Inspection Reports for
The Nathaniel Witherell

The complaint investigation involved Resident #1 who fell during a mechanical lift transfer without a second staff member present. The resident was found to have uncontrolled diabetes with no routine hemoglobin A1C monitoring. The fall resulted in a hospital transfer but no injuries. The facility failed to follow policies requiring two staff for mechanical lifts and failed to include transfer status in the care plan.

The facility failed to develop a comprehensive care plan including transfer status for Resident #1, failed to monitor hemoglobin A1C levels for a diabetic resident, and did not ensure adequate supervision during mechanical lift transfers, resulting in a resident fall. The resident was transferred to the hospital but sustained no injuries.

The complaint investigation was substantiated based on interviews with student nurse aides who witnessed NA #1 verbally abusing Resident #1 and Resident #2 with inappropriate sexual comments and gestures. The facility investigation confirmed these allegations. Additionally, a prior abuse allegation involving Resident #3 was not reported timely due to staff disbelief, which was also substantiated.

The facility substantiated allegations that NA #1 verbally abused and made inappropriate sexual gestures toward Resident #1 and Resident #2. The facility also failed to provide abuse education to student nurse aides prior to their placement, and there were delays in timely reporting of suspected abuse incidents. Additionally, a prior allegation involving Resident #3 was not reported promptly due to staff disbelief.

The facility failed to ensure the clinical record was complete and accurate by not implementing a new fall intervention in the care plan after Resident #1's fall on 9/10/24, despite staff education on the intervention. The resident fell due to an empty bed not being in a low position, and although the resident was sent to the hospital and returned without injury, the care plan was not updated accordingly.

The facility was found deficient in multiple areas including failure to ensure residents had easy access to state survey results, incomplete advanced directive documentation, delayed physician notification of resident condition changes, inadequate grievance follow-up, failure to remove staff from schedule after abuse allegations, untimely ordering of discharge equipment, incomplete significant change assessments for hospice residents, incomplete care plan updates, failure to provide showers per care plan, improper pressure ulcer care, inadequate fall prevention interventions, insufficient supervision of elopement risk residents, failure to confirm weight loss, lack of ongoing IV therapy competency training, meal service timing issues, inconsistent food labeling and stocking, incomplete abuse investigation documentation, multiple infection control deficiencies including improper glucometer disinfection and PPE availability, and lack of an active antibiotic stewardship program.

The complaint investigation involved allegations of abuse by a nursing assistant (NA #8) toward Resident #227, failure to remove the staff member from the schedule during the investigation, failure to order necessary medical equipment for Resident #176's discharge, inadequate fall prevention and supervision for Residents #22 and #47, and incomplete clinical documentation after abuse allegations. The allegations were substantiated with findings of minimal harm or potential for harm affecting a few residents.

The facility failed to remove an alleged abusive staff member from the schedule during an ongoing investigation, failed to order necessary Durable Medical Equipment timely for discharge, did not implement adequate fall prevention and supervision interventions, and failed to document nursing assessments after abuse allegations. Multiple residents were affected with minimal harm or potential for harm.

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.

Complaint Investigation #38533 was substantiated with violations identified. The facility failed to report an unwitnessed fall of Resident #1 and did not conduct adequate assessments or documentation following the incident.

The inspection found violations related to failure of a staff member to report a resident's fall, inadequate documentation and assessment following the fall, and issues with monitoring and care of the resident. A violation letter was issued with a plan of correction required.

The complaint investigation was substantiated; the nursing assistant did not report the resident's fall on 4/11/24, resulting in delayed assessment and treatment for injuries including a subarachnoid hemorrhage.

The investigation found that a nursing assistant failed to report Resident #1's fall to licensed staff, delaying assessment and treatment. Resident #1 sustained bruising and a subarachnoid hemorrhage requiring emergency department transfer. The facility's policy requires incident reporting and evaluation for all falls, which was not followed.

The complaint involved Resident #1's change in condition not being reported timely to the physician and responsible party, resulting in delayed treatment and death. For Resident #2, the complaint involved physical abuse by a nurse (LPN #4) who grabbed and pushed the resident, and the facility's failure to report the abuse timely and conduct a thorough investigation.

The facility failed to timely report a change in condition for Resident #1, resulting in delayed treatment and death. The facility also failed to prevent physical abuse of Resident #2 by a nurse, failed to report the abuse timely to the state agency, and failed to conduct a thorough investigation of the abuse allegations.

The facility failed to ensure that Resident #1 with multiple pressure ulcers received timely wound center consultation and proper physician or APRN assessment. Documentation did not reflect implementation of wound care center recommendations, and the wound care declined, resulting in infection and hospital transfer. The facility lacked a certified wound care specialist, relying on an RN without wound certification.

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

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.

The complaint investigation involved two residents: Resident #2 was reportedly treated without dignity by a Recreation Aide who touched and verbally disrespected the resident. Resident #1 alleged being punched by a nurse aide, which was substantiated by bruising and investigation. The facility delayed reporting the abuse to the State Agency by four days and did not immediately remove the alleged staff member from the schedule.

The facility failed to ensure a resident was treated with dignity and respect, as evidenced by inappropriate staff behavior toward Resident #2. Additionally, the facility failed to timely report and immediately remove an alleged employee after an abuse allegation involving Resident #1. Both incidents were substantiated with minimal harm or potential for harm.

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 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.

The complaint investigation focused on Resident #1 who was dehydrated and required IV fluids. The investigation found delays in IV fluid administration due to unavailability of fluids on site and delayed pharmacy delivery. The resident was transferred to the hospital and later expired. The complaint was substantiated with findings of delayed care and inadequate documentation.

The facility failed to notify the provider that prescribed IV fluids were not available in house stock, delaying initiation of IV fluids for Resident #1, who was dehydrated and subsequently transferred to the hospital where the resident expired. Additionally, the facility failed to document meal and fluid consumption adequately for Resident #1.

The complaint investigation involved allegations of mistreatment and abuse of Resident #97, including verbal abuse by a nurse aide, failure to report abuse timely, failure to monitor significant weight loss for Resident #162, failure to protect Resident #128 from abuse by Resident #39, and other care and safety concerns. The abuse allegation against NA #1 was substantiated despite lack of direct witness reports.

The facility was found to have failed in multiple areas including ensuring resident dignity and respect, timely reporting of abuse investigations, monitoring significant weight loss and notifying physicians and families, maintaining a safe and homelike environment, revising care plans after incidents, documenting code status discussions, implementing psychiatric medication recommendations, providing adequate nutrition and weight monitoring, maintaining clean medication carts and secure storage, ensuring kitchen cleanliness and proper food storage, and documenting vaccination consent and administration.

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.

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.

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.

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.

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.

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.

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.

The complaint investigation included allegations of physical abuse, failure to follow resident preferences, inadequate investigations of abuse, and failure to provide adequate supervision. Some allegations were substantiated, such as abuse by a dietary aide leading to termination. Other allegations, such as physical abuse by LPN#6, were not substantiated but resulted in staff re-education and reassignment.

The facility failed to treat a resident with dignity, ensure resident preferences were followed, keep residents free from abuse, conduct thorough investigations of alleged abuse, transmit MDS data timely, accurately code resident assessments, and provide adequate supervision during meals. Several staff members were involved in incidents of mistreatment or failure to follow care plans. The facility took some corrective actions such as staff re-education and termination of a dietary aide.