Village Green Rehabilitation And Healthcare Center

F-F657 No care plan update with development of the stage 1 heel pressure ulcer.

_________________________________

03/10/25 10:22 AM

has an [NAME] on left heel

03/10/25 01:10 PM Observation of the left outer heel with the wound nurse shows intact pink skin left outer heel. tender staff say due to neuropathy, wearing not skid socks no bootie or pressure relief. resident was repositioned by charge and wound nurses.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 40 075198 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 075198 B. Wing 03/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Village Green Rehabilitation and Healthcare Center 23 Fair Street 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 0686 03/11/25 03:07 PM -

Level of Harm - Minimal harm or MDs quarterly 2/1/2025- no pressure ulcer at risk for pressure ulcer, had a clinical assessment potential for actual harm diagnosis- Residents Affected - Few Cerebral infarction, type 2 diabetes, dementia,

Treatment orders-

apply skin prep to left heel q shift

every shift for wound care

Other Active 3/6/2025 15:00

Pressure-redistribution mattress to bed

No directions specified for order.

Other Active 7/26/2024

Non skid footwear for safety

No directions specified for order.

Other Active

Weekly skin checks

Atlas

3/10/25

3/4/25

2/25

2/20/25

2/13/25

genesis

2/6/2025

1/2

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 40 075198 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 075198 B. Wing 03/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Village Green Rehabilitation and Healthcare Center 23 Fair Street 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 0686 1/9

Level of Harm - Minimal harm or 1/16 potential for actual harm 1/23 1/30 Residents Affected - Few 9/23/2024

10/3/24

10/10/24

10/13/24

10/19/24

11/2/14

11/9/24

8/2/24 genesis

Nursing notes

3/10/2025 10:06 Nurses Note (Structured Progress Note)

Nurses Note: [NAME] had a scheduled skin check. The resident has no new skin alterations.

Left heel - pressure 1 resolving treatment in place, Coccyx - masd resolved

Interview with the wound nurse [NAME] and [NAME] the regional RN 3:50 PM on 3/11/2025

Care Plan- not updated with develoment of stage 1 left heel pressure ulcer- air matress not on care plan

Resident at risk for skin breakdown related to________ Type:___________ Location_______ decreased activity , frail fragile skin, impaired Cognition , impaired sensation

has BLE scattered bruising H

At Risk Goal: The resident will not show signs of skin breakdown x __90__ days H

float heels as resident allows

[Nsg] + H

offload or reposition four times a shift

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 40 075198 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 075198 B. Wing 03/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Village Green Rehabilitation and Healthcare Center 23 Fair Street 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 0686 [Nsg] + H

Level of Harm - Minimal harm or Pat (do not rub) skin when drying potential for actual harm [Nsg] H Residents Affected - Few [NAME], [NAME] (48792) (additional information recieved and no longer moving forward)

Based on Resident Record Review, Facility documentation, Facility Policy, and Staff Interviews for the only resident (Resident #46) reviewed for skin conditions, the facility failed to follow their policy for pressure risk assessment frequency.

_______________________________________________________________________________________ ___________________________________________________________________________

03/09/25 01:20 PM Toes on right foot had a hematoma and it is now an open area. No EBP. Observed RN entering room without gowning. Did have gloves on. No signage for EBP

Interview with RN #2 Supervisor:

Q Should this resident be on EBP as he has an open area on his toes?

A: I don't know. I only work here every other Sunday.

Q: Would you expect that any resident requiring dressing changes for open areas to be on EBP?

A: I don't know.

3/10/25 8:30 observation made and resident has EBP signage on door subsequent to surveyor inquiry 3/9/25

Interview with Wound RN #1 Q: yesterday there was no signage for EBP on the door and I noticed you went into the room without gowning. Should he be EBP?

A: I do not know I didn't think so. I will ask the IP.

8:45 AM Wound RN stated that he should have been on EBP and he hasn't been .

Resident at risk for skin breakdown

related to actual skin breakdown Type:

__lesion_________ Location_right dorsal

foot______ decreased activity , frail fragile

skin, impaired sensation, incontinence,

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 40 075198 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 075198 B. Wing 03/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Village Green Rehabilitation and Healthcare Center 23 Fair Street 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 0686 limited mobility, poor safety awareness,

Level of Harm - Minimal harm or skin lesion potential for actual harm Date Initiated: 02/17/2025 Residents Affected - Few Revision on: 02/17/2025

At risk Goal: Resident will

remain free of skin tear and/or

bruising x________90______days

Date Initiated: 02/17/2025

Revision on: 03/04/2025

Target Date: 05/22/2025

At Risk Goal: The resident will

not show signs of skin

breakdown x __90__ days

Date Initiated: 02/17/2025

Revision on: 03/04/2025

Target Date: 05/22/2025

Healing Goal: The resident's

wound /skin impairment will heal

as evidenced by decrease in

size, absence of erythema and

drainage and/or presence of

granulation

X_____90_______days

Date Initiated: 02/17/2025

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 40 075198 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 075198 B. Wing 03/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Village Green Rehabilitation and Healthcare Center 23 Fair Street 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 0686 Revision on: 03/04/2025

Level of Harm - Minimal harm or Target Date: 05/22/2025 potential for actual harm encourage / assist in repositioning/off loading 4xshift as patient allows/tolerates Residents Affected - Few Date Initiated: 02/17/2025

Revision on: 03/01/2025

Nsg

encourage/assist in off loading/heels up 4xshift as patient allows/tolerates

Date Initiated: 02/17/2025

Revision on: 03/01/2025

Nsg

Pat (do not rub) skin when drying

Date Initiated: 02/17/2025

Nsg

Provide patient and/or healthcare decision maker education regarding risk factors

and interventions

Date Initiated: 02/17/2025

Nsg

Provide preventative skin care i.e. lotions, barrier creams as ordered

Date Initiated: 02/17/2025

Nsg

Apply barrier cream with each cleansing

Date Initiated: 02/17/2025

Nsg

Observe skin for signs/symptoms of skin breakdown i.e. redness, cracking,

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 40 075198 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 075198 B. Wing 03/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Village Green Rehabilitation and Healthcare Center 23 Fair Street 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 0686 blistering, decrease sensation, and skin that does not blanche easily

Level of Harm - Minimal harm or Date Initiated: 02/17/2025 potential for actual harm Nsg Residents Affected - Few Evaluate for any localized skin problems, i.e. dryness, redness, pustules,

inflammation

Date Initiated: 02/17/2025

Nsg

Observe skin condition daily with ADL care and report abnormalities

Date Initiated: 02/17/2025

Nsg

Off Load/Float heels while in bed

Date Initiated: 02/17/2025

Revision on: 03/04/2025

LPN

CNA

Weekly skin check by license nurs

Enhanced barreir precautions rlt wound

every shift

Other Active 3/9/2025 15:00

Open area on toes 2/17/25.

Braden Scale completed on 2/13, 2/20, no further assessments found. Per policy should be completed on admission and weekly for the first month. Subsequent to Surveyor Inquiry Braden Scales 2/27 and 3/6 were documented on paper. (computer system down on those days and staff documented on paper)

Weekly skin checks completed 2/20, 2/21, 3/11. Missing 2/28 skin check.

No wound deterioration noted. Wound is healing.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 40 075198 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 075198 B. Wing 03/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Village Green Rehabilitation and Healthcare Center 23 Fair Street 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 0686 Has appointment with Podiatry 3/12/25.

Level of Harm - Minimal harm or 3/12/25 9:15 AM Interview with Wound nurse Q: What is your policy for Braden scales related to frequency? potential for actual harm A: I am not sure I would have to check. Q: I reviewed the policy and it says weekly x 1 month. How about your policy for skin checks? A: They should be weekly on shower day. Q; Resident has had a Braden on Residents Affected - Few 2/13 and 2/20. Were any other Braden Scales completed or risk for pressure ulcer assessments? A: I do not see that there are any other assessment in the record. Q: How do you track when these assessments are due? A: When we were owned by Genesis the MDS would auto-populate to schedule them. Since we became Atlas, they assessments are not auto-populated. I have to talk to the MDS to see if they can be auto-populated again so that we do not miss them.

3/12/25 9:30 AM interview with MDS coordinator. Q: Do you auto-populate Bradens and skin assessments? A: not since we became Atlas. When we were Genesis we did auto populate but we do not now. I am going to talk to the regional to find out if we can start doing that again. I have yet to meet with the Regional MDS person.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 40 075198 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 075198 B. Wing 03/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Village Green Rehabilitation and Healthcare Center 23 Fair Street 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 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 37721 Residents Affected - Few Based on clinical record review, observation, facility documentation, review of facility policy and interviews Note: The nursing home is for 1 of 7 sampled residents (Resident #124) reviewed for accidents, the facility failed to ensure necessary disputing this citation. care and services were immediately sought and provided to ensure Resident # 124 safety and prevent a fall with major injury, when Resident # 124 exhibited a change in condition, subsequently fell out of bed and sustained an eyelid laceration and fracture to the face and failed to ensure the area designated for smoking was free from accident hazards. The findings included:

1. Resident #124's diagnoses included a history of Cerebrovascular Accident (CVA) with right sided hemiparesis/hemiplegia (weakness and paralysis), epilepsy and chronic respiratory failure with tracheostomy (trach).

The admission MDS assessment dated [DATE REDACTED] identified Resident #124 was severely cognitively impaired with a BIMS of 4, required assistance of one with bed mobility, total assistance of two for transfers and toileting.

The care plan dated 5/13/24 identified Resident #124 had impaired cognitive function, required assistance with ADL care, was at risk for falls and at risk for respiratory complications related to the tracheostomy. Interventions included: monitoring changes in cognitive function, providing assist of one with ADL, assistance with two with transfers, to ensure the call bell was within reach, observe/report increased wheezing and lower activity tolerance.

The care card for 6/2024 directed assistance of one for care and for dressing maximal assistance. The resident required partial assistance with mobility.

A Physical Therapy Evaluation and Resident Plan of Care dated 6/13/24 identified Resident #124 was hospitalized [DATE REDACTED] through 6/12/24 for encephalopathy, SIRS (systemic inflammatory response syndrome) and urinary tract infection. Resident #124's functional capacity was determined as moderate assistance of one for rolling (in bed) and maximum (two people) for transfers.

The physician's orders dated 6/14/24 directed to cap the trach as tolerated 8:00 AM to 8:00 PM and add nasal cannula to keep oxygen saturation above 90% every day and evening shift.

A respiratory progress noted dated 6/14/24 identified Resident #124 was stable, capped and placed on nasal cannula 2 l PM (liters per minute) and tolerating well new orders for patient to be capped from 8:00 AM to 8:00 PM as tolerated.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 40 075198 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 075198 B. Wing 03/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Village Green Rehabilitation and Healthcare Center 23 Fair Street 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 A Nurse Practitioner (NP #1) note dated 6/14/24 at 00:00 identified Resident #124 rolled out of bed to ground, and the incident was witnessed by nursing staff. Resident #1 was alert and responded to commands Level of Harm - Actual harm and noted with bleeding from nose and right lower eyelid, with no other visible injury/ bleeding. Oxygen via trach/ mask was 94-97% range (within normal limits), moving upper and lower extremities within baseline Residents Affected - Few and no loss of consciousness. Resident #124 had a previous history of left frontal hemorrhagic stroke resulting in right sided hemiparesis, has a trach, and history of seizure disorder (nursing reported s/he was Note: The nursing home is flapping hands prior to incident). Resident #124 was sent to the emergency department (ED) for a Computed disputing this citation. Tomography CAT(CT) scan, evaluation to rule out an acute injury or fracture complication.

A nurse's note dated 6/14/2024 at 1:25 PM (written by RN #6) identified Resident #124 fell out of bed, sustaining a bloody nose and right cheek bone bleeding was stopped with ice. The NP was aware and completed an assessment. Resident #124 was transferred to the ED for evaluation/ CT scan of the head.

The Inter-Agency Patient Referral Report dated 6/14/24 at 8:57 PM identified Resident #124 was evaluated following a fall. Per Emergency Medical Services (EMS), staff were turning the resident when s/he rolled out of bed.

A CT scan dated 6/14/24 of the facial bones identified severe comminuted fracture or the right maxillary sinus and orbital floor fracture and corneal abrasion.

Resident #124 returned to the facility on [DATE REDACTED] with 2 sutures in the right lower eye with instructions that directed follow-up with the primary care physician and Oral and Maxillofacial Surgery in one week and to continue erythromycin for treatment of the corneal abrasion.

A Safety Report (no date) identified on 6/14/24 after 12:00 PM, a request was made for NA #9 to change Resident #124's brief , gown and bed (while in bed).NA #9 recalled from previous interactions, Resident #124 moved around a lot but was able to turn h/her side to side without difficulty until the last turn when Resident #124 started to flop h/her body around a lot NA #9 went to check if Resident #124 was receiving oxygen when h/her legs began to fall off the bed. NA 9 ran to catch Resident #124 but was too late. Resident #124 fell flat on h/her face. NA #9 then ran out of the room and yelled for help later returning with the nurse.

A Reportable Event Summary dated 6/17/24 identified NA #9 reported during care the resident's body started to flop a lot. NA #9 checked to make sure the resident was receiving oxygen when his/her leg was noted off the side of the bed. NA #9 was unable to catch the resident's leg. The respiratory therapist had previously capped the resident around 12:30 PM. Resident # 124 was transferred to the hospital and later identified with a maxillary sinus fracture and right orbital fracture. The resident received two sutures on the right eye lid.

The care plan was revised to include assistance of two staff who received education on to suspend care if resident anxious or agitated and to ensure the resident is calm before continuing with care, air mattress/bed with bolsters and fracture management.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 40 075198 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 075198 B. Wing 03/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Village Green Rehabilitation and Healthcare Center 23 Fair Street 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 An interview with RN #6 on 3/11/25 at 9:24 AM identified h/she was the assigned nursing supervisor on 6/14/25 during the 7:00 AM to 3:00 PM shift at the time RN #6 was called to Resident #124's room with a Level of Harm - Actual harm report of a fall out of bed. Although unclear of all the details, RN #6 indicated Resident #124 was new to having h/her trach capped and started moving around a lot in bed while NA #9 who was finishing a complete Residents Affected - Few bed change. The RN# 6 identified Resident # 124 was moving around a lot, perhaps in discomfort from being new to capping. NA #9, who was on the other side of the bed, left the side of the bed to check Resident Note: The nursing home is #124's oxygen on the opposite side. During that moment Resident #124's legs started falling off the side of disputing this citation. the bed and gravity took over and Resident #124 fell out of bed. RN #6 further identified Resident #124 used enable rails to assist with positioning and normally would have been able to assist with positioning.

An interview with the Director of Nursing Services (DNS) on 3/11/25 at 10:58 AM identified NA #9 was at the top of the bed between the wall and head of bed completing a bed change for Resident #124 when s/he observed Resident #124 moving around a lot and in questionable distress. The DNS identified the root cause of the fall was NA #9 not calling for help when Resident #124 began moving around and showing questionable signs of distress and being unable to intervene when his/her legs began to fall off the side of

the bed while focusing her attention on oxygen equipment. Education was subsequently provided to stop and call for the nurse for a questionable change of condition.

An interview with the Medical Director on 3/11/25 at 12:09 PM identified the nurse aide should have called for help for any change of condition and focused on the resident while providing care.

An interview with the Director of Rehabilitation on 3/14/25 at 10:19 AM identified while Resident #124 could normally assist with positioning side to side with the use of enabler bars, any change of condition could compromise h/her ability to do so. The nurse aides should be calling for help if a resident was experiencing a questionable change of condition. Additionally, the Director of Rehabilitation indicated the nurse aides should not be at the head of the bed between the wall and bed when providing care and instead at the side of the bed. NA #9 would not have been able to effectively intervene to prevent a fall if she was at the head of the bed.

Although requested, a policy for nurse aide reporting of a change of condition was not provided.

Attempts to interview NA #9, who is no longer employed at the facility, were unsuccessful.

2. A review of the facility smoking list identified (4) residents, Resident # 16, Resident #18, Resident #41 and Resident #125 actively smoked.

An observation on 3/11/25 at 9:04 AM identified a canopy set up in the designated smoking area. The top of

the canopy cover was made up of cloth like material. The label directed to keep away from all flames.

An interview with the Director of Maintenance on 3/11/25 at 9:14 AM identified the canopy was placed the evening before as a replacement to the previous canopy damaged in the storm.

The canopy was subsequently removed after surveyor inquiry with a plan to research adequate accommodations for the designated smoking area.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 40 075198 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 075198 B. Wing 03/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Village Green Rehabilitation and Healthcare Center 23 Fair Street 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 A review of the manufacturer guidelines related to safety directed to keep all flame and heat sources away from the tent fabric. The tent may burn if left in continuous contact with any flame source. Level of Harm - Actual harm Although requested, a facility policy for ensuring a safe environment was not provided. Residents Affected - Few 46046 Note: The nursing home is disputing this citation.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 40 075198 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 075198 B. Wing 03/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Village Green Rehabilitation and Healthcare Center 23 Fair Street 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 0693 Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46046

Residents Affected - Few Based on clinical record review and interviews for the only resident reviewed for tube feeding (Resident #224), the facility failed to ensure staff obtained a treatment order indicating the location where the treatment Note: The nursing home is should be applied. The findings include: disputing this citation. Resident #224's diagnoses included dysphagia and gastrostomy (G-tube) status.

A physician's order dated 1/14/2025 directed to cleanse site daily with normal saline, pat dry, apply Bacitracin and cover with a dressing every day and as needed. However, the physician's order failed to identify the location or site for the application of the treatment.

The care plan dated 1/17/2025 indicated Resident #224 had an enteral feeding tube. Interventions included: to keep the head of the bed elevated 30-45 degrees during feeding, to monitor for changed in the gastrointestinal status, to monitor the skin surrounding the gastrostomy tube site and provide skin care and dressing change as ordered.

The Admission Minimum Data Set (MDS) assessment dated [DATE REDACTED] indicated Resident #224 was cognitively intact and had a mechanically altered diet.

A clinical record review and interview with RN #4 (DNS) on 3/12/25 at 12:24 PM indicated the order was missing the location of the treatment and staff should not assume the location is the G-tube site. The DNS further indicated she/he would clarify the order.

After surveyor inquiry, a physician's order dated 3/13/2025 indicated to apply Bactroban external ointment 2% to the G tube site after cleansing with normal saline, applying calcium alginate and a split gauze dressing every evening and as needed if soiled or dislodged.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 40 075198 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 075198 B. Wing 03/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Village Green Rehabilitation and Healthcare Center 23 Fair Street 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 0695 Provide safe and appropriate respiratory care for a resident when needed.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46046 potential for actual harm Based on observations, review of facility policy and interviews for 1 of 4 residents ( Resident # 224) reviewed Residents Affected - Few for Respiratory Care, the facility failed to ensure staff notified the physician with a change of condition and obtained orders for an invasive procedure and failed to maintain an easily accessible, organized emergency equipment area at the resident's bedside. The findings included:

Resident #224's diagnoses included Chronic Obstructive Pulmonary Disease (COPD), pneumonia and acute respiratory failure and neoplasm of the larynx.

1. a. A physician's order dated 1/14/2025 directed to provide Oxygen at 3 liters per minute via a trach mask (a mask that covers and provides oxygen through Resident #224's tracheostomy stoma site located in the neck area) with 28% humidification at bedtime and off in the AM.

The care plan dated 1/17/2025 indicated Resident #224 was at risk for Multiple Drug-Resistant Organisms (MDRO) due to having a tracheostomy. An intervention directed to maintain Enhanced Barrier precautions.

The Admission Minimum Data Set (MDS) assessment dated [DATE REDACTED] indicated Resident #224 was cognitively intact required oxygen therapy, no suctioning and no tracheostomy care.

An after hours encounter document dated 2/16/2025 with no time indicated Resident #224 had rhonchi sounds in the lungs and the plan was to obtain a stat chest x-ray and laboratory work had already been ordered for the morning.

A nursing progress note dated 2/16/2025 at 9:07 PM indicated Resident #224 was complaining of a new cough with breath sounds decreased in the based and congestion was noted in the upper lobes. The on-call provider was notified and an ordered was obtained for a stat chest x-ray and indicated the responsible party was notified of the change.

An after-hours telehealth consult dated 2/17/2025 at 1:00 AM indicated in part the encounter was for a follow up on the resident's chest x-ray results which showed a mild left lower lobe infiltrate improved from moderate infiltrates on 12/29/2024. The plan directed follow up with the day provider/team for antibiotic selection, continue monitoring and follow up as needed and notify physician with any changes or problems.

A nursing progress note dated 2/17/2025 at 6:52 PM indicated Resident #224 complained of having difficulty breathing, had heavy secretions, and the respiratory therapist suction the resident and provided Resident#224 with a respiratory treatment.

A nursing progress note dated 2/17/2025 at 10:23 PM identified spoke with responsible party concerning vital signs, chest x-ray, laboratory work, and overall status. The responsible party initially indicated wanting resident to be sent to the hospital but after further discussion agreed to the provider decision to treat within

the facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 40 075198 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 075198 B. Wing 03/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Village Green Rehabilitation and Healthcare Center 23 Fair Street 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 0695 A provider note dated 2/18/2025 at 00:00 indicated in part Resident #224 was being seen for increased congestion and respiratory secretions, laboratory work (white blood cells normal) the repeat chest x-ray Level of Harm - Minimal harm or showed improvement from prior chest x-ray in December 2024. Having completed intravenous antibiotics on potential for actual harm 2/4/2025 for a Multi Drug Resistant Bacteremia. Additionally, the provider noted identified observation of the skin at the trach site was noted with moisture associated skin disorder and thick yellowish phlegm. The Residents Affected - Few assessment and plan indicated the congestion, and increased secretion was stable and to continue supportive care. The plan of care was discussed with the responsible party who was in agreement.

A nursing progress note dated 2/19/2025 at 2:08 PM indicated Resident #224 was suctioned once for thick green mucous.

A social service note dated 2/20/2025 at 11:47 AM indicated the repsonsible party/ family came to the facility and spoke with (APRN #1) and the charge nurse( LPN #11) and requested Resident #224 be sent to the hospital.

A Transfer to Hospital Summary Note dated 2/20/2025 at 11:34 AM indicated Resident #224 was transferred to the hospital at 11:30 AM.

A physician order dated 3/10/2025 directed to suction resident as needed for increased secretions.

An interview on 3/12/2025 at 12:13 PM with APRN #1 identified s/he had seen Resident #224 on Tuesday 2/18/2025 and the note had indicated thick yellowish phlegm and was notified by staff Resident #224 needed to be suctioned on 2/19/2025 secondary to thick green mucous (phlegm). APRN #1 indicated she/he was not working Wednesday but would have expected nursing to have notified the physician with a change of condition per protocol. APRN #1 further indicated she/he did not examine Resident #224 on 2/20/2025 but was notified of the change, and the responsible party wanting to send to the resident to the hospital which she/he was in agreement to transfer to the hospital.

The facility policy labeled Change in condition: Notification date 4/15/2024 indicated the facility staff immediately inform the resident, consult with the resident's provider and notify the responsible party when

the following, in part occurs; a deterioration in the resident's physical, mental, or psychological status that is

a life-threatening condition or clinical complications, or a need to alter treatment.

b. An interview with LPN #11 on 3/12/2025 at 2:18 PM identified not being aware there was no physician's order to suction Resident #224 on 2/19/2025. She/he, may have updated the nursing supervisor of the need to suction Resident #224 for thick green mucous and indicated everyone knew Resident #224 was sick.

An interview and record review on 3/11/2025 at 11:18 AM with RN #4 Director of Nursing Services (DNS), indicated on 2/19/2025 there was no physician's order to suction Resident #224 found in the medical record.

The DNS further indicated if the resident required suctioning and the color of the sputum changed the nursing supervisor, and the physician should have been notified of the change in condition.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 40 075198 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 075198 B. Wing 03/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Village Green Rehabilitation and Healthcare Center 23 Fair Street 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 0695 An interview on 3/19/2025 at 2:12 PM with the nursing supervisor, RN # 8 on duty 2/19/2025 7-3 PM shift identified she/he was not asked by LPN #11 to see Resident #224. RN # 8 indicated she/he did not notify the Level of Harm - Minimal harm or physician of any changes during the shift. potential for actual harm

The facility policy and procedure labeled Tracheostomy Suctioning dated 4/15/2025 indicated in part to verify Residents Affected - Few the provider order for suctioning and to notify provider of abnormally thick, copious, malodorous, or blood-tinged secretions.

2. An observation on 3/9/2025 at 10:45 AM identified an open cardboard box of treatment supplies that had another open box both containing treatment supplies, was on the floor next to Resident #224's right side of

the bed. Behind the boxes on the floor was a table with one shelf area. The tabletop had a suction machine

on its top along with an open undated bottle of sterile water and a green hospital belongings bag which had

an opened trach mask with attached tubing. Two containers of a topical moisturizing cream were on the tabletop in front of the suction machine, an open box to its right contained one suctioning kit. The shelf under

the tabletop had various items and behind them was another Ambu bag. The bedside chair next to the table had a bag containing another Ambu bag. While reviewing the physician's orders no order for suctioning was noted.

An observation and interview with RN #7 on 3/11/2025 at 3:55 with the Administrator and SW #1 present identified an adaptive type of wheelchair and a walker in front of two open cardboard boxes on the floor which were in front of a table with a suction machine on top and other items on the tabletop and the shelf below and a bedside chair to its right in disarray. RN #7 indicated s/he would move the chair and walker to gain access to the emergency equipment, and at which time identified the open boxes on the floor were treatment supplies for Resident #224 that should not be on the floor and indicated she/he would obtain a bin to organize them. RN #7 further indicated upon opening a green hospital bag on the shelf of the table that contained an open trach mask attached to some tubing which required disposal. RN #7 further indicated another item on the back of the shelf was an Ambu bag (Used to provide breaths in the event of an emergency requiring breathing to be conducted manually) and another Ambu bag. The administrator indicated RN #7 would arrange the supplies and table for ease of use.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 40 075198 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 075198 B. Wing 03/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Village Green Rehabilitation and Healthcare Center 23 Fair Street 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 0726 Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46040

Residents Affected - Few Based on review of facility documentation, facility policy review and interview for 4 of 4 Nurse Aides(NA) ( Nurse Aides #1, # 2 # 3 and # 4), the facility failed to ensure that annual competencies were completed for nurse aide staff for 2023 and 2024. The findings include:

Review of a facility employee listing provided to the survey team upon entrance to the facility as part of an annual recertification survey identified NA #3 had a hire date of 10/2/2000, NA #4 had a hire date of 7/3/12, and NA #2 had a hire date of 12/12/23.

During a review of annual competencies for facility nurse aide staff for 2023, the facility failed to provide any documentation of annual competencies for 2023 completed for NA #3. Further review of the annual competencies for 2024 failed to identify any competencies for NA #2 and NA #4.

Interview with LPN #1 (Infection Control Nurse) on 3/12/25 at 12:00 PM identified the facility did not have a dedicated staff development nurse and the DNS, who was unavailable to speak with during the survey, was responsible for ensuring that all nursing staff completed annual in services, education clinical competencies. LPN #1 identified she was unable to locate any documentation or tracking sheets to show the dates and years nurse aides completed annual competencies but was in the process of attempting to locate documentation. LPN #1 also identified the facility was in the process of changing ownership, and that a regional staff development nurse from the new owner would be taking over education and competencies until

a permanent staff development nurse was hired. LPN #1 identified that all nursing staff, including nurse aides, were expected to complete in services and clinical competencies at least annually.

The facility clinical competency validation checklist for 2023/2024 directed that nurse aide competencies included hand hygiene, personal protective equipment (PPE) donning and doffing, Foley care, intake and output monitoring, gait belt use, peri care, oral care, and oral vent care.

The Facility assessment dated ,d+[DATE REDACTED] directed that education, in services, mandatory inservices, and vital learning would be used for staff competencies and education, and topics would include infection control protocols, hand hygiene competencies, Covid signs/symptoms, cleaning of equipment and PPE donning and doffing. The Facility Assessment also directed that staff training and competencies were necessary to provide the level and types of care needed for the facility resident population.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 40 075198 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 075198 B. Wing 03/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Village Green Rehabilitation and Healthcare Center 23 Fair Street 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 - Minimal harm or 46040 potential for actual harm Based on review of employee files, facility documentation review, and facility policy review and interviews, Residents Affected - Few the facility failed to ensure annual performance evaluations were completed for nurse aide staff for 2023 and 2024. The findings included:

Review of a facility employee listing provided to the survey team upon entrance to the facility as part of an annual recertification survey identified NA #3 had a hire date of 10/2/2000, NA #4 had a hire date of 7/3/12, and NA #2 had a hire date of 12/12/23.

A review of annual performance evaluations for facility nurse aide staff for 2023, the facility failed to provide any documentation of annual performance evaluations for completed for NA #3 and NA #4.

A review of annual performance evaluations for facility nurse aide staff for 2024, the facility failed to provide any documentation of annual performance evaluations for completed for NA #2 and NA #4.

Interview with the Director of HR on 3/12/25 at 11:05 AM identified she was responsible for notifying the DNS of the facility when nursing staff had performance evaluations that were due to be done. The Director of HR identified she kept this information on an excel document which she saved to her computer and that when

she did a monthly review of the document, she would then provide the DNS the names and performance evaluation paperwork to complete for each employee. Following a request to see the document to determine when the evaluations for NA #2, NA #3 and NA #4 were due, the Director of HR then identified she had gotten behind in updating the document due to her workload and declined to provide any documentation.

The Director of HR identified that the DNS did not keep any track of evaluations that were due and it was her responsibility to notify the DNS. The Director of HR identified that performance evaluations were to be done at 30 days, 90 days, and then annually thereafter.

Although requested, the facility failed to provide any polices related to annual performance evaluations.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 40 075198 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 075198 B. Wing 03/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Village Green Rehabilitation and Healthcare Center 23 Fair Street 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 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46046 potential for actual harm Based on review of the clinical record, observation, facility policy and interviews for the only resident Residents Affected - Few reviewed for skin conditions (Resident #46) and the only resident (Resident #224) reviewed for tube feeding,

the facility failed to follow the Enhanced Barrier Precautions guidelines. The findings include:

1. Resident #46's diagnoses included Venous Insufficiency, edema, essential hypertension.

The Resident Care Plan dated 2/17/25 identified the resident had a lesion on his/her right dorsal foot. Interventions included weekly skin checks by licensed nurses, and floating heels while in bed.

The admission Minimum Data Set assessment dated [DATE REDACTED] identified Resident #46 was cognitively intact and required maximum assistance with showering, toileting, and required moderate assistance with personal hygiene.

A physician's order dated 3/9/2025 directed to place resident on enhanced barrier precautions every shift secondary to a wound.

A physician's note dated 2/14/25 at 7:56 AM written by Medical Doctor (MD #2) identified Resident #46 had

an abscess like lesion to foot and needed a follow up with a podiatrist for possible identification.

Observation and interview with RN #2 (supervisor) on 3/9/25 at 1:20 PM identified there was no EBP signage

on the resident's door and the Wound Care Nurse was completing a dressing change. RN #2 identified that there was no signage on the door and further stated she was unsure if the resident should be on EBP as she only works every other Sunday. When asked if she would expect a resident with an open wound to be on EBP, RN # 2 indicated she did not know.

Observation on 3/10/25 at 8:30 AM identified EBP signage on the resident's door After surveyor inquiry.

In an interview with Wound Care Nurse on 3/10/25 at 8:30 AM indicated she was unsure if the resident should be on EBP, and she would speak to the Infection Control Preventionist (ICP). At 8:45 AM the Wound Nurses confirmed that the resident should have been on EBP and has not been as per the ICP.

Review of the facility policy, Enhanced Barrier Precautions, dated 1/8/24 presently in effect, directed, in part

the purpose was to reduce the risk of transmission of epidemiologically important microorganisms by direct or indirect contact.

2. Resident #224's diagnoses included dysphagia and gastrostomy status.

A physician's order dated 1/14/2025 directed to provide enhanced barrier precautions.

A physician's order dated 1/14/2025 directed to cleanse site daily with normal saline, pat dry, apply Bacitracin and cover with a dressing every day and as needed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 40 075198 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 075198 B. Wing 03/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Village Green Rehabilitation and Healthcare Center 23 Fair Street 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 0880 The care plan dated 1/17/2025 indicated Resident #224 had an enteral feeding tube. Interventions included : to keep the head of the bed elevated 30-45 degrees during feeding, to monitor for changed in the Level of Harm - Minimal harm or gastrointestinal status, to monitor the skin surrounding the gastrostomy tube site and provide skin care and potential for actual harm dressing change as ordered.

Residents Affected - Few The Admission Minimum Data Set (MDS) assessment dated [DATE REDACTED] indicated Resident #224 was cognitively intact and had a mechanically altered diet.

An interview with LPN #11 on 3/10/2025 at 1:19 PM indicated Resident #224 had yet to change the gastrostomy tube dressing. LPN #11 further indicated Resident #224 may refuse to have the dressing changed since it was changed on 3/9/3035 at 10:00 PM. The surveyor went in to see Resident # 224 and the state Ombudsman Person was present. Resident #224 agreed to having the dressing changed, the surveyor was to observe process after the resident visit with the Ombudsman .

An observation and interview with LPN #11 on 3/10/25 at 01:30 PM for the daily gastrostomy tube (G-tube) site care and dressing change. LPN #11 ( charge nurse) on the unit, entered Resident #224's room bringing

a box of gloves and treatment supplies. After applying the gloves, the bedside table was cleansed with a bleach wipe, a clean protective covering was placed on the table along with the supplies ordered and a trash bag, the gloves were removed, and hand hygiene was conducted before applying clean gloves. The old dressing dated 2025 at 10:00 PM was removed from around the G-tube site noting a small to moderate amount of tan drainage, no surrounding redness and skin intact, LPN #11 indicated it was tube feeding on

the dressing and placed it into a trash bag, the gloves were removed, hand hygiene conducted, new gloves applied, and the G-tube site care and dressing was conducted as ordered. The new dressing was dated with

the date and time. Resident #224 indicated the drainage had increased over time and the area surrounding area has increased tenderness. LPN #11 indicated s/he would notify the APRN to evaluate Resident #224's concern. After all items were bagged and the tabletop cleansed with a bleach wipe and resident items placed within reach LPN #11 and the surveyor exited the room and noted a large, opened box sitting on a white bin with drawers next to a tall cart with items on the right side of Resident #224's room. Behind the open boxed lid was a sign labeled Enhanced Barrier Precautions. When asked which resident did this apply to and should LPN #11 have donned a gown in addition to wearing gloves while providing a dressing change to Resident #224. LPN #11 indicated s/he should have worn a gown during the dressing change.

An interview and observation of the blocked enhanced barrier signage with RN #4( Director of Nursing Services) outside Resident #224's room on 3/11 2025 at 2:00 PM identified LPN #11 should have worn a gown and RN #4 would ensure the signage and the personal protective equipment bin was visible.

The facility policy labeled Enhanced Barrier Precautions dated 4/15/2025 indicated in part the purpose of Enhanced Barrier Precautions is to reduce the risk of transmission of epidemiologically important microorganisms by direct or indirect contact.

48792

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 40 075198 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 075198 B. Wing 03/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Village Green Rehabilitation and Healthcare Center 23 Fair Street 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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48880 potential for actual harm Based on clinical record reviews, observations, review of facility policy and interviews for 2 of 5 ( Residents # Residents Affected - Few 40 and # 325) reviewed for the environment,, the facility did not ensure that residents call bell were within reach. The findings included:

1. Resident #40 was admitted to the facility on [DATE REDACTED] with diagnoses that included a neurological disorder and dependence on a ventilator.

A care plan dated [DATE REDACTED] indicated Resident #40 was at risk for alteration in comfort related to chronic pain. Interventions included advising the resident to request pain medication before the pain becomes severe. The care plan also indicated the resident had an Advanced Directive to perform Cardio CPR during an emergency.

The quarterly MDS assessment dated [DATE REDACTED] indicated the resident had severe cognitive impairment, usually understood others. The MDS assessment further indicated the resident required substantial/maximal assistance with mobility and was dependent on personal hygiene and toileting.

An observation in Resident #40's room on [DATE REDACTED] at 11:48 AM identified Resident #40 was connected to a ventilator and the call bell was not within the resident's reach. The call bell was on the tray table next to the bed two feet away. The resident was observed to not be able to move arms up. During the observation, Resident #40 was mouthing words and asked the surveyor for pain medication for his/her neck. LPN #7 was called in to assist. An interview with LPN#7 indicated Resident #40 was able to use the call bell and the bell should have been within the resident's reach.

2. Resident #325 was admitted to the facility on [DATE REDACTED] with diagnoses that included dependence on a ventilator and muscle weakness.

An Admission Assessment by recreation identified Resident #325 was alert and was able to make their needs known to staff. The assessment also indicated the resident was able to answer yes/no questions, write some words, and mouth words.

An observation in Resident #325's room on [DATE REDACTED] at 12:50 PM identified the resident was connected to a ventilator and Resident # 325's call bell was on the floor next to the bed. NA#4 was called in to assist. An

interview with NA#4 indicated she was not familiar with the resident's ability to call since the resident was new to the facility. NA#4 also indicated the resident should have had the call bell clipped to his/her sheets. NA#4 then proceeded to clip the call bell to the sheets, and Resident #325 was asked to test the button. Although Resident #325 held the call bell in his/her hand and attempted to push the button with his/her thumb, the resident was unable to push the button fully to activate the call bell. NA#4 further indicated the resident might benefit from a blue call bell, which is an adaptive call bell that is easier to push.

The facility policy for call lights identified that all residents would have a call light or alternative communication device within their reach at all times when unattended.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 40 075198 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 075198 B. Wing 03/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Village Green Rehabilitation and Healthcare Center 23 Fair Street 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 0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46046

Residents Affected - Few Based on clinical record reviews, observations, review of facility documents, review of policy and interviews,

the facility failed to ensure 2 therapeutic modality machines in the Therapy Department had been evaluated annually for safety in 2022 and 2023 and for 1 of 4 residents ( Resident # 8) reviewed for Respiratory Care,

the facility failed to ensure signage was on a resident's door to indicate oxygen was in use. The findings included:

1. An observation on 3/11/2025 starting at 2:00PM and ending at 3:15 PM of the Therapy Department that uses the same room and equipment for residents in the facility and for outpatient physical therapy. Further

observations identified the therapy modality machines was without stickers to indicated when was the last time the machine had been evaluated for safety.

An interview with the Maintenance Director on 3/11/2025 at 3:15 PM indicated she/he could not find stickers

on either modality machine of when the last safety evaluation was conducted and indicated she/he would look at the service documents and provide an update to the surveyor.

An interview and document review with the Maintenance Director on 3/11/2025 at 4:15 PM indicated she/he could provide service documents for the evaluation of the modality machines for 2023 or 2024. After surveyor inquiry, the Maintenance Director called the equipment servicing company who indicated they would be out in the following week to service the two machines. The Maintenance Director removed both machines were locked up and out of the area until they could be serviced.

2. Resident #8 's diagnoses included Chronic Obstructive Pulmonary Disease ( COPD), Congestive Heart Failure and anxiety.

The care plan dated 1/17/25 identified Congestive Heart Failure. Interventions included to administer Oxygen as ordered.

A physician's order dated 1/17/25 directed Oxygen to be set at 3-5 liters via Nasal Cannula continuously.

The admission Minimum Data Set (MDS) assessment dated [DATE REDACTED] identified Resident #8 was cognitive intact and required maximal assistance with personal care and supervision/ touching assistance with bed mobility and transfers. The MDS also indicated Resident #8 experiences shortness of breath or trouble breathing with exertion and shortness of breath when lying flat.

Observations on 3/9/25 at 10:50 AM, identified Resident #8 in his/her room using Oxygen. There was no sign posted outside of the resident's room indicating oxygen was in use.

Interview with LPN #3 on 3/9/25 at 11:15 AM identifed she is unsure why the oxygen in use sign was not up and stated the maintenance is usually responsible for putting up signs. LPN #3 further indicated she would bring this matter to maintenance attention.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 40 075198 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 075198 B. Wing 03/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Village Green Rehabilitation and Healthcare Center 23 Fair Street 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 0921 Interview with the Maintenance Director on 3/9/25 at 11:17 AM identified nursing staff typically handles ensuring resident who require signs are put up. Level of Harm - Minimal harm or potential for actual harm After surveyor inquiry, on 3/9/25 at 1:30 PM LPN #3 identifed that an oxygen in use sign has been placed outside resident's room. Residents Affected - Few Per facilities Oxygen High Pressure Cylinders (reviewed 12/16/24) section 1.3 in part indicated A No smoking- Oxygen in use sign must be posted in any area where high pressure cylinders are stored.

49100

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 40 075198

F-F686 Based on clinical record review interviews and facility policy for 1 of 6 Residents reviewed for Pressure ulcer (#24), the facility failed to ensure staff completed weekly skin checks consistently, completed skin risk assessments quarterly or with change of condition and documented notification of the physician and responsible party with a new change in skin status. The findings include:

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