Ark Healthcare & Rehabilitation At Governor's Ho

F 0550

the facility.Review of the facility policy for abuse identified that residents have the right to be treated with dignity and respect.

Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Note: The nursing home is disputing this citation.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/30/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Ark Healthcare & Rehabilitation at Governor's Ho

36 Firetown Rd Simsbury, CT 06070

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)

Federal health inspectors cited ARK HEALTHCARE & REHABILITATION AT GOVERNOR'S HO in SIMSBURY, CT for a deficiency under regulatory tag F-F0580 during a standard health inspection conducted on 2025-12-30.

Category: Resident Rights Deficiencies

The facility was found deficient in the following area: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 8 deficiencies cited during this inspection of ARK HEALTHCARE & REHABILITATION AT GOVERNOR'S HO.

Correction Status: Deficient, Provider has no plan of correction.

F 0641

Ensure each resident receives an accurate assessment.

Level of Harm - Potential for minimal harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, review of the clinical record, and interviews for one sampled resident (Resident #74) reviewed for resident assessment, the facility failed to ensure the MDS was coded accurately to reflect the current wheelchair mobility status of the resident. The findings include:Resident #74's diagnoses included severe protein calorie malnutrition, Marfan syndrome, osteoarthritis, and Alzheimer's.The physician's order dated 5/16/25 directed to have one person assist with bed mobility, two people assist with transfer, and non-ambulatory.The Occupational Therapy (OT) evaluation and plan of treatment dated from 5/21/25 to 8/11/25 identified Resident #74 required partial to moderate assistance with wheelchair mobility.The quarterly MDS assessment dated [DATE REDACTED] identified Resident #74 had severe cognitive impairment and was dependent on staff for toileting, personal hygiene, dressing, transfers, and was non-ambulatory. Further

review of the assessment identified Resident #74 was coded as independent for wheelchair mobility. The Physical Therapy (PT) evaluation and plan of treatment dated from 9/19/25 to 12/10/25 identified Resident #74 was dependent on staff for wheelchair mobility.The quarterly MDS assessment dated [DATE REDACTED] identified Resident #74 had severe cognitive impairment and was dependent on staff for toileting, personal hygiene, dressing, transfers, and was non-ambulatory. Further review of the assessment identified Resident #74 was coded as independent for wheelchair mobility. The Resident Care Plan (RCP) dated 10/6/25 identified Resident #74 had limited physical mobility related to weakness and impaired balance. The care plan interventions directed the assistance of 1 person for bed mobility, toileting, assist of 2 people for transfers, and non-ambulatory. Observation on 12/24/25 at 10:10 AM identified Resident #74 sitting in a wheelchair with leg rests in place and the wheelchair was locked near the nurse station.Interview with NA #1 on 12/24/25 at 10:25 AM identified she was the regular nursing aide for Resident #74 on 7 AM -3 PM shift. She identified Resident #74 was dependent on staff for personal hygiene, toileting, dressing and required two people assist for transfer and he/she was not ambulatory. In addition, she identified that Resident #74 required staff assistance with wheelchair mobility and he/she could not self-propel while sitting on a wheelchair. She further identified that Resident #74 could not self-propel for over a year after he/she broke

a hip.Interview with LPN #1 (MDS Coordinator) on 12/29/25 at 11:10 AM identified that she was responsible for coding section GG of the MDS assessment. She identified that she would make her own

observation of the resident during the look back period and code the section GG based on her

observations. She further identified that Resident #74 was independent with wheelchair mobility.Interview with OT #1 on 12/30/25 at 8:50 AM identified that she had treated Resident #74 for functional wheelchair mobility and identified Resident #74 required 2 people assist for transfer, and max assistance to total dependent with wheelchair mobility. She identified that Resident #74 was not independent with wheelchair mobility. Interview with OT #2 on 12/30/25 at 11:40 AM identified that Resident #74 was totally dependent for personal hygiene, toileting, transfer, non-ambulatory, and wheelchair mobility. She identified that Resident #74 was not independent with wheelchair mobility in the nursing unit and had a pending order for

a customized wheelchair.The Resident Assessment Instrument (RAI) manual 3.0 in part of section GG functional abilities and goals indicated that a qualified clinician would code the data element based on the type and amount of assistance provided by a helper to reflect the resident's functional abilities.

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/30/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Ark Healthcare & Rehabilitation at Governor's Ho

36 Firetown Rd Simsbury, CT 06070

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)

Federal health inspectors cited ARK HEALTHCARE & REHABILITATION AT GOVERNOR'S HO in SIMSBURY, CT for a deficiency under regulatory tag F-F0658 during a standard health inspection conducted on 2025-12-30.

Category: Resident Assessment and Care Planning Deficiencies

The facility was found deficient in the following area: Ensure services provided by the nursing facility meet professional standards of quality.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 8 deficiencies cited during this inspection of ARK HEALTHCARE & REHABILITATION AT GOVERNOR'S HO.

Correction Status: Deficient, Provider has no plan of correction.

Federal health inspectors cited ARK HEALTHCARE & REHABILITATION AT GOVERNOR'S HO in SIMSBURY, CT for a deficiency under regulatory tag F-F0684 during a standard health inspection conducted on 2025-12-30.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 8 deficiencies cited during this inspection of ARK HEALTHCARE & REHABILITATION AT GOVERNOR'S HO.

Correction Status: Deficient, Provider has no plan of correction.

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

identified that Resident #42 was using oxygen that was not humidified.Interview with APRN#1 on 12/30/25 at 11:15 AM identified the expectation was for staff to follow orders as they were written and to notify the physician if there were concerns or changes needed. APRN#1 indicated that use of the non-rebreather would require a doctor's order and high flow oxygen which would not be available on the resident room oxygen concentrators.Interview with the Medical Director on 12/30/25 at 2:33 PM identified she expected oxygen to be administered to residents as ordered by the doctor and that Resident #42 should be receiving humidified oxygen if that was how it is ordered. The Medical Director indicated that a non-rebreather should not be used with low flow oxygen and would require an MD order to change the method of delivery from the ordered nasal cannula.Review of facility respiratory training for 2025 identified use of a non-rebreather should be ordered by the provider and used with high flow oxygen. Although the facility provided appropriate respiratory education, the LPN and both NAs responsible for Resident #42's care did not receive the training.Review of facility policy for oxygen administration identified the purpose for use of the non-rebreather mask was to deliver high flow oxygen through nose and mouth, per the physician's order (generally 10-15 LPM). Additionally, the policy indicated that oxygen flow rate should maintain reservoir bag at least one third to one-half full-on inspiration and are generally used for emergent situations and only for short periods of time.

Event ID:

Facility ID:

If continuation sheet

Federal health inspectors cited ARK HEALTHCARE & REHABILITATION AT GOVERNOR'S HO in SIMSBURY, CT for a deficiency under regulatory tag F-F0761 during a standard health inspection conducted on 2025-12-30.

Category: Pharmacy Service Deficiencies

The facility was found deficient in the following area: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 8 deficiencies cited during this inspection of ARK HEALTHCARE & REHABILITATION AT GOVERNOR'S HO.

Correction Status: Deficient, Provider has no plan of correction.

Federal health inspectors cited ARK HEALTHCARE & REHABILITATION AT GOVERNOR'S HO in SIMSBURY, CT for a deficiency under regulatory tag F-F0812 during a standard health inspection conducted on 2025-12-30.

Category: Nutrition and Dietary Deficiencies

The facility was found deficient in the following area: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 8 deficiencies cited during this inspection of ARK HEALTHCARE & REHABILITATION AT GOVERNOR'S HO.

Correction Status: Deficient, Provider has no plan of correction.