Wallingford Skilled Nursing and Rehabilitation Cen

Inspectors wroteBased on clinical records review and staff interview, it was determined that the facility failed to follow the wound care physician's order for one of two residents reviewed (Resident CL1).

Inspectors wroteBased on a review of facility policy, observations, and staff interviews, it was determined that the facility failed to make sure that medical supplies and medications were properly stored and/or disposed of in two of two medication rooms (Two South and Two North) and two of four medication carts (Two South Long Hall and Two South Short Hall). Review the facility policy, Storage of Medications dated, indicated, Medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to keep their integrity and to support safe, effective drug administration. [...]

Inspectors wroteBased on a review of facility documents, policy review, observations, and staff interviews, it was determined that the facility failed to properly restrain hair and failed to properly store food items to prevent possible cross-contamination in the Main Kitchen.

Inspectors wroteBased on review of facility documents and staff interviews it was determined that the facility failed to document grievance resolutions for four of six residents (Resident R4, R5, R6, and R7).

Inspectors wroteBased on review of state laws, facility policies, clinical records, and staff interviews, it was determined that the facility failed to implement policies and procedures to report allegations of neglect for failing to implement policies and procedures to report allegations of abuse and/or neglect for six of ten residents (Resident R4, R5, R7, R8, R9, and R10).

Inspectors wroteBased on review of state laws, facility policies, clinical records, and staff interviews, it was determined that the facility failed to fully investigate allegations of neglect for four of six residents (Resident R4, R5, R8, and R9).

Inspectors wroteBased on facility policy, observations, resident and staff interviews, and review of pest control documentation it was determined that the facility failed to maintain an effective pest control program on two of four nursing units (One North and Two South nursing units).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to protect residents from abuse for one of six residents (Resident R10). Review of the facility policy, Abuse Prohibition dated 5/21/25, defined verbal abuse as any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to patients or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include but are not limited to: threats of harm; saying things to frighten a patient, such as telling a patient that they will never be able to see their family again. Review of the clinical record indicated Resident R10 was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on review of facility policies, clinical record review, and staff interviews, it was determined that the facility failed to obtain the required dental services for three of five residents. (Resident R1, R2, and R3)

Inspectors wroteFindings include: Review the facility policy, Storage of Medications dated, indicated, Medications should be stored so that various routes of administration are separated. Internally administered medications are stored separately from medications used extremally such as lotions, creams, ointments, and suppositories. During an observation on 7/31/25, at approximately 5:37 p.m., the treatment cart stored in the Two North Medication room was observed. Upon opening the top drawer, it was noted that the treatment supplies were placed haphazardly in the drawer, with no separation of medications/biologicals based on resident or route of administration. A partial list of what was noted in the cart:Santyl ointmentsCollagenase ointmentsZinc oxide paste. Voltaren cream. Multiple types of gauze and dressing suppliesWound measuring tools. Anti-dandruff shampoo. Medi-honey. Antifungal sprays. [...]

Inspectors wroteBased on clinical record review, observations, and interviews with residents and staff it was determined that the facility failed to maintain personal dignity for two of six residents observed (Resident R1, R2) Findings Include: Facility policy titled Residents Rights Under Federal Law , revised 2023, revealed the facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his/her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. Clinical record revealed Resident R1 was admitted to the facility on [DATE] with a diagnosis that included fracture of upper end of left humerus, schizophrenia (mental health condition that affects how people think, feel, and behave), and muscle weakness. [...]

Inspectors wroteBased on a review of select facility policies and procedures, clinical record review, observation, and staff interview, it was determined that the facility failed to implement enhanced barrier precautions for four out of 35 residents reviewed (Resident 11, Resident 59, Resident 64, and Resident 164).

Inspectors wroteBased on a review of the facility's policy, clinical records review, and staff interview, it was determined that the facility failed to notify the physician of a significant weight change for one of the 35 residents reviewed (Resident 114).

Inspectors wroteBased on clinical record review and employee interview it was determined that the facility failed to ensure physician's orders were followed for one of 35 residents reviewed (Resident 19).

Inspectors wroteBased on observation, clinical records review, and staff interview, it was determined that the facility failed to ensure adequate assistance was provided to prevent a fall for one of the 35 residents reviewed (Resident 156).

Inspectors wroteBased on review of facility procedure, observation, and clinical record review, it was determined that the facility failed to provide documented evidence that consistent, adequate catheter care was provided to one of five residents reviewed for catheters (Resident 167).

Inspectors wroteBased on review of facility procedure and clinical record review, it was determined that the facility failed to adequately monitor and address significant weight loss in one of nine residents reviewed for nutrition (Resident 130).

Inspectors wroteBased on clinical records review and staff interview, it was determined that the facility failed to ensure medication to treat Diabetes (A group of metabolic disorders characterized by a high blood sugar level over a prolonged period of time) was made available for one of 35 residents reviewed (Resident 13).

Inspectors wroteBased on clinical records review and staff interview, it was determined that the facility failed to provide a consistent non-pharmacological intervention (NPI) and failed to provide an appropriate indication for the use of as-needed psychotropic medication for one of five residents reviewed (Resident 164).

Inspectors wroteBased on a review of the facility's policy, observations, and staff interview, it was determined that the facility failed to ensure medications were properly stored and labeled for one of the two units observed (1 North).

Inspectors wroteBased on clinical record review, facility policy and procedure review, and staff interview it was determined the facility failed to accurately assess and identify a newly admitted resident as a fall risk and develop interventions to prevent falls causing actual harm to Resident 263 who fell causing injuries that required hospitalization for one of 3 residents reviewed (Resident 263)

Inspectors wroteBased upon clinical record review, it was determined that the facility failed to ensure that medication irregularities were acted upon by a physician for four of five residents reviewed (Resident 16, 29, 77, and 137).

Inspectors wroteBased upon clinical record review, it was determined that the facility failed to ensure residents were free from unnecessary psychotropic medications by attempted dosage reductions and periodical reevaluation of psychotropic drug usage for three of five residents reviewed (Residents 16, 29, and 137).

Inspectors wroteBased on job description reviews, it was determined that the Nursing Home Administrator and Director of Nursing failed to effectively manage the facility of ensuring that the beverage temperature policy/guidelines included parameters identifying safe beverage temperatures for hot liquids and failed to protect residents from potentially suffering a medical emergency related to hot beverage burns.

Inspectors wroteBased on the clinical records review interview with staff and physician, it was determined that the facility failed to notify the physician of an abnormal blood result for one of the three residents reviewed (Resident R1).

Inspectors wroteBased on review of facility policy and procedure, clinical record, and staff interview it was determined the facility failed to thoroughly investigate an injury of unknown origin for one of 24 residents reviewed. (Resident 264)

Inspectors wroteBased on clinical records review and staff interview, it was determined that the facility failed to ensure medication ordered by the physician was followed for one of the 33 residents reviewed (Resident 70).

Inspectors wroteBased on clinical record review, it was determined that the facility failed to monitor and address significant weight changes in a timely manner for two of six residents reviewed for nutrition (Residents 54 and 60).

Inspectors wroteBased on Clinical record review and staff interview it was determined the facility failed to provide enteral nutrition (feeding delivered through a feeding tube) as ordered by the physician for one of five residents reviewed. (Resident 54)

Inspectors wroteBased on clinical record review, it was determined that the facility failed to ensure non-pharmalogical interventions (NPIs) were attempted prior to the administration of as-needed narcotic pain medication for one of thirty-three residents reviewed (Resident 98).

Inspectors wroteBased on clinical records review and staff interview, it was determined that the facility failed to perform laboratory services for one of the 33 residents reviewed (Resident 29).

Inspectors wroteBased on clinical record review, it was determined that the facility failed to ensure the radiological diagnostic studies were done in a timely manner for one of thirty-three residents reviewed (Resident 101).

Inspectors wroteBased on review of facility policy and facility documentation, and staff interview, it was determined that the facility failed to ensure one of three residents reviewed was free from abuse (Resident CL1).

Inspectors wroteBased on clinical record review and staff interview it was determined that [NAME] Skilled Nursing and Rehabilitation Center failed to ensure that residents were assessed and monitored to prevent pressure ulcers for one of one residents reviewed (Resident R72).

Inspectors wroteBased on observations, facility policy review, clinical record review, and interviews with staff, it was determined that the facility failed to ensure residents were free from physical abuse by Resident 88 who previously demonstrated physical aggression towards other residents, which resulted in harm requiring emergency medical treatment of Resident 141. The facility failure resulted in an immediate jeopardy situation for 42 additional residents (Residents 15,18, 22, 23, 24, 29, 33, 38, 39, 40, 41, 42, 45, 47, 60, 65, 66, 73, 75, 76, 77, 81, 89, 94, 99, 105, 110, 112, 115, 119, 120, 121, 127, 131, 135, 138, 139, 141, 146, 150, 154, and Resident 157) who resided on the same unit as Resident 88.

Inspectors wroteBased on observations, facility policy review, clinical record review, and interviews with staff, it was determined that the facility failed to provide adequate and safe supervision for a resident who demonstrated physical aggression, which resulted in harm to Resident 141 as evidenced by laceration to the forehead requiring emergency hospital treatment. The facility failure resulted in an immediate jeopardy situation for 42 additional residents (Residents 15,18, 22, 23, 24, 29, 33, 38, 39, 40, 41, 42, 45, 47, 60, 65, 66, 73, 75, 76, 77, 81, 89, 94, 99, 105, 110, 112, 115, 119, 120, 121, 127, 131, 135, 138, 139, 141, 146, 150, 154, and Resident 157) who resided on the same unit as Resident 88. The facility failed to ensure interventions were in place to prevent falls for two residents (Residents 67 and 68) reviewed resulting in actual harm to Resident 68 who sustained a fracture.

Inspectors wroteBased on Clinical record review and staff interview it was determined the facility failed to accurately code Minimum Data Set assessments for five of 24 residents reviewed. (Residents 4, 72, 78, 85, 92,) Findings Include: Review of Resident 4's Significant Change Minimum Data Set (MDS- periodic assessment of resident needs) dated June 6, 2023 revealed sections C Cognitive Patterns and D Mood were all dashed indicating they were not completed at the time of submission of the MDS. Review of Resident 72's Modification of Quarterly Minimum Data Set (MDS- periodic assessment of resident needs) dated May 11, 2023 revealed sections C Cognitive Patterns and D Mood were all dashed indicating they were not completed at the time of submission of the MDS. [...]

Inspectors wroteBased upon review of facility policy and procedure and clinical record review, it was determined that the facility failed to follow physician orders for the administration of medication for two of 31 residents reviewed (Resident 69 and Resident 142).

Inspectors wroteBased on clinical record review and staff interview it was determined the facility failed to have a consultant pharmacist provided a monthly medication review or a physician respond to the recommendations made by the pharmacist during the monthly medications review for five of 5 residents reviewed (30, 33, 35, 68, 92)

Inspectors wroteBased on observations, a review of medication manufacturer's guidelines, and staff interviews, it was determined that the facility failed to ensure that medications were properly labeled and stored in two of six medication carts observed (1 North long hall and 1 North short hall medication cart).

Inspectors wroteBased on job description reviews, it was determined that the Nursing Home Administrator and Director of Nursing failed to effectively manage the facility by implementing monitoring, supervision, and effective safety measures to for a resident who demonstrated physical aggression, which resulted in harm to Resident 141 as evidenced by laceration needing emergency medical treatment. The Administration failure resulted in an immediate jeopardy situation for 42 additional residents who resided on the same unit as Resident 88.

Inspectors wroteBased on clinical record review, observations and staff interview it was determined the facility failed to ensure the dignity of resident for two of 24 resident reviewed. (Residents 68 and 78) Findings Include: Review of resident 68's quarterly Minimum Data Set (MDS- periodic assessment of resident needs), dated July 5, 2023 revealed the resident had cognitive impairment. Observation of resident 68's room on July 31, 2023 at 9:45 a.m. and August 1, 2023 at 10:00 a.m. revealed a sign on the wall above the bed with instructions on how to use the resident's palm guard, ensure items are within resident's reach, and provide a scoop dish and handled mug at each meal. The sign was dated June 2023 and was signed by an occupational therapist. Review of Resident 78's quarterly MDS dated [DATE] revealed the resident had cognitive impairment. [...]

Inspectors wroteBased on clinical record review, it was determined that the facility failed to ensure a comprehensive care plan was initiated for a resident receiving hospice services for one of 31 residents reviewed (Resident 4).

Inspectors wroteBased upon review of facility documentation and clinical record review, it was determined the facility failed to ensure care plans were revised and updated after falls and an episode of aggression for two of 31 residents reviewed.(Resident 88 and Resident 100).

Inspectors wroteBased upon review of facility policy and procedure, clinical record review, and interview it was determined the facility failed to obtain weights upon admission and failed to obtain weekly weights for nutrition maintenance for two of 31 residents reviewed. (Resident 68 and Resident 153).

Inspectors wroteBased on clinical records, and interviews with residents and staff, it was determined that the facility failed to make certain that the medications ordered were available and administered by the acceptable standards of care for one of the 31 residents reviewed (Resident 20).

Inspectors wroteBased on clinical records review and staff interview, it was determined that the facility failed to ensure that an appropriate indication was present and non-drug interventions were attempted before administering an as-needed anti-anxiety medication for two of the 31 residents reviewed (Resident 35 and Resident 69).

Inspectors wroteBased on observations, review of facility policies and interviews with staff, it was determined that the facility failed to store food in accordance with professional standards for food service safety. Based on observation of the first-floor pantry refrigerator and cabinets on August 1, 2023, at 9:23 a.m. it was determined that there were six unlabeled 4 oz milk cartons that expired on June 26, 2023. Additional observation of the refrigerator showed four peanut butter and jelly sandwiches, two open loaves of bread, a pizza box, a container of macaroni and cheese and four bags of take-out food all of which were unlabeled and undated. Further observation of the refrigerator showed and an open 16 oz ginger ale soda that was unlabeled. [...]

Inspectors wroteBased on interview with staff and clinical record review, it was determined that the facility failed to maintain complete and accurate medical records related to medications and treatments for one of six residents reviewed (Resident 35).

Inspectors wroteBased on clinical record review, it was determined that the facility failed to notify the Office of the State Long Term Care Ombudsman of resident transfers in writing for four of five residents reviewed Resident (69, 100, 127, and 412)