Noble Horizons in Salisbury was fined $6,660 for incidents related to elopement risks.

On Sept. 23, 2018, a resident with dementia left the facility when a WanderGuard sensor malfunctioned. A driver in a pickup truck found the resident walking down the facility’s driveway. A registered nurse entering the driveway spotted the resident in the truck and returned the resident to the facility, the citation said.

The resident left through a door that should have locked when a resident wearing the WanderGuard approached the door, according to DPH. Also, the resident should have been reassessed for elopement risk following the incident, but documents did not show that was done.

Separately, documentation from April 1 through Sept. 30, 2018, did not show that another resident’s WanderGuard was monitored for proper placement or function, according to the citation.

Also, the facility failed to conduct weekly checks of all doors equipped with wander alert devices, such as alarms, to ensure that they were working properly, the citation said. A staff member responsible for the checks said that he couldn’t remember the last time he did checks and indicated that it had been “quite some time.”

St. Joseph’s Living Center in Windham was fined $6,000 after a licensed practical nurse (LPN) was seen improperly cleaning a glucometer.

On Sept. 27, 2018, the LPN cleaned a glucometer with a sanitizing wipe, and had done so after each test of several residents’ blood sugar. According the citation, the glucometer’s manufacturer said a different type of wipe is the only kind that should be used on the device. The director of nursing services didn’t know the wipes being used by staff weren’t the recommended wipes, according to DPH.

“St. Joseph Living Center practices the highest standards of infection control. Although a CDC-approved Sani-wipe was used to disinfect blood-borne pathogens, the manufacturer of the glucometer recommended a different Sani-wipe,” said Ginny Person, St. Joseph’s administrator. “The facility responded immediately and was put back into compliance by DPH.”

Woodlake at Tolland Nursing and Rehabilitation Center was fined $3,720 after a resident fell from a bed to the floor while receiving incontinence care.

On April 7, 2018, a nurse aide rolled the resident onto the left side and the resident’s feet went over the edge of the bed. According to the citation, the aide tried to stop the resident from falling but couldn’t.

The resident, who was identified as a high risk for falls, suffered acute blunt knee trauma and a femoral fracture, and was sent to a hospital. It was unclear whether one or two staff should have been helping with bed mobility, according to DPH, and staff weren’t sure whether there was a physician’s order in place regarding the number of staff required.

Advanced Center for Nursing and Rehabilitation in New Haven was fined $3,060 after a resident obtained contraband for another resident.

On June 18, 2018, a resident with diagnoses of alcohol intoxication and withdrawal was found lying in a courtyard lethargic and unresponsive to verbal stimuli. According to DPH, the resident had “some drinks” before smoking marijuana obtained from another resident.

The resident was taken to a hospital, given Narcan, and tested positive for cannabinoids, alcohol and cocaine. An investigation found the resident had gotten the “contraband substance” from another resident, who obtained it during a 42-minute leave of absence request, according to DPH. An investigation also found facility documentation misclassified the incident.

Administrator Daniel Brencher declined to comment, saying he was legally prohibited from discussing resident-specific information.

Cassena Care at New Britain was fined $1,530 for an incident in which a resident was hospitalized after passing a 3-foot-long blood clot.

After the resident passed a clot “resembling intestines” from the rectum on Friday, June 22, 2018, an advanced practice registered nurse was notified and directed staff to monitor the resident’s vital signs for 72 hours and re-evaluate the resident on Monday, according the citation. But the resident was taken to a hospital on June 23 with hypoactive bowel sounds, nausea and vomiting and weakness, and was diagnosed with gastrointestinal bleeding.

Apple Rehab Laurel Woods in East Haven was fined $1,080 after a resident with dementia was restrained in a wheelchair when a nurse aide tied a sheet around the resident’s waist.

The resident became agitated on March 4, 2018, while being put into a wheelchair by two nurse aides and a nurse. According to DPH, one of the nurse aides later tied a sheet around the resident’s waist. The nurse aide was terminated when the allegation of abuse was substantiated.

Officials at Noble Horizons, Woodlake at Tolland, Cassena Care, and Apple Rehab did not return a phone call seeking comment.

The state Department of Public Health (DPH) has fined Madison House in Madison $2,265 for an incident in which a resident was found face-down and unresponsive in bed.

The resident was admitted to the facility in November 2015, according to DPH, with a broken hip. The resident had surgery and subsequently went into cardiogenic shock five days later and required “extensive care,” according to the citation.

The resident was found unresponsive Dec. 26 and resuscitation attempts were unsuccessful. An investigation found that documentation failed to show that nurses notified a physician that the resident had been short of breath and needed oxygen on Dec. 24.

The facility worked with DPH and “very quickly regained regulatory compliance,” said spokeswoman Jeanne Moore. “Madison House is committed to providing quality care to its patients and residents.”

Montowese Health and Rehabilitation Center in North Haven was fined $1,950 for an incident in which a resident was injured in a fall and died two days later.

In November 2015, a resident with chronic kidney disease and other ailments was admitted. A consent form signed for the use of enablers, which help the resident turn and move in bed, didn’t specify how many side rails were to be used on the bed, according to the citation.

The resident fell from bed onto the floor Nov. 25 and suffered a blood clot in the brain and other injuries. The resident was treated at a hospital, readmitted to Montowese and was found on the floor Nov. 27 with no cardiac activity, according to DPH. Officials at the facility did not return a call seeking comment.

The DPH cited St. Joseph’s Center in Trumbull twice.

In one case, the facility was fined $1,060 for two instances in which residents didn’t receive timely incontinence care.

In October 2015, a resident with end-stage renal disease complained that the wait for incontinence care took more than an hour, according to the citation.

Then in December 2015, a resident with quadriplegia and other illnesses complained about not receiving incontinence care “in a timely manner.” The resident reported that a nursing assistant became argumentative about the lack of care.

In a separate citation, St. Joseph’s was fined $2,580 for an October 2015 incident in which DPH found insufficient documentation was kept.

Lab work showed a resident had an abnormal level of Dilantin, a prescribed anti-seizure medication, but documentation did not reflect whether the resident’s doctor was aware of the abnormality. The resident was taken to a hospital emergency department where it was determined the resident suffered “a breakthrough seizure” due to having a sub-therapeutic level of Dilantin.

St. Joseph’s Center worked with state inspectors to become compliant and strives to provide quality care to its residents, said spokeswoman Jeanne Moore.

Riverside Health and Rehabilitation in East Hartford was fined $3,000 for two violations, including one in which a resident did not receive incontinence care for more than five hours.

In September 2015, according to the citation, a resident requested help with incontinence care from a nursing assistant and went 5.5 hours without care. The resident was supposed to receive incontinence help every two hours, according to the care plan.

Also at the facility, a Feb. 29, 2016, inspection found 12 of 17 residents in a unit were not wearing identification bands as is required.

“Riverside is confident that the issues raised in the report were isolated and not consistent with the care and customer service at our center,” said spokesman Timothy Brown. “We have retrained the staff involved in policies, procedures and expectations for our customer service standards.”

Village Crest Center for Health and Rehabilitation in New Milford was fined $1,950 after a resident’s hand was cut and needed eight sutures.

The resident, who suffered from dementia, became agitated while showering and was hurt after grabbing the shower head and swinging it around, according to DPH.

An investigation found the nursing assistant helping the resident shower should have stopped the shower to report the incident, but didn’t, and that the resident’s aggressive behavior was not documented.

An administrator at the facility, run by New Milford Crossings LLC, could not be reached for comment.

Noble Horizons in Salisbury, was fined $540 for a February 2016 incident in which a witness saw a nursing assistant pull the arm and three times slap the face of a resident, according to DPH. The nursing assistant subsequently was fired, according to the citation.

Facility administrator Eileen Mulligan said no harm was done to the resident and it was “a one-time, unpredictable event.”

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.