Inspection Reports for The Nathaniel Witherell

The inspection visit was conducted as a desk audit and onsite visit to review the implementation of the Plan of Correction for previously identified violations.

All violations listed in the prior violation letter dated 2024-08-27 were identified as corrected as of 2024-09-17. The Director of Nursing was notified by telephone on 2024-10-29 that all violations were corrected.

The inspection was conducted as part of a renewal licensing inspection and included review of complaint investigations.

The report indicates that violations of the General Statutes of Connecticut and/or regulations were identified during the inspection, with references to multiple complaint investigations. The certification file was reviewed.

The inspection included review of complaint investigations #030387, CT 3597, CT 40832, CT 40231, and 3992.

A desk audit was conducted to review the implementation of the Plan of Correction for a prior violation letter dated 5/2/24.

The audit found that Violation #1 was corrected as of 6/5/24, and the Director of Nursing was notified that all violations were corrected.

A desk audit was conducted to review the implementation of the Plan of Correction for a prior Violation letter dated 3/27/24.

Violations 1, 2, 3, and 4 were corrected as of 4/22/24, and on 5/9/24 the Director of Nurses was notified via telephone that all violations were corrected.

The inspection was conducted as a complaint investigation related to Complaint Investigation #38533 regarding violations of Connecticut State regulations identified during the visit.

The investigation found that a facility staff member failed to report a fall of a resident (Resident #1) to licensed staff, despite evidence of injury. The resident had bruises and was admitted to the hospital for a subarachnoid hemorrhage and urinary tract infection. The facility's Falls Management and Prevention Policy requires incident reporting and evaluation for unwitnessed falls, which was not followed.

Complaint Investigation #38533 was substantiated with violations identified. The complaint involved failure to report and properly assess a resident's fall and injuries.

The inspection was conducted as a desk audit on 1/30/2024 to review compliance and verify correction of previous violations.

No violations of the General Statutes of Connecticut and/or regulations were identified at the time of this inspection. Previous violation #1 was corrected as of 12/21/23, and the Department of Social Services was notified that all violations were corrected.

The inspection was a Desk Audit conducted on 1/30/2024 to review compliance with regulations.

No violations of the General Statutes of Connecticut and/or regulations were identified at the time of this inspection.

The inspection was conducted as a complaint investigation related to Complaint #36248, with violations of Connecticut State regulations identified during the visit.

The facility failed to ensure proper wound care for a resident with a declining wound, including inadequate documentation and treatment, leading to multiple stage 2 pressure ulcers and infection. The facility does not currently have a certified wound care specialist, and corrective actions are planned.

Complaint #36248 was investigated, and violations were substantiated as noted in the attached violation letter dated 11/30/23.

An unannounced visit was conducted on August 10, 2023, as a complaint investigation (#35258) by the Department of Public Health to assess violations of Connecticut State regulations at The Nathaniel Witherell facility.

The investigation found violations related to resident dignity and abuse. Resident #2 was treated in a non-dignified manner by a recreation aide, and Resident #1 was subject to abuse by a nurse aide, which was substantiated. The facility failed to report the abuse allegation timely and did not immediately remove the alleged employee from duty.

Complaint investigation #35258 was substantiated with findings of abuse and dignity violations involving two residents. Resident #2 was verbally humiliated by a recreation aide, and Resident #1 was punched by a nurse aide. The facility did not timely report the abuse and failed to remove the accused staff member immediately.

The inspection visit was conducted as a complaint investigation referenced by Complaint Investigation #31500.

No violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection.

Complaint Investigation #31500 was referenced, and the complaint was not substantiated as no violations were found.

The inspection was conducted as a licensing inspection for renewal purposes and included complaint investigations identified by numbers CT 31716, CT 30493, and CT 31802.

Violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified during the inspection, with an attached violation letter dated 7/18/22. The report includes verification of CMP fund, CRF grant, and infection prevention and control specialist involvement.

Complaint investigations referenced by numbers CT 31716, CT 30493, and CT 31802 were part of the inspection process.

An unannounced visit was conducted on May 6, 2020, by the Department of Public Health for the purpose of conducting a COVID-19 infection control survey at Nathaniel Witherell.

The facility failed to ensure staff followed appropriate infection control practices to prevent COVID-19 transmission, including poor supervisory and nursing staff understanding, inaccurate door signage, poor mask etiquette, improper reuse and storage of PPE gowns, and use of plastic bags instead of PPE gowns. Multiple corrective actions and ongoing monitoring plans were outlined.

An unannounced visit was conducted on April 23, 2020 by the Department of Public Health for the purpose of conducting an inspection at Nathaniel Witherell.

The facility failed to place appropriate signage outside of two suspected COVID-19 positive residents' doors, which was a violation of infection prevention protocols during the COVID-19 pandemic. The report details deficiencies related to failure to post COVID-19 status signs and inadequate staff awareness of signage requirements.

A COVID-19 Focused Survey was conducted on April 23, 2020 at Nathaniel Witherell 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.

The facility failed to place appropriate signage outside of two suspected COVID-19 positive residents' doors, which could lead to improper use of personal protective equipment and increased risk of transmission. Staff were not fully informed of residents' COVID-19 status, and signage indicating pending COVID-19 test results was missing until added after surveyor inquiry.

An unannounced visit was conducted at Nathaniel Witherell on January 20 and 23, 2020 for the purpose of conducting a complaint investigation (CT#26813) related to immediate jeopardy findings.

The facility was found to have immediate jeopardy due to failure to provide adequate supervision to prevent elopement, failure to notify the state agency when a resident was missing, and failure to post appropriate COVID-19 signage during a later inspection. The immediate jeopardy was verified as corrected during the onsite visit on 1/23/20.

Complaint investigation #26813 was substantiated with findings of immediate jeopardy related to elopement risk and failure to notify the state agency of a missing resident.

Visit or revisit for the purpose of desk audit for violation letters dated August 14, 2019 and August 20, 2019, and reviewed plan of correction.

Violations identified in previous letters were found to be corrected at the time of this desk audit. No violations of the General Statutes of Connecticut and/or regulations were identified during this inspection.

A survey and investigation were conducted on August 9, 2019, by the State of Connecticut Department of Public Health to determine compliance with Federal requirements for nursing homes participating in Medicare and Medicaid programs.

The survey found isolated deficiencies constituting no actual harm but with potential for more than minimal harm, classified at a 'D' level. An enforcement cycle was initiated based on these deficiencies, requiring submission of a Plan of Correction.

Unannounced visits were made to the facility on 8/5/19 through 8/9/19 by representatives of the Facility Licensing & Investigations Section for the purpose of conducting a licensure inspection, certification survey, and multiple investigations.

The facility was found to have multiple deficiencies including failure to treat residents with dignity and respect, failure to ensure resident self-determination, failure to keep residents free from abuse and neglect, failure to thoroughly investigate abuse allegations, failure to timely transmit Minimum Data Set (MDS) assessments, inaccurate MDS coding, and failure to provide adequate supervision during meals for residents at risk of aspiration.

A desk audit review was conducted on 9/13/18 by a representative of the FLIS for the purpose of reviewing the Plan of Correction for the violation letter dated 7/19/18.

Violations 1-6 identified in the prior inspection were reviewed and found to be corrected as of the desk audit on 9/13/18.