Inspection Report Summary
The most recent inspection on March 19, 2025, identified deficiencies related to violations of Connecticut statutes and regulations, including a substantiated complaint investigation. Earlier inspections showed a pattern of issues primarily involving communication facilitation between residents and families, infection control practices during COVID-19, and medication and resident safety concerns. Prior complaint investigations found deficiencies in assisting residents with communication and ensuring proper use of personal protective equipment, with some corrective actions implemented in follow-up visits. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility’s inspection history shows some improvement after earlier citations, but recent findings indicate ongoing challenges with regulatory compliance.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
3.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
32% better than Connecticut average
Connecticut average: 5.6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
38% occupied
Based on a March 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Renewal
Census: 83
Capacity: 217
Deficiencies: 0
Mar 19, 2025
Visit Reason
The inspection was conducted as a licensing inspection including renewal and complaint investigation (Complaint Investigation # CT# 39267).
Findings
Violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection. Additional narrative or violation letter is attached but not included in this report.
Complaint Details
Complaint Investigation # CT# 39267 was referenced in the inspection report.
Report Facts
Licensed Bed Capacity: 217
Census: 83
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Yakov Kramnek | Administrator | Personnel contacted during the inspection. |
| Elizabeth Buzzanello | DNS | Personnel contacted during the inspection. |
Inspection Report
Renewal
Deficiencies: 0
Feb 3, 2025
Visit Reason
The inspection was a licensing renewal inspection conducted as a desk audit for survey EID 12/19/24 to review the facility's plan of correction documentation.
Findings
The desk audit found that the facility had completed corrections as of 2025-01-27 with no new non-compliance identified.
Report Facts
Date of correction completion: Jan 27, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Linda M Gagnon | Survey Team Leader | Named as surveyor conducting the inspection |
| Y. Kramer | Administrator | Personnel contacted during inspection |
| Beth Buzzannco | RN | Personnel contacted during inspection |
Inspection Report
Follow-Up
Census: 88
Capacity: 217
Deficiencies: 1
Dec 30, 2024
Visit Reason
An on-site follow-up visit was conducted to review the implementation of the Plan of Correction for the violation letter dated 2024-12-06.
Findings
Violation #1a was identified as corrected as of 2024-12-20. The administrator was notified in-person on 2024-12-26 that all violations were corrected.
Deficiencies (1)
| Description |
|---|
| Violation #1a |
Report Facts
Licensed Bed Capacity: 217
Census: 88
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Beth Buzzannco | Director of Nursing | Personnel contacted during inspection |
Inspection Report
Complaint Investigation
Census: 75
Capacity: 217
Deficiencies: 1
Aug 17, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including infection prevention and control practices. Additionally, an investigation (ACTS reference number CT27909) was reviewed.
Findings
The facility failed to ensure interventions required to facilitate desired communication between Resident #1 and his/her family were implemented. Despite the family's request for daily contact, Resident #1 received only six documented electronic visits and one outdoor visit over 22 days. Staff did not adequately accommodate or communicate the visitation needs, resulting in deficient practice.
Complaint Details
The visit was complaint-related, triggered by concerns about the facility's failure to provide assistance to Resident #1 for daily communication with family. The complaint was substantiated as deficiencies were identified.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure interventions required to facilitate desired communication between Resident #1 and family members were implemented. | SS=D |
Report Facts
Capacity: 217
Census: 75
Documented E-visits: 6
Outdoor visits: 1
Days at facility: 22
Inspection Report
Follow-Up
Census: 73
Capacity: 217
Deficiencies: 2
Aug 17, 2020
Visit Reason
An unannounced visit was made to Greenwich Woods Rehabilitation to conduct a Covid-19 focused infection control survey and to review the letter of violation dated 06/29/2020.
Findings
The survey found that Resident #1 had limited assistance with phone communication and visitation, with only partial accommodation of family contact requests. The facility had implemented corrective actions including staff education and visitation audits. No new violations were identified at the time of this follow-up inspection.
Complaint Details
Complaint CT #27909 was the basis for the initial investigation and subsequent follow-up.
Deficiencies (2)
| Description |
|---|
| Resident #1 was unable to get staff assistance to make phone calls or provide status updates, despite family requests for daily contact. |
| Facility staff failed to ensure health care providers wore PPE that offered adequate source control in a setting with persons under investigation (PUI) for COVID. |
Report Facts
Licensed Bed Capacity: 217
Census: 73
Plan of Correction Compliance Date: 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Norma Schuberth | Supervising Nurse Consultant | Named in letter regarding violation and plan of correction instructions |
| Priscilla Sarpong | DNS | Personnel contacted during inspection |
| Carla Dunford | Administrator | Personnel contacted and named in findings |
| Errolee Bryan Miller | RN MSN | Report submitter and reviewer of plan of correction |
Inspection Report
Plan of Correction
Deficiencies: 1
Aug 17, 2020
Visit Reason
An unannounced visit was conducted at Greenwich Woods Rehabilitation on August 17, 2020, by the Department of Public Health for a Covid-19 focused infection control survey.
Findings
The facility failed to ensure interventions to facilitate communication between Resident #1 and their family were implemented, despite the resident's cognitive impairment and family requests for daily contact. Documentation and interviews revealed insufficient assistance was provided for phone communication, and visitation accommodations were inadequate.
Complaint Details
Complaint CT #27909 was the basis for the visit. Substantiation status is not explicitly stated.
Deficiencies (1)
| Description |
|---|
| Failure to ensure interventions required to facilitate desired communication between Resident #1 and family members were implemented. |
Report Facts
Dates of documented Face Time visits: 4
Outdoor visits: 1
Documented E-visits: 6
Compliance Date: Sep 28, 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Carla Dunford | Administrator | Named as the facility administrator responsible for compliance and interviewed regarding visitation issues. |
| Norma Schuberth | Supervising Nurse Consultant | Author of the notice and contact for questions regarding violations. |
Inspection Report
Plan of Correction
Deficiencies: 1
Jun 24, 2020
Visit Reason
An unannounced visit was made to Greenwich Woods Rehabilitation on June 24, 2020, by a representative of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting an investigation and a COVID-19 monitoring focused survey.
Findings
The facility failed to ensure health care providers wore PPE that offered adequate source control in a setting with known COVID-19 persons under investigation. Specifically, two licensed practical nurses were observed wearing cloth masks improperly and were reeducated and released from duty as a last warning. The facility was cited for failure to ensure adequate source control PPE use.
Deficiencies (1)
| Description |
|---|
| Failure to ensure health care providers wore PPE that offered adequate source control in a setting with known COVID-19 persons under investigation, including improper use of cloth masks by licensed practical nurses. |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alice Martinez | Supervising Nurse Consultant | Signed letter regarding the plan of correction and investigation. |
Inspection Report
Abbreviated Survey
Census: 72
Capacity: 217
Deficiencies: 0
May 14, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted to determine compliance with 42 CFR §483.80 Infection Control regulations for Long Term Care Facilities.
Findings
The facility has implemented the CMS and CDC recommended practices related to COVID-19. No deficiencies were cited as a result of this survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
May 6, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted to determine compliance with 42 CFR §483.80 Infection Control regulations for Long Term Care Facilities.
Findings
The facility implemented the CMS and CDC recommended practices related to COVID-19. No deficiencies were cited as a result of this survey.
Inspection Report
Plan of Correction
Census: 75
Deficiencies: 1
May 6, 2020
Visit Reason
An unannounced visit was made to Greenwich Woods Rehabilitation on May 6, 2020, by a representative of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting a COVID-19 infection control survey.
Findings
The facility failed to ensure COVID-19 infected residents were cohorted appropriately and failed to ensure proper cleaning, storage, and disposal of Personal Protective Equipment (PPE). Staff were found to be reusing PPE gowns improperly and taking single-use gowns home to launder. Multiple staff wore KN-95 masks providing care to infected residents without fit testing capability at the time of the survey.
Deficiencies (1)
| Description |
|---|
| Failed to ensure COVID-19 infected residents were cohorted appropriately and PPE was properly cleaned, stored, and discarded according to professional standards. |
Report Facts
Census: 21
Census: 15
Census: 19
Census: 20
Residents with confirmed COVID-19 infection: 7
Residents with confirmed COVID-19 infection: 5
Residents with confirmed COVID-19 infection: 2
Residents with confirmed COVID-19 infection: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Carla Dunford | Administrator | Interviewed regarding COVID-19 cohorting and PPE practices |
| Norma Schuberth | Supervising Nurse Consultant | Author of the report |
Inspection Report
Routine
Census: 88
Capacity: 217
Deficiencies: 0
Apr 15, 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
Complaint Investigation
Census: 128
Capacity: 214
Deficiencies: 8
Oct 2, 2018
Visit Reason
Unannounced visits were made to Greenwich Woods Rehabilitation on October 2, 3 and 4, 2018 by representatives of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting multiple investigations related to complaints.
Findings
The facility was found to have multiple violations including misappropriation of resident property, failure to maintain documentation of narcotic medication destruction, failure to conduct comprehensive assessments after resident falls, and failure to ensure adequate supervision and safe transport of residents. Several staff members were involved in these deficiencies and corrective actions were required.
Complaint Details
Complaints #23079, 23162, 22803, 22695, 22684 were investigated. The facility was found noncompliant with multiple regulations related to resident safety, medication management, and infection control.
Deficiencies (8)
| Description |
|---|
| Facility failed to ensure the resident was free from misappropriation of personal property. |
| Facility failed to maintain documentation that narcotic medications were destroyed after resident discharge. |
| Facility failed to ensure a comprehensive assessment was conducted when a fall was reported. |
| Facility failed to ensure maintenance services to maintain an orderly and comfortable interior environment. |
| Facility failed to ensure accurate coding of PASRR assessments. |
| Facility failed to ensure adequate supervision and safe positioning of resident in transport wheelchair, resulting in a fall and fracture. |
| Facility failed to develop and implement interventions for resident with significant weight loss. |
| Facility failed to ensure staff followed infection control practices. |
Report Facts
Licensed Bed Capacity: 214
Census: 128
Inspection Dates: 2018-10-02 to 2018-10-04
Plan of Correction Due Date: Nov 14, 2018
Deficiency Count: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Chiappinelli | Administrator | Named in relation to the inspection and plan of correction. |
| Karen Gworek | Supervising Nurse Consultant | Signed the complaint investigation report. |
| Susan Almeida | Director of Nursing Services (DNS) | Named in relation to medication destruction and corrective measures. |
| Siobhan O'Neill | Nurse Consultant | Reported on desk audit and staffing review. |
| Marie Mather | Submitted report dated 12/10/18. |
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