Ingraham Manor Rehab And Nursing
Inspection Findings
F-Tag F0684
F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
transfer to the hospital on 7/5/2025. Review of Resident #1's wandering risk assessment dated [DATE REDACTED] identified she was unaware section G and H were blank. The DON stated staff should complete the assessment in accordance with the assessment directions, and section H should be completed as a screening. The DON stated although the assessment dated [DATE REDACTED] identified Resident #1 was a low risk, if
the staff had completed sections in accordance with the directions (complete section H for the admission screening), Resident #1's new score would have been eleven (11), indicative of a high risk to wander.
Interview failed to identify why the wander assessment was incomplete and inaccurate. a. Record review identified all physician orders for Resident #1 were discontinued on 7/17/2025 due to the transfer to hospital, and he/she was no longer in the facility. Review identified the orders that were discontinued included an order for wander guard use and to check wander guard placement every shift and function daily. Record review identified Resident #1 was readmitted to the facility on [DATE REDACTED]; nursing note dated 7/24/2025 at 2:45 PM identified Resident #1 was alert and oriented to person only. The readmission Resident Care Plan dated 7/24/2025 identified an elopement risk/wanderer. Interventions directed Resident #1 to wear a wander guard, check for placement and function as ordered, document wandering behavior, distract from wandering by offering pleasant diversions, structured activities, food, conversation, television, or a book, and to provide structured activities such as toileting, walking inside and outside, reorientation strategies to include signs, pictures, and memory boxes. APRN note 7/25/2025 at 11 AM identified Resident #1 was seen after readmission, Resident #1 ambulated with a walker independently, and was alert and oriented to person only. Review of the nursing progress notes from 7/25 to 8/6/2025 identified Resident #1 was noted to have wandering behaviors on 7/25, 7/28, 8/3, 8/4, and 8/5/2025. Record review identified although prior orders were re-instated upon readmission on [DATE REDACTED], the order for wander guard use was not re-instated/renewed. Interview and record review with the DON (Director of Nursing) on 9/8/2025 at 2:05 PM identified Resident #1 was at risk for wandering/elopement and used a wander guard bracelet prior to transfer to the hospital on 7/5/2025. Interview identified Resident #1 remained a wander risk after readmission on [DATE REDACTED]. The DON stated a wander guard was reapplied upon readmission on [DATE REDACTED], in accordance with the resident plan of care, but was unable to provide documentation of the application. Further, the DON was unable to provide documentation of physician orders that directed use of
a wander guard and to check placement every shift and function daily. Although the DON indicated staff should have entered new physician orders for use of a wander guard and to check placement every shift and function daily, interview failed to identify why that was not done. Review of the facility undated Wandering Risk Policy, directed in part, all residents who are at risk for harm because of wandering behavior will be identified for wandering/elopement risk upon admission to the facility. The wandering/elopement risk assessment will be utilized in the EMR (electronic medical records). Residents identified as high risk will have a wander guard bracelet applied.
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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
09/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Ingraham Manor Rehab and Nursing
400 N Main St 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-Tag F0689
F 0689 Level of Harm - Actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
right hip fracture. Interview with the Administrator and Director of Maintenance on 9/8/2025 at 9:30 AM identified the door leading into the stairwell where Resident #1 was found sounds an alarm when the door is opened to alert staff someone is exiting through the door. Interview with the Administrator on 9/8/2025 at 11:00 AM identified Resident #1 was at risk for wandering/elopement and had a wander guard device at the time of the incident. The Administrator stated the facility did not have a locked (dementia) unit and the egress doors on Resident #1's unit do not have a wander guard alarm but alarm to alert staff that someone is exiting. Interview and observation with the Administrator on 9/8/2025 at 12:30 PM identified Resident #1 resided on the third (3rd) floor and was found on 8/6/2025 lying on the floor in the stairwell, at the bottom of
the first (1st) flight of stairs. Coming from the 3rd floor, Resident #1 made it down one (1) set of stairs and was found on the floor on the landing. Interview failed to identify how Resident #1, with known wandering behaviors, was able to access the stairwell from his/her unit without staff knowledge. Interview and record
review with the DON (Director of Nursing) on 9/8/2025 at 2:05 PM identified on 8/6/2025, she responded to
a code STAT and noted that Resident #1 had fallen in the emergency stairwell and was found at the bottom of the first flight of stairs from the third (3rd) floor. Resident #1 was transferred to the hospital and admitted to the hospital with a diagnosis of a right hip fracture. Interview failed to identify how Resident #1, with known wandering behaviors, was able to access the stairwell from his/her unit without staff knowledge.
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INGRAHAM MANOR REHAB AND NURSING in BRISTOL, CT inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in BRISTOL, CT, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from INGRAHAM MANOR REHAB AND NURSING or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.