Gardner Heights Health Care Center, Inc

note why she didn't see it was the left foot instead of the right, when she responded that it did not dawn on her at the time.

Review of the weekly wound report documentation failed to identify Resident #56's right great toe was thoroughly assessed/monitored and documented on weekly from the date it was discovered, 4/1/26 through 4/22/26.Interview on 4/24/26 at 11:53 AM with LPN #2 in the presence of the DNS, the ADNS and RN #1 identified wounds including skin discoloration are seen weekly by the wound care APRN and the wound nurse and is documented on until the area is resolved.

LPN #2 identified she was unaware of the area to the right great toe so there was no weekly documentation or monitoring completed.

Review of the Wound and Skin Care Protocol policy identified skin areas will have weekly documentation until healed, and wounds will be reviewed at the weekly at risk meeting utilizing the skin and pressure ulcer tracking sheet.

Review of the physician order for the period of April 7, 2026, through April 22, 2026, failed to identify a treatment directing care of the wound to the right great toe.Interview on 4/24/26 at 11:53 AM with LPN #2 in the presence of the DNS, the ADNS and RN #1 identified she had deleted the current treatment for the right great toe on 4/7/26 when the resident was first seen by APRN #1 and the new order for the left second toe was entered into the electronic medical record. LPN #2 identified she had made a mistake as the order had stated right great toe when she discontinued the order.

Review of the Wound and Skin Care Protocol policy identified residents are assessed by the nurse for risk of skin breakdown.

Weekly body audits will be completed on bath/shower day by a licensed nurse.

The policy further identified skin areas will have weekly documentation until healed.

075368 04/27/2026

Gardner Heights Health Care Center, Inc 172 Rocky Rest Road Shelton, CT 06484

that she should have let the nurse know when she had noticed the length of the toenails.

Interview with APRN #1 (Wound care Specialist) on 4/22/26 at 2:46PM identified a resident with diabetes should automatically have an order for daily diabetic foot checks.

When asked what are the complications that could occur if toenails are not trimmed and she responded it could lead to skin break down, infections and ingrown nails.

Interview with the Charge Nurse LPN #5 on 4/23/26 at 3:20 PM identified she completes weekly skin check on the resident's shower days which includes checking the resident's nails, and when an issue is identified with the skin, she would then write a progress note.

She further identified that they knew about Resident #56's toenail. LPN #5 further identified she could not recall seeing the length of his/her toenail, nor could she recall if any of the nurse aide told her about the resident's toenail.

She indicated that if she was told about a resident toenail needing to be trimmed, she would report it to the nursing supervisor and could not recall if she did.

Interview with Person #1 (Senior Account Manager for the contracted service provider that is used by the facility for ancillary services) on 4/23/26 at 11:29 AM identified for a resident to be enrolled in podiatry services the facility would only need to send over the resident's face sheet and the completed physician order form provided by their company by indicating the services in which the resident need.

After these documents are received the resident will automatically be added to the list to be seen by the provider on their next visit to the facility.

She further identified Resident #56 was enrolled in podiatry on 3/13/26 and was not added to the list of residents to be seen on 3/18/26 as the podiatrist list was full at the time, hence the resident was placed on the May 11, 2026, list.

She further identified if a resident had a greater need to be seen by the podiatrist the facility would need to let the podiatrist know before the visit or at the time of the visit, so they could be seen.

Interview with the ADNS, LPN #2, in the presence of the DNS and RN #1 on 4/24/26 at 11:53 AM identified Resident #56 toenails would be a priority to be seen by the podiatrist immediately.

However, they failed to identify that the podiatrist was made aware of the resident urgent need on 3/13/26, and at the time of the podiatrist visit on 3/18/26 and after.

The ADNS identified she contacted the contracted company again on 4/1/25 when the resident was noted to have a darkened area with a small opening to the side of the right great toe and sent over the company's physician order form.

Review of the Ancillary Services policy identified ancillary services include, but are not limited to, podiatry, dentistry, optometry, audiology, and other specialized care as required by the resident's condition.

The policy further identifies the resident's ancillary service needs will be evaluated during admission and as part of ongoing assessments by the interdisciplinary care team and primary physician.

075368 04/27/2026

Gardner Heights Health Care Center, Inc 172 Rocky Rest Road Shelton, CT 06484

on days and evenings and 1:40 on nights and ratio of direct care staff (NAs) of 1:8-10 on days, 1:10-15 on evenings and 1:20-25 on nights.

Review of the facility schedule dated 4/13/26 (Monday) identified that the ADNS and the DNS were pulled from their positions to staff units in the facility.

However, review of the DNS time sheet for the week identified hours worked on 4/13/26 (Monday) indicated the time worked 7:30 AM to 5:00 PM was identified as DNS hours and not RN supervisor hours.Interview with the DNS on 4/27/26 at 12:32 PM identified that she denotes on her time card what position she held for the designated day of work.

The DNS indicated that if she worked something other than as the DNS, it would be written in on the time sheet.

The DNS could not recall her main duties on 4/13/26.

Interview with the Human Resources Dir (HR) and the Administrator on 4/24/26 at 10:58 AM identified HR was responsible for submitting the PBJ staffing (which indicated the facility had low weekend staffing October through December 2025. HR indicated she had a staffing form that she used to confirm adequate staffing.

The Administrator identified the form as an old form and left the office to get an updated form. HR put the form away and did not provide a copy for me.Interview with the scheduler on 4/24/26 at 11:10 AM identified she fills the schedule according to direction from the administrator.

The scheduler indicated she did not figure out staffing based on hourly requirements according to census but followed direction from the Administrator.

The scheduler was not aware of how many hours per resident were needed to staff Licensed staff nor NA staff.

Interview with the Administrator on 11/19/24 at 1:48 PM identified he is aware of the 3.0 staffing requirements. He indicated that the high staffing turnover in the facility was the cause of the facility not being able to meet the staffing requirements.

The Administrator further identified that the facility's policy was the 3.0 staffing requirements were provided by corporate but could not identify if the corporate guidance reflected requirements, and indicated staffing assignments were based on acuity.Interview with the Administrator on 4/27/26 at 12:44 PM identified that both SW#1 and SW#2 had BS in Human Services.

The Administrator indicated she was aware of the 3.0 staffing and was looking for the direction for staffing received from corporate and was not familiar with the hours per resident required for staffing.

Interview with HR on 4/27/26 at 12:35 PM identified she was responsible for submitting the PBJ staffing but could not identify if the facility was short on staffing.

The HR indicated if they are short, the ADM might get an email.Interview with NA#3, NA#4, NA#5 and NA#6 on 4/27/26 between 2:07 PM and 2:20 PM identified that, at times, NA assignments included more than 10 residents per NA.

All of the NA's identified that the assignments kept them busy throughout the day, they could use additional NAs, they identified good teamwork and the ability to manage the resident load.Interview with ADM on 4/27/26 at 2:25 PM identified she did not know what the facility staffing compliance grid was based on and indicated that was what the facility followed for staffing and was directed from corporate and would need to be reviewed.

075368 04/27/2026

Gardner Heights Health Care Center, Inc 172 Rocky Rest Road Shelton, CT 06484

side of the building after entering through the front door.

The unit consisted of two entrance doors accessible from the inside of the facility that required a numeric code to be entered to enter or exit the unit.

Inside the unit, there were four additional doors to exit the unit.

One door required a numeric code to exit and exited into an internal courtyard.

One door required a numeric code to exit and exited outside the rear of the building.

Two doors, which were one door into a vestibule containing another door, required a numeric code to exit or enter. To come back into the building the interior door had an entrance button, not a numeric code to come back in.

The exterior doors were confirmed to have a delayed, alarmed egress in the event of an emergency.

The unit consisted of three hallways with cameras that fed to a monitor at the secured unit nurses' station.

The unit capacity was 35 residents.Observations on all days of the survey 4/20, 4/21, 4/22, 4/23, 4/24 and 4/27/26 identified sensors on the walls in the hallways and near exit doors throughout the entire building identified as sensors to support the wanderguard system for wandering residents.

The system was confirmed to be working.Review of facility documentation identified criteria for admission to a secured dementia unit that included a diagnosis of dementia and behaviors, elopement or wandering, that required closer supervision for safety.

Review of the facility assessment dated [DATE] identified the number of licensed beds was 130 and served residents with common diagnoses that included Alzheimer's disease, non-Alzheimer's dementia, impaired cognition and other behaviors that require intervention.

The assessment indicated that acuity of residents with behavioral symptoms and cognitive performance had an average number of residents identified as 36 and indicated special treatments for behavioral health needs an average number of 36.

Section 2 of the assessment identified resident support/care needs that included care of someone with cognitive impairment and indicated all staff on hire and annually receive competency training on caring for people with dementia, Alzheimer's and cognitive impairments.

The physical environment and building/plant needs failed to identify a wander guard system and failed to identify the facility had a secure unit.Interview with the Administrator on 4/22/26 at 10:39 AM identified a secured unit policy that was implemented [DATE] and indicated the unit was called the secured dementia unit.

Further interview with the Administrator on 4/22/26 at 11:16 AM indicated that she was unable to locate the secured unit in the facility assessment and that it must have been an oversight.

Additionally, the Administrator confirmed capacity of the facility was 120 beds.