Salmon Brook Rehab And Nursing

F-F689.

Record review failed to identify an RN assessment was conducted following the elopement.

Interview and record review with the DNS, Administrator, and Regional Nurse on 2/19/2025 at 12:50 PM identified staff located Resident #1 outside and was brought to the DNS office. The DNS stated RN #2 completed an RN assessment, however the DNS was unable to provide documentation of the assessment.

The DNS stated RN #2 should have documented the assessment in the clinical record and he did not know why it was not documented.

Interview with RN #2 was not obtained during survey.

Review of the Charting and Documentation policy dated 6/2023 directed the following information was to be documented in the resident medical record: events, incidents or accidents involving the resident and documentation in the medical record will be objective complete, and accurate.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 13 075060 Department of Health & Human Services Printed: 09/07/2025 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 075060 B. Wing 02/27/2025

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

Salmon Brook Rehab and Nursing 72 Salmon Brook Drive Glastonbury, CT 06033

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 0947 Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Level of Harm - Minimal harm or potential for actual harm 50094

Residents Affected - Few Based on facility documentation review and interviews for two of five employee files (NA #2 and NA #3) reviewed for in-service training, the facility failed to ensure the Nurse Aides had 12 hours of annual training.

The findings include:

Review of NA #2 employee file identified NA #2 was hired on 8/10/2023. Additional review identified the only education provided during 2023, 2024 and through 2/27/2025 included Intravenous (IV) therapy education. No additional education, including general orientation education was provided.

Review of NA #3 employee file identified NA #3 was hired on 7/20/2023. Additional review identified NA #3's annual education included education on resident rights, abuse/retaliation, and dementia.

Review of facility employee files for NA #2 and NA #3 failed to identify 12 hours of annual in-service training was provided.

Interview with the DNS on 2/27/2025 at 10:52 AM identified all NAs should have a minimum of 12 hours annual in-service training. The DNS was unable to explain why NA #2 and NA #3 did not have the required 12 hours of annual in-service education training completed since NA #2 and #3 were hired during 2023.

Review of Facility Assessment Tool dated 8/2024 directed annual education was to be completed on the following topics:

Abuse

Resident rights

Confidentiality

Hazard and safety

Blood borne pathogens

Handwashing

Infection control prevention

Disaster and emergency plan

Fire and safety

Resident handling safety

Sexual harassment

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 13 075060 Department of Health & Human Services Printed: 09/07/2025 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 075060 B. Wing 02/27/2025

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

Salmon Brook Rehab and Nursing 72 Salmon Brook Drive Glastonbury, CT 06033

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 0947 Falls and elopement

Level of Harm - Minimal harm or COVID-19 potential for actual harm Proper protective equipment donning and doffing Residents Affected - Few Ongoing education and noted issues with the facility

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 13 075060

F-F947.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 13 075060 Department of Health & Human Services Printed: 09/07/2025 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 075060 B. Wing 02/27/2025

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

Salmon Brook Rehab and Nursing 72 Salmon Brook Drive Glastonbury, CT 06033

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 0835 Based on the deficiencies during the survey, immediate jeopardy and substandard care was identified in the area of Accidents. Level of Harm - Minimal harm or potential for actual harm Interview with the DNS, Administrator and Regional Nurse on 2/27/2025 at 11:11 AM failed to identify a process for administrative oversight of the facility processes for a Governing Body, appointment of the Residents Affected - Few Medical Director, medication storage, notification to the State Agency of reportable events, annual in-service training, annual policy review, physician orders, resident access to unlocked egress from the facilty, and elopement policy/procedure.

The facility failed to utilize resources effectively to attain/maintain the resident's well-being.

No facility policy was provided for review.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 13 075060 Department of Health & Human Services Printed: 09/07/2025 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 075060 B. Wing 02/27/2025

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

Salmon Brook Rehab and Nursing 72 Salmon Brook Drive Glastonbury, CT 06033

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 0837 Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing Level of Harm - Minimal harm or the facility. potential for actual harm 50094 Residents Affected - Few Based on facility documentation, facility record review, and interviews for governing body review, the facility failed to ensure that they had a governing body, or designated persons functioning as a governing body that is legally responsible for establishing and implementing policies regarding the management and operation of

the facility, and failed to ensure the Administrator was appointed by a governing body. The findings include:

Review of facility documentation failed to identify a facility governing body.

Review of the Administrator's employee file failed to identify the Administrator was appointed by the facility governing body.

The review of facility policy and procedure master manual failed to identify an annual review of the facility policies was conducted.

Review of facility Elopement Policy with no date provided on 2/19/2025, and review of facility Elopement Policy dated 6/2023 provided on 2/28/2025 identified the policies did not match.

Interview with the DNS, Administrator, and Regional Nurse on 2/25/2025 at 11:36 AM identified the facility had three (3) Elopement Policies currently in effect, and each policy was different. One (1) policy was from

the emergency preparedness book, one (1) was from the nursing policy book, and the third policy had an unidentified source. Interview failed to identify which policy the staff had been educated on prior to the elopement on 2/18/2025. Although the Administrator worked at the facility since May 2024, and the DNS since October 2024, interview identified the facility policies the Administrator and DNS had not reviewed the policies. Further, although the policies should be reviewed annually, the policies had not been reviewed annually by Medical Staff.

Interview with the DNS, Administrator, and Regional Nurse on 2/27/2025 at 11:11 AM identified the facility did not have a governing body.

Review of facility Governing Body By-Laws (undated) directed the Governing Board is charged with the responsibility to exercise due care and diligence in the overall supervision and management of the organization with the primary focus on the provision for the well-being of the residents entrusted to the facilities care. The Governing Body will meet quarterly.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 13 075060 Department of Health & Human Services Printed: 09/07/2025 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 075060 B. Wing 02/27/2025

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

Salmon Brook Rehab and Nursing 72 Salmon Brook Drive Glastonbury, CT 06033

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 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50094

Residents Affected - Few Based on record review, facility documentation, and staff interviews for one of three residents (Resident #1) reviewed for quality of care, the facility failed to ensure the record was complete and accurate to include an RN assessment following an elopement. The findings include:

Record review identified Resident #1 had a diagnosis of Alzheimer's disease and delusional disorders.

Admission Minimum Data Set (MDS) dated [DATE REDACTED] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition, and ambulated independently. The Resident Care Plan (RCP) dated 1/14/2025 identified an elopement risk/wanderer related to disoriented to place. Interventions directed to distract from wandering by offering diversions, identify patterns of wandering, reorient, and use wander guard bracelet.

Facility reportable event dated 2/18/2025 at 5:00 AM identified Resident #1 was noted to be missing from his/her room at 4:00 AM. Staff were alerted and the building and grounds were searched. The local police,

the Administrator, DNS, responsible party and physician were notified, the police responded, and the search continued. The report further indicated Resident #1 wandered and found him/herself in the dryer/laundry area and was located while police were searching for resident with dust and lint on person. Resident #1 was located at 8:30 AM.

Review of local police report dated 2/18/2025 identified the police were dispatched to the facility at 5:59 AM

on a missing person complaint. At approximately 8:35 AM Resident #1 was observed walking outside near

the rear kitchen entrance/exit and brought inside. Resident #1 was observed to have dryer lint on his/her clothes. The Report indicated the police believed Resident #1 walked outside the rear kitchen exit and entered an unlocked maintenance door to the industrial dryers around the corner. EMS arrived on scene and evaluated Resident #1.

Please cross reference