Inspection Reports for
Pomperaug Woods
80 Heritage Rd, Southbury, CT 06488, United States, CT, 06488
Back to Facility ProfileDeficiencies (last 8 years)
Deficiencies (over 8 years)
11.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
104% worse than Connecticut average
Connecticut average: 5.6 deficiencies/year
Deficiencies per year
36
27
18
9
0
Occupancy
Latest occupancy rate
81% occupied
Based on a April 2025 inspection.
Occupancy rate over time
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 29, 2025
Visit Reason
The inspection was conducted following a complaint regarding the misappropriation of a resident's property, specifically an iPad that was reported missing from the facility.
Complaint Details
The complaint investigation was substantiated with findings that Resident #1's iPad was missing, an investigation and police report were filed, and the suspect was identified as NA #4 who was placed on administrative leave and subsequently terminated.
Findings
The facility failed to ensure a resident was free from misappropriation of property when an iPad belonging to Resident #1 was taken from the facility. An investigation and police report were initiated, and a nursing assistant (NA #4) was identified as the suspect and placed on administrative leave pending termination.
Deficiencies (1)
Failure to protect Resident #1 from misappropriation of property when an iPad was taken from the facility.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA #4 | Nursing Assistant | Identified as the suspect in the misappropriation of Resident #1's iPad and placed on administrative leave pending termination. |
| RN #2 | Registered Nurse | Reported the missing iPad and conducted a search; notified the Director of Nursing Services. |
| Director of Nursing Services | DNS | Notified of the missing iPad, coordinated investigation and police involvement, and managed staff related to the incident. |
| Human Resource Assistant #1 | Human Resource Assistant | Provided a witness statement and documentation related to the termination of NA #4. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 29, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the misappropriation of a resident's property, specifically an iPad reported missing from the facility.
Complaint Details
The complaint was substantiated involving the misappropriation of Resident #1's iPad. The facility conducted an investigation, notified police, and took disciplinary action against the staff member involved. The investigation is ongoing with police involvement.
Findings
The facility failed to ensure a resident was free from misappropriation of property when an iPad was taken from the facility. An investigation and police report were initiated, and the suspected staff member was placed on administrative leave and subsequently terminated.
Deficiencies (1)
F 0602: Protect each resident from the wrongful use of the resident's belongings or money. The facility failed to prevent the misappropriation of Resident #1's iPad, which was taken from the facility and later located outside the facility.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA #4 | Nursing Assistant | Suspected of misappropriating Resident #1's iPad, placed on administrative leave, and terminated. |
| RN #2 | Registered Nurse | Reported the missing iPad and conducted initial search. |
| Director of Nursing Services | DNS | Notified of the missing iPad, coordinated investigation and police involvement. |
| Human Resource Assistant #1 | Human Resource Assistant | Provided witness statement and documentation related to termination of NA #4. |
Inspection Report
Complaint Investigation
Census: 30
Capacity: 37
Deficiencies: 0
Date: Apr 24, 2025
Visit Reason
The inspection visit was conducted as a complaint investigation related to complaint numbers #43783 and #43834.
Complaint Details
Complaint investigation related to complaint numbers #43783 and #43834; no violations were substantiated.
Findings
No violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Vicki Gyba | Executive Director | Personnel contacted during the inspection. |
| Connie Vumback | RN | Report submitted by. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 7, 2025
Visit Reason
An unannounced visit was made to Pomperaug Woods Health Center on January 7, 2025, by the Department of Public Health to conduct an investigation based on additional information received through January 8, 2025.
Complaint Details
Complaint #42057 triggered the investigation. The complaint was substantiated as the facility was found noncompliant with narcotic medication control and documentation requirements.
Findings
The facility failed to ensure proper control and accounting of a controlled medication, Oxycodone, as one blister pack and its corresponding disposition sheet were unaccounted for. An investigation revealed missing medication despite audits and searches, indicating a deficiency in narcotic medication management and documentation.
Deficiencies (1)
Failure to ensure a controlled medication, Oxycodone, and its disposition sheet were not removed from the facility and were properly accounted for.
Report Facts
Medication tablets missing: 28
Audit date: Jan 21, 2025
Corrective action date: Jan 31, 2025
Audit frequency: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Karen Gworek | Supervising Nurse Consultant | Author of the notice letter regarding the complaint investigation. |
| Director of Nursing | Named in the investigation and responsible for narcotic audits and corrective actions. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 7, 2025
Visit Reason
The inspection was conducted following a report of misappropriation of personal property involving a controlled medication, Oxycodone, missing from the facility during a routine twice monthly narcotic audit.
Complaint Details
The complaint investigation was substantiated as the facility confirmed the misappropriation of a controlled medication, Oxycodone, for Resident #1. The Director of Nursing initiated an investigation, contacted the pharmacy, police, and DEA, but the medication was not recovered.
Findings
The facility failed to ensure that a blister pack of Oxycodone and the corresponding controlled substance record were not removed from the facility. Despite an investigation by the Director of Nursing, pharmacy, police, and DEA, the medication could not be located. Facility policies on controlled drug audits and abuse prevention were reviewed.
Deficiencies (1)
Failure to protect a resident from wrongful use of personal property involving missing Oxycodone medication and disposition sheet.
Report Facts
Tablets missing: 28
Date of narcotic audit discovery: Nov 26, 2024
Date of medication delivery: Nov 7, 2024
Date medication was required but missing: Nov 9, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Conducted narcotic audit, initiated investigation, and interviewed staff regarding missing medication. |
Inspection Report
Complaint Investigation
Census: 35
Capacity: 37
Deficiencies: 0
Date: Jan 7, 2025
Visit Reason
The inspection visit was conducted as a complaint investigation related to Complaint Investigation #42057.
Complaint Details
Complaint Investigation #42057 was the basis for the visit. Violations were substantiated as violations were identified during the inspection.
Findings
Violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection, as noted in an attached violation letter dated 2025-01-16.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Vicki Gyba | Administrator | Personnel contacted during the inspection. |
| Connie Vumback | RN | Report submitted by. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 7, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the misappropriation of a resident's controlled medication, specifically Oxycodone, which was found missing during a routine narcotic audit.
Complaint Details
The complaint investigation was substantiated as the facility confirmed the misappropriation of Resident #1's Oxycodone medication during a routine narcotic audit. The Director of Nursing initiated an investigation involving pharmacy, police, and DEA, but the medication was not recovered.
Findings
The facility failed to ensure that a blister pack of Oxycodone and the corresponding controlled substance record were not removed from the facility. Despite an investigation including staff interviews and searches, the medication could not be located, indicating a failure in proper accounting and control of controlled substances.
Deficiencies (1)
F 0602: Protect each resident from the wrongful use of the resident's belongings or money. The facility failed to ensure a controlled medication, Oxycodone, and its disposition sheet were not removed from the facility, compromising resident safety.
Report Facts
Tablets missing: 28
Date of narcotic audit discovery: Nov 26, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Conducted the routine narcotic audit and investigation into missing medication. |
Inspection Report
Complaint Investigation
Census: 35
Capacity: 37
Deficiencies: 0
Date: Jan 7, 2025
Visit Reason
The inspection visit was conducted as a complaint investigation referenced by complaint #42057.
Complaint Details
Complaint investigation #42057 was conducted and violations were substantiated as indicated by the attached violation letter.
Findings
Violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection, with an attached violation letter dated 2025-01-16.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Vicki Gyba | Administrator | Personnel contacted during the inspection. |
Inspection Report
Follow-Up
Census: 33
Capacity: 37
Deficiencies: 0
Date: Dec 11, 2024
Visit Reason
A follow-up visit was conducted to review the implementation of the Plan of Correction for violations identified in a previous violation letter dated 2024-10-30.
Findings
All previously identified violations (Violation #1a, 2a, 3a, 4a, 5a, 5c, 6a, 6b, 7a, 8a, 9a, 9b, 9c, 9d) were corrected as of 2024-11-22, and the administrator was notified in person on 2024-12-11 that all violations were corrected.
Report Facts
Violation numbers corrected: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Vicky Gyba | Administrator | Notified in-person of correction of all violations on 2024-12-11 |
| James Tan | Survey Team Leader | Conducted follow-up inspection on 2024-12-11 |
| Connie Greene | Supervisor | Supervising NC/Health Program Supervisor for inspection |
Inspection Report
Deficiencies: 8
Date: Oct 16, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, abuse reporting, medication administration, accident prevention, food safety, infection control, quality assurance, and environmental safety at Pomperaug Woods Health Center.
Findings
The facility was found deficient in honoring resident food preferences, timely reporting injuries of unknown origin, accurate transcription of physician medication orders, fall prevention and supervision, food safety practices, quality assurance documentation, infection control PPE use, and proper storage and labeling of personal care items in shared bathrooms.
Deficiencies (8)
F 0558: The facility failed to honor Resident #22's food preference by repeatedly serving instant mashed potatoes instead of fresh mashed potatoes as ordered.
F 0609: The facility failed to timely report an injury of unknown origin (bruise) on Resident #2 to the overseeing state agency as required.
F 0684: The facility failed to ensure accurate transcription of a physician's order for Risperdal, resulting in Resident #16 receiving the medication every 8 hours instead of every evening at 8 PM.
F 0689: The facility failed to follow care plans for Residents #26, #2, and #10, resulting in falls with major injury and inadequate supervision or assistance during transfers and toileting.
F 0812: The facility failed to maintain refrigerator and dishwasher temperature logs for 10/1/24 to 10/10/24 and failed to ensure storage containers were clean in the kitchen.
F 0867: The facility failed to implement appropriate corrective plans of action and documentation for quality deficiencies identified through the QAPI program.
F 0880: The facility failed to provide and ensure use of PPE gowns by laundry staff when handling soiled linens, resulting in contamination risks.
F 0921: The facility failed to store personal care items in a clean, sanitary, and labeled manner in shared bathrooms used by multiple residents.
Report Facts
Days medication administered incorrectly: 13
Bruise size: 6.5
Bruise size: 4
Hospital admission days: 5
Fall incident dates: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MD #2 | Psychiatric Medical Doctor | Ordered Risperdal medication for Resident #16 with incorrect transcription. |
| RN #2 | Registered Nurse | Identified medication order discrepancy for Resident #16 and reported to Director of Nursing. |
| Director of Nursing | Director of Nursing (DNS) | Oversaw abuse allegations, medication error investigation, and quality assurance program. |
| NA #1 | Nurse Aide | Involved in fall incident with Resident #2 and provided statements regarding care. |
| NA #8 | Nurse Aide | Provided care for Resident #26 during fall incident shift. |
| NA #5 | Nurse Aide | Provided care for Resident #10 prior to fall incident. |
| Director of Rehabilitation | Director of Rehabilitation (DOR) | Provided information on transfer assistance requirements for Resident #2. |
| Culinary Director | Culinary Director | Identified issues with kitchen temperature logs and storage container cleanliness. |
| Laundry Aide #1 | Laundry Aide | Observed not using PPE gowns when handling soiled linens. |
| Director of Laundry | Director of Laundry (DOL) | New to position and unaware of PPE gown use requirements. |
| RN #1 | Registered Nurse | Identified unlabeled personal care items in shared bathrooms and labeled them after surveyor inquiry. |
Inspection Report
Routine
Deficiencies: 8
Date: Oct 16, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, abuse reporting, medication administration, accident prevention, food safety, quality assurance, infection control, and environmental safety at Pomperaug Woods Health Center.
Findings
The facility was found deficient in honoring resident food preferences, timely reporting injuries of unknown origin, accurate transcription of physician medication orders, adherence to fall prevention plans, maintaining food safety logs and cleanliness, implementing effective quality assurance plans, providing proper infection control PPE, and ensuring personal care items were stored and labeled properly in shared bathrooms.
Deficiencies (8)
Failed to honor a resident's food preference by serving instant potatoes instead of fresh potatoes as ordered.
Failed to report an injury of unknown origin to the overseeing state agency.
Failed to ensure accurate transcription of a physician's order for a newly ordered psychotropic medication, resulting in administration every 8 hours instead of every evening at 8 PM.
Failed to follow the plan of care resulting in a fall with major injury and failed to provide transfers and toileting according to physician orders and care plans.
Failed to maintain refrigerator and dishwasher temperature logs and failed to ensure storage containers were clean.
Failed to implement appropriate plans of action to correct quality deficiencies identified through Quality Assurance and Performance Improvement (QAPI).
Failed to ensure staff were provided Personal Protective Equipment (PPE) gowns while sorting and washing soiled linens.
Failed to store personal care items in a clean and sanitary manner in rooms with a shared bathroom; items were unlabeled and improperly stored.
Report Facts
Bruise size: 6.5
Bruise size: 4
Medication administration days: 13
Hospital admission days: 5
Fall incident time: 9.5
Fall incident time: 8.87
Temperature log gap days: 10
Storage container weight: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MD #2 | Medical Doctor | Psychiatric provider who ordered Risperdal medication |
| RN #2 | Registered Nurse | Nurse who transcribed medication order and identified order discrepancy |
| Director of Nursing | Director of Nursing (DNS) | Oversaw abuse allegations, medication error investigation, and QAPI documentation |
| NA #1 | Nurse Aide | Involved in fall incidents and transfer of Resident #2 |
| NA #8 | Nurse Aide | Provided care to Resident #26 during fall incident shift |
| NA #5 | Nurse Aide | Provided care to Resident #10 during fall incident shift |
| Culinary Director | Identified food service deficiencies including temperature logs and cleaning | |
| Laundry Aide #1 | Laundry Aide | Observed not using PPE gowns while handling soiled linens |
| Director of Laundry | Director of Laundry | New to position, unaware of PPE gown use requirements |
| RN #1 | Registered Nurse | Identified personal care items should be labeled and stored properly |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Oct 16, 2024
Visit Reason
The inspection was conducted due to complaints regarding failure to follow care plans resulting in falls and injuries among residents, specifically for Residents #26, #2, and #10.
Complaint Details
The investigation was complaint-driven, focusing on allegations that the facility failed to follow care plans for residents at risk of falls, resulting in actual harm. The complaints were substantiated based on clinical record reviews, interviews, and facility documentation.
Findings
The facility failed to follow the plan of care for multiple residents, resulting in falls with injuries, inadequate assistance during transfers, and failure to implement scheduled toileting and fall prevention interventions as outlined in care plans.
Deficiencies (3)
Failure to follow the plan of care resulting in a fall with major injury for Resident #26.
Failure to ensure a transfer was provided according to physician order for Resident #2.
Failure to implement interventions according to the plan of care resulting in falls for Resident #10.
Report Facts
Hospital admission duration: 5
BIMS score: 3
BIMS score: 12
Date of fall incidents: Nov 22, 2023
Date of fall incidents: Jul 10, 2024
Date of fall incidents: Jun 3, 2024
Date of fall incidents: Oct 14, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA #8 | Nurse Aide | Provided care for Resident #26 during the 3 PM to 11 PM shift on 11/22/23 and gave statements regarding the fall incident. |
| LPN #1 | Licensed Practical Nurse | Assigned to provide care for Resident #26 during the 3 PM to 11 PM shift on 11/22/23 and provided statements about the incident. |
| NA #1 | Nurse Aide | Assigned to provide care for Resident #26 and Resident #10 during various shifts and provided statements related to care and fall incidents. |
| RN #2 | Registered Nurse | Reviewed and reported on the fall incidents and conducted interviews related to Resident #26 and Resident #10. |
| NA #3 | Nurse Aide | Provided care for Resident #2 during the 3 PM to 11 PM shift on 7/10/24 and gave statements about the fall incident. |
| Director of Nursing | Director of Nursing | Interviewed regarding Resident #2 and Resident #10 fall incidents and care requirements. |
| Director of Rehabilitation | Director of Rehabilitation | Interviewed regarding Resident #2's transfer requirements and fall incident. |
| LPN #2 | Licensed Practical Nurse | Provided statement regarding Resident #10 fall incident on 6/3/24. |
| NA #5 | Nurse Aide | Provided care for Resident #10 during the 3 PM to 11 PM shift on 10/14/24 and gave statements about the fall incident. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 16, 2024
Visit Reason
The inspection was conducted due to complaints regarding failure to follow care plans, resulting in falls and injuries among residents.
Complaint Details
The investigation was complaint-driven, focusing on allegations that the facility failed to follow care plans for Residents #26, #2, and #10, resulting in falls and injuries. The complaints were substantiated with evidence of inadequate toileting, transfer assistance, and supervision.
Findings
The facility failed to follow care plans for three residents, resulting in falls with injuries and inadequate supervision or assistance during transfers and toileting. Deficiencies included failure to provide scheduled toileting, proper transfer assistance, and fall prevention interventions.
Deficiencies (1)
F 0689: The facility failed to ensure a nursing home area was free from accident hazards and did not provide adequate supervision to prevent accidents, resulting in a fall with major injury for Resident #26 and falls for Residents #2 and #10 due to failure to follow care plans.
Report Facts
Hospital admission duration: 5
Brief Interview for Mental Status (BIMS) scores: 3
Brief Interview for Mental Status (BIMS) score: 12
Date of fall incident: 2023
Date of fall incident: 2024
Date of fall incident: 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA #8 | Nurse Aide | Provided care statements regarding Resident #26's fall incident on 11/22/23. |
| LPN #1 | Licensed Practical Nurse | Provided statements regarding Resident #26's status prior to fall. |
| NA #1 | Nurse Aide | Assigned to care for Residents #26, #2, and #10 during relevant shifts; involved in transfer and toileting deficiencies. |
| NA #3 | Nurse Aide | Provided statements regarding Resident #2's fall incident on 7/10/24. |
| RN #2 | Registered Nurse | Completed facility Event Report and Post Fall Evaluation for Resident #26 and Resident #10. |
| NA #5 | Nurse Aide | Provided care for Resident #10 during 3 PM to 11 PM shift on 10/14/24; involved in toileting and fall incident. |
| Director of Nursing | Director of Nursing | Interviewed regarding care and transfer status of Residents #2 and #10. |
| Director of Rehabilitation | Director of Rehabilitation | Interviewed regarding transfer assistance requirements for Resident #2. |
Inspection Report
Complaint Investigation
Capacity: 37
Deficiencies: 0
Date: Oct 10, 2024
Visit Reason
The inspection was conducted as a licensing inspection renewal combined with a complaint investigation (Complaint Investigation #36764).
Complaint Details
Complaint Investigation #36764 was part of the inspection process; no substantiation status or findings are explicitly stated in this document.
Findings
The report indicates that violations of the General Statutes of Connecticut and/or regulations were reviewed, but no specific violations or citations were noted in this summary page. Additional narrative or violation letters may be attached but are not included here.
Report Facts
Licensed Bed Capacity: 37
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Vicki Ogden | Administrator | Personnel contacted during the inspection |
| Dennis Fitzgerald | Director of Services (DOS) | Personnel contacted during the inspection |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Sep 18, 2024
Visit Reason
The inspection was conducted following complaints and incidents involving improper resident transfers and potential abuse at Pomperaug Woods Health Center.
Complaint Details
The complaint investigation was triggered by an allegation of rough handling and improper transfer of Resident #2 by NA #1, who was suspended and later terminated. The investigation also included incidents involving Resident #1 who was improperly transferred alone by NA #2, resulting in a fall and femur fracture. The facility was unable to provide physician transfer orders for Resident #1 prior to the fall.
Findings
The facility failed to ensure residents were transferred according to physician orders, resulting in unsafe transfers and a resident sustaining a femur fracture. Additionally, the facility lacked proper documentation of transfer orders and failed to provide adequate supervision and assistance during transfers.
Deficiencies (3)
Failed to ensure Resident #2 was transferred in accordance with physician orders, resulting in unsafe transfer by a single staff member.
Failed to ensure Resident #1 was transferred with assistance of two staff, resulting in resident sliding out of wheelchair and sustaining a femur fracture.
Failed to maintain complete and accurate clinical records including transfer status orders for Resident #1.
Report Facts
Date of physician order for transfer assistance: Aug 26, 2024
Date of incident report: Sep 5, 2024
Date of incident report: Aug 26, 2024
BIMS score: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA #1 | Nursing Assistant | Named in allegation of rough handling and improper transfer of Resident #2; employment terminated. |
| NA #2 | Nursing Assistant | Transferred Resident #1 alone from toilet to wheelchair, resulting in fall. |
| NA #3 | Nursing Assistant | Assisted with transfer of Resident #1 and involved in incident where resident slid out of wheelchair. |
| Director of Nursing | Director of Nursing | Interviewed regarding transfer incidents and lack of physician orders; confirmed transfer requirements. |
| Physical Therapist #1 | Physical Therapist | Provided information on transfer orders for Resident #1. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Sep 18, 2024
Visit Reason
The inspection was conducted following complaints and incidents involving improper resident transfers and alleged abuse at Pomperaug Woods Health Center.
Complaint Details
The investigation was initiated after Resident #2 alleged rough handling and improper transfer by a nursing assistant. The complaint was substantiated as the staff member transferred the resident alone against physician orders and was terminated. Additional findings involved Resident #1 who sustained a femur fracture due to improper transfer and positioning by staff.
Findings
The facility failed to ensure residents were transferred according to physician orders and care plans, resulting in unsafe transfers and a resident sustaining a femur fracture. Additionally, the facility lacked complete and accurate clinical records including transfer status orders.
Deficiencies (3)
F 0684: The facility failed to ensure Resident #2 was transferred in accordance with physician orders requiring two staff for transfers, resulting in a staff member transferring the resident alone. The staff member was terminated.
F 0689: The facility failed to ensure Resident #1 was transferred with assistance of two staff as required, resulting in the resident sliding out of a wheelchair and sustaining a left femur fracture.
F 0842: The facility failed to maintain complete and accurate clinical records for Resident #1, including missing physician orders for transfer status prior to the fall.
Report Facts
Date of incident: 2024
Date of alleged abuse report: 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding transfer incidents and staff termination | |
| NA #1 | Staff member who transferred Resident #2 alone and was terminated | |
| NA #2 | Transferred Resident #1 alone off toilet, involved in fall incident | |
| NA #3 | Assisted with Resident #1 transfer and repositioning during fall incident | |
| Physical Therapist #1 | Provided information on transfer orders for Resident #1 |
Inspection Report
Complaint Investigation
Census: 31
Capacity: 37
Deficiencies: 0
Date: Dec 11, 2023
Visit Reason
The inspection visit was conducted as a complaint investigation referenced by Complaint Investigation #36816.
Complaint Details
Complaint Investigation #36816 was conducted and found no violations; the complaint was not substantiated.
Findings
No violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Moshier | Executive Director | Personnel contacted during the inspection. |
| Vicki Gyba-Marshall | Assistant Executive Director | Personnel contacted during the inspection. |
| Dennis Fitzgerald | DNS | Personnel contacted during the inspection. |
Inspection Report
Complaint Investigation
Census: 31
Capacity: 37
Deficiencies: 0
Date: Dec 11, 2023
Visit Reason
The inspection visit was conducted as a complaint investigation referenced by complaint #36816.
Complaint Details
Complaint investigation #36816 was conducted and found no violations; the complaint was not substantiated.
Findings
No violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Moshier | Executive Director | Personnel contacted during the inspection. |
| Vicki Gyba-Marshall | Assistant Executive Director | Personnel contacted during the inspection. |
| Dennis Fitzgerald | DNS | Personnel contacted during the inspection. |
Inspection Report
Routine
Deficiencies: 6
Date: Apr 18, 2023
Visit Reason
The inspection was conducted as a routine survey to assess compliance with regulatory requirements related to resident rights, medication administration, medication error rates, medication storage, and dietary services.
Findings
The facility was found deficient in ensuring completion of advance directives documentation, timely medication administration, proper medication supervision, thorough RN assessments at time of death, maintaining medication error rates below 5%, safe storage of expired medications, and adequate cleanliness and staffing in the dietary department.
Deficiencies (6)
Failed to ensure the Advanced Directive/Treatment Decisions form was completed and signed by the resident's responsible party, physician, and a facility staff representative.
Failed to obtain an order to administer a late medication, failed to ensure LPN remained with resident to ensure medication consumption, and failed to complete a thorough RN assessment at time of death.
Medication error rate was 7.41%, exceeding the acceptable rate of 5%.
Failed to ensure safe and secure storage of expired or discontinued medications in medication carts and storage rooms.
Failed to provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service, resulting in inadequate cleaning of the kitchen.
Failed to ensure the kitchen and equipment were maintained in a sanitary manner, including accumulation of dirt, dust, grime, and lack of proper labeling and thermometer in food storage areas.
Report Facts
Medication error rate: 7.41
Medication administration delay: 190
Expired medication storage duration: 6
Expired medication storage duration: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #3 | Registered Nurse | Administered Eliquis late and failed to notify physician or document late administration |
| DNS | Director of Nursing Services | Interviewed regarding advance directives and medication administration policies |
| LPN #2 | Licensed Practical Nurse | Failed to remain with Resident #21 to ensure medication consumption |
| RN #1 | Unit Manager | Interviewed regarding medication administration and resident self-administration |
| MD #1 | Physician | Interviewed regarding late medication orders and verbal orders |
| Pharmacist #2 | Pharmacist | Interviewed regarding medication dosing and administration |
| Pharmacy Supervisor | Interviewed regarding expired medication removal responsibilities | |
| Food and Beverage Director | Interviewed regarding dietary department cleanliness and staff compliance | |
| Dietary Manager | Interviewed regarding staffing shortages impacting kitchen cleanliness | |
| Dietary Aide #1 | Observed not wearing hairnet during food temperature checks |
Inspection Report
Routine
Deficiencies: 6
Date: Apr 18, 2023
Visit Reason
Routine inspection of Pomperaug Woods Health Center to assess compliance with regulatory standards including advance directives, medication administration, medication storage, and dietary services.
Findings
The facility failed to ensure completion of advance directive forms, timely medication administration, proper medication storage, and adequate dietary department cleanliness and staffing. Several medication errors and unsafe practices were observed, and the kitchen was found to be inadequately cleaned due to staffing shortages.
Deficiencies (6)
F 0578: The facility failed to ensure the Advanced Directive/Treatment Decisions form was completed and signed by the resident's responsible party, physician, and a facility staff representative.
F 0658: The facility failed to obtain an order for late medication administration, ensure staff remained with resident until medication was consumed, and complete a thorough RN assessment at time of resident death.
F 0759: The facility failed to ensure medication error rates were below 5%, with an observed error rate of 7.41% during medication administration observations.
F 0761: The facility failed to ensure safe and secure storage of expired or discontinued medications in medication carts and storage rooms.
F 0802: The facility failed to provide sufficient support personnel to safely and effectively carry out cleaning functions in the dietary department, resulting in accumulation of dirt, dust, and grime.
F 0812: The facility failed to maintain the kitchen and equipment in a sanitary manner, with multiple areas noted to have dirt, dust, grime, and lack of proper labeling or thermometers.
Report Facts
Medication error rate: 7.41
Expired medication storage duration: 6
Expired medication storage duration: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #3 | Registered Nurse | Administered late Eliquis medication without physician order or documentation |
| LPN #2 | Licensed Practical Nurse | Left medications with resident without ensuring consumption and administered incorrect Metamucil dose |
| DNS | Director of Nursing Services | Interviewed regarding medication administration policies and deficiencies |
| MD #1 | Physician | Interviewed regarding late medication orders and verbal orders |
| Pharmacist #2 | Pharmacist | Interviewed regarding Metamucil dosing and medication labeling |
| Pharmacy Supervisor | Pharmacy Supervisor | Interviewed regarding expired medication removal responsibilities |
| Food and Beverage Director | Food and Beverage Director | Interviewed regarding dietary department cleanliness and staffing |
| Dietary Manager | Dietary Manager | Interviewed regarding kitchen cleaning schedule and staffing shortages |
| Dietary Aide #1 | Dietary Aide | Observed not wearing hair net during food temperature checks |
Inspection Report
Renewal
Census: 31
Capacity: 37
Deficiencies: 0
Date: Apr 13, 2023
Visit Reason
The inspection was conducted as a renewal licensing inspection for the facility.
Findings
Violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection, as noted in an attached violation letter dated May 10, 2023.
Inspection Report
Follow-Up
Census: 23
Capacity: 37
Deficiencies: 0
Date: Mar 15, 2022
Visit Reason
A desk audit was conducted on 3/15/22 to review the implementation for the plan of correction from the Violation letter dated 1/4/2021.
Findings
Violations #1 (a), (b), (c), #2, and #3 have been corrected. The MDS Coordinator was notified that State Violations #1-3 were corrected, and an email was sent to the Administrator and DNS.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Tobin | MDS Coordinator | Personnel contacted during the inspection |
| Fran Ferraiolo | RN | Signature of FLIS Staff and report submitter |
Inspection Report
Complaint Investigation
Census: 23
Capacity: 33
Deficiencies: 3
Date: Dec 20, 2021
Visit Reason
Unannounced visits were made to Pomperaug Woods Health Center on December 20, 21, and 22, 2021 for the purpose of conducting a complaint investigation.
Complaint Details
Complaint investigation #31297 was conducted. Violations were substantiated as noted in the findings and violation letter dated 01/04/2022.
Findings
Violations of the Regulations of Connecticut State Agencies and/or General Statutes were identified related to inadequate assessments and documentation of pressure ulcers, failure to document effectiveness of laxative medication, and failure to monitor nutritional supplement intake and resident weights as per physician orders.
Deficiencies (3)
Failure to conduct complete assessments and documentation of pressure ulcers for residents, including size, drainage, odor, and weekly evaluations.
Failure to document effectiveness of as needed laxative medication after administration for Resident #4.
Failure to monitor and document percentage of nutritional supplement consumed and weekly weights for Resident #6 as ordered by physician.
Report Facts
Licensed Bed Capacity: 33
Census: 23
Inspection Dates: 3
Plan of Correction Submission Deadline: Plan of correction to be submitted by January 14, 2022.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kate Petersen | Director of Nursing | Personnel contacted during inspection. |
| Kevin Moshier | Administrator | Personnel contacted during inspection. |
| Karen Gworek | Supervising Nurse Consultant | Author of the violation notice and contact for follow-up. |
| RN #1 | Interviewed regarding pressure ulcer assessments. | |
| Dietitian #1 | Interviewed regarding nutritional supplement monitoring. |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jun 8, 2021
Visit Reason
Annual inspection survey of Pomperaug Woods Health Center to assess compliance with health regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Deficiencies: 0
Date: Jun 8, 2021
Visit Reason
The document is a statement of deficiencies and plan of correction for Pomperaug Woods Health Center following a survey completed on June 8, 2021.
Findings
No health deficiencies were found during the survey.
Inspection Report
Abbreviated Survey
Census: 23
Capacity: 37
Deficiencies: 1
Date: Sep 11, 2020
Visit Reason
A COVID-19 Focused Survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including infection prevention and control practices to prevent COVID-19 transmission.
Findings
The facility failed to ensure appropriate eye protection was worn by staff when providing care to residents on transmission-based droplet precautions in the COVID-19 suspected unit, contrary to CDC guidance.
Deficiencies (1)
Failure to ensure appropriate eye protection was worn when providing care to residents on transmission-based droplet precautions.
Report Facts
Capacity: 37
Census: 23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Aide #1 | Nurse Aide | Observed providing care without eye protection |
| Licensed Practical Nurse #1 | Charge Nurse, Licensed Practical Nurse | Observed providing care without eye protection |
| Infection Preventionist Nurse | Infection Preventionist Nurse | Interviewed regarding eye protection policy |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Sep 11, 2020
Visit Reason
The visit was conducted to investigate compliance with COVID-19 transmission-based droplet precautions in the facility's COVID-19 suspected unit.
Findings
The facility failed to ensure appropriate eye protection was worn by staff when providing care to residents on transmission-based droplet precautions. Multiple staff members were observed providing care without wearing face shields or goggles as required.
Deficiencies (1)
Failure to ensure appropriate eye protection was worn when providing care to residents on transmission-based droplet precautions.
Report Facts
Number of residents identified with diagnoses: 7
Audit frequency: 5
Audit frequency: 3
Audit frequency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Aide (NA) #1 | Observed providing care without wearing face shield or goggles. | |
| Licensed Practical Nurse (LPN) #1 | Observed providing care without wearing face shield or goggles. | |
| Infection Preventionist Nurse | Interviewed and identified that staff were not required to wear face shields when entering resident rooms unless administering nebulized medication. |
Inspection Report
Routine
Deficiencies: 1
Date: Sep 11, 2020
Visit Reason
An unannounced visit was conducted on September 11, 2020 at Pomperaug Woods Health Center by the Department of Public Health for the purpose of conducting a COVID-19 focused infection control survey.
Findings
The facility failed to ensure appropriate eye protection was worn by staff when providing care to residents on transmission-based droplet precautions in the COVID-19 suspected unit. Observations showed multiple staff members providing care without face shields or goggles, contrary to CDC guidance and facility policy.
Deficiencies (1)
Failure to ensure appropriate eye protection was worn by staff when providing care to residents on transmission-based droplet precautions in the COVID-19 suspected unit.
Report Facts
Residents reviewed: 7
Observation times: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Karen Gworek | Supervising Nurse Consultant | Author of the notice and contact for questions regarding violations. |
Inspection Report
Monitoring
Census: 25
Capacity: 36
Deficiencies: 1
Date: Sep 11, 2020
Visit Reason
The visit was an unannounced COVID-19 infection control survey conducted on September 11, 2020, to assess compliance with infection control measures related to COVID-19.
Findings
Violations of Connecticut State regulations were identified related to failure to ensure appropriate eye protection was worn by staff when providing care to residents on transmission-based droplet precautions. Specific observations included staff providing care without face shields or goggles and improper storage of PPE.
Deficiencies (1)
Staff failed to maintain droplet precautions by not wearing appropriate eye protection when providing care to residents on the COVID-19 suspected unit.
Report Facts
Licensed Beds: 36
Census: 25
Citation Number: 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Ann Frazao | Infection Prevention Nurse | Personnel contacted during the inspection. |
| Megan Edson-Sawyer | NC | Report submitted by this nurse. |
| Karen Gworek | Supervising Nurse Consultant | Signed the violation notice letter. |
Inspection Report
Abbreviated Survey
Census: 30
Capacity: 37
Deficiencies: 0
Date: Jul 30, 2020
Visit Reason
A COVID-19 Focused Survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including proper infection prevention and control practices to prevent the development and transmission of COVID-19.
Findings
No deficiencies were cited as a result of this COVID-19 focused survey.
Inspection Report
Routine
Census: 31
Capacity: 37
Deficiencies: 0
Date: Jul 8, 2020
Visit Reason
A COVID-19 Focused Survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including proper infection prevention and control practices to prevent the development and transmission of COVID-19.
Findings
The survey found no deficiencies related to infection prevention and control practices for COVID-19 at Pomperaug Woods Health Center.
Inspection Report
Routine
Census: 29
Capacity: 37
Deficiencies: 0
Date: Jun 17, 2020
Visit Reason
A COVID-19 Focused Survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including proper infection prevention and control practices to prevent the development and transmission of COVID-19.
Findings
No deficiencies were cited as a result of this COVID-19 focused survey.
Inspection Report
Abbreviated Survey
Census: 32
Capacity: 37
Deficiencies: 0
Date: Jun 3, 2020
Visit Reason
A COVID-19 Focused Survey was conducted on June 3, 2020 at Pomperaug Woods Health Center to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including proper infection prevention and control practices to prevent the development and transmission of COVID-19.
Findings
Deficiencies were not cited as a result of this COVID-19 focused survey.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: May 21, 2020
Visit Reason
The visit was conducted to address infection control practices related to COVID-19, specifically regarding the use of personal protective equipment (PPE) by private duty caregivers.
Findings
The Director of Nursing identified that private duty caregivers did not consistently use gloves or gowns when caring for residents on isolation precautions. The facility provided infection prevention education and updated policies to ensure proper PPE use and transmission-based precautions.
Deficiencies (1)
Private duty caregivers did not don gloves or gowns when caring for residents on isolation with PPE present.
Report Facts
Audit frequency: 3
Audit frequency: 5
Audit frequency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Identified infection control issues and responsible for ensuring compliance with plan of correction. |
Inspection Report
Abbreviated Survey
Census: 32
Capacity: 37
Deficiencies: 1
Date: May 21, 2020
Visit Reason
A COVID-19 Focused Survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including proper infection prevention and control practices to prevent the development and transmission of COVID-19.
Findings
The facility failed to ensure appropriate infection control practices regarding personal protective equipment and signage for COVID-19 precautions. Observations included inadequate signage indicating specific precautions, improper storage of N95 masks, inappropriate use of rain ponchos instead of disposable gowns, and failure of a private duty caregiver to use PPE and clean equipment properly.
Deficiencies (1)
Failure to ensure appropriate infection control practices regarding personal protective equipment and signage for COVID-19 precautions.
Report Facts
Capacity: 37
Census: 32
Residents with pending COVID-19 test results: 9
Private duty caregivers in same room: 2
Frequency of audits for signage: 5
Frequency of audits for signage: 2
Frequency of audits for signage: 1
Frequency of audits for PPE usage interviews: 5
Frequency of audits for PPE usage interviews: 2
Frequency of audits for PPE usage interviews: 1
Frequency of audits for cleaning equipment: 3
Frequency of audits for cleaning equipment: 2
Frequency of audits for cleaning equipment: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Infection Prevention Nurse | Interviewed regarding signage, PPE storage, and infection control practices | |
| Licensed Practical Nurse (LPN) #1 | Interviewed about use of rain ponchos and PPE | |
| Director of Nursing (DON) | Interviewed regarding private duty caregiver infection control and responsible for monitoring plan of correction |
Inspection Report
Monitoring
Deficiencies: 1
Date: May 21, 2020
Visit Reason
An unannounced visit was made to Pomperaug Woods Health Center on May 21, 2020 for the purpose of conducting an investigation and a COVID-19 infection control monitoring visit.
Findings
The facility failed to ensure appropriate infection control practices regarding personal protective equipment to prevent and control the transmission of COVID-19. Observations included inadequate signage for COVID-19 precautions, improper storage of N95 masks, inappropriate use of rain ponchos by nursing staff, and a private duty caregiver not following infection control protocols.
Deficiencies (1)
Failure to ensure appropriate infection control practices regarding personal protective equipment to prevent and control COVID-19 transmission, including inadequate signage, improper N95 mask storage, misuse of rain ponchos, and lack of PPE use by a private duty caregiver.
Report Facts
Residents with pending COVID-19 test results: 9
COVID-19 positive residents observed: 1
Plastic bags with N95 masks and facial shields: 2
Residents cared for by private duty caregiver: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Karen Gworek | Supervising Nurse Consultant | Signed the notice letter and provided contact for questions regarding violations. |
| Kevin Moshier | Director of Nursing | Interviewed regarding infection control practices and private duty caregiver compliance. |
| Licensed Practical Nurse #1 | Charge Nurse | Interviewed about use of rain ponchos for additional protection on COVID-19 unit. |
| Infection Prevention Nurse | Interviewed about signage, PPE storage, and staff infection control practices. |
Inspection Report
Complaint Investigation
Deficiencies: 8
Date: Apr 16, 2019
Visit Reason
The inspection was conducted due to complaints and allegations of mistreatment, verbal abuse, medication diversion, and failure to maintain proper care and safety standards at Pomperaug Woods Health Center.
Complaint Details
The complaint investigation involved allegations of mistreatment, verbal abuse, medication diversion, and failure to maintain proper care and safety standards. Some allegations were substantiated based on witness interviews and investigations, leading to staff terminations and corrective actions.
Findings
The facility was found to have multiple violations including mistreatment of residents, verbal abuse, failure to timely report abuse allegations, inadequate skin integrity care, medication diversion, failure to maintain side rails properly, and infection control deficiencies. Several staff members were terminated or reeducated, and plans of correction were implemented.
Deficiencies (8)
Failure to ensure residents were treated in a dignified manner, including verbal mistreatment and failure to stop inappropriate behavior by staff.
Failure to ensure a resident was free from verbal abuse, substantiated by witnessed incidents.
Failure to ensure allegations of abuse were reported timely and investigated promptly.
Failure to consistently provide weekly measurements of wounds and proper documentation for skin integrity.
Failure to ensure side rails were installed and maintained according to manufacturers' guidelines, resulting in injury.
Failure to conduct facility investigation timely after medication diversion and failure to report narcotic discrepancies.
Failure to maintain dietary department in a sanitary manner, including storage of utensils and food preparation surfaces.
Failure to maintain infection control documentation and antibiotic usage review according to criteria.
Report Facts
Resident count reviewed for mistreatment: 5
Resident count reviewed for skin integrity: 4
Resident count reviewed for accidents: 3
Number of side rails with issues: 11
Number of narcotic pills replaced: 7
Number of residents administered antibiotics: 69
Number of resident bowls noted wet: 13
Number of resident plates noted wet: 3
Number of food preparation surface sanitizing containers tested: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kim Hriceniak | Public Health Services Manager | Signed letter regarding complaint investigation and deficiencies. |
| Cassie Odilia Haley | Administrator | Named in multiple findings and plans of correction. |
| NA#6 | Nurse Aide | Suspended and terminated for verbal mistreatment of Resident #24. |
| NA#1 | Nurse Aide | Involved in verbal abuse incident with Resident #79. |
| RN #2 | Registered Nurse | Witnessed verbal abuse incident and reported observations. |
| RN #3 | Registered Nurse | Nursing supervisor involved in verbal abuse investigation. |
| RN #7 | Registered Nurse Supervisor | Reviewed clinical records and wound care documentation. |
| RN #8 | Registered Nurse | Identified medication diversion and notified police. |
| LPN #1 | Licensed Practical Nurse | Reported concerns about emergency medication packaging. |
| Director of Nursing (DON) | Director of Nursing | Responsible for ensuring compliance and involved in multiple interviews and findings. |
| Maintenance Director | Maintenance Director | Responsible for ensuring side rails compliance and maintenance. |
| Food and Beverage Director | Food and Beverage Director | Responsible for dietary department compliance. |
Inspection Report
Complaint Investigation
Deficiencies: 9
Date: Apr 15, 2019
Visit Reason
Unannounced visits were made to Pomperaug Woods Health Center on April 15, 16, and 18, 2019 by representatives of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting an investigation based on complaints.
Complaint Details
Complaint investigation was substantiated with findings of mistreatment, verbal abuse, failure to report abuse timely, medication diversion, and other regulatory violations.
Findings
The facility was found to have multiple violations including mistreatment and verbal abuse of residents, failure to ensure timely reporting of abuse allegations, inadequate skin integrity care, failure to maintain side rails according to manufacturer guidelines, incomplete employee performance evaluations, medication diversion and discrepancies, and failure to maintain sanitary conditions in the dietary department. Several residents were involved in these findings, and staff members were suspended or terminated as a result.
Deficiencies (9)
Failure to ensure residents were treated in a dignified manner; substantiated verbal mistreatment by a Nurse Aide.
Failure to ensure residents were free from verbal abuse; substantiated verbal abuse by a Nurse Aide.
Failure to ensure allegations of abuse were reported timely.
Failure to provide consistent weekly wound measurements and documentation for residents with skin breakdown.
Failure to ensure side rails were installed and maintained according to manufacturers' guidelines, resulting in resident injury.
Failure to complete annual performance evaluations for employees in accordance with facility policy.
Failure to conduct timely investigation and reporting of medication diversion and discrepancies.
Failure to maintain dietary department in a sanitary manner, including improper storage and handling of food and utensils.
Failure to ensure infection control and antibiotic usage documentation met required standards.
Report Facts
Residents reviewed for mistreatment: 5
Residents reviewed for skin integrity: 4
Residents reviewed for accidents: 3
Residents reviewed for medication diversion: 3
Residents reviewed for infection control: 69
Beds with side rails checked: 35
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kim Hriceniak | Public Health Services Manager | Named as contact for Supervising Nurse Consultant regarding deficiencies. |
| NA #6 | Nurse Aide | Suspended and terminated for verbal mistreatment of Resident #24. |
| NA #1 | Nurse Aide | Terminated for substantiated verbal abuse of Resident #79. |
| RN #3 | Registered Nurse | Terminated for substantiated verbal abuse of Resident #79. |
| DON | Director of Nursing | Responsible for ensuring compliance with plan of correction and reporting abuse. |
| LPN #1 | Licensed Practical Nurse | Had concerns about medication packaging but failed to report timely. |
| RN #8 | Registered Nurse | Observed medication diversion and reported to DNS and police. |
| Maintenance Director | Responsible for audits and correction of side rails. | |
| Food and Beverage Director | Responsible for ensuring dietary department compliance. | |
| Human Resources Director | Responsible for ensuring timely employee performance evaluations. |
Inspection Report
Complaint Investigation
Census: 28
Capacity: 37
Deficiencies: 7
Date: Apr 15, 2019
Visit Reason
Unannounced visits were made to Pomperaug Woods Health Center for the purpose of conducting an investigation related to complaints of mistreatment, abuse, neglect, medication diversion, and failure to ensure resident safety and proper care.
Complaint Details
The investigation was complaint-driven, involving allegations of mistreatment, abuse, neglect, medication diversion, and failure to ensure resident safety. The allegations were substantiated based on interviews, clinical record reviews, and observations.
Findings
The facility was found to have multiple violations including failure to prevent verbal abuse and mistreatment of residents, inadequate supervision and reporting of abuse, failure to ensure proper skin integrity care, medication diversion, and failure to maintain safe environment including side rails and dietary services. Several residents were mistreated verbally and physically, and the facility failed to properly investigate and report these incidents.
Deficiencies (7)
Failure to prevent verbal abuse and mistreatment of residents, including staff yelling and inappropriate interactions with residents.
Failure to ensure consistent and proper skin integrity care, including lack of weekly wound measurements and inadequate treatment documentation.
Failure to ensure side rails were installed and maintained according to manufacturers' guidelines, leading to resident injury.
Medication diversion identified with narcotic discrepancies and failure to report and investigate properly.
Failure to maintain dietary services in a sanitary manner, including improper storage of utensils and food preparation surfaces.
Failure to complete annual performance evaluations for staff as required by facility policy.
Failure to maintain infection control documentation and antibiotic stewardship according to criteria.
Report Facts
Licensed beds: 37
Census: 28
Residents reviewed for mistreatment: 5
Residents reviewed for skin integrity: 4
Residents reviewed for accidents: 3
Residents reviewed for medication diversion: 3
Side rails inspected: 35
Dates of inspection: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kim Hriceniak | Public Health Services Manager | Named as the contact person for complaint investigations. |
| Cassie Odilia Haley | Administrator | Facility administrator during the inspection period. |
| Registered Nurse #2 | Interviewed regarding verbal abuse and mistreatment incidents. | |
| Registered Nurse #3 | Interviewed regarding verbal abuse and mistreatment incidents. | |
| Nurse Aide #1 | Involved in mistreatment allegations and interviews. | |
| Nurse Aide #6 | Suspended and terminated following substantiated abuse allegations. | |
| Director of Nursing | DON | Responsible for ensuring compliance with plans of correction and reporting. |
| Licensed Practical Nurse #8 | Involved in medication diversion investigation. | |
| Food and Beverage Director | Responsible for dietary service violations and corrective actions. | |
| Maintenance Director | Responsible for side rail safety and maintenance. |
Inspection Report
Plan of Correction
Deficiencies: 9
Date: Apr 15, 2019
Visit Reason
Unannounced visits were made to Pomperaug Woods Health Center on April 15, 16, and 18, 2019 by representatives of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting an investigation.
Complaint Details
Complaint numbers 24322, 24055, and 23674 were investigated. Several allegations of mistreatment and verbal abuse were substantiated based on interviews, clinical record reviews, and investigations.
Findings
The facility was found to have multiple violations related to mistreatment, verbal abuse, failure to provide consistent wound measurements, failure to maintain dietary department sanitation, failure to ensure side rails were installed correctly, failure to complete annual performance evaluations, and failure to conduct timely investigations of medication diversion. Several allegations of mistreatment and verbal abuse were substantiated, resulting in staff suspensions and terminations.
Deficiencies (9)
Failure to ensure residents were treated in a dignified manner, including substantiated verbal mistreatment and inappropriate staff interactions.
Failure to ensure a resident was free from verbal abuse, substantiated by witnessed incidents and staff terminations.
Failure to ensure timely reporting of allegations of abuse and mistreatment.
Failure to consistently provide weekly measurements of a resident's wound.
Failure to ensure side rails were installed and maintained according to manufacturers' guidelines, resulting in resident injury.
Failure to ensure annual performance evaluations were completed for staff.
Failure to conduct a timely investigation of medication diversion and discrepancies in narcotic packaging.
Failure to maintain the dietary department in a sanitary manner, including issues with food storage and preparation surfaces.
Failure to ensure side rails were in place according to manufacturers' guidelines for multiple beds.
Report Facts
Resident count reviewed for mistreatment: 5
Resident count reviewed for skin integrity: 4
Resident count reviewed for accidents: 3
Resident count reviewed for medication diversion: 2
Resident count reviewed for dietary services: 13
Beds with side rails checked: 35
Date of plan of correction submission deadline: Jul 4, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kim Hriceniak | Public Health Services Manager | Signed the amended notice letter and referenced as Supervising Nurse Consultant contact. |
| Cassie Odilia Haley | Administrator | Facility administrator addressed in the letter and plan of correction. |
| NA #6 | Nurse Aide | Involved in verbal mistreatment incident with Resident #24. |
| NA #5 | Nurse Aide | Interviewed regarding Resident #24 care and mistreatment allegations. |
| NA #1 | Nurse Aide | Involved in verbal abuse incident with Resident #79; subsequently terminated. |
| RN #2 | Registered Nurse | Witnessed verbal abuse incident involving NA #1 and Resident #79. |
| RN #3 | Registered Nurse | Nursing supervisor who investigated verbal abuse allegations. |
| Director of Nurses | Director of Nursing | Interviewed multiple times regarding abuse allegations and investigations. |
| NA #4 | Nurse Aide | Interviewed regarding Resident #80 care and incontinence. |
| RN #5 | Registered Nurse | Identified injury to Resident #80 and summoned emergency assistance. |
| Maintenance Director | Interviewed regarding side rail installation and maintenance. | |
| Registered Nurse #3 | Registered Nurse | Employee with missing annual performance evaluation. |
| Director of Human Resources | Interviewed regarding staff performance evaluations. | |
| Registered Nurse #8 | Registered Nurse | Counted narcotics and reported medication diversion. |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Counted narcotics with RN #8. |
| Administrator | Interviewed regarding medication diversion and narcotic storage. | |
| Director of Food and Beverage | Interviewed regarding dietary sanitation issues. | |
| Dietary Aide #1 | Dietary Aide | Observed in dietary sanitation inspection. |
| Dietary Aide #2 | Dietary Aide | Observed in dietary sanitation inspection. |
Inspection Report
Annual Inspection
Census: 32
Capacity: 37
Deficiencies: 5
Date: May 7, 2018
Visit Reason
Unannounced visits were made to Pomperaug Woods Health Center concluding on May 10, 2018, by representatives of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting multiple investigations, licensing, surveys, and inspections.
Findings
Violations of the Regulations of Connecticut State Agencies and/or General Statutes were identified during the inspection, including issues with medication administration, resident environment safety, water management plan for Legionella risk, and emergency preparedness. The facility was found noncompliant in several areas and required to submit a plan of correction.
Deficiencies (5)
Facility failed to follow physician order for medication resulting in a resident receiving the wrong medication.
Facility failed to maintain resident's environment free from accidental hazards (storage of oxygen cylinders in resident rooms).
Facility failed to ensure a water management plan was in place to reduce Legionella risk in healthcare water systems.
Facility failed to ensure fire sprinkler system was serviced as required and failed to follow facility fire plan during a fire drill.
Facility failed to maintain emergency preparedness plan with required staff contact telephone numbers.
Report Facts
Licensed Bed Capacity: 37
Census: 32
Inspection Dates: Inspection conducted on May 7, 8, 9, and 10, 2018.
Medication Dosage: 300
Oxygen Cylinders: 6
Fire Drill Observations: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cassie Odilia Haley | Administrator | Named as facility administrator and contact for inspection and plan of correction. |
| Kate Petersen | Director of Nursing Services (DNS) | Personnel contacted during inspection. |
| Patricia Tyrell | RN, BSN, RNC | Report submitted by Patricia Tyrell RN, BSN, RNC. |
| Cher E. Michaud | Supervising Nurse Consultant | Signed letter regarding violations and inspection findings. |
| Anthony M. Bruno | Building Construction & Fire Safety Unit Supervisor | Signed letter regarding fire safety violations and plan of correction. |
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