The Gardens at Winsted LLC

Inspectors wroteBased on interview and document review, the facility failed to ensure residents' call lights were responded to timely to meet resident needs for 5 of 6 residents (R4, R6, R13, R20, and R38) reviewed for call light response times. This failure resulted in residents experiencing prolonged wait times for assistance and placed residents at risk for unmet care needs, including toileting, hygiene, and other requests for assistance.

Inspectors wroteBased on observation, interview and document review, the facility failed to maintain the walk-in freezer in a clean and safe condition, as evidenced by a large accumulation of ice on the freezer floor and on stored food boxes, and spilled food items. The facility failed to maintain the dining room resident refrigerator/freezer as evidenced by spilled and undated food items. Additionally, the facility failed to ensure staff completed hand hygiene and wore the appropriate hair coverings in the kitchen. This had the potential to affect all 32 residents residing in the facility.

Inspectors wroteBased on interview and document review, the facility failed to ensure 1 of 1 infection preventionist (IP) who was also the director of nursing (DON) had appropriate oversight of the infection control (IC) program that included employee surveillance of all employees. This had the potential to affect all 32 residents.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure a self-administration of medications assessment was completed for all medications kept at bedside for 3 of 3 residents (R1, R13, R30) observed with medications at their bedside.

Inspectors wroteBased on interview and document review, the facility failed to provide reasonable accommodation of needs and preferences for 1 of 1 resident (R28) reviewed for environmental scents.

Inspectors wroteBased on interview and document review, the facility failed to ensure a resident remained free from physical restraints not required to treat a medical symptom when the facility incorporated the use of law enforcement handcuffs into resident's care plan for 1 of 1 resident (R45) reviewed for restraints.

Inspectors wroteBased on interview and document review, the facility failed to ensure residents were free from unnecessary psychotropic medications, including failure to ensure as needed (PRN) psychotropic medications had appropriate stop dates for 1 of 5 residents (R20) reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure 1 of 1 resident's (R43) discontinued controlled narcotic medication was not stored with in-use medications in 1 of 3 medication carts.

Inspectors wroteBased on interview and record review, the facility failed to ensure there are a sufficient number of nursing personnel to provide care and respond to each resident's basic needs as required by the resident's diagnoses or plan of care resulting in delayed responses to call lights and an inability to provide timely care. The failure affected multiple residents (R1, R5, R6, R8, R9) and placed all residents at risk for unmet care needs, avoidable discomfort, and potential decline.

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards and practices for 1 of 3 residents (R7) reviewed for non-pressure related skin injuries.

Inspectors wroteBased on interview and document review the facility failed to ensure the facility assessment included the required components of involvement from direct care staff, considering staffing needs of each unit in the facility, and a plan to recruit and retain staff. This had the opportunity to affect all 33 residents.

Inspectors wroteBased on observation, interview and document review the facility failed to maintain residents' dignity for 2 of 3 residents (R4, R5) reviewed for dignity when it took 20 minutes for staff to answer call lights causing R4 and R5 to become incontinent.

Inspectors wroteBased on observation, interview and document review, the facility failed to develop and implement interventions to maintain continence for 2 of 3 residents (R4, R5) reviewed for care plans.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure residents incontinent of bladder and bowel received services to maintain continence when 2 of 3 residents (R4, R5) reviewed for continence care did not receive timely care, resulting in bladder incontinence.

Inspectors wroteBased on interview and document review, the facility failed to report an allegation of sexual abuse to the State Agency (SA) within two hours, as required, for 1 of 3 residents (R1) reviewed.

Inspectors wroteBased on interview and document review, the facility failed to ensure contracted agency staff were trained on the facility's abuse policy and annual abuse training which had the potential to affect all 37 residents currently residing in the facility at the time of the survey.

Inspectors wroteBased on observation, interview and document review, the facility failed to perform hand hygiene and change gloves appropriately for 1 of 1 residents (R2) observed for personal cares. In addition, the facility failed to develop a trending and tracking program system for monitoring residents who showed signs of illness, but were not on an antibiotic, these practices had the potential to affect all 37 residents currently residing in the facility. Findings Include: R2's 3/21/25, significant change Minimum Data Set (MDS) identified her cognition was severely impaired, and she was dependent on staff for activities of daily living (ADL)s. [...]

Inspectors wroteBased on interview and document review, the facility failed to ensure resident mail was delivered to residents on Saturdays for 2 of 2 residents (R3 and R28) who voiced concerns with mail delivery during Resident Council. This had the potential to affect all 37 residents residing in the facility.

Inspectors wroteBased on observations, interviews and document review, the facility failed to ensure resident living areas are free from odors for 2 of 2 residents (R8 and R14) in the sample whose room odors permeated the surrounding halls. This had the potential to affect residents in surrounding rooms, visitors and facility staff. In addition the facility failed to fully investigate missing personal items for 1 of 1 residents (R9) with reports of missing clothing that was reported missing for approximately two months.

Inspectors wroteBased on observation, interview and documentation, the facility failed to identify personal activity preferences, develop resident specific care plan, and coordinate activities of interest for 5 of 5 residents (R3, R22, R28. R31,and R36 ) reviewed for activities.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure a self-administration of medications assessment was completed, and orders obtained, for all medications kept at bedside for 1 of 1 residents (R9) observed with medications at their bedside.

Inspectors wroteBased on observation, interview and document review, the facility failed to act and ensure voiced concerns in the resident council were addressed in a timely manner. This had potential to affect 6 of 6 residents (R8, R28, R33, R7. R3, and R11), identified to have attended the meetings in the past two months.

Inspectors wroteBased record review and interview the facility failed to follow up on grievances for 1 of 1 residents (R7) reviewed for grievances during the period 9/7/24 to 5/1/25.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure the hospice plan of care had been integrated with the facility care plan for 1 of 1 resident (R2), identified to receive hospice services.

Inspectors wroteBased on observation, interview and document review, the facility failed to implement appropriate monitoring of wanderguard function for 1 of 1 residents (R32) reviewed for elopement. Additionally, the facility failed to assure proper ongoing storage and use for e-cigarette (inhaled nicotine) device were implemented for 1 of 5 residents (R9) reviewed for smoking. In addition, the facility failed to provide supervision in the dining room during meal for 1 of 1 residents (R30) reviewed for safety while eating.

Inspectors wroteBased on observation, interview, and record review, the facility failed to consistently communicate with dialysis department, and follow through on directions for 1 of 1 residents (R141) reviewed for dialysis

Inspectors wroteBased on observations, interviews and document review, the facility failed to ensure resident medical social services were provided for 2 of 2 residents (R8 and R14) whose room odors permeated the surrounding halls. This had the potential to affect residents in surrounding rooms, visitors and facility staff.

Inspectors wroteBased on interview and document review, the facility failed to ensure 1 of 5 residents (R5) reviewed for immunizations were offered and/or provided the pneumococcal vaccine series as recommended by the Centers for Disease Control (CDC) to help reduce the risk of associated infection(s).

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure both recertification survey results, as well as additional complaint investigations, were available for review. This had the potential to effect all 37 residents residing in the facility, along with family, visitors and staff.

Inspectors wroteBased on observation, interview and document review the facility failed to ensure Enhanced Barrier Precautions (EBP) were used for 1 of 3 residents (R3) reviewed for wound care.

Inspectors wroteBased on observation and interview, the facility failed to ensure 1 of 3 residents (R5) room was kept clean to reside in. Furthermore, the facility failed to maintain sanitary condition in the dining room. This had the potential to affect all 24 residents who ate food in the dining room.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure personal protective equipment (PPE) was utilized for 3 of 4 residents (R1, R2, R4) reviewed for infection control concerns. Furthermore, the facility failed to ensure enhanced barrier precaution (EBP) [measure intended to prevent the spread of multi drug-resistant organisms] was implemented for 2 of 4 residents (R1, R4) reviewed for foley catheter cares.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure resident's ordered medications were fully communicated to the filling pharmacy. In addition, the facility failed to ensure all licensed staff (including pool agency staff) understood and utilized the emergency medication kit (E-Kit) for 1 of 3 residents (R1) who did not have all physician ordered medications delivered from pharmacy for continuity of care.

Inspectors wroteBased on interview and document review the facility failed to notify the resident's representative following resident change of condition for 1 of 1 resident (R1) who had a decline in condition resulting in hospitalization.

Inspectors wroteBased on interview and document review the facility failed to effectively monitor and communicate wound status for early recognition of changes on 1 of 2 residents (R1) reviewed for worsening pressure ulcers.

Inspectors wroteBased on interview and document review, the facility failed to notify the attending physician of a change in condition for 1 of 1 resident's (R42) reviewed for new onset of hallucinations and delusions.

Inspectors wroteBased on observation, interview and document review the facility failed to follow the interventions for 1 of 1 residents (R34) reviewed for weight loss and nutrition leading to a 15 lbs (8.37%) weight loss over the course of 47 days.

Inspectors wroteBased on interview and document review, the facility failed to ensure residents were free of significant medication errors for 1 of 1 (R94), residents reviewed for medication orders and administration.

Inspectors wroteBased on interview and document review, the facility failed to provide adequate supervision for 1 of 3 residents (R1) who were at risk for elopement. This resulted in an immediate jeopardy (IJ) however, the facility implemented corrective action prior to the investigation so the deficiency remained at past non-compliance. The IJ began on 1/17/24 at 7:09 p.m. when the administrative hallway exit door alarm sounded and staff did not respond appropraitely. At 7:36 p.m. R1 on was located outside, approximately 15 feet from the building. AccuWeather temperature identified it was between 10 degrees Fahrenheit (F) and -3 degrees F on 1/17/24. The facility administrator and director of nursing (DON) were notified of the IJ on 1/25/24 at 3:02 p.m. The facility had implemented corrective action on 1/22/24, prior to the start of the survey and was issued at past non-compliance.