Inspection Reports for Pomperaug Woods
80 Heritage Rd, Southbury, CT 06488, United States, CT, 06488
Back to Facility ProfileInspection Report Summary
The most recent inspection on April 24, 2025, found no deficiencies during a complaint investigation. Earlier inspections showed a mix of results, including a substantiated deficiency in January 2025 related to missing controlled medication and documentation issues. Prior reports identified themes such as medication management, resident care documentation, infection control, and safety concerns, with substantiated complaints involving verbal abuse, mistreatment, and medication diversion in 2019. Enforcement actions included staff terminations and corrective plans, but no fines or license suspensions were listed in the available reports. The facility appears to have addressed many past issues, as recent inspections show fewer deficiencies and some corrected violations.
Deficiencies (last 8 years)
Deficiencies (over 8 years)
6.1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
9% worse than Connecticut average
Connecticut average: 5.6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
81% occupied
Based on a April 2025 inspection.
Census over time
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
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
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
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
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
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
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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