Ingraham Manor Rehab And Nursing
INGRAHAM MANOR REHAB AND NURSING in BRISTOL, CT — inspection on February 20, 2026.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
was a full code.Interview with the Director of Nursing Services (DNS) on [DATE] at 3:02 PM
was transitioning from paper charts to an EMR system.
Administration identified they were initially
reviewing several paper charts and locating advance directive documents under the advance directive tab.
Administration identified the facility did not have a process to ensure advance directives for newly admitted residents were readily identifiable in the paper chart.
Administration identified advance directives for newly admitted residents could be located within hospital documents or physician order sections of the paper chart but were unable to identify how long it would take to locate the documents during a medical emergency due to the volume of documentation in those sections.
Administration reported they were unaware that LPN #1 was unable to identify where to access Resident #1's advance directives outside of the EMR.The Advanced Directive policy identified adult persons had the fundamental right to control the decisions related to the rendering of their own medical care and that advanced directives are a legally recognized written declaration specifying the person's wishes in directing future care.
075329 02/20/2026
Ingraham Manor Rehab and Nursing 400 N Main St Bristol, CT 06010
however, indicated he/she should have initiated CPR once Resident #1 was identified without pulse
jeopardy to resident health or Nursing Services (DNS) on [DATE] at 3:02 PM identified when a resident with a full code status is safety found without a pulse and respirations, staff should call for help, call a code blue three (3) times over the intercom with the room number and location, and initiate CPR immediately.
The DNS further
admission from the hospital.
Review of the CPR policy directed that CPR would be performed on appropriate residents by CPR certified staff members and that the supervisor or charge nurse would be in charge of providing organization and directives.The facility submitted a Plan of Correction for past noncompliance dated [DATE] which was accepted by the State Agency during an on-site inspection on [DATE] at 5:08 PM.
The Plan of Correction included the following: The facility audited all resident charts to confirm code status was active in the electronic medical record (EMR).Educated all nursing staff on Response to Unresponsive Residents and Code Status, CPR, and a Mock Code was conducted followed by a code debrief on all 3 shifts.A Code Procedure Checklist (competency evaluation) was performed for all licensed staff.Code blue mock drills would be conducted weekly x4 then monthly x3.The Corrective action plan was scheduled for QAPI review on [DATE].
075329 02/20/2026
Ingraham Manor Rehab and Nursing 400 N Main St Bristol, CT 06010
Resident #1's head, tapped his/her face, and called out his/her name but received no response. LPN
further identified there was no stiffness of the extremity or fingers. LPN #2 identified she did not
identified without pulse and respiration, a code should have been called, and EMS activated.Interview with the Director of Nursing Services (DNS) on [DATE] at 3:02 PM identified when a resident with a full code status is found without a pulse and respirations, staff should call for help, call a code blue three (3) times over the intercom with the room number and location, and initiate CPR immediately.
The DNS further indicated that the resident would be considered a full code unless otherwise decided following admission from the hospital.
The DNS identified a physician's order was required for an RNP.
Review of the CPR policy directed that CPR would be performed on appropriate residents by CPR certified staff members and that the supervisor or charge nurse would be in charge of providing organization and directives.The Pronouncement of Death policy identified it was the policy of the facility to permit a Registered Nurse (RN) to make a determination and pronouncement of death when certain conditions, as outlined in the procedures below, have been met.
These procedures included: an attending physician must determine that the prognosis for a patient is for an anticipated death (anticipated death was defined as death which was expected to occur within 120 days due to illness, infirmity, or disease), the physician must document such determination in the patient's medical or clinical record, and the physician must authorize in writing, at the time of determination and documentation, that Registered Nurses in the facility may make a determination and pronouncement of death.