Apple Rehab West Haven was fined $6,960 after a resident reported being sexually assaulted by a visitor.

On Oct. 2, 2018, a licensed practical nurse (LPN) saw the resident and a male visitor naked in the resident’s room, and the resident told the LPN they’d just had sex, according to DPH. The LPN asked the resident several times if she was alright and the resident replied that the male was her boyfriend. The LPN reported the incident to the director of nursing and asked if the resident’s guardian should be notified, but the director said there was nothing they could do if the sex was consensual.

The following morning, the resident—exhibiting injuries on the neck, back and right leg—reported to a RN that she was sexually assaulted, the citation said. The resident was taken to a hospital and a rape kit tested positive, the citation said.

DPH said a nurse aide had failed to find out who the visitor was before showing him to the resident’s room, and the resident, who suffered from a developmental disorder, was unable to make an informed decision to consent to sexual relations.

Regalcare at Southport was fined $10,000 for several violations. A resident with dementia fell six times between Oct. 27 and Nov. 28, 2018, suffering foot, ankle and nasal fractures during various falls, DPH said. Following each fall, staff failed to implement appropriate interventions and failed to ensure the resident took precautions.

On Nov. 27, 2018, an LPN was seen cleaning a glucometer with an alcohol wipe after testing a resident’s blood sugar. The LPN knew the device should be cleaned with a manufacturer-approved wipe. But the LPN used the alcohol wipe because the approved wipe made the LPN nauseous, DPH said. An investigation found the LPN tested residents’ blood sugar approximately 30 times during that month without cleaning it properly.

Maefair Health Care Center in Trumbull was fined $6,960 after a resident suffered a broken right femur and needed surgery.

The resident, who required help from two staff and a Hoyer lift for transfers, tried to self-transfer on Sept. 3, 2019, after a nurse aide left to look for a lift and help. According to DPH, the aide should have used a call button to summon help instead of leaving the resident unattended.

“Maefair Health Care Center takes the care of its patients and residents very seriously,” said Tim Brown, spokesman for parent company Athena Health Care Systems. “We are confident that the issue raised in the report was isolated and not consistent with the care and customer service at our center. The staff member involved with this incident was re-educated on our policies regarding two-person assist care and the importance of following policies.”

Portland Care and Rehabilitation Centre Inc. was fined $9,060 after a resident choked on a pierogi while eating on May 16, 2019, according to DPH. The resident was taken to a hospital and treated for an onset of atrial fibrillation “perhaps incited by the stressful event of choking,” the citation said.

The resident, who was on a soft diet, required food cut into dime-sized pieces and supervised meals. But on that day, according to the citation, the resident was served an entire pierogi and tried to eat it whole.

New London Sub-Acute and Nursing in Waterford was fined $6,960 after a resident received the wrong medications and became unresponsive.

The resident was found unresponsive on Oct. 10, 2019, after an LPN administered the resident’s roommate’s medications to the resident by mistake, including the sedative Ativan, antidepressant Lexapro, and antipsychotic Clozapine, according to DPH. Emergency medical personnel took the resident to a hospital, where the resident was intubated and subsequently discharged Oct. 27 to a long-term care facility. The LPN who administered the medication was fired.

Apple Rehab Rocky Hill was fined $4,800 for three incidents in which residents left the facility.

On Oct. 12, 2019, a resident in a locked dementia unit left the building following an LPN who went outside to the parking lot. Staff returned the resident to the facility without injury.

On Nov. 15, 2019, a resident wearing a WanderGuard bracelet was found outside. The resident left through an unlocked door, and the alarm failed to sound.

On Sept. 22, 2019, a resident climbed out a window and fell, suffering a knee injury. According to the citation, the resident removed a window from its frame the day prior.

Officials at Apple Rehab West Haven, Regalcare at Southport, Portland Care and Rehabilitation Centre, New London Sub-Acute and Nursing, and Apple Rehab Rocky Hill didn’t return calls seeking comment.

On Aug. 10, Gardner Heights Health Care Center in Shelton was fined $3,000 in connection with a resident who died after being outside in a garden for more than three hours on July 27 in 95-degree weather, according to the state Department of Public Health (DPH) citation.

The resident, who frequently sat in the garden, was in good condition at 2:30 p.m. that day but at 5 p.m., was found to be unresponsive and died about 40 minutes later, the citation said. A review of video at the home could not substantiate that the resident had been checked by staff between 2:30 and 5 p.m., the citation said.

Ann Collette, a spokeswoman for Apple Rehab, which owns Gardner Heights, said the company cares for more than 10,000 patients a year and takes all incidents seriously and investigates them fully.

“All patients who enjoy independent activities are evaluated and care [is] planned for accordingly,” she said. “We are deeply saddened by the loss of our patient and have closely investigated the incident.”

On Aug. 5, another Apple home, Watrous Nursing Center in Madison, was fined $2,130 in connection with a nurse’s aide who held down a resident’s hands on June 6 when the resident was combative, the citation said.

The resident, who reported being afraid of the aide, was bruised on the hands and wrists, the citation said. The aide was fired after the physical abuse was substantiated, the citation said.

Collette said Apple maintains a zero-tolerance policy for abuse.

“The care, safety and preservation of dignity are our primary focus,” she said. “All staff [at Watrous] received one-to-one education regarding our abuse policy and were required to sign off that they understood the policy and the ramifications for failure to comply.”

A third Apple home, Orchard Grove Specialty Care Center in the Uncasville section of Montville, was fined $1,740 on June 23 in connection with a resident who slid off a shower chair Jan. 13 and broke a hip.

DPH’s citation said an official at the home concluded that a nurse’s aide should have used a shower chair with foot supports and a seat belt.

Collette said all of the Apple homes have strict fall prevention programs.

“Policies and practices regarding fall prevention were reviewed [at Orchard Grove] and in-service education was administered to staff on all shifts,” she said.

On July 8, Talmadge Park Health Care of East Haven was fined $2,230 in connection with a resident who was cut on the head during a fall from a mechanical lift July 24, 2015, DPH’s citation said.

The home’s investigation found that two nurse’s aides should not have had a bed in its lowest position when moving the resident onto the bed from a wheelchair, the citation said. The aides also should have reported to a nurse that the resident was restless before the transfer was attempted, the citation said. The aides were retrained on making transfers with a lift.

The home was also cited in connection with a resident who was hospitalized after being fed 800 milliliters of nutrients through a tube instead of the 150 milliliters that a doctor had ordered, the citation said. The home found that a licensed practical nurse had connected the feeding tube incorrectly, the citation said.

Administrator Ted Vinci said the home has provided additional training for its staff. He added, “The facility strives to provide quality care to its residents and has taken appropriate disciplinary actions.”

RegalCare Prospect was fined $1,530 on July 18 in connection with a resident who fell from a wheelchair and broke a hip on June 4, the citation said.

Staff at the home failed to document that an assessment had been done of the resident before footrests were removed from the resident’s wheelchair, the citation said.

RegalCare’s administrator could not be reached for comment.

The state Department of Public Health (DPH) fined Madison House in Madison a total of $3,640 in separate citations on Feb. 5 and March 3. It was fined $1,940 in connection with a nurse’s aide who was verbally abusive to a resident on Aug. 8. A registered nurse heard the aide swearing and being disrespectful but did not report the incident, the citation said. The aide was fired, the citation said.

That citation also involved a registered nurse who failed to enter a new medication order in the home’s computer system. A resident was given a higher dose than ordered for 16 days and had a seizure on April 7, the citation said.

In the March 3 citation, the home was fined $1,740 in connection with a resident who developed a deep tissue injury that worsened between November 2015 and February 2016, the citation said.

Jeanne Moore, a spokesperson for Genesis Health Care, which owns Madison House, said the home took action when DPH found deficiencies.

“We worked with the state survey agency and very quickly regained regulatory compliance,” she said. “Madison House is committed to providing quality care to its patients and residents.”

On Feb. 8, Westfield Care & Rehabilitation of Meriden was fined $1,940 in connection with a resident who broke two leg bones in May 2015, DPH’s citation said. The nursing home found no evidence that the resident had been abused, but it could not determine the cause of the fractures, the citation said.

The home was also cited in connection with a resident who fell in June 2015 and again in November while leaning forward on a toilet, the citation said. The resident was not hurt the first time but sustained a cut on the head in the second fall. During the second fall, a nurse’s aide had briefly turned away from the resident when the person fell, the citation said.

Apple Rehab owns Westfield, and its spokesperson, Ann Collette, released a statement: “All policies and procedures regarding patient safety as well as policies regarding safe transfers and the prevention of falls is reviewed on an ongoing basis and competencies maintained.”

Greensprings Healthcare & Rehabilitation Center in East Hartford was fined $1,630 on Jan. 25 in connection with a resident who fell July 24 and sustained bruises on the chest, the citation said.

The home determined that the resident had fallen in a shower room and was lifted by a nurse’s aide and a licensed practical nurse without the required use of a gait belt.

The home was also cited in connection with a resident leaving the facility and reaching a plaza across the street on Dec. 12. An employee of the home said a registered nurse should not have let the person go outside, and records failed to document that the resident frequently removed a Wanderguard bracelet, the citation said.

On Feb. 10, Wadsworth Glen Healthcare & Rehabilitation Center of Middletown was fined $1,740 in connection with a resident who broke an arm during a fall Aug. 22 when standing up unassisted from a shower chair, the citation said.

A nurse’s aide admitted turning away from the resident and failing to lock the shower chair to keep it from moving, the citation said. The home is owned by Athena Health Care Systems.

DPH fined another Athena home, Shady Knoll Health Center in Seymour, $1,635 on Feb. 25 in connection with a resident who sustained a large cut on the leg when one nurse’s aide, instead of two, moved the person to a bathroom, the citation said. The home’s policy called for newly admitted residents to be moved by two aides until being evaluated by the physical therapy department, the citation said.

Administrators at Greensprings, Wadsworth Glen and Shady Knoll could not be reached for comment.

On Dec. 8, DPH fined Walnut Hill Care Center in New Britain $1,440 in connection with a resident with severe pain from sickle cell disease who was told there was no pain medication in the facility and who had to wait two hours to be taken to a hospital, DPH’s citation of the Sept. 18 incident said.

An investigation concluded that morphine was available and a registered nurse was aware of this and should have gotten the medication for the resident, the citation said.

Administrator Janet Shahen said the home was recently bought and is now called Grandview Rehabilitation Health Care Center. She released the following statement: “We disagree with some of the findings; however, we strive to ensure a top level of quality of care is provided all of our residents and patients.”

Bridgeport Manor was fined $1,230 on Jan. 20 in connection with a resident who fell and was cut on the head Sept. 28. DPH’s citation said a nurse’s aide was fired in connection with the incident for not using a lift as called for in the resident’s plan of care.

The home was also cited in connection with a resident who broke two leg bones on Nov. 6 when the resident’s boot caught on a wheelchair during a transfer into bed, the citation stated. Nurse’s aides were retrained to be more careful when moving residents into and out of a lift, the citation said.

Administrator Carla Ward said the home self-reported the incident to DPH.

“The well-being of our residents is our greatest concern,” she said. “We work hard to keep our residents safe from accidents, but unfortunately, accidents do occur on occasion. We have worked with the DPH to try and improve our practices and ensure the quality of the care we provide to our residents.”

The resident lived at Apple Rehab Saybrook, and a medical examiner ruled the death an accident, the DPH citation dated Tuesday said.

On July 31, the resident was found on the floor, yelling, with a bruise on a wrist.

On Aug. 4, the resident was seen by a doctor for abdominal pain and a temperature of 100 degrees. A day later, the resident complained of discomfort in the hip and abdomen and had a bruised groin, the citation said. On Aug. 6, a doctor ordered a hip X-ray, which was normal. On Aug. 8, the resident was found sitting on the floor with no injuries.

Two days later, the resident was transferred to an emergency room and then a second hospital and was diagnosed with several fractured ribs and a fractured pelvis, the citation said. The person died there, and the cause of death was complications from a blunt injury to the torso with pelvic fractures, the citation said.

DPH found that a registered nurse failed to document that interventions were in place to prevent further falls after the resident had fallen July 31, the citation said. The nurse also failed to note that the resident repeatedly attempted to climb out of bed.

Ann Collette, an Apple Rehab spokeswoman, said the home’s staff was re-trained after the incident. She said, “Patient safety and fall prevention policies and protocols [were] reviewed with all staff and remains part of our ongoing staff education and quality improvement initiatives.”

The state also found in September that the water temperature in four bathrooms at the home was too high, at 134 degrees.

In a separate citation on Oct. 29, the same home was fined $210 in connection with a resident who was burned on the thighs March 24 when spilling hot soup.

DPH found that a licensed practical nurse failed to notify a shift supervisor or doctor of the incident and failed to document it. The same nurse did not monitor the injury for seven days, and the home did not obtain a treatment order from a doctor for seven days, the DPH citation said.

Another Apple Rehab nursing home, Laurel Woods in East Haven, was fined $1,440 on Oct. 15 in connection with three residents who developed pressure ulcers.

In one case, DPH found that four of five weekly body audits of a resident were not completed between July and September, the citation said.

In another case, a nurse’s aide forgot that a resident was not supposed to wear shoes and put sneakers on the person, the citation said.

On Sept. 14, DPH found that the water temperature in one room was 236 degrees. The problem was fixed within two days, the citation said.

Collette said the homes have taken action in response to the citations.

“All policies and procedures regarding patient safety as well as policies regarding the prevention of skin breakdown and wound care have been reviewed with staff,’’ she said.

“Water temperatures in all centers have been tested and are within normal limits and meet code.

Other recent DPH citations include:

The Springs at Watermark East Hill in Southbury was fined $1,370 on Aug. 26 in connection with a resident who developed a pressure blister on a heel. A licensed practical nurse was observed cleaning the person’s heel without washing hands between different steps of the treatment and without sanitizing scissors, DPH found.

The nursing home was also cited after a resident fell June 12 and broke a hip. DPH concluded that a required investigation of the fall was not completed and that the resident’s care plan was revised after the resident was found on the floor five times before June 12. Administrator Vitaly Polikoff could not be reached for comment.

On Feb. 17, Rosegarden Health & Rehabilitation Center in Waterbury was fined $1,230 in connection with a resident who sustained second-degree burns on an arm, hand and foot Jan. 26 when boiling water in a microwave.

After the burns, the kitchen was locked. DPH found that although the resident had a history of not following safety rules, the home failed to supervise residents or provide devices that would have prevented the second-degree burns.

Administrator Veronica Cretella declined to comment.

On Oct. 29, Pierce Memorial Baptist Home in Brooklyn, Connecticut was fined $1,095 in connection with a resident who developed a pressure sore on the heel Oct. 8. A registered nurse and the director of nursing services determined that interventions should have been in place to prevent skin breakdown when the person was admitted on Oct. 3.

In the case of another resident who developed a pressure sore, the director of nursing services was unable to find documentation that the wound had been re-evaluated or treated between Sept. 8 and Sept. 22, the DPH citation said.

Laura Crosetti, the home’s new administrator, said Pierce has made improvements since the incidents.

“Following the most recent inspection, we have initiated improved protocols related to skin care for our residents to ensure the best possible quality of care,” she said. “The residents involved are doing well following the attentive care received, and Pierce plans to continue to ensure our knowledgeable staff have the necessary resources to provide our patients with the state-of-the-art care they deserve.”

The residents who died were at Bridgeport Manor and Arden House Rehabilitation & Nursing Center in Hamden.

On Nov. 24, Bridgeport Manor was fined $1,020 in connection with the Oct. 6 death of a resident whose tracheostomy tube was dislodged.

DPH records say that the resident, who had been admitted to the home Sept. 21 with throat cancer, was spotted on the floor with the tube in her hands. DPH found that a nurse failed to call a “stat” emergency for 20 minutes. It also found that a nurse’s aide failed to stay with the resident twice and that a registered nurse supervisor failed to call 911 quickly when the resident was in distress.

Nurses tried to reinsert the tracheostomy tube and when the resident’s pulse stopped, they tried CPR. A half hour after the resident was found, the supervisor called a doctor, who directed the nurse to call 911, DPH found. The resident was sent to a hospital and died there of cardiac arrest, DPH records show.

In response to the incident, the home re-trained its clinic staff in emergency procedures. At the time of the resident’s death, a niece told WTNH that the family was left with many questions about the death. The niece could not be reached for comment about the fine.

The home’s administrator also could not be reached for comment.

On Dec. 15, Arden House was fined $1,650 in connection with a resident who died of bleeding on the brain on Aug. 28.

The resident, who had dementia, was found on the floor of the home on Aug. 26, but had normal neurological signs, according to records. Throughout that night and into the next morning, the resident refused six times to have his or her neurological signs checked, records show. Later that morning, the resident could not be woken up and was sent to a hospital, where he or she was diagnosed with an acute subdural hematoma, DPH found.

The home found that a licensed practical nurse should have notified a registered nurse that the person was unresponsive, records show.

Arden House was also cited in connection with the case of a resident who broke a hip when he or she fell out of bed on Nov. 29, records show. DPH found that the resident’s records failed to reflect that he or she was supposed to wear “gripper socks” to prevent falls. The resident did not have socks on when the fall took place, DPH found.

Arden House was also cited in connection with a resident who left the facility without permission on Nov. 19. A search was conducted and the person was found safe, records show. The citation said Arden House failed to ensure the person’s whereabouts for most of an evening shift until he or she was discovered missing at 10 p.m., records show.

The home was also cited for failing to wash a resident or change his or her clothes on Oct. 13, records show.

Jeanne Moore, a spokesperson for Genesis Healthcare, which owns Arden House, said the home worked with DPH to regain compliance with all regulations.

Another Genesis home, Salmon Brook Center in Glastonbury, was fined $1,420 on Sept. 24 in connection with a resident who developed a pressure ulcer. DPH found that records failed to reflect that the resident was treated for the pressure ulcer from June 12 through June 30. It also found that the home had delayed in getting a doctor’s order to treat the sore.

Following the citation and fine, Salmon Brook worked with DPH to regain regulatory compliance, Moore said.

On Nov. 28, Cherry Brook Health Care Center in Canton was fined $1,090 in connection with a resident who broke a hip in October.

The resident, who had been deemed at risk for falls, was found on the floor in a bathroom with a walker nearby on Oct. 18, DPH’s citation states. The next day, the resident complained of substantial leg pain and had bruises from the knee to the hip. The resident was diagnosed with the hip fracture and transferred to a hospital.

Before the fall, the resident had been seen about nine times walking alone, and a review of the home’s records found that the home failed to intervene to reduce the person’s risk for falling, records show.

Jacob S. Bompastore, Cherry Brook’s administrator, said the home takes very seriously the obligation to provide quality service.

“As a result of this incident, we have performed an internal review of our processes and will continue to look for ways to improve the care we provide to all our residents,” he said.

Chesterfields Health Care Center in Chester was fined $1,090 on Nov. 24 in connection with a resident whose leg was broken when he or she was being transferred from a bed to a toilet without the use of a “gait belt,” a device used to help move people who cannot walk or have trouble with balance.

On May 8, an aide was trying to move the resident, but could not bear the person’s weight and lowered the person to the floor. The aide then received help lifting the person from another aide, and neither notified nurses about the fall, records show. DPH records show that both aides were fired.

Ann Collette, a spokeswoman for Apple Rehab, which owns Chesterfields, confirmed that the aides no longer work at the home. She added that the nursing staff has been re-trained on the importance of following the plan of care for transfers, including using gait belts and obtaining assistance from other staff members.

On Nov. 17, Apple Rehab Coccomo in Meriden was fined $1,160 in connection with a resident who sustained a deep cut on the leg on April 17 while being transferred to a wheelchair to a bed, records show.

The home found that the resident was probably cut on a metal latch on the chair and has since been using a padded chair for the resident, DPH’s citation said.

Collette said the nursing staff was trained on the importance of checking a resident’s legs before transferring the person from a wheelchair to a bed in order to prevent injuries.

On Nov. 3, West Hartford Health & Rehabilitation Center was fined $1,090 in connection with the cases of a resident who developed pressure sores in June. In its citation of the home, DPH concluded that the home failed to ensure that timely measures were taken to prevent or treat such sores.

Theresa Sanderson, administrator of the home, said the home disagreed with some of the findings, but privacy laws prevent her from commenting about a specific resident.

“West Hartford Health & Rehabilitation Center is committed to providing quality care and services to all of our residents,’’ she said.

Other cases involved residents who developed pressure sores, one who sustained a cut on the forehead during a fall and another who left a home and wandered across the street.

The Kent Ltd. of Kent, which is owned by Apple Rehab, was fined $1,195 on April 4 in connection with two residents for whom CPR was delayed or stopped without a doctor’s order, records show.

On May 5, 2013, there was a delay of nine minutes in starting CPR on an 88-year-old resident while a supervisor was notified and while equipment was gathered, records show. The former director of nursing services said he or she got a call from a staff member saying that a doctor had ordered the CPR to be stopped, but the doctor later said he or she would not have given such an order over the phone, records show.

The resident died, William Gerrish, DPH’s spokesman, said.

On Nov. 22, a 73-year-old Kent resident died in a case in which CPR was stopped without a physician’s order, records show.

Ann Collette, an Apple spokeswoman, said both residents were hospitalized and that neither died at The Kent. She said the facility is continuing to educate its staff and to review its procedures by holding mock “code” drills.

“Kent nursing staff has [been] given extensive education on conducting codes, ensuring nurses know how to react [in a] timely [way] in emergency situations,” she said.

The home was also cited in connection with a resident soiling him or herself on Feb. 25 because gaps in communication led aides who were busy with other duties to fail to assist the resident, records show.

Brightview Nursing and Retirement Center in Avon, another Apple Rehab home, was fined $1,510 on April 23 in connection with a resident who became dehydrated after a delay in treatment, DPH records show.

DPH records show there was not an assessment of the resident’s hydration levels from Jan. 1 to Jan. 8, and that a doctor’s order for lab tests was made on Jan. 3, but not carried out until Jan. 7.

Collette said the citation involved a resident who received IV fluids at Brightview and was hospitalized for an unrelated medical condition. A dehydration assessment was completed and the doctor was notified 48 hours later, she said. The resident recovered, she said.

“The citation was the result of an oversight on [the] part of a nurse and remains an isolated incident,’’ said Collette, who added that all of the nurses were trained in the timely reporting of changes in a resident’s condition.

Orange Health Care Center was fined $1,420 on March 20 in connection with the sexual assault of one resident by another, records show.

A resident with schizophrenia who had already been found to have inappropriately touched a staff member was found on top of another resident on the floor by the second resident’s bed on Dec. 16, records show. The resident who was assaulted was hospitalized and treated for bruises, records show.

On the day of the assault, the staff failed to make its required checks of the second resident every 15 minutes, DPH found.

Orange Health Care’s administrator could not be reached for comment.

Cassena Care of Norwalk was fined $1,370 on March 24 in connection with lapses in care of two residents.

In February, a resident was hospitalized for weakness and abdominal pain. DPH records show the resident had bowel problems that were not reported to a nurse before the hospitalization occurred.

Also in February, a resident with a pressure sore did not receive morphine sulfate for three days despite a doctor’s order that the resident should receive the medication, records show.

A Cassena official declined to comment.

Highview Health Care Center of Middletown, a third Apple Rehab home, was fined $1,160 on April 28 in connection with the cases of three residents who developed pressure sores.

A resident who was recovering from a hip fracture in February developed a sore on a heel, and the home failed to document that the heels were properly elevated, records show.

In the case of another resident who developed a pressure sore on a heel in February, a doctor said the sores developed because the heels were not properly elevated, records show. DPH records show the facility was aware it had a problem with the prevention of pressure sores and not elevating heels.

In March, the director of nursing services signed a weekly pressure documentation without having looked at another resident’s pressure sore because of other duties, DPH records show.

Collette, the Apple spokeswoman, said the citation was related to an issue of ensuring that residents who are at risk for skin breakdown are properly “off-loaded.”  That involves positioning the resident so as to remove pressure from the heels, she said. Highview has updated its care plans and educated its staff on the importance of off-loading, she said.

Ingraham Manor, which is owned by Bristol Hospital, was fined $360 on March 31 in connection with a resident with dementia who left the home on Feb. 25 and walked across the street.

The person was located within five minutes of an alarm sounding. DPH said the home’s records failed to document that the person was at risk for leaving the home and staff members reported that they thought the resident could not walk that far unassisted.

Chris Boyle, a Bristol Hospital spokesman, said the home has since strengthened its procedures for identifying residents who are at risk for “elopement.”

“We have enhanced our security measures to better monitor the movements of our residents, and we also had a full re-survey from the Department of Public Health which indicated full compliance,’’ Boyle said.

Pope John Paul II Center in Danbury was fined $1,090 on March 25 in connection with a resident who fell from a shower chair on June 4, 2013 and sustained a cut on the forehead that required 14 stitches to close, records show.

The resident leaned forward, loosening a Velcro belt on the chair, while a nurse’s aide was reaching for a washcloth, records show. The home subsequently changed the resident’s care plan to require two aides to assist the resident in the shower.

The home’s administrator could not be reached for comment.

On March 13, 2014, Ledge Crest Health Care Center in the Kensington section of Berlin was fined $780 in connection with a March 2013 incident involving the resident who died.

Records show the resident had chronic constipation and was supposed to be monitored for abdominal discomfort and vomiting. Despite the vomiting and low blood pressure on March 4, 2013, a nurse’s note failed to say whether a doctor had been notified about the change in the resident’s condition and failed to show whether additional blood pressure checks had been done, DPH records said.

State records report that six hours later, the resident was admitted to a hospital for gastrointestinal bleeding and sepsis, a life-threatening inflammation prompted by an infection. The nursing home resident died,  William Gerrish, DPH’s spokesman, said.

Ann Collette, a spokeswoman for Apple Rehab, which owns Ledge Crest, said a doctor was in the center the day the resident was transferred to the hospital. The nurse who failed to document the doctor notification and all other licensed staff members have been educated about the importance of documenting such notifications when a resident’s condition changes, she said.

Westport Health Care Center was fined $1,160 in an amended citation on March 4 in connection with the case of a resident with dementia who had two falls, resulting in a broken arm and a cut scalp, DPH records show.

The resident had fallen and broken an arm after being left unattended in a bathroom, a nursing supervisor said told state officials in December 2013. The resident, who often refused to wear a protective helmet, had also been found bleeding on the floor on Jan. 31, 2013, records show. The resident was transferred to an acute care facility and was diagnosed with seizures and a cut on the scalp, records show.

DPH found that the center lacked documentation to show that interventions were in place to prevent the resident from sustaining a head injury.  An administrator at the Westport home declined to comment.

On March 24, Aaron Manor Nursing & Rehabilitation Center in Chester was fined $1,090 in connection with two incidents, including one in which a resident with dementia repeatedly touched and kissed female residents, records show.

Several times between April and August 2013, the resident was found to have rubbed the shoulders, chest, neck, leg or backside of the residents, records show. The resident also kissed one female resident on the cheek and another on the mouth, records show.

Each time, the home intervened by monitoring the resident every 15 minutes or ordering psychiatric evaluations or changes in medication, including administering drugs to reduce the resident’s testosterone and sexual function, records show. An evaluation determined the resident’s behavior was not sexual in nature and the person was not a danger to others, records show.

On Aug. 24, in the last incident, the resident tried to unbutton a woman’s shirt, records show. DPH concluded that while the home intervened after each incident, the interventions failed to ensure that the resident was monitored or adequately supervised to prevent inappropriate behavior.

The second incident at Aaron Manor occurred April 29 when a resident with dementia was found slumped in a wheelchair and bleeding from a large cut on the leg, records show. An investigation found that the chair’s leg rest was unlatched and the resident was cut when he or she slid out of the chair, records show. The resident received a new wheelchair, and aides were trained to be sure that leg rests were locked in place, records show.

Aaron Manor officials could not be reached for comment.

On March 4, Noble Horizons of Salisbury was fined $220 in connection with a Feb. 13 incident in which a nurse’s aide verbally abused a resident and left the resident alone and naked in a shower, records show. The resident, who has Alzheimer’s disease, was not injured but was “very weepy and upset,” records show. The home found that verbal abuse and neglect had taken place and fired the aide, records show.

Noble Horizons officials could not be reached for comment.

According to the DPH, the resident was diagnosed with mental retardation, dementia, schizophrenia, diabetes and dysphagia and “required extensive assistance while eating’’ and “direct supervision during meals.’’  A visitor was given permission by a licensed practical nurse to give the resident two regular-sized marshmallows to eat.  The patient became unresponsive, and cardiopulmonary resuscitation was initiated.

The resident was transported to the hospital and died two days later.  The DPH citation notes that the nurse was not familiar with the diet restrictions for the patient.  The facility’s vice president of clinical services said “the expectation would be that the nurse would always refer to the physician’s orders in the clinical record.’’  The nurse was fired for failing to follow the doctor’s orders or the care plan, according to the citation. The facility was fined $650.

Other action by the state includes:

• The Apple Rehabilitation West Haven was cited after the state found that 15 patients who were being treated for various illnesses, including congestive heart failure, hypertension, depression, dementia, gastro-esophageal reflux disease and multiple sclerosis were not being given the correct daily dosage of medications.

Eleven of the residents did not receive the proper drug dosage for a year, according to the citation, which followed a February inspection.  In fining the facility $600, the state found that while each resident did not receive medication as prescribed, ‘’there were no identified adverse outcomes.”

• The Masonic Health Center of Wallingford was fined $815 after a state inspection found that two residents were injured while being transported in wheelchairs, and two other residents suffered sudden weight losses.  According to the citation, a nurse’s aide used a wheelchair without footrests to transport a patient who was identified as needing assistance in moving. The patient suffered an ankle injury when his or her foot was caught under the wheelchair.  The center’s director of nursing indicated that the nurse’s aide should have applied footrests to the chair before moving the patient. In the second incident, a patient fell out of a wheelchair and was injured while being transported down a hallway by a nurse’s aide.

The inspection also found that one resident had lost 17 pounds in 10 days, and a second patient lost 7 pounds in about a month.

• New London Rehabilitation And Care of Waterford was fined $510 after a resident was injured while being moved with a Hoyer lift. In addition, the state cited the facility for not properly monitoring the patient’s injury.

• Apple Rehabilitation Laurel Woods of East Haven was fined $510 when a patient was injured during a transfer in the bathroom.  A doctor’s order indicated that the patient should be assisted by two people, not one.

The DPH has fined the Aurora Senior Living of Cromwell $615 for deficits in care that led to the hospitalization of a cognitively-impaired resident in November. A care plan directed the nursing home’s staff to monitor the resident’s weight weekly and to ensure that he or she eat at least 75 percent of meals, a state inspection report says. But after the resident’s weight dropped 13 percent in four months, a dietician’s recommendations to improve food intake were not promptly implemented.

Instead, the resident’s weight continued to drop—down to 77 lbs. in November—and the resident refused to eat most of the time, according to the report. On Nov. 25, the patient was taken to the hospital and treated for dehydration, sepsis, pneumonia and other ailments.

Other nursing homes cited by the state include:

• The West River Health Care Center of Milford faces a $600 fine for five instances of inadequate care, including administering the wrong medication to a resident with congestive heart failure and failing to properly care for another patient’s pressure sores.

Three of the incidents involved the late delivery of medications from the pharmacy. On another occasion, a resident suffering from congestive heart failure was mistakenly given insulin and 14 other medications that were intended for a different patient, the state report says. The nurse who administered the medications realized the error, and the resident was taken to the hospital for evaluation.

The nursing home also was cited for failing to properly care for a resident with pressure ulcers who was incontinent. Nursing staff did not check on the patient every two hours, as directed, and did not apply protective dressing to the sores, the inspection report says.

• Crestfield Rehabilitation Center in Manchester faces a $615 fine for two incidents in which residents were injured because of care lapses. One of the residents suffered a head laceration from falling against a headboard when a nurse’s aide was attempting to get him or her into bed. The resident’s care plan specified that two aides were needed to move the resident. Two months later, the resident fell again, this time cutting his or her head on a nightstand. Only one aide was assisting the resident at the time, a state report says. In a second case cited by the DPH, a resident at high risk for falling slipped off a shower chair and suffered a broken hip, after an aide had removed a seatbelt from the chair.

•The Bethel Health Care Center, of Bethel, faces a $605 fine for two incidents in which residents were injured. In one instance, a resident recovering from a hip replacement sustained a muscle tear during physical therapy, a state report says. Another resident who was supposed to be supervised because of the risk of falling and fainting slipped and fell in the bathroom while unattended and was injured, the report says.

• Apple Rehab Coccomo of Meriden faces a $580 fine from for an incident in which a nursing assistant dropped a wheelchair leg rest on a resident’s leg, causing a laceration that required 10 sutures. After the incident, the assistant was re-trained in properly attaching leg rests, a state report says.

• The Mansfield Center for Nursing and Rehabilitation in Storrs faces a $510 fine for an incident in which a resident was found with multiple bruises that were not promptly addressed.