmeal, and applesauce, with little or no intake. In one instance, a NA attempted to assist after the meal had been present for over an hour and stated the resident only ate a couple bites even with assistance. Staff later acknowledged that the resident had been sleeping more since the fall and might ask for food later. The dietary record documented poor oral intake, intermittent refusals, and significant weight loss, while nursing and dietary staff stated they had not been aware earlier that the resident was not eating well or might need feeding assistance.
Air mattress settings and ordered vital signs not followed
Penalty
Summary
The facility failed to ensure that air mattresses were set according to physician orders for two residents. One resident had Alzheimer’s disease, COPD, anxiety, severe cognitive impairment, a Stage 4 coccyx pressure ulcer, and was dependent for eating, transfers, and bed mobility. The resident’s care plan directed use of a specialized mattress and every-shift checks of the air mattress function and setting. A physician order directed the mattress to be set at 80 and alternating, but survey observations on multiple occasions found the pump knob positioned between 80 and 120 and the static setting light illuminated instead of alternating. An LPN signed off in the EMR that the mattress was checked and matched the order, but when shown the pump and order, still identified the setting as correct despite the observed mismatch. A second resident had diabetes, dementia, congestive heart failure, severe cognitive impairment, and was dependent for eating, bed mobility, and chair/bed transfers. The resident’s care plan directed an air mattress set at 2 and alternating with every-shift checks. A physician order also directed the mattress to be set at 2 and alternating. Survey observations found the mattress pump with 3 lights lit for firmness instead of 2, while the alternating light was lit. An LPN again signed off in the EMR that the mattress was checked and matched the order, but during observation with the surveyor, identified the setting as correct even though it did not match the physician order. The unit manager later observed the mattress was still set at 3 lights lit and alternating, and the nursing supervisor stated the charge nurse should check and verify the settings each shift. The facility also failed to follow a physician order for obtaining vital signs for a resident with dementia, chronic thrombocytopenia, and COPD. After the resident developed a new large red raised area to the abdomen and right flank and reported discomfort, an APRN ordered monitoring of the area every shift for 5 days and vital signs every shift for 3 days. The physician order was entered, but the treatment and medication records did not identify the vital signs order, and the vital signs log showed that from the date of the order through the next several days, vital signs were obtained only 3 of 9 shifts. An RN later acknowledged that the resident’s vital signs were not completed every shift as ordered and that the floor nurse on each shift was responsible for ensuring physician orders were completed and documented.
Delayed treatment order for coccyx pressure ulcer
Penalty
Summary
The facility failed to ensure timely treatment was ordered when a pressure ulcer was identified for Resident #144, who was admitted with diagnoses including elevated white blood cells, a terminal colon condition, and depression. On admission, the resident was cognitively intact, required moderate assistance with ADLs including bed mobility, and was identified as at risk for pressure ulcers with a Braden Scale score of 17. The care plan included skin monitoring, incontinent care, inspection during care, turning and positioning, and use of a pressure-reducing mattress. The admission MDS indicated the resident was at risk for pressure ulcers but did not have one on admission. A weekly skin assessment documented that the resident developed a skin issue on the coccyx, measuring 1.0 cm by 0.3 cm by 0.1 cm, but the area was not staged and no physician order for treatment was obtained at that time. Two days later, an LPN noted an open area on the coccyx measuring 0.5 cm by 0.5 cm by 0.1 cm with a small amount of serous drainage and surrounding redness, and a treatment order for Triad Paste with a dry, clean dressing daily and as needed for soiling was then obtained. The RN who completed the skin assessment stated she would normally document a skin issue in a nursing note after the weekly skin check or if staff identified an area during care, but could not explain why no treatment order or corresponding nursing note was completed when the coccyx area was first identified. The wound physician stated that if the area was noted on the coccyx, a treatment order should have been put in place when it was identified.
Unsecured Medication and Unlocked Bed Wheels
Penalty
Summary
The facility failed to ensure a resident’s medication was properly secured when a resident with COPD, bipolar disorder, and anxiety was observed with an unsecured Albuterol inhaler at the bedside without an order for self-administration. The resident’s care plan identified the resident as non-compliant and resistive to care and medication, and included interventions for staff to check the resident’s mouth after medication administration and to provide consistent caregivers. During observation, the inhaler was found at the bedside, labeled from the facility’s contracted pharmacy, and the resident stated it had been there for a while. An LPN stated the resident had not received the morning dose because the resident was sleeping, and an RN confirmed the resident did not have an order for self-administration and should not have medication at the bedside per facility policy. The facility also failed to ensure bed wheels were locked for multiple residents whose beds were observed in an unlocked or partially locked condition. Residents interviewed included individuals with diagnoses such as dementia, COPD, mild cognitive impairment, overactive bladder, cirrhosis, osteoarthritis, abnormal gait, muscle weakness, bipolar disorder, and a history of falling. Observations showed several beds were freely movable because the wheels at the foot of the bed were unlocked, partially locked, or broken. In one room, a resident was observed washing in the bathroom while one of the two locking wheels at the foot of the bed was unlocked; the resident stated housekeeping unlocks the wheels. In other rooms, staff observed beds with both foot-end wheels unlocked, one wheel partially locked, or a broken wheel that still allowed the bed to move easily. One resident with intact cognition and a fall risk care plan reported sustaining a skin tear after attempting to get out of bed independently when the bed moved because the wheels were unlocked. The resident stated the bed moved into the wooden footboard, causing a large skin tear on the left forearm, and later stated the bed had been found unlocked multiple times before. Other residents stated they often noticed their beds were unlocked and had nearly fallen because the beds moved, and one resident reported using the bed rail for transfers but noticing the entire bed moved when the wheels were not locked. The facility was unable to provide a policy specifically addressing bed locks and instead provided a general fall prevention and management policy.
Delayed Re-Weight and Documentation of Significant Weight Loss
Penalty
Summary
The facility failed to ensure a re-weight was obtained in a timely manner to identify a significant weight loss for a resident with dementia, a pelvis fracture, anxiety, and severe cognitive impairment. The resident’s care plan identified risk for malnutrition related to variable food intake, significant weight change, and advanced age, and included monitoring weights as ordered. The resident also had a left pelvis fracture, with interventions related to pain assessment, therapy, and transfers per MD orders. The resident’s weight history showed 127.2 lbs. on 12/4/25, 124.6 lbs. on 12/11/25, 127.8 lbs. on 12/18/25, and 123.4 lbs. on 12/25/25. A dietary assessment noted the resident’s intake was generally good, the resident received Boost daily, and the weight was stable for 6 months. Later, a nursing note documented that the resident had been refusing to get out of bed and refusing weights after the hip fracture, and that multiple attempts to obtain weights had been unsuccessful. The dietician and APRN were notified, but no new orders were in place at that time. Interview and record review showed that a weight of 108.6 lbs. was obtained but struck out because it was thought to be inaccurate, and a reweight of 104.6 lbs. had been obtained but not documented in the clinical record. Staff were unable to explain why the reweight was not obtained sooner or why the weight loss was not identified for several days. The LPN stated she forgot to enter the reweight and had not documented the significant weight loss or the notifications made to the speech therapist, dietician, MD/APRN, and responsible party. The APRN stated he had not been notified of the resident’s refusal of weights or of the significant weight loss until he reviewed the record, and the RN stated he was not aware of the weight loss because he had not seen a weight ordered on the day he worked and relied on nurse aides to report poor intake.
Delayed Tube Feeding and Failure to Verify G-Tube Placement
Penalty
Summary
The facility failed to ensure a tube feeding was initiated on time and failed to ensure gastric-tube (g-tube) length was verified before administration of tube feeding per physician orders for one resident with a feeding tube. The resident had diagnoses including diabetes, dementia, and congestive heart failure, was severely cognitively impaired, and received 51% or more of total calories through the feeding tube. The care plan identified the feeding tube was in place to assist with maintaining nutritional status due to inadequate oral intake, and interventions included checking tubing placement as ordered and providing nutrition and flushes via the feeding tube per physician orders. A physician order directed Jevity 1.5 to be administered at 67 ml/hr for 18 hours starting at 12:00 PM and ending at 6:00 AM or when the volume goal of 1206 ml was reached. On observation, the tube feeding was not in place at the ordered start time, and the nurse did not begin the feeding until 3:00 PM. The nurse stated he attempted to hang the tube feeding late because he could not do everything at the exact time it was ordered for. The nurse also stated he would have the night nurse leave the tube feeding on for an extra hour, and the next morning the feeding was still running with 1031 ml delivered. The dietician stated the volume goal was the amount that should be administered and that the feeding should only be stopped at 6:00 AM if the full 1206 ml had been reached. The facility also failed to follow the physician order to verify g-tube length prior to administration of tube feeding, flushes, or medications. The order required checking the g-tube length each shift, but it did not identify the proper length. During observation, the nurse prepared the feeding, checked residual, administered a 150 ml water flush, and then started the tube feeding without verifying the tube length first. The nurse acknowledged he had forgotten to administer an additional ordered 200 ml flush at 12:00 PM and said he would give it later. He stated that because he obtained 10 ml of residual, he did not need to check the g-tube length before the flushes or feeding and would measure it later. Another nurse stated placement was checked by verifying the securement piece had not migrated and checking for residual, and that if residual was present, visualization of tube placement was not necessary.
Failure to Measure and Document PICC Line Length and Arm Circumference
Penalty
Summary
The facility failed to measure and document the arm circumference and external catheter length for a resident with a double lumen PICC line receiving IV antibiotics. Resident #13 had diagnoses including osteomyelitis of the left ankle and foot, severe sepsis, and bacteremia, and was admitted with a left basilic vein PICC line inserted at the hospital. Physician orders addressed PICC dressing changes and IV antibiotics, and the resident’s care plan later identified the PICC line and included weekly measurement of the left arm circumference and external catheter length with dressing changes. During record review and staff interviews, the DNS stated that for a resident with a PICC line, catheter length and arm circumference measurements were to be taken weekly and documented, but the clinical record did not show orders were in place or that the measurements were documented. The APRN who removed the PICC line later noted that the resident tolerated removal, but she did not measure the line or document that it was fully intact. Facility staff stated the admitting nurse or supervisor should have obtained the physician’s orders for the weekly PICC measurements, and the facility policy directed that upper arm circumference be measured on admission and weekly and that external catheter length be monitored on admission and weekly.
Oxygen Concentrator Set Above Ordered Flow Rate
Penalty
Summary
The facility failed to ensure oxygen was set at the physician-ordered rate for a resident with COPD, respiratory failure with hypercapnia, emphysema, and pneumonia. Physician orders directed oxygen at 2 liters per minute via nasal cannula, and the resident’s care plan also directed continuous oxygen at 2 liters per minute. The resident was moderately cognitively impaired and dependent for toileting, transfers, and bed mobility, and the MDS indicated the resident was receiving oxygen therapy. During observations, the resident was found in bed with oxygen via nasal cannula while the oxygen concentrator was running and set at 3 liters per minute on two separate occasions. The concentrator was out of the resident’s reach and positioned with the front facing the wall, making it inaccessible to the resident. A nursing note later documented no respiratory or cardiac distress and oxygen at 2 liters per minute continuously. RN #2 confirmed the concentrator was set incorrectly and adjusted it to 2 liters per minute, and LPN #7, the charge nurse, stated she had signed the TAR without checking the setting and had assumed it was correct from the previous shift. The DNS stated it was the charge nurse’s responsibility to check the oxygen concentrator every shift and ensure the correct setting.
Improper Storage and Labeling of Controlled Medications
Penalty
Summary
The facility failed to ensure medications were stored and labeled according to professional standards and failed to ensure controlled narcotic medications were stored under double lock at all times. Review with the DNS identified multiple controlled medications, including Morphine Sulfate, Lacosamide, Ativan, Morphine, Tramadol, Valium, Ritalin, Oxycodone, and Oxycontin, stored in the DNS office under one flip-type lock in a file cabinet credenza made of particleboard material, with a sliding window accessible from ground level. The DNS stated she considered her office door the second lock because she was the only one with a key and kept the office locked when unoccupied, but observation found the office door open without the DNS or staff present. The Administrator stated maintenance had extra keys to all offices, including the DNS office, and he also had a key to the DNS office. The facility also failed to ensure medications were properly handled on the medication cart. An LPN was observed removing two medication cups from the top drawer of the BH medication cart and discarding them before surveyor review; the cups contained an unidentified number of medications and were identified as being discarded due to resident refusals. Further review of the cart found a third medication cup containing 11 medications and a recapped syringe containing 20 cc of an unidentified substance, both in the top drawer without labels. The LPN could not identify the substance in the syringe, when it was prepared, or who prepared it, and could not identify the policy or procedure for resident refusals. An RN stated it was against facility policy to pre-pour medications or keep prepared medications in the top drawer, and that refusals should be reapproached and the supervisor and provider notified.
Failure to Provide Ordered Adaptive Eating Utensils
Penalty
Summary
The facility failed to provide adaptive eating equipment and utensils at mealtime for a resident with dementia, essential tremor, and unspecified lack of coordination. A physician’s order directed red foam on utensils during all meals, and the resident’s nutritional assessment, MDS, and care plan identified the resident as needing meal assistance, setup, and red foam built-up utensils. The care plan also included interventions to provide the red foam built-up utensils and assist with cutting up foods. During observations, the resident was seen eating meals with a regular fork and difficulty cutting and picking up food, without the ordered adaptive utensils. On one occasion, a NA served and set up the resident for lunch without the red foam built-up utensils, later stating she had forgotten to provide them. The NA then located the resident’s labeled utensils from a clear bin on the beverage cart and gave them to the resident. Interviews with the FSD, DNS, and OT confirmed the adaptive utensils were prepared and sent to the unit, and that nursing staff were responsible for passing them to the resident at mealtime.
Resident Council Concerns About Staff Cell Phone and Ear Bud Use Were Not Properly Followed Up
Penalty
Summary
The facility failed to provide follow-up to residents attending Resident Council meetings regarding concerns raised about nursing staff using cell phones and ear buds during work and care, and it failed to attempt alternative measures when the same issue kept recurring. During the 1/29/26 Resident Council meeting, 7 residents attended and stated that if they brought concerns to staff at council meetings, they would not know whether the concern was addressed and assumed it was not. Residents reported that nursing staff using phones and ear buds during care was so widespread that they no longer identified specific staff members, and they stated the issue had been brought up multiple times without noticeable change or feedback from the facility. Review of Resident Council minutes from January 2025 through January 2026 showed repeated concerns about staff on cell phones and using ear buds. In February 2025, a resident raised concern about 3:00 PM to 11:00 PM staff wearing ear buds during working hours, and a grievance form documented that concern. In March 2025, residents again reported nurse aides working with headphones in their ears and talking on phones while working. In December 2025 and January 2026, residents again reported staff members being on cell phones too often and observed ear buds and phone use on the 3rd floor during the 3:00 PM to 11:00 PM shift. Several meeting minutes did not document discussion of actions taken by the facility in response to the concerns raised at prior meetings. Interviews with the Interim Recreation Director and the Administrator showed the meeting process and follow-up were not consistently carried out as described in policy. The Interim Recreation Director stated he would reference prior minutes, document concerns, report them to the Administrator, and follow up during the meeting to ensure concerns had been addressed. The Administrator stated follow-up to Resident Council concerns was kept in a binder and that he received the minutes monthly, but he could not identify what was reviewed in the meetings. The facility policy required Resident Council minutes to include residents in attendance, discussions and actions taken, and to retain copies of resolutions addressing concerns, but the minutes reviewed did not consistently document those discussions or actions.
Unclean and Poorly Maintained Shower Room
Penalty
Summary
The facility failed to keep the second floor Ledgewood 2 shower room clean and in good repair. During an initial tour, the shower room ceiling was observed with chipping and cracked paint, a black/brown substance was present on the floors and walls, and a used white wet washcloth was on the shower floor. An LPN later identified that environmental rounds were completed every other week and stated the black substance on the floors and walls was dirt, grout, or caulk, and that the grout or caulk needed to be replaced because the shower was not clean. The Maintenance Director also observed that the ceiling needed repainting and that the brown/black substance was glue for the baseboard that should be cleaned off, and confirmed the shower room was not clean. Review of the Environmental Rounds logs did not identify concerns for any of the 6 showers in the facility for the past 6 months.
Failure to Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors as a deficiency in the facility's process for keeping relevant parties informed about significant events impacting the resident's care and well-being.
Failure to Ensure Timely Insulin Delivery Due to Poor Pharmacy Collaboration
Penalty
Summary
A deficiency occurred when the facility failed to collaborate effectively with the pharmacy to ensure a new admission received prescribed insulin, resulting in the resident missing four days of medication. The resident, who had diagnoses including type 2 diabetes mellitus, end stage renal disease, and morbid obesity, was discharged from the hospital with an order for Humulin R U-500 insulin. Upon admission, a physician's order was entered for this medication, but due to its unusual concentration, the pharmacy required clarification before filling it. Subsequently, the order was changed to Humulin-R 100 units/mL, but the pharmacy did not fill this new order, and the medication was not available for administration on multiple days. Review of the Medication Administration Record (MAR) showed that the insulin was not administered on four separate days, and there was no documentation that nursing supervisors, providers, or the pharmacy were notified of the missed doses. Interviews revealed that the pharmacist was unaware of the new order and did not fill it, while the Director of Nursing stated that nursing staff should have followed up with the pharmacy each time the medication was unavailable. The lack of communication and follow-up led to the resident missing critical doses of insulin.
Failure to Document Missed Insulin Doses and Notifications
Penalty
Summary
The facility failed to document in the clinical record when a prescribed medication, Humulin-R insulin, was not available for a resident with diagnoses including type 2 diabetes mellitus, end stage renal disease, and morbid obesity. The resident was admitted with orders to receive Humulin R U-500 insulin, which was later changed to Humulin-R insulin 100 units/mL, 40 units subcutaneously every evening. The Medication Administration Record (MAR) showed that the Humulin-R insulin was not administered on several dates, and notes indicated the medication was on order or not available. However, there was no documentation that the nursing supervisor, provider, or pharmacy were notified of the missed doses on these dates. Nursing notes indicated that on one occasion, after being unable to locate the insulin, the Advanced Practice Registered Nurse (APRN) was updated and directed staff to hold the dose, follow up with the pharmacy, and monitor blood sugars. Despite this, subsequent MAR notes for other missed doses did not reflect any notification to supervisory staff, providers, or the pharmacy. The facility's documentation policy requires nursing staff to complete documentation reflecting all care and services provided, including missed medications and related interventions, but this was not followed in the instances identified.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Monitoring
Penalty
Summary
The facility failed to ensure adequate supervision for a resident with known exit-seeking behaviors, resulting in the resident being able to exit the facility without staff knowledge. The resident, who had a history of dementia and was at risk for falls, was found 0.3 miles away from the facility after eloping. Despite having a wander guard in place, the resident managed to remove it, and the facility did not have proper documentation or monitoring in place to prevent this incident. The facility's records showed that the resident had increased exit-seeking behavior, but there was no documentation of an elopement assessment or notification to the family or psychiatric nurse practitioner prior to the placement of the wander guard. Additionally, the facility failed to ensure that the wander guard's placement and function were checked regularly, as required by their policy. Staff interviews revealed a lack of communication and understanding regarding the resident's elopement risk and the use of the wander guard. The facility's policy on elopement prevention was not followed, as evidenced by the lack of a physician order for the wander guard, failure to notify the family and APRN, and absence of tracking for placement and function checks. The facility's documentation also failed to include education for staff on responding to alarms and ensuring wander guard placement and function checks. This oversight contributed to the resident's ability to elope from the facility, resulting in a finding of Immediate Jeopardy.
Failure to Notify Family and APRN of Resident's Change in Condition
Penalty
Summary
The facility failed to notify the family and the Advanced Practice Registered Nurse (APRN) of a resident's change in condition, specifically the application of a wander guard due to exit-seeking behaviors. The resident, who had diagnoses including dementia and a history of hip fracture, was initially assessed as not being an elopement risk. However, on a subsequent date, the resident was transferred to a different floor with a wander guard in place due to increased exit-seeking behavior. Despite this significant change, there was no documentation that the resident's family or physician were informed of the application of the wander guard or the change in behavior. Interviews with facility staff, including the Administrator, Registered Nurses (RNs), and the Director of Nursing (DON), revealed a lack of communication and adherence to the facility's policy regarding notification of significant changes in a resident's condition. The staff involved could not recall placing the wander guard or notifying the necessary parties, and the facility's policy clearly directed that the resident's physician and representative should be made aware of any significant changes. This oversight in communication and policy adherence led to the deficiency identified in the report.
Failure to Update Care Plan for Resident with Wandering Behaviors
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident with known wandering behaviors. The resident, who was admitted with dementia, a history of hip fracture, and malnutrition, was initially assessed as not being an elopement risk. However, subsequent nursing notes indicated increased exit-seeking behavior, and a wander guard was applied. Despite these observations, the care plan was not updated to reflect the resident's wandering behaviors or the application of the wander guard. On a later date, the resident was found 0.3 miles away from the facility, indicating a failure to address the elopement risk adequately. Interviews with staff, including the Director of Nursing, revealed that the care plan was not updated to include the resident's wandering behaviors or the use of the wander guard. The facility's care planning policy requires that care plans be comprehensive and updated to reflect changes in a resident's status, which was not adhered to in this case.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 548 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Branford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Whispering Pines Rehabilitation And Nursing Center | 0.9 mi | ★★★★★ | 7 | 1 |
| Apple Rehab Laurel Woods | 2.2 mi | ★★★★★ | 11 | 0 |
| New Haven Center For Nursing & Rehabilitation Llc | 3.5 mi | ★★★★★ | 46 | 1 |
| Mary Wade Home, The Incorporated | 4.1 mi | ★★★★★ | 4 | 0 |
| Leeway, Inc | 5 mi | ★★★★★ | 10 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.