Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
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 Ingraham Manor Rehab And Nursing during CMS and state inspections, most recent first.
A resident admitted as Full Code with multiple medical conditions was found pulseless and not breathing by an LPN who did not know the resident’s code status, did not verify it in the EMR, and did not call a code blue or start CPR. The LPN instead left to notify another LPN and an RN. The RN arrived several minutes later, confirmed the resident had no respirations, and did not initiate CPR based on a belief that rigor mortis had set in, while another LPN also confirmed no pulse and noted no stiffness in the extremities but likewise did not begin resuscitation. Interviews with the MD and DNS confirmed that CPR and EMS activation should have been initiated for a Full Code resident found without pulse and respirations, and that residents are considered Full Code unless otherwise changed after admission.
A resident admitted with multiple medical conditions, including Type II diabetes, acute kidney injury, and atherosclerotic heart disease, was documented as Full Code in the hospital discharge summary, admission assessment, and physician orders. During an early-morning blood glucose check, an LPN found the resident pulseless and not breathing but did not know the code status, could not access the EMR, and believed that was the only source for this information. The LPN performed a sternal rub, left to notify another LPN and an RN, and did not call a code blue or start CPR. An RN arrived several minutes later, found the resident without pulse or respirations, and pronounced the resident expired without initiating CPR, stating they believed rigor mortis had begun, despite later acknowledging CPR and EMS activation should have occurred and that facility practice was to follow the Full Code status on the hospital discharge documents. Administration reported there was no clear process to make advance directives for newly admitted residents readily identifiable in the paper chart during a transition from paper to EMR.
A resident admitted with multiple medical conditions and clearly documented as Full Code was found pulseless and not breathing by an LPN, who did not know or confirm the code status, did not call a code blue, did not initiate CPR, and did not activate EMS. A second LPN also assessed the resident, confirmed absence of pulse and respirations, noted no stiffness of extremities, and likewise did not start CPR or call a code. An RN arrived several minutes after notification, assessed the resident, determined the resident had expired, did not initiate CPR based on a belief that rigor mortis had set in, and pronounced death without a physician order authorizing RN pronouncement, despite facility policies and the physician’s expectation that CPR and EMS activation were required for a Full Code resident.
A resident with mobility difficulties and intact cognition, who required one-person assistance with a rolling walker for transfers, was assisted by staff without the prescribed walker. Instead, the resident was stood up holding onto a locked wheelchair, leading to a fall that resulted in fractures to the right arm and knee. Staff interviews and documentation confirmed that the wheelchair was improperly used as a support device, contrary to physician orders and facility policy.
A resident with severe cognitive impairment and a known history of wandering was able to leave their unit and access a stairwell without staff knowledge, despite care plan interventions requiring a wander guard device. The resident was found injured in the stairwell after passing through an alarmed, delayed-egress door, and sustained a hip fracture and lacerations. The failure to reinstate the wander guard order and provide adequate supervision led to the incident.
A resident with vascular dementia and a history of wandering was not properly assessed for elopement risk upon readmission, as key sections of the wander risk assessment were left incomplete, resulting in an inaccurately low risk score. Previous orders for a wander guard and related checks were not reinstated, and there was no documentation of new orders or consistent application of the device, despite the care plan identifying the resident as an elopement risk. Facility policy required these interventions for high-risk individuals, but they were not properly implemented or documented.
Failure to Initiate CPR and Activate EMS for a Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide basic life support, including CPR and EMS activation, to a resident who was documented as Full Code. The resident had been admitted from the hospital with diagnoses including Type II diabetes, acute kidney injury, and atherosclerotic heart disease, and the hospital discharge summary, nursing admission assessment, and physician’s orders all identified the resident as Full Code. Vital signs obtained after admission showed elevated blood pressure and a decreasing temporal temperature. Later, a progress note by an RN documented that the resident was found pulseless and without respirations and was pronounced expired, with subsequent notification of the resident representative and provider. When an LPN went to the resident’s room to obtain a blood glucose level, the LPN found the resident pulseless and without respirations. The LPN stated they did not know the resident’s code status and did not confirm it because their computer was not on, and indicated that the EMR was the only place they could find code status. The LPN performed a sternal rub with no response, then left the room, asked another LPN to check on the resident, and paged the RN to report that the resident was pulseless and not breathing. The LPN acknowledged that they should have confirmed the code status, overhead paged a code blue, and initiated CPR. The RN reported arriving at the room approximately four to five minutes after being notified that the resident was not breathing, assessed the resident, and did not initiate CPR because they believed rigor mortis had already set in, despite acknowledging that CPR should have been started. Another LPN who checked the resident confirmed the absence of a pulse, noted the resident’s hands were folded with fingers intertwined, and reported that the resident’s arm and fingers were not stiff when moved to palpate a radial pulse, yet did not initiate CPR and later stated CPR, a code call, and EMS activation should have occurred. The physician interviewed stated that CPR and EMS activation should have been initiated once the resident was found pulseless and without respirations, and that EMS activation was required because there was no physician’s order authorizing an RN to pronounce death. The DNS stated that for a Full Code resident found without pulse and respirations, staff should call for help, announce a code blue over the intercom with room and location, and immediately start CPR, and that residents are considered Full Code unless otherwise decided after admission.
Removal Plan
- Audited all resident charts to confirm code status was active in the electronic medical record (EMR).
- Educated all nursing staff on Response to Unresponsive Residents and Code Status, CPR, and conducted a Mock Code followed by a code debrief on all shifts.
- Performed a Code Procedure Checklist (competency evaluation) for all licensed staff.
- Conducted code blue mock drills.
- Scheduled the corrective action plan for QAPI review.
Failure to Ensure Readily Accessible Code Status Resulted in No Emergency Response for Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s advance directives/code status were readily accessible to staff during an emergency, resulting in no emergency response being initiated for a resident documented as Full Code. The resident was admitted from the hospital with diagnoses including Type II diabetes, acute kidney injury, and atherosclerotic heart disease, and the hospital discharge summary, nursing admission assessment, and physician’s orders all identified the resident as Full Code. When an LPN entered the resident’s room early in the morning to obtain a blood glucose level, the resident was found pulseless and without respirations. The LPN did not know the resident’s code status, could not access the EMR because the computer was not on, and believed the EMR was the only place to confirm code status. The LPN performed a sternal rub with no response, then left the room, asked another LPN to check on the resident, and paged an RN, but did not call a code blue or initiate CPR. When the RN arrived approximately four to five minutes after being notified, the RN assessed the resident, determined the resident was pulseless and not breathing, and pronounced the resident expired without initiating CPR, stating that they believed rigor mortis had already set in. The RN later acknowledged that CPR should have been initiated, that a code should have been called, and that EMS should have been activated, and confirmed that facility practice was to follow the hospital discharge documents, which indicated the resident was Full Code. Another LPN also stated that facility practice was to follow the hospital discharge summary for advance directives but was unaware that this resident was Full Code. Facility administration reported the facility was transitioning from paper charts to an EMR system and did not have a process to ensure advance directives for newly admitted residents were readily identifiable in the paper chart; such directives could be located within hospital documents or physician order sections, but administration could not say how long it would take to find them during an emergency. The facility’s own policy stated that adults have the right to control decisions related to their medical care and that advance directives are legally recognized written declarations specifying a person’s wishes for future care.
Failure to Initiate CPR and Improper RN Pronouncement for a Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary emergency services, including CPR and EMS activation, for a resident who was documented as Full Code, and the pronouncement of death by an RN without a physician order authorizing RN pronouncement. The resident had been discharged from the hospital with a documented Full Code status and was admitted to the facility with diagnoses including Type II diabetes, acute kidney injury, and atherosclerotic heart disease. On admission, the nursing assessment confirmed the resident was oriented and Full Code, and physician orders also reflected Full Code status. Vital signs obtained during the night showed a blood pressure of 168/70 with a temperature of 98°F, and later a blood pressure of 137/44 with a temperature of 95°F. In the early morning, an LPN went to the resident’s room to obtain a blood glucose level and found the resident pulseless and without respirations. The LPN did not know the resident’s code status, did not confirm it because the computer was not on, and identified the EMR as the only place to find code status. The LPN performed a sternal rub with no response, then left the room, asked another LPN to check on the resident, and paged the RN to report that the resident was pulseless and not breathing. The LPN did not call a code blue, did not initiate CPR, and did not activate EMS, later acknowledging that he/she should have confirmed the code status, called a code blue, and started CPR. The second LPN, after being informed the resident had expired, assessed the resident, found no pulse, noted no stiffness of extremities or fingers, and also did not initiate CPR, later stating that CPR, a code call, and EMS activation should have occurred once the resident was found without pulse and respirations. The RN responded approximately four to five minutes after being notified that the resident was not breathing, assessed the resident by auscultating lungs and heart, evaluating the eyes, and checking for blood pressure, and determined the resident had expired. The RN did not initiate CPR, stating the belief that rigor mortis had already set in, and contacted the Administrator to report the resident’s death. A subsequent progress note documented the resident as pulseless, without respirations, and pronounced expired, and later that the provider was notified and an order received to release remains to the funeral home. The facility’s Director of Nursing stated that for a Full Code resident found without pulse and respirations, staff should call for help, overhead page a code blue three times with room and location, and immediately initiate CPR, and confirmed that a physician’s order is required for RN pronouncement of death. The facility’s policies required CPR to be performed on appropriate residents by CPR-certified staff and specified that RN pronouncement of death is only permitted when the attending physician has documented an anticipated death and authorized RN pronouncement in writing, conditions that were not met in this case. The attending physician stated that CPR and EMS activation should have been initiated once the resident was found pulseless and apneic, and that EMS activation was required because there was no physician order authorizing RN pronouncement.
Failure to Use Prescribed Assistive Device During Transfer Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when staff failed to provide safe assistance during a transfer for a resident with diagnoses of difficulty walking and osteoarthritis. The resident, who had intact cognition and required assistance of one staff member with a rolling walker for transfers per physician order, was being assisted by a nursing assistant who did not use the prescribed walker. Instead, the resident was stood up facing the front of a wheelchair, holding onto its arms while the wheelchair was locked. During this process, the resident's knee buckled, causing a fall to the floor. As a result of the fall, the resident sustained a fractured right humerus and a fractured right patella, requiring transfer to the hospital for evaluation and treatment. Facility documentation and staff interviews confirmed that the wheelchair was used as a support device during the transfer, contrary to both physician orders and facility fall prevention policy, which directed the use of appropriate assistive devices such as a walker, grab bar, or railing. The incident demonstrated a failure to ensure adequate supervision and use of proper assistive devices to prevent accidents.
Failure to Prevent Wandering Resident from Accessing Stairwell Resulting in Injury
Penalty
Summary
A deficiency occurred when a resident with vascular dementia and a high risk for wandering was able to leave their unit without staff knowledge, resulting in a fall with injury in a stairwell. The resident had a history of agitation, combative behavior, and was previously identified as a high elopement risk, with interventions including the use of a wander guard device. Upon readmission to the facility after a hospital stay, the order for the wander guard was not reinstated, despite the care plan indicating the need for such an intervention. The resident continued to display wandering behaviors after readmission, as documented in nursing progress notes. The care plan directed staff to ensure the resident wore a wander guard and to check its placement and function, but this was not implemented. The resident was last seen by nursing staff at the nursing station and was found approximately 20 minutes later by housekeeping staff on the landing of a stairwell, having accessed an egress door equipped with a delayed-egress mechanism and alarm. The alarm system was designed to alert staff when the door was opened, but the resident was able to enter the stairwell and fall without staff intervention. Interviews with facility leadership and staff did not clarify how the resident was able to access the stairwell unnoticed, despite known wandering behaviors and the presence of an alarm system. The resident sustained a right hip fracture and lacerations, requiring transfer to the hospital. The failure to reinstate the wander guard order and to provide adequate supervision and monitoring for a resident at high risk for wandering directly contributed to the incident.
Failure to Complete Wander Assessment and Implement Wander Guard Orders for High-Risk Resident
Penalty
Summary
The facility failed to accurately complete a wander risk assessment and to ensure appropriate interventions and orders were in place for a resident with a known history of wandering and elopement risk. The resident, who had diagnoses including vascular dementia and anxiety disorder, was initially assessed as high risk for wandering prior to a hospital transfer. Upon readmission, the wander risk assessment was incomplete, with key sections left blank, resulting in an inaccurately low risk score. According to the facility's own assessment directions, the missing sections should have been completed and would have indicated a high risk for wandering. Additionally, after the resident's transfer to the hospital, all previous physician orders, including those for the use of a wander guard and checks for its placement and function, were discontinued. Upon readmission, although the care plan identified the resident as an elopement risk and included interventions such as the use of a wander guard, there was no documentation that a new physician order for the wander guard was obtained or that checks for placement and function were ordered or documented. The DON confirmed that the assessment was incomplete and that staff should have entered new orders for the wander guard but could not provide documentation that this was done. Facility policy required that residents identified as high risk for wandering have a wander guard applied, but the lack of a complete assessment and missing physician orders meant that this intervention was not properly implemented or documented. The deficiency was identified through review of clinical records, facility documentation, and staff interviews, which confirmed the failures in assessment completion, order initiation, and adherence to the plan of care for a resident at risk for wandering.
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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.
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Nursing homes near Bristol
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pines At Bristol For Nursing & Rehabilitation, The | 0.4 mi | ★★★★★ | 3 | 0 |
| Civita Care Sheriden Woods | 1.4 mi | ★★★★★ | 33 | 0 |
| Village Green Rehabilitation And Healthcare Center | 2.3 mi | ★★★★★ | 1 | 0 |
| Countryside Manor Of Bristol | 3.4 mi | — | 0 | 0 |
| Apple Rehab Farmington Valley | 4.9 mi | ★★★★★ | 1 | 0 |
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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.