Civita Sheriden Woods

F 0657

assessment.

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

01/30/2026

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Sheriden Woods Health Care Center Inc

321 Stonecrest Drive Bristol, CT 06010

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 0689 Level of Harm - Actual harm Residents Affected - Few

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

knee he/she felt grinding in the left knee and immediate pain. Resident #1 identified NA #1 also heard the sound and the resident reported his/her left leg was touching the mattress, so NA #1 was able to pull him/her onto the edge of the bed and get him/her into bed without a fall occurring. Resident #1 indicated

the transfer was very difficult and NA #1 did not utilize a gait belt.Interview with NA #1 on 1/30/26 at 1:17 PM identified as she was walking by Resident #1's room on 1/16/26, she observed Resident #1 leaning forward in the wheelchair with his/her hands on the side rail and it appeared Resident #1 was trying to stand. NA #1 indicated Resident #1 had been incontinent and although she knew Resident #1 was an assist of two (2) stand pivot with the walker for transfers, she did not call out or use the call bell to request assistance. NA #1 identified she did not place a gait belt around Resident #1 and did not utilize the walker to assist in the transfer. NA #1 explained she assisted Resident #1 in standing while Resident #1 held onto

the side rail and as Resident #1 started to pivot, she heard a pop sound and Resident #1 yelled out in pain.

NA #1 identified Resident #1 was close enough to the bed so she was able to get Resident #1 on the edge of the bed and lay Resident #1 into the bed and then left the room immediately to notify the nursing supervisor. NA #1 reported looking back, she should have yelled for assistance, waited so Resident #1 could safely be transferred to the bed, should have put the gait belt on and utilized the walker prior to transferring Resident #1 to bed.Interview with the 3-11PM nursing supervisor, Registered Nurse (RN) #1,

on 1/30/26 at 12:18 PM identified on 1/16/26 the 3-11 PM nurse aide, Nurse Aide (NA) #1, came to her around 4:15 PM to report the incident. RN #1 indicated NA #1 reported she went to provide care to Resident #1 because Resident #1 had been incontinent and the incident occurred when she transferred Resident #1 into bed. RN #1 identified she assessed Resident #1 and although Resident #1 complained of pain with movement of the left leg and knee, she did not observe any redness or swelling so she did not report the incident to the provider immediately. RN #1 identified the 3-11PM charge nurse, Licensed Practical Nurse (LPN) #2, came to her just after 10:30 PM and reported Resident #1 had swelling to the left knee and continued to complain of pain with any movement of the left leg. RN #1 explained she assessed Resident #1 and then called the provider to report the initial incident and the subsequent swelling and pain.

RN #1 reported NA #1 should not have transferred Resident #1 without a second staff member present and identified Resident #1 had significant lymphedema to both lower legs.Interview with Physical Therapist #1 and Occupational Therapist #1 on 1/30/26 at 2:02 PM identified Resident #1 had been on therapy services until 12/18/25, when Resident #1 was then discharged as an assist of two (2) for stand pivot transfers from

the bed to the wheelchair and from the wheelchair to the bed. They indicated Resident #1 was not capable of pulling or pushing him/herself up out of the wheelchair unassisted.Interview with the Director of Nursing (DON) on 1/30/26 at 1:29 PM identified at the time of the 1/16/26 incident, Resident #1 was an assist of two (2) stand pivot transfer with the walker per the resident care card and physician's order.Review of the Use of Care Cards policy dated 3/12/25 directed, in part, that the facility utilizes Care Cards as a supplement tool to communicate essential, resident-specific care information to staff that highlights key care needs to support safe, consistent daily care and that they may include the following minimum necessary information to include mobility/transfer status. Noncompliance will be addressed through re-education and corrective action as needed.Review of the Gait Belt policy dated 9/1/22 directed, in part, that gait belts must be used for any residents who requires assistance with transfers or ambulation. A gait belt is required unless the resident is independently mobile or its use is contraindicated.

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

01/30/2026

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Sheriden Woods Health Care Center Inc

321 Stonecrest Drive Bristol, CT 06010

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 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

although Resident #1 complained of pain with movement to the left leg and knee, she did not observe any redness or swelling so she asked the charge nurse to take Resident's vital signs and administer Tylenol for pain relief. Interview with the 3-11PM charge nurse, Licensed Practical Nurse (LPN) #2, on 1/30/26 at 12:40 PM identified the nursing supervisor, RN #1, came to her requesting she take Resident #1's vital signs and administer Tylenol for pain relief just before 4:15 PM on 1/16/26. LPN #1 reported she administered Tylenol and then went to check on Resident #1 again a little after 5:00 PM, Resident #1 was comfortable and the Tylenol had been effective. LPN #2 identified when she went to check on Resident #1 again around 10:40 PM, she lifted Resident #1's left leg, and Resident #1 yelled out in pain, the left knee was noted to be swollen so she immediately notified the nursing supervisor who called the provider. LPN #2 identified she should have administered the Tylenol again to Resident #1 when she discovered the pain around 10:40 PM. Interview with the 11PM-7AM charge nurse, LPN #3, on 1/30/26 at 12:29 PM identified both LPN #2 and the 11PM-7AM nursing supervisor, RN #2, reported to her Resident #1 had been in pain at the end of

the 3-11PM shift, and although Resident #1 appeared to be uncomfortable when she checked on Resident #1 throughout the night, she did not medicate Resident #1 with Tylenol prior to 5:12 AM because she assumed LPN #2 had administered it since Resident #1 had just been assessed at the end of the 3-11PM shift. LPN #3 identified she did not verify on the Medication Administration Record when the Tylenol was last given and around 5:00 AM, the nurse aides reported to her they were going to do care, so she administered Tylenol at 5:12 AM in preparation for care. LPN #3 reported she stayed to assist throughout

the care, Resident #1 appeared to be very uncomfortable with movement and when she checked on Resident #1 again after 6:00 AM, Resident still appeared to be restless and uncomfortable, so she notified

the nursing supervisor. LPN #3 indicated because she notified RN #2 of the unrelieved pain, she assumed RN #2 would notify the provider with the pain concerns as well as the x-ray results. Interview with Advanced Practice Registered Nurse (APRN) #1 on 1/30/26 at 2:27 PM identified if the acetaminophen was not effective in managing Resident #1's pain following the 5:12 AM administration, this should have been reported to the provider so additional pain relief could have been ordered. Interview with the Director of Nursing (DON) on 1/30/26 at 1:29 PM identified the 3-11PM charge nurse, LPN #2, should have administered Tylenol upon observing Resident #1 to be in pain with movement to the left knee/leg around 10:40 PM and the provider should have been notified Resident #1 had unrelieved pain after the 5:12 AM dose so that an alternative pain medication could have been ordered and Resident #1 kept comfortable, especially with the transport to the hospital. Review of the Pain Assessment and Management policy (undated) directed, in part, that acute pain should be assessed every thirty (30) to sixty (60) minutes after

the onset and reassessed as indicated until relief is obtained. Review the medication administration record to determine how often the individual requests and receives as needed pain medication, and to what extent

the administered medications relieve the resident's pain. If pain has not been adequately controlled, the multidisciplinary team, including the physician, shall reconsider approaches and make adjustments as indicated. Report the following information to the physician or practitioner: significant changes in the level of

the resident's pain and prolonged, unrelieved pain despite care plan interventions.

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

01/30/2026

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Sheriden Woods Health Care Center Inc

321 Stonecrest Drive Bristol, CT 06010

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 0730

Observe each nurse aide's job performance and give regular training.

Level of Harm - Potential for minimal harm

Based on review of facility documentation, review of facility policy, and interviews for one (1) of three (3) nurse aides, the facility failed to complete an annual performance evaluation. The findings include:Review of

a 3-11PM nurse aide's, Nurse Aide (NA) #1, personnel file identified a hire date of 11/26/12 and the last performance evaluation was completed on 12/18/22. The facility failed to identify a yearly performance evaluation was completed in 2023, 2024, and 2025. Interview with the Administrator on 1/20/2026 at 2:45 PM identified each employee was required to have a performance evaluation completed annually based on their date of hire, yearly anniversary. The Administrator identified although the facility does not currently have a Human Resources (HR) staff member, HR was expected to make the notification of when the performance evaluation was due, and the annual evaluation was then distributed to the nursing supervisor to complete, HR was then responsible for ensuring the annual performance evaluations were completed and in the employee's record. The How to Complete the Performance Evaluation policy identified that the facility reviews and summarizes the employee counseling session to identify a trend and pattern. The facility also reviews the job description performance rating with the employee to ensure the employee understands

the performance rating for the function of their position and the performance evaluation is filed in accordance with facility policy.

Residents Affected - Some

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

Event ID:

Facility ID:

If continuation sheet