One facility was cited for allowing an assistant director of nursing, who tested positive for COVID, to work for five days. Plans of correction were submitted by each home. None of the facilities were fined.

The unannounced, in-person inspections resulted in enhanced staff training and additional deliveries of personal protective equipment (PPE), according to the Department of Public Health (DPH). During the pandemic, health care workers have complained about a lack of PPE, having to reuse their equipment.

Here’s a summary of the homes and the violations:

• Abbott Terrace Health Center of Waterbury was cited for failing to ensure that residents wore masks outside of their rooms and that residents maintained social distancing while outside their rooms.

• A registered nurse at Apple Rehab Coccomo of Meriden was observed not wearing a mask while walking through the facility and a nurse aide entered a unit without wearing a mask or face covering. Yellow gowns were found hanging outside rooms of residents rather than inside.

• Avon Health Center was cited for failing to ensure that a curtain was drawn between a resident who was awaiting the results of a COVID-19 test and a resident who did not have the virus.

• An inspector observed a certified nursing assistant exit a resident’s room at Bayview Health Care in Waterford without wearing the proper PPE. Also, the inspection found the potential cross-contamination of monitoring devices, such as the oxygen saturation scanner, which was set down on a table after use, cleaned, but then returned to the table which was not cleaned.

• Beacon Brook Health Center of Naugatuck was cited for allowing several residents to eat meals together, when communal dining should have been stopped.

• An inspector found that Bethel Health Care failed to separate residents with the virus from residents without the virus and that a nurse aide used the same PPE while caring for COVID and non-COVID residents.

• At Cassena Care, New Britain, an inspector found that the facility failed to ensure that room curtains were drawn between residents’ beds.

• At Countryside Manor, Bristol, a transportation service crew was observed removing a COVID resident from the COVID-positive wing through a non-infected wing without proper facial covering for the resident.

• During an inspection at Evergreen Health Care Center, Stafford Springs, a housekeeping staff member was observed removing soiled linen bags from soiled linen carts without wearing protective equipment, including a gown. The linens hit rubbed against the staffer’s body.

• Fox Hill Center of Rockville was cited for failing to notify a responsible party when a resident’s condition changed.

• Groton Regency Center was cited after an inspector observed that the dietary manager was not practicing proper hand hygiene when working in the facility.

• A licensed practical nurse at Madison House was observed exiting a resident’s room and placing a used face shield on a cart that contained PPE.

• Nathaniel Witherell of Greenwich was cited for failing to have signage outside a room indicating that a COVID-19 test was pending.

• RegalCare at New Haven was cited for the incorrect use of PPE, for not having enough PPE, and for not checking staff members’ temperatures before allowing them to enter the work area.

• A staff member at St. Camillus Rehabilitation & Nursing Center, Stamford, was observed leaving a room that has a droplet precaution sign on door and proceeding down the hallway and then removing the gown and gloves. Staff should have removed PPE inside the room before exiting.

• An inspection found that an assistant director of nursing at The Suffield House worked for five days at the nursing facility despite testing positive for COVID-19. Inspector wrote “she reported to work in the long-term care facility for five days and potentially placed other staff and residents at risks for contracting coronavirus.”

• Twin Maples Healthcare in Durham was cited for staff members’ incorrect usage of protective eyewear while caring for a resident who was on droplet transmission-based isolation. The resident was a recent admission to the facility. The home was also cited for a housekeeper’s practice of touching a soiled utility-room doorknob and then touching clean linens; and for the mixing of clean and used incontinence briefs.

• West Hartford Health & Rehabilitation was cited for failing to separate a COVID-positive resident from a resident who did not have COVID.

• An inspector observed a licensed practical nurse at Windsor Health & Rehabilitation Center working at a medication cart without wearing a mask. The LPN indicated that she did not need to wear a mask because she had recovered from coronavirus, but was told that all staff need to wear masks.

In response to the inspection findings, Matt Barrett, president and CEO of the Connecticut Association of Health Care Facilities, and Mag Morelli, president of LeadingAge Connecticut wrote in a press release, “We believe Connecticut nursing homes are performing at an extraordinary level given the challenges of fighting this insidious virus while faced with changing guidance, an inadequate PPE supply chain and a statewide testing initiative that has only recently begun. And while we would prefer that these focused inspections did not result in any findings, we absolutely welcome the Department’s oversight and efforts in ensuring that Connecticut nursing home infection control procedures are in adherence with the latest of what has been ever-changing CDC guidance.”

This week, Dr. Deidre Gifford, acting commissioner of public health and commissioner of the Department of Social Services, said that the state is conducting a “point prevalence surveys in every nursing home and testing every resident” to better understand the high rate of infections.

The testing is also being done to provide information to facilities so that they can cohort COVID positive residents from residents who are virus free, which will further decrease the chance of spread, Gifford said.

On Monday, the Centers for Medicare & Medicaid Services issued new guidelines for the reopening of nursing homes. CMS recommends “baseline” testing of residents (which CT is doing) and staff followed by weekly testing of staff. Facilities should ensure that they have adequate protective gear. CMS also recommends that nursing homes be “among the last” of entities in the state to reopen.   The guidelines are nonbinding, leaving it up to each state to determine when nursing homes should be reopened to visitors.

CORRECTION: An earlier version of this story reported that Twin Maples Healthcare in Durham had a COVID resident. It does not.

Apple Rehab Farmington Valley in Plainville was fined $2,140 for three violations that occurred in 2016. In one case, a resident died Oct. 23 after choking during dinner.

The resident, who had dementia, was found by a licensed practical nurse (LPN) choking in bed. The LPN delivered dinner to the resident, who was on a “mechanical soft diet” due to difficulty chewing, and had left the room after cutting the food for the resident, according to a state Department of Public Health (DPH) citation.

The LPN told investigators that a piece of garlic bread with the meal seemed hard and was difficult to cut, but the LPN left it on the plate since it was permitted on the resident’s diet. According to DPH, when the LPN returned to the room the resident was choking.

Staff performed the Heimlich maneuver, finger sweeps and abdominal thrusts. When paramedics arrived, a cardiac monitor showed no electrical activity or blood flow to the heart, according to DPH. The resident had do-not-resuscitate directives in place and was pronounced dead.

In another incident, a resident with a shellfish allergy was served shrimp gumbo on Nov. 7. The resident complained of difficulty swallowing and was given allergy medications Benadryl and Solu-Medrol, which helped.

According to DPH, policy dictates all staff should check for allergies and diet restrictions before serving residents food. Staff was educated about the policy, the citation said.

In another case, a resident with gastric cancer who complained of increasing pain likely missed six doses of a narcotic painkiller that a physician had prescribed, according to the citation.

The resident was supposed to receive the medication every four hours, but it is unclear how much medication the resident received between Oct. 28 and Oct. 30. According to DPH, documentation was incomplete. Officials at the facility did not return a call seeking comment.

Madison House in Madison was fined $2,310 after a resident suffered right arm bruising and swelling and DPH determined staff didn’t provide bed mobility and perform transfers properly.

The resident was taken to an emergency department on Feb. 20 and admitted to the hospital, according to DPH. The resident did not return to the facility at the family’s request.

The citation said two nurse’s aides, on separate occasions, moved the resident without the help of a second person, even though the resident’s care plan called for two-person assistance. Staff was re-educated on how to transfer residents safely, according to DPH.

Officials at the facility did not return a call seeking comment.

Parkway Pavilion Health & Rehabilitation Center in Enfield was fined $1,530 for a Jan. 2 incident in which a nurse’s aide touched a resident’s vaginal area while repositioning the resident in bed.

According to the citation, the resident—who had her right leg amputated above the knee, a fractured right elbow, and other diagnoses—had a care plan stipulating that two staff members were to assist with bed positioning, but a nurse aide believed a second staff member was unnecessary.

The facility fired the aide Jan. 6.

“This isolated incident was immediately reported to the local authorities and all appropriate regulatory agencies,” said Sharon Ellis, the facility spokeswoman. “The facility investigated the matter and took all necessary actions to ensure our ongoing compliance with state and federal regulations. We place the health and safety of our residents as our top priority.”

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.”

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.”