Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Monsignor Bojnowski Manor during CMS and state inspections, most recent first.
A resident with dementia, multiple comorbidities, and moderate cognitive impairment exhibited escalating agitation, continuous yelling, and restlessness that staff were unable to redirect. Despite a care plan and dementia policy requiring physician or mental health referral when behaviors declined or interventions were ineffective, staff did not notify the physician of the behavioral change. Instead, a supervising RN directed that the resident be brought to the nurse’s station, then placed the resident in the medication room behind the nurse’s station with the door closed for about one and one-half hours for "close observation," while other staff later described the situation as solitary confinement.
A resident with dementia, multiple comorbidities, and total dependence for care, who frequently yelled out and was sometimes calmed when near the nurse’s station, was placed in the medication room with the door closed for about one and one-half hours due to agitation, yelling, and attempts to get out of bed. A CNA brought the resident to the nurse’s station for anxiety and restlessness, and the supervising RN, unable to fit the wheelchair behind the nurse’s station, directed that the resident be placed in the medication room and shut the door so other residents could sleep, stating it was easier to watch the resident there. Staff later described the situation as “solitary confinement,” confirmed the door was shut though unlocked, and documented that the resident remained there until after midnight before being returned to their room. This conduct conflicted with the facility’s abuse policy, which prohibits involuntary seclusion defined as separating a resident from others or from their room against the will of the resident or representative.
A resident with dementia, ESRD, failure to thrive, depression, and moderate cognitive impairment, fully dependent for care and wheelchair bound, was placed in a medication room with the door shut by an RN after the resident had been screaming, anxious, and trying to get out of bed. Multiple staff, including an NA and LPNs, observed the resident in the closed medication room, questioned the practice, and one LPN referred to it as solitary confinement, but none reported it as suspected abuse at the time despite prior abuse/neglect training and awareness that involuntary seclusion is a form of abuse. The DON only became aware of the incident days later during conversations with staff, and the facility’s abuse policy requiring immediate reporting of suspected abuse to the Administrator within two hours was not followed.
The facility failed to secure medications designated for destruction or return to the pharmacy, as observed in the DNS office, which was found open and unoccupied on multiple occasions. Various medications were visible and accessible, contrary to the facility's policy. Interviews revealed that the DNS did not secure the office door, believing residents and visitors would not enter, leading to unsecured medications.
The facility failed to administer pneumococcal and influenza vaccines to residents, despite consents being given. A resident with hypertension and another with dementia were not offered the influenza vaccine, and there was no record of pneumococcal vaccine administration for five residents. The DNS confirmed the oversight, indicating a lapse in the facility's vaccination program.
A resident with vascular dementia and anxiety frequently refused care and medications, particularly Trazodone, but the facility failed to update the care plan to address these refusals. Interviews with staff revealed that the resident was redirectable, yet the care plan lacked interventions for reapproaching the resident. The facility did not have a specific policy on refusals, and the care plan was not updated despite the resident's transition to hospice care.
A resident with dementia and a history of wandering eloped to a courtyard patio due to inadequate supervision and staff's failure to respond to door alarms. The resident, who was at risk for elopement, managed to exit the building unnoticed, despite having a wander guard. Staff interviews revealed that alarms were not promptly investigated, leading to the resident being found outside and brought back inside by an LPN.
An LPN failed to follow hand hygiene procedures during medication administration and resident care, as observed in a facility. The LPN did not sanitize hands between resident interactions or after glove removal, despite the facility's policy requiring hand hygiene between resident contacts and before handling medications. The LPN was unfamiliar with the facility's hand hygiene policy, which was confirmed through interviews.
A resident with epilepsy and dementia missed three doses of prescribed Clobazam because the medication was not available, despite refills remaining. The MAR and EMR showed the medication should have been refilled, but the pharmacy's records did not reflect this, leading to a lapse in administration. The resident developed symptoms and was sent to the hospital for evaluation, where it was confirmed that the medication had not been given as ordered. Staff interviews revealed confusion and miscommunication regarding the refill process for controlled substances.
A facility failed to notify the Ombudsman of a resident's transfer to the hospital, as required. A resident with osteomyelitis and other conditions was found unresponsive and transferred to the ER. The Social Worker, responsible for reporting transfers, was unaware of this duty, resulting in a lack of notification for several months. The Administrator confirmed the oversight, as the Social Worker was on leave and he lacked access to the reporting portal.
The facility failed to properly label and store food, and did not ensure kitchen staff adhered to hygiene standards. Observations revealed unlabeled and uncovered food items in storage, and staff not wearing required hair and beard guards while preparing food. Interviews confirmed these actions were against facility policy.
The facility failed to accurately encode MDS assessments for five residents, leading to discrepancies in their immunization records. Residents were reported as having up-to-date vaccinations, but records showed no documentation of recent pneumococcal or influenza vaccines. Interviews with an LPN revealed that the assessments were not accurately coded, and the clinical records lacked necessary information. The DNS acknowledged signing off on the assessments but emphasized the MDS Coordinator's responsibility for accuracy.
Two residents in a facility sustained injuries due to improper transfers. One resident, with osteoarthritis, was not transferred using a rolling walker as required, resulting in a leg laceration. Another resident, with Alzheimer's, was transferred without a rolling walker, leading to a leg injury from a bed rail. Both incidents occurred due to staff not following care plans.
The facility failed to provide required orientation, including emergency procedures and abuse training, to three agency NAs before they began working. The Administrator confirmed the absence of documentation for these orientations, which is against the facility's policy.
Failure to Notify Physician of Behavioral Change and Inappropriate Use of Medication Room for Observation
Penalty
Summary
The deficiency involves the facility’s failure to notify the physician of a significant change in a resident’s behavior and the subsequent placement of the resident in a medication room with the door closed for an extended period. The resident had diagnoses including dementia, insomnia, end stage renal disease, failure to thrive, and depression, and was identified as moderately cognitively impaired, dependent for all care, and wheelchair bound. The resident’s care plan directed staff to assess mood every shift and obtain psychiatric services if mood declined. In the days leading up to the incident, nurse’s notes documented that the resident often yelled out continuously and was sometimes calmed when brought near the nurse’s station. An FNP note indicated recent falls, increased confusion, anxiety, and a discussion with family about starting Trazodone, which the family declined. On the date of the incident, staff reported that the resident was anxious, trying to get out of bed, and screaming throughout the shift, with usual redirection attempts unsuccessful. NA #1 brought the resident to the nurse’s station due to restlessness and high fall risk. RN #2, the nursing supervisor, determined the resident should be kept under direct observation and attempted to position the resident behind the nurse’s station, but the custom wheelchair would not fit. RN #2 then placed the resident in the medication room located directly behind the nurse’s station and shut the door. Written statements and interviews indicated that the resident remained in the medication room in the wheelchair with the door shut for approximately one and one-half hours, and that staff referred to this as “solitary confinement.” Review of the clinical record and nurse’s notes for the 24 hours preceding the incident showed no documentation that the physician was notified of the resident’s increased agitation and behavioral escalation, despite the facility’s dementia care policy directing appropriate referrals to the physician or mental health provider when current interventions were ineffective or when there was a decline in psychosocial, mood, or behavioral status. Interviews confirmed that staff were unable to de-escalate the resident’s behaviors and that the family member was not contacted for assistance until early the following morning. The facility documentation and staff interviews collectively demonstrated that the resident’s significant change in behavior was not reported to the physician and that the resident was instead placed in the medication room with the door closed for close observation.
Involuntary Seclusion of a Cognitively Impaired Resident in Medication Room
Penalty
Summary
The deficiency involves the involuntary seclusion of a resident with dementia and multiple comorbidities who was placed in the facility’s medication room with the door closed for approximately one and one-half hours due to agitated behaviors and continuous yelling. The resident had diagnoses including dementia, insomnia, end-stage renal disease, failure to thrive, and depression, and was assessed as moderately cognitively impaired, unable to make reasonable and consistent decisions, dependent for all care, and wheelchair bound. The resident’s care plan addressed self-care deficits and mood concerns but did not include interventions involving separation from other residents or placement in a medication room. In the days leading up to the incident, nursing notes documented that the resident frequently yelled out continuously throughout shifts, with some decrease in yelling when brought near the nurse’s station. On the day of the incident, staff reported the resident was anxious, trying to get out of bed, and screaming throughout the shift. A nursing assistant brought the resident to the nurse’s station, and the supervising RN directed that the resident be brought there for closer observation. When the resident’s wheelchair could not be accommodated behind the nurse’s station, the supervising RN placed the resident in the medication room and shut the door, stating it was easier to watch the resident there and to allow other residents to sleep. Written statements and interviews confirmed that the resident remained in the medication room with the door shut, with staff referring to the situation as “solitary confinement” and acknowledging the resident had been yelling all evening. The medication room door was unlocked and had clear glass panels, allowing visual observation, and at some point after midnight, vital signs were obtained and the resident was returned to their room, where they slept for the remainder of the night. The facility’s abuse policy stated that residents would be protected from involuntary seclusion, defined as separation from other residents or the resident’s room against the will of the resident or the resident’s representative. The placement of the resident in the medication room with the door closed for behavioral reasons constituted the separation that led to the cited deficiency.
Failure to Timely Report Allegation of Involuntary Seclusion
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of involuntary seclusion involving one resident. The resident had dementia, insomnia, end stage renal disease, failure to thrive, depression, was moderately cognitively impaired with a BIMS score of 9, unable to make reasonable and consistent decisions, dependent for all care, and wheelchair bound. The resident’s care plan called for assessment every shift, medication administration as ordered, encouragement to participate in care, and psychiatric services and emotional support if mood declined or the resident self-isolated. On the evening in question, the resident was reportedly screaming, anxious, trying to get out of bed, and attempting to climb out of bed. Multiple staff members, including nursing assistants and nurses, observed that the resident was placed in the medication room with the door shut for close observation and to prevent disruption to other residents. Staff accounts documented that an RN directed that the resident be brought to the nurse’s station and then placed the resident in the medication room with the door shut, referring to the situation as a way to watch the resident and allow others to sleep. Other staff, including an NA and LPNs, noted they had never seen a resident placed in the medication room in this manner, questioned the appropriateness of the action, and one LPN described it as “solitary confinement.” Despite having received abuse and neglect training and being aware that involuntary seclusion is a form of abuse, these staff did not report the incident as suspected abuse at the time it occurred, citing reasons such as not realizing it was wrong or believing the resident was not their patient. The DON later learned of the incident only when speaking with staff about interactions with the RN involved, at which point the facility initiated an investigation and completed a Reportable Event Form several days after the incident, contrary to the facility’s abuse policy requiring suspected abuse to be reported to the Administrator immediately and no longer than two hours after an allegation is made.
Unsecured Medications in DNS Office
Penalty
Summary
The facility failed to ensure that medications designated for destruction or return to the pharmacy were secured, as observed during multiple instances. On several occasions, the Director of Nursing Services (DNS) office door was found open and unoccupied, with a yellow basket containing various medications visible on top of the medication safe. This office is located on a nursing unit that opens to the resident corridor, where residents and visitors were present. The medications included Eliquis, Amox-Clav, Cephalexin, Ciprofloxacin, Prednisone, and others, which were not secured as per the facility's policy. Interviews with RN#2 and the DNS revealed that discontinued and expired medications are typically stored in a cabinet in the medication storage room until they are taken by the DNS for destruction or return to the pharmacy. However, the DNS admitted that the medications in the office were supposed to be destroyed but had not yet been processed. Despite the presence of ambulatory residents and visitors near the open office, the DNS did not secure the door, believing that residents and visitors would not enter the office. This oversight led to the medications being unsecured and accessible, contrary to the facility's policy for medication storage.
Failure to Administer Vaccines
Penalty
Summary
The facility failed to ensure that pneumococcal and influenza vaccines were assessed and administered to residents, as evidenced by the review of clinical records, facility policy, and interviews. Five residents were reviewed for immunizations, and it was found that the pneumococcal vaccine was not offered or administered to any of them. Specifically, Resident #12 and Resident #31 were not offered the influenza vaccine. The DNS, who was covering for the Infection Preventionist, confirmed that these residents should have been offered and given the PCV 20 vaccine based on their pneumococcal history. Resident #12 had diagnoses including hypertension, osteoarthritis, and hypercholesterolemia. Despite giving consent for the pneumococcal vaccine, there was no record of administration. Similarly, Resident #31, with diagnoses of dementia, depressive disorder, and gastrointestinal hemorrhage, had no documentation of receiving the pneumococcal vaccine, nor was there evidence of refusal. The DNS identified that the responsibility for reviewing and assessing vaccination status, obtaining consents, and ensuring administration within 30 days lies with the infection control nurse. The facility's policies for pneumococcal and influenza vaccinations were not followed, as evidenced by the lack of documentation and administration of vaccines. The DNS acknowledged that the influenza vaccine should have been offered to Resident #12 and Resident #31 during the facility's vaccination clinic. The report highlights a systemic issue in the facility's vaccination program, as the DNS was only made aware of the oversight during a COVID-19 clinic, indicating a lapse in the facility's adherence to its vaccination policies.
Failure to Address Resident's Refusal of Care in Care Plan
Penalty
Summary
The facility failed to ensure that a comprehensive care plan addressed a resident's consistent refusals of care and medication. The resident, who was admitted in October 2024, had diagnoses including vascular dementia with agitation, anxiety disorder, and insomnia. Despite having intact cognition, the resident frequently refused care and medications, particularly Trazodone, which was refused 26 times in December 2024 and 23 times in January 2025. The care plan dated January 3, 2025, did not address these refusals, nor did it include interventions for reapproaching the resident. Interviews with facility staff revealed that the resident was redirectable but often refused care depending on the staff and their mood. The Director of Nursing Services (DNS) and other staff members indicated that refusals should be addressed in the care plan, and the RN Supervisor and APRN should be notified of consistent refusals. However, the facility lacked a specific policy on refusals of care or medications, and the care plan was not updated to reflect the resident's behavior of refusing care, treatments, and medications. The MDS Coordinator acknowledged that the care plan should have included interventions for refusals, such as reapproach strategies. Despite the resident's transition to hospice care, the care plan did not adequately address the resident's refusals, which were documented in nursing notes and the medication administration record. The facility's care planning policy requires that care plans be reviewed and updated to reflect changes in the resident's status, but this was not done in the case of this resident.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent an elopement incident involving Resident #16, who had a history of dementia, poly-osteoarthritis, restlessness, and agitation. The resident was identified as being at risk for elopement, with a physician's order for a wander guard to be checked every shift. Despite these precautions, the resident managed to elope to the courtyard patio without staff noticing, as the door alarm was not responded to in a timely manner. On the day of the incident, Resident #16 was last seen in the dining room and later observed sitting near the nurses' station. The resident then walked towards the dining room, opened a door leading to the courtyard, and exited the building. The nursing supervisor was on the phone and did not notice the resident leaving. The door alarm was activated, but staff did not respond immediately. The resident was eventually found knocking on a window outside and was brought back inside by an LPN who had not heard the alarm. Interviews with staff revealed that the door alarms were functioning, but staff failed to investigate the alarm signals. One nursing aide admitted to hearing the alarm but did not check which door was opened. The facility's policy on elopement and wandering residents emphasized the need for adequate supervision and timely response to alarms, which was not adhered to in this case.
Failure to Follow Hand Hygiene Procedures
Penalty
Summary
The facility failed to ensure proper hand hygiene procedures were followed by staff involved in direct resident contact. During medication administration, an LPN was observed taking a resident's blood pressure and exiting the room without performing hand hygiene. The LPN then prepared and administered medications to the resident without sanitizing hands. The resident had a new complaint of a rash on both arms. The LPN continued to interact with multiple residents, including taking blood pressure and providing care, without performing hand hygiene between tasks or after glove removal. The LPN, who was from an agency but had been working regularly at the facility, admitted to being unfamiliar with the facility's hand hygiene policy. The facility's policy requires hand hygiene to be performed between resident contacts, before and after glove use, and before preparing or handling medications. The policy also specifies that hand hygiene should be performed with an alcohol-based hand rub or by washing with soap and water when hands are visibly soiled. The failure to adhere to these procedures was confirmed through interviews with the LPN and an RN, who reiterated the importance of hand hygiene in preventing infection.
Failure to Administer Ordered Medication Due to Refill and Communication Errors
Penalty
Summary
A deficiency occurred when a resident with diagnoses including epilepsy, dementia, and anxiety did not receive their prescribed Clobazam 10mg for three consecutive days, as ordered by the physician. The medication administration record (MAR) showed that the doses were missed because the medication was not available in the facility, despite a 30-day supply having been delivered and refills remaining. The pharmacy's records incorrectly indicated that no refills were available, while the facility's electronic medical record (EMR) showed otherwise. Multiple staff interviews confirmed that the medication was not administered due to this discrepancy, and the pharmacy was contacted several times without resolution. During the period when the medication was missed, the resident exhibited symptoms including not feeling well, difficulty pronouncing words, and labored breathing with an expiratory wheeze. The advanced practice registered nurse (APRN) and the resident's family were notified, and the resident was sent to the hospital for evaluation. The hospital confirmed that the resident had not received three doses of Clobazam, and laboratory results showed the medication level was within the normal range. The resident was evaluated for a stroke, and the facility did not notify the family about the missed doses until after the hospital evaluation. Interviews with facility staff and the pharmacist revealed confusion and miscommunication regarding the medication refill process, particularly for controlled substances. The facility's policy required medications to be administered as ordered and for discrepancies to be reported and corrected, but this was not followed in this instance. The failure to ensure the medication was available and administered as ordered led to the resident missing three doses and being hospitalized for evaluation.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to ensure the Ombudsman's office was notified of a resident's transfer to the hospital, as required by regulations. Resident #34, who had diagnoses including osteomyelitis, anemia, and osteoarthritis of the knee, was found unresponsive and was subsequently transferred to the emergency room for evaluation. The facility's policy mandates that the Ombudsman be notified of such transfers, but this was not done in this case. The Social Worker, who was responsible for sending the monthly report of transfers and discharges to the Ombudsman's office, was unaware of this responsibility and did not complete the report. The facility's records showed multiple transfers and discharges over several months, but the required notifications were not sent to the Ombudsman. The Administrator acknowledged that the Social Worker was on leave and that he did not have access to the Ombudsman's reporting portal. The Social Worker, who started working at the facility in September 2024, admitted to not being aware of the responsibility to complete the report. This oversight resulted in the Ombudsman not being informed of the transfers and discharges from September 2024 through January 2025, including the emergency transfer of Resident #34.
Deficiencies in Food Labeling and Kitchen Hygiene
Penalty
Summary
The facility failed to adhere to proper food labeling and storage protocols, as well as personal hygiene standards in the kitchen. During an observation, it was noted that bologna in the refrigerator was wrapped in plastic without a label indicating the date it was opened or a discard date. A tray of pasta with meat sauce in the walk-in freezer was found partially uncovered, exposing the food to open air. Additionally, bags of fish squares and yellow cake mix in the freezer and dry storage were not labeled with open or expiration dates. Interviews with supervisors confirmed that these items should have been properly labeled and covered according to facility policy. Furthermore, the facility did not ensure that kitchen staff adhered to personal hygiene standards. A dietary aide was observed preparing food without a beard guard, despite having a full beard. Another supervisor was seen placing food into the steam table without a head covering, only putting on a hat after noticing the surveyor. The facility's policy requires staff to wear hair and beard guards while preparing food, which was not followed in these instances. The dietary manager confirmed that the facility's policy mandates proper labeling of food and the use of hair restraints in the kitchen.
Inaccurate MDS Assessments for Resident Immunizations
Penalty
Summary
The facility failed to ensure accurate encoding of Minimum Data Set (MDS) assessments for five residents, leading to discrepancies in their immunization records. Resident #12, diagnosed with hypertension, osteoarthritis, and hypercholesterolemia, was reported as having received an influenza vaccine and being up-to-date with the pneumococcal vaccine, but records showed no documentation of these vaccinations. Resident #31, with dementia and depressive disorder, was also inaccurately reported as having up-to-date vaccinations, with no evidence of recent pneumococcal or influenza vaccines. Resident #43, who has type 2 diabetes mellitus and peripheral vascular disease, was noted as having an up-to-date pneumococcal vaccine, but records did not support this claim. Similarly, Resident #46, with sepsis and sleep apnea, and Resident #49, with dementia and hypercholesterolemia, were both inaccurately reported as having up-to-date pneumococcal vaccinations, despite lacking documentation of recent vaccinations. Interviews with the MDS Coordinator, LPN #4, revealed that the assessments were not accurately coded, and the clinical records did not contain the necessary information to support the MDS assessments. The Director of Nursing Services (DNS) acknowledged signing off on the assessments but emphasized that it was the MDS Coordinator's responsibility to ensure accuracy. The facility's policy requires comprehensive and accurate assessments, with each section attested to by the responsible staff member.
Improper Resident Transfers Result in Injuries
Penalty
Summary
The facility failed to ensure that Resident #1 was transferred according to the plan of care, resulting in an injury. Resident #1, who had diagnoses including osteoarthritis and required partial/moderate assistance with transfers, was supposed to be transferred with the assistance of one staff member using a rolling walker and gait belt. However, on 12/28/2024, NA #1 did not use the rolling walker during the transfer from a wheelchair to a bed, leading to Resident #1's leg grazing the metal part of the wheelchair and sustaining a laceration that required hospital treatment and sutures. NA #1 admitted to not being aware of the need for a walker and did not consult the care card for transfer instructions. Resident #2, diagnosed with Alzheimer's disease and requiring substantial/maximal assistance with transfers, also experienced an improper transfer. On 9/2/2023, two NAs were involved in transferring Resident #2 without using the required rolling walker, as per the care plan. During the transfer, Resident #2's leg got caught on the bed's side rail, resulting in a skin cut that required stitches. The NAs involved did not provide physical assistance during the transfer, and the walker was not listed on the care card, leading to the improper execution of the transfer. Both incidents highlight the facility's failure to adhere to the established care plans and transfer protocols, resulting in injuries to the residents. The facility's documentation and interviews with staff confirmed that the proper use of assistive devices, such as rolling walkers, was not followed, contributing to the accidents. The Director of Nursing and Administrator acknowledged that the injuries could have been prevented if the care plans had been followed correctly.
Failure to Provide Orientation to Agency Staff
Penalty
Summary
The facility failed to ensure that agency nursing assistants (NAs) received proper orientation, including emergency procedures and abuse training, before commencing work. This deficiency was identified through a review of clinical records, facility documentation, and agency staff files for three agency NAs. Specifically, the files for Agency NA #1, #2, and #3 lacked documentation of a general orientation that included facility emergency procedures and abuse training. These NAs worked shifts at the facility without the required orientation, which is a violation of the facility's orientation policy. During an interview and review of facility documentation and policies, the Administrator confirmed that the medical records/scheduler is responsible for orienting agency staff, which includes providing a tour and training on emergency procedures and abuse. However, the facility did not have documentation to confirm that this orientation was provided to the three agency NAs in question. The Administrator was unable to explain the absence of this documentation, indicating a lapse in the facility's adherence to its own orientation policy, which mandates that all new staff and contractual service providers complete a general orientation before having formal contact with residents.
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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 New Britain
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Jerome Home | 1 mi | ★★★★★ | 0 | 0 |
| Grandview Rehabilitation And Healthcare Center | 1.1 mi | — | 14 | 1 |
| Apple Rehab Farmington Valley | 2.9 mi | ★★★★★ | 1 | 0 |
| Autumn Lake Healthcare At New Britain | 2.9 mi | ★★★★★ | 0 | 0 |
| Civita Care Center At Newington | 3.1 mi | ★★★★★ | 42 | 1 |
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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.