Inspection Report Summary
The most recent inspection on October 29, 2024, found that all previously identified violations had been corrected. Earlier inspections showed a pattern of deficiencies related mainly to resident care issues such as failure to report and assess falls, inadequate wound care, and concerns about resident dignity and abuse. Several complaint investigations were substantiated, including findings of abuse and failure to report incidents timely. Enforcement actions such as plans of correction were required, but fines or license suspensions were not listed in the available reports. The facility’s record shows improvement over time, with recent audits confirming correction of prior violations.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
5.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
5% better than Connecticut average
Connecticut average: 5.6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
85% occupied
Based on a October 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Monitoring
Census: 176
Capacity: 208
Deficiencies: 0
Date: Oct 29, 2024
Visit Reason
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.
Findings
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.
Report Facts
Violation numbers corrected: 38
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Louise Comeau | Director of Nursing | Notified by telephone on 10/29/24 that all violations were corrected. |
| John Mastronardi | Administrator | Personnel contacted during the inspection on 10/29/24. |
Inspection Report
Renewal
Census: 70
Capacity: 200
Deficiencies: 0
Date: Aug 1, 2024
Visit Reason
The inspection was conducted as part of a renewal licensing inspection and included review of complaint investigations.
Complaint Details
The inspection included review of complaint investigations #030387, CT 3597, CT 40832, CT 40231, and 3992.
Findings
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.
Report Facts
Licensed Bed Capacity: 200
Census: 70
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John Mastronardi | ADM Nurse Compliance | Personnel contacted during inspection |
Inspection Report
Follow-Up
Census: 167
Capacity: 202
Deficiencies: 0
Date: Jun 21, 2024
Visit Reason
A desk audit was conducted to review the implementation of the Plan of Correction for a prior violation letter dated 5/2/24.
Findings
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.
Report Facts
Licensed Bed/Bassinet Capacity: 202
Census: 167
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Louise Comeau | Director of Nursing | Notified via telephone that all violations were corrected |
Inspection Report
Follow-Up
Census: 167
Capacity: 202
Deficiencies: 1
Date: May 9, 2024
Visit Reason
A desk audit was conducted to review the implementation of the Plan of Correction for a prior Violation letter dated 3/27/24.
Findings
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.
Deficiencies (1)
Violations 1, 2, 3, and 4 from the prior inspection
Report Facts
Licensed Bed Capacity: 202
Census: 167
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Louise Comeau | Director of Nurses | Contacted during inspection and notified of correction of violations |
| Terri Anderson-Murray | Report submitted by | |
| Karen Ellison | Signature of FLIS Staff |
Inspection Report
Complaint Investigation
Census: 182
Capacity: 202
Deficiencies: 1
Date: Apr 24, 2024
Visit Reason
The inspection was conducted as a complaint investigation related to Complaint Investigation #38533, triggered by allegations concerning the facility's compliance with state regulations.
Complaint Details
Complaint Investigation #38533 was substantiated with findings of noncompliance related to failure to report and assess a resident's fall and injuries.
Findings
Violations of Connecticut State regulations were identified during the inspection, specifically involving failure of nursing staff to report a resident's fall and incomplete documentation related to the incident. The report details a resident's fall and subsequent injuries that were not properly assessed or reported by staff.
Deficiencies (1)
A staff member failed to report a fall to licensed staff when the resident had an unwitnessed fall, and there was no documentation of a recent fall in the resident's record despite observed bruising and injuries.
Report Facts
Census: 182
Total Capacity: 202
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John Mastronardi | Administrator | Personnel contacted during inspection |
| Louise Comeau | Director of Nursing (DON) | Personnel contacted during inspection |
| Karen Gworek | Supervising Nurse Consultant | Author of the violation notice letter |
Inspection Report
Census: 162
Capacity: 202
Deficiencies: 0
Date: Jan 30, 2024
Visit Reason
The inspection was conducted as a desk audit on 1/30/2024 to review compliance and verify correction of previous violations.
Findings
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.
Report Facts
Licensed Bed Capacity: 202
Census: 162
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Louise Comeau | DHS | Personnel contacted during the inspection on 1/30/24 at 12:23 pm |
Inspection Report
Census: 162
Capacity: 202
Deficiencies: 0
Date: Jan 30, 2024
Visit Reason
The inspection was a Desk Audit conducted on 1/30/2024 to review compliance with regulations.
Findings
No violations of the General Statutes of Connecticut and/or regulations were identified at the time of this inspection.
Report Facts
Licensed Bed Capacity: 202
Census: 162
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Louise Comeau | DNS | Personnel contacted during the inspection on 1/30/24 at 12:23 pm |
| Allison Benson | Report submitted by |
Inspection Report
Complaint Investigation
Census: 198
Capacity: 202
Deficiencies: 1
Date: Nov 9, 2023
Visit Reason
The inspection was conducted as a complaint investigation related to Complaint #36248, with violations of Connecticut State regulations identified during the visit.
Complaint Details
Complaint #36248 was investigated, and violations were substantiated as noted in the attached violation letter dated 11/30/23.
Findings
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.
Deficiencies (1)
Failure to ensure a resident with a declining wound was seen at a wound center as recommended and failure to document wound care properly.
Report Facts
Census: 198
Total Capacity: 202
Complaint Number: 36248
Completion Date: Dec 21, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John Mastronardi | Administrator | Named in relation to complaint and inspection |
| Louise Comeau | DNS | Personnel contacted during inspection |
| Karen Gworek | Supervising Nurse Consultant | Author of the notice of violation letter |
Inspection Report
Complaint Investigation
Census: 180
Capacity: 202
Deficiencies: 2
Date: Aug 10, 2023
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (2)
Failure to ensure Resident #2 was treated in a dignified manner, including inappropriate behavior by Recreation Aide #1.
Failure to report and immediately remove an alleged abusive employee after an abuse allegation involving Resident #1.
Report Facts
Licensed Beds: 202
Census: 180
Complaint Number: 35258
Plan of Correction Submission Deadline: 27
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Louise Comeau | Director of Nursing Services (DNS) | Personnel contacted during the inspection. |
| Nicholas Tomczyk | Nurse Consultant | Report submitted by. |
| Margaret McKinney | Supervising Nurse Consultant | Author of the notice letter regarding the complaint investigation. |
Inspection Report
Complaint Investigation
Census: 175
Capacity: 202
Deficiencies: 0
Date: Jun 10, 2022
Visit Reason
The inspection visit was conducted as a complaint investigation referenced by Complaint Investigation #31500.
Complaint Details
Complaint Investigation #31500 was referenced, and the complaint was not substantiated as no violations were found.
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 |
|---|---|---|
| Nadia Benson | Director of Nursing | Personnel contacted during the inspection. |
Inspection Report
Renewal
Census: 186
Capacity: 202
Deficiencies: 0
Date: Feb 27, 2022
Visit Reason
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.
Complaint Details
Complaint investigations referenced by numbers CT 31716, CT 30493, and CT 31802 were part of the inspection process.
Findings
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.
Report Facts
Licensed Bed/Bassinet Capacity: 202
Census: 186
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marie Mathieu | Signature of FLIS Staff and report submitted by | |
| Damutz Bruzas | Signature of FLIS Staff | |
| Richard Howe | Signature of FLIS Staff | |
| Anna Mildares | Signature of FLIS Staff |
Inspection Report
Routine
Deficiencies: 8
Date: May 6, 2020
Visit Reason
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.
Findings
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.
Deficiencies (8)
Poor supervisory understanding and poor nursing staff understanding of basic infection control practices.
Inaccurate door signage on entry to resident rooms with COVID-19 diagnosis.
Nursing staff with poor mask etiquette, including constant readjusting of face masks.
Facility reusing single use PPE gowns over many days with improper cleaning and storage.
Nursing staff using clear plastic bags wrapped around shoes and white plastic aprons instead of PPE gowns.
Multiple used gowns stored on the floor in the staff break room.
Multiple clear plastic bags used in the staff break room for storage of used PPE gowns and N95 masks.
Multiple nursing staff asking for help regarding supervisors not giving them PPE.
Report Facts
Date of observation: May 6, 2020
Plan of correction submission deadline: May 28, 2020
Training date: May 11, 2020
Audit start date: Jun 8, 2020
Plan of correction approval date: Jun 11, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Norma Schuberth | Supervising Nurse Consultant | Signed letter regarding the inspection and plan of correction |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Apr 23, 2020
Visit Reason
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.
Findings
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.
Deficiencies (1)
Failure to post appropriate COVID-19 status signage on residents' doors indicating pending COVID-19 test results.
Report Facts
Date of inspection: Apr 23, 2020
Plan of correction submission deadline: May 14, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cher Michaud | Supervising Nurse Consultant | Signed the notice letter regarding the inspection and plan of correction |
| Allen Brown | Administrator | Facility administrator addressed in the notice letter |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Apr 23, 2020
Visit Reason
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.
Findings
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.
Deficiencies (1)
Failure to place appropriate signage outside of two suspected COVID-19 positive residents' doors to indicate COVID-19 status.
Report Facts
Date of survey: Apr 23, 2020
Number of residents reviewed for infection prevention: 3
Date of Minimum Data Set (MDS) assessment for Resident #2: Apr 18, 2020
Date of Minimum Data Set (MDS) assessment for Resident #1: Apr 9, 2020
Time of COVID-19 swab for Residents #1 and #2: 845
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nurses (DNS) | Interviewed regarding residents' COVID-19 status and signage | |
| Occupational Therapist (OT) #1 | Interviewed about awareness of resident COVID-19 status and PPE use | |
| Registered Nurse (RN) #1 | Interviewed about signage for COVID-19 pending test results and communication |
Inspection Report
Complaint Investigation
Census: 182
Capacity: 202
Deficiencies: 3
Date: Jan 23, 2020
Visit Reason
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.
Complaint Details
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.
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.
Deficiencies (3)
Failure to ensure adequate supervision to prevent elopement resulting in immediate jeopardy.
Failure to notify state agency as required when a resident was identified as missing from the facility.
Failure to post signage indicating COVID-19 test pending on residents' doors.
Report Facts
Licensed Bed Capacity: 202
Census: 182
Inspection Dates: 2020-01-20 and 2020-01-23
Citation Number: 2012
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Allen Brown | Administrator | Named in relation to complaint investigation and findings. |
| Joanne Kotulski | Administrator | Named in relation to complaint investigation and findings. |
| Lisa A. DiLorenzo | Supervising Nurse Consultant | Signed the report and involved in the investigation. |
| Cher Michaud | Supervising Nurse Consultant | Mentioned in correspondence related to inspection. |
Inspection Report
Census: 189
Capacity: 202
Deficiencies: 0
Date: Oct 9, 2019
Visit Reason
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.
Findings
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.
Report Facts
Licensed Bed Capacity: 202
Census: 189
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Allen Brown | Administrator | Personnel contacted during inspection and referenced in findings |
| P. Henrietta Simmons | RN, DPH Nurse Consultant | Report submitted by and involved in inspection findings |
Inspection Report
Plan of Correction
Deficiencies: 7
Date: Aug 9, 2019
Visit Reason
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.
Findings
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.
Deficiencies (7)
Failure to treat Resident #83 in a dignified manner, including allegations of physical abuse by staff.
Failure to ensure Resident #55's preference related to getting out of bed was followed.
Failure to keep Resident #145 free from abuse, including verbal and physical incidents.
Failure to complete a thorough investigation of a bruise of unknown origin for Resident #41.
Failure to ensure timely submission of Minimum Data Set (MDS) for Resident #2.
Failure to correctly code MDS for Residents #140 and #172 related to bowel and bladder function and PASRR Level II assessment.
Failure to ensure supervision during meals for Resident #83, who required constant supervision due to risk of aspiration.
Report Facts
Plan of Correction submission deadline: 10
Plan of Correction submission deadline: 20
Substantial compliance deadline: Sep 20, 2019
Provider agreement termination date: Feb 5, 2020
Audit completion dates: Oct 4, 2019
Audit completion dates: Dec 4, 2019
Education completion date: Sep 16, 2019
Education completion date: Dec 30, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Allen Brown | Administrator | Named in Plan of Correction letter and responsible person for compliance |
| Judy Birtwistle | Supervising Nurse Consultant | Author of the initial notice letter from the Department of Public Health |
| LPN #6 | Involved in physical abuse allegation with Resident #83 | |
| RN #1 | Registered Nurse | Interviewed regarding Resident #55's care and supervision |
| Dietary Aid #1 | Involved in abuse incident with Resident #145 | |
| Person #3 | Witnessed abuse incident involving Resident #145 | |
| LPN #8 | Witnessed abuse incident involving Resident #145 | |
| RN #2 | Registered Nurse | Interviewed regarding MDS coding and Resident #140 and #172 |
| RN #11 | Registered Nurse | Interviewed regarding bruising incident with Resident #41 |
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Aug 9, 2019
Visit Reason
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.
Findings
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.
Deficiencies (7)
Failure to treat Resident #83 in a dignified manner and failure to protect resident rights.
Failure to ensure Resident #55's preference related to getting out of bed was followed.
Failure to keep Resident #145 free from abuse; dietary aide yelled at and pulled resident's chair.
Failure to thoroughly investigate alleged abuse of Resident #41 with bruise of unknown origin.
Failure to timely transmit Minimum Data Set (MDS) assessments for Resident #2.
Failure to accurately code MDS assessments for urinary incontinence (Resident #140) and PASRR Level II (Resident #172).
Failure to provide adequate supervision during meals for Resident #83 who required 1:1 supervision due to aspiration risk.
Report Facts
Dates of unannounced visits: 5
Number of shifts Resident #140 was incontinent: 10
MDS submission delay days: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #6 | Licensed Practical Nurse | Named in allegation of physical abuse to Resident #83; received letter of warning and customer service re-education |
| Dietary Aid #1 | Dietary Aide | Terminated for yelling at and pulling chair of Resident #145 |
| RN #1 | Registered Nurse | Interviewed regarding Resident #55 and Resident #83 care and supervision |
| RN #2 | Registered Nurse | Interviewed regarding MDS submissions and Resident #140 and #172 assessments |
| Assistant Director of Nursing Services | Assistant Director of Nursing | Interviewed regarding Resident #83 and abuse investigations |
| Director of Nursing Services | Director of Nursing | Reviewed video evidence of abuse incident involving Dietary Aid #1 |
Inspection Report
Desk Audit
Census: 177
Capacity: 202
Deficiencies: 0
Date: Sep 13, 2018
Visit Reason
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.
Findings
Violations 1-6 identified in the prior inspection were reviewed and found to be corrected as of the desk audit on 9/13/18.
Report Facts
Licensed Bed Capacity: 202
Census: 177
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Edward Omondi | DNS | Personnel contacted during desk audit |
| Kelly Madden | NC | Report submitted by Kelly Madden, NC |
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