Ark Healthcare & Rehabilitation At Branford Hills

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

sugars were stable, a provider should have been notified for each missed administration for a possible alternative order. APRN #1 stated the pharmacy should have been contacted to inquire about the medication's whereabouts. Review of the blood sugar documentation for Resident #1 identified a range from 165 to 273. Interview with the pharmacy technician on 8/25/25 at 1:10 PM identified the Humulin-R insulin 100 u/mL was not filled. Interviews with the charge nurses, Licensed Practical Nurse (LPN) #1 and LPN #2, on 8/25/25 identified they did not notify the nursing supervisor, the provider or call the pharmacy when the doses of Humulin-R insulin 100 u/mL were not administered to Resident #1 on 7/22/25, 7/25/25 or 7/26/25. They identified they were not aware they had to notify the nursing supervisor for each missed administration so that the nursing supervisor could contact the provider for possible alternative orders and

they identified Humulin-R insulin was not available in the facility's emergency stock medication. Interview with LPN #3 on 8/25/25 at 3:30 PM identified she signed off the Humulin-R insulin was administered to Resident #1 on 7/23/25 when it had not yet arrived from the pharmacy. LPN #3 identified if the medication was unavailable for administration, she should have called the pharmacy to check on the status and then notified the supervisor of the missed administration and documented the conversations in the clinical record. Interviews with Registered Nurse (RN) #6, RN #7, and RN #8 on 8/25/25 identified they could not recall being notified by LPN #1, LPN #2 or LPN #3 on 7/22/25, 7/23/25, 7/25/25 or 7/26/25 that Resident #1's Humulin-R insulin was not available, explaining if they had, they would have notified the provider, wrote

a note to identify the notification and any new orders that were obtained. RN #6 reported although she wrote the note on 7/24/25 identifying she was going to follow-up with the pharmacy regarding the Humulin R insulin, she did not call the pharmacy directly to speak with someone to inquire about the delay but instead faxed a request for the insulin. Interview with the Director of Nursing (DON) on 8/25/25 at 1:48 PM identified insulin was not part of the stock in the facility's emergency supply and staff should have inquired with the pharmacy and then notified the nursing supervisor of each missed administration of the Humulin R insulin so the nursing supervisor could have notified the provider for possible alternative orders. Review of

the Diabetes Management policy (undated) directed, in part, that nursing staff is to administer diabetes medications, including insulin, according to physician's orders and care plans. Observe for and report any adverse reactions or side effects promptly. Keep detailed records of assessments, care plans, blood glucose readings, medication administration and any incidents. Report any significant changes in the residents' condition to the healthcare provider immediately. Although requested, facility policies for Provider Notification and MedicationAdministration were not provided.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Ark Healthcare & Rehabilitation at Branford Hills

189 Alps Road Branford, CT 06405

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755

insulin was not available

Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Ark Healthcare & Rehabilitation at Branford Hills

189 Alps Road Branford, CT 06405

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Potential for minimal harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility policy and interviews for one (1) of three (3) sampled residents (Residents #1) reviewed for medication administration, the facility failed to document in the clinical record when the medication was not available and what interventions were initiated. The findings include: Resident #1's diagnoses included type 2 diabetes mellitus, end stage renal disease and morbid obesity. Review of the hospital Discharge summary dated [DATE REDACTED] directed to administer Humulin R U-500 injectable pen 40 units daily before dinner. A physician's order dated 7/21/25 directed to administer Humulin R U-500 units per milliliter (concentrated) inject 40 units subcutaneously in the evening. The admission Nursing assessment dated [DATE REDACTED] identified Resident #1 was alert and oriented to person, place, time and situation. A physician's order dated 7/22/25 directed to discontinue Humulin R U-500 units per milliliter (concentrated) inject 40 units subcutaneously in the evening and administer Humulin-R insulin 100 units per milliliter (u/mL), inject 40 units subcutaneously every evening for type 2 diabetes mellitus. Review of the July 2025 Medication Administration Record (MAR) identified the Humulin-R solution was not administered on 7/22/25, 7/24/25, 7/25/25 and 7/26/25 and to see the progress notes. Upon further review of the MAR the Humulin-R solution was noted to be signed off as administered on 7/23/25. The Electronic Medication Administration Record note dated 7/22/25 identified the Humulin-R solution was on order. There was no documentation identifying the nursing supervisor, the provider or pharmacy were notified of the missed administration of Humulin-R solution on 7/22/25. The nurse's note dated 7/24/25 at 8:21 PM identified the 7AM-7PM nursing supervisor, Registered Nurse (RN) #6 was called to the unit to help the charge nurse, RN #9, locate Resident #1's Humulin-R Insulin. The note indicated after searching and unable to locate the insulin, the Advanced Practice Registered Nurse (APRN) was updated and the APRN directed to hold the 7/24/25 dose, follow-up with the pharmacy and obtain blood sugars three (3) times daily prior to meals and notify a provider if the blood sugar is greater than 400. The note indicated Resident #1's blood sugar at 6:44 PM was 273. Review of the Electronic Medication Administration Record notes dated 7/25/25 and 7/26/25 identified the Humulin-R insulin was not available. The notes failed to reflect documentation the nursing supervisor, provider, or pharmacy were notified of the missed administration of Humulin-R insulin.Interview with the Director of Nursing (DON) on 8/25/25 at 1:48 PM identified the nurses are expected to document accurately in the clinical record. Review of the Documentation policy dated 6/2023 directed, in part, that all nursing staff are required to complete their documentation to reflect any care and services provided to the residents, which includes EMAR, Treatment Administration Record (TAR), nursing notes, nursing assessments, vital signs and care plan updates/revisions.

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If continuation sheet