Ingraham Manor: Wandering Resident Fell Down Stairs - CT
Federal inspectors cited the facility for actual harm following a complaint investigation completed September 8, 2025.
The resident, identified in inspection records only as Resident #1, lived on the third floor and was known to wander. The facility had equipped the resident with a wander guard device, a sensor typically worn on the wrist or ankle that triggers an alarm when the wearer approaches a designated exit. The egress doors on the unit were also equipped with alarms, the administrator confirmed to inspectors, designed to alert staff when someone passes through.
Neither system stopped what happened.
The Director of Nursing told inspectors she responded to the code STAT herself and found Resident #1 at the bottom of the first flight of stairs, having descended from the third floor. The resident was transported to the hospital and admitted with a diagnosis of a right hip fracture.
When inspectors asked both the administrator and the Director of Nursing how a resident with known wandering behaviors managed to enter the stairwell without staff knowledge, neither could answer. The inspection report notes the same finding twice, once after the administrator interview and once after the nursing director's: "Interview failed to identify how Resident #1, with known wandering behaviors, was able to access the stairwell from his/her unit without staff knowledge."
That unanswered question sits at the center of the citation.
The administrator acknowledged during the 11:00 AM interview that the facility does not operate a locked dementia unit. Residents at risk for wandering are instead managed through wander guard technology and door alarms. The administrator confirmed Resident #1 had the wander guard device at the time of the fall. What the administrator could not explain was why the alarm, if it sounded, produced no intervention before the resident descended a staircase, or whether the alarm sounded at all.
The stairwell itself was an emergency exit, not a general-use corridor. The door leading into it, the administrator and Director of Maintenance confirmed in a joint interview that morning, does alarm when opened. That means at least one alarm, and possibly two, was in place between Resident #1 and that stairwell. The resident got through anyway, and got far enough to fall.
A right hip fracture in an elderly resident is not a minor injury. It typically requires surgery, carries significant risks of complications, and often marks a turning point in a person's functional decline. The inspection report does not describe Resident #1's condition after hospitalization.
The violation was cited under F0689, the federal tag covering the requirement that facilities protect residents from accident hazards. Inspectors classified the level of harm as actual harm, not potential, not a near miss. The harm had already occurred before the complaint was filed and before inspectors arrived.
What the record does not show is any explanation of what the facility has changed since August 6. The inspection report documents what staff said on September 8 when asked about the incident. It does not document a revised wandering protocol, a review of how the wander guard system functioned that morning, or an accounting of where staff were positioned when the door opened. Those questions went unanswered in the interviews, and the report does not indicate they were answered elsewhere.
Somewhere between a wander guard device, a door alarm, and a staff that responded to a code, a resident who was known to be a wandering risk made it down a flight of emergency stairs alone.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Ingraham Manor Rehab and Nursing from 2025-09-08 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 23, 2026 · Our methodology
INGRAHAM MANOR REHAB AND NURSING in BRISTOL, CT was cited for violations during a health inspection on September 8, 2025.
Federal inspectors cited the facility for actual harm following a complaint investigation completed September 8, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.