Inspection Reports for Whispering Pines Rehabilitation and Nursing Center
CT
Back to Facility ProfileInspection Report Summary
The most recent inspection on April 3, 2025, found no deficiencies during a complaint investigation. Earlier inspections showed a pattern of deficiencies related mainly to resident care issues, infection control practices, and documentation, with some citations involving failure to follow policies for emergency discharges and timely care. Complaint investigations generally resulted in unsubstantiated findings, though some violations were substantiated in prior years, including issues with privacy, restraint use, and infection prevention. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s record shows some improvement over time, with recent follow-up visits confirming correction of prior deficiencies.
Deficiencies (last 6 years)
Deficiencies are regulatory violations found during state inspections.
Deficiencies per year
Census
Based on a April 2025 inspection.
Census over time
| Name | Title | Context |
|---|---|---|
| Helen Byron | Administrator | Personnel contacted during the inspection |
| Savonna Ormond | DNS | Personnel contacted during the inspection |
| Description |
|---|
| Violation #1 identified in prior inspection |
| Name | Title | Context |
|---|---|---|
| Savonna Ormond | DNS | Notified of violation corrections |
| Michelle Povilonis | RN NC | Survey team leader and report submitter |
| Maureen Golas-Markure | SNC | Supervisor |
| Name | Title | Context |
|---|---|---|
| Helen Byron | Administrator | Notified via telephone that the violation was corrected. |
| Cesar Castillo | Survey Team Leader | Submitted the report. |
| Name | Title | Context |
|---|---|---|
| Helen Byron | Administrator | Personnel contacted during the inspection. |
| Savonna Ormond | Director of Nursing | Personnel contacted during the inspection. |
| Deborah Smith | RN, NC | Report submitted by. |
| Description |
|---|
| Failure to allow readmission of a resident cleared by the hospital for return to the facility, and lack of a specific policy for emergency discharges. |
| Name | Title | Context |
|---|---|---|
| Karen Gworek | Supervising Nurse Consultant | Author of the notice letter regarding violations and plan of correction instructions |
| Description |
|---|
| Violations #1-11 identified in prior inspection |
| Name | Title | Context |
|---|---|---|
| Savonna Ormond | DNS | Personnel contacted during inspection |
| Description |
|---|
| Violation #1 identified in previous inspection |
| Name | Title | Context |
|---|---|---|
| Helen Byron | Administrator | Notified via telephone that all violations were corrected |
| Danielle Castro | RN, NC | Report submitted by |
| Krystle Daniels | RN, NC | Signature of FLIS Staff |
| Description |
|---|
| Failure to ensure care and services were provided at the time the resident requested assistance for toileting needs, including denial of bathroom access and inadequate staff response. |
| Name | Title | Context |
|---|---|---|
| Nicholas Tomczyk | Nurse Consultant | Conducted the complaint investigation and authored the licensing inspection narrative report |
| Giovanna Griffin | Administrator | Facility administrator involved in the inspection and recipient of the notice |
| Savonna Ormond | Director of Nursing Services (DNS) | Interviewed during the investigation and named as monitor in the plan of correction |
| Karen Gworek | Supervising Nurse Consultant | Signed the important notice letter regarding the inspection findings and plan of correction |
| Nurse Aide #1 | Interviewed during investigation regarding the toileting incident with Resident #1 | |
| Licensed Practical Nurse (LPN) #1 | Interviewed during investigation regarding the toileting incident with Resident #1 |
| Description |
|---|
| Failure to ensure staff wore appropriate Personal Protective Equipment (PPE) while providing care to a resident on contact and droplet precautions and improper handling of soiled linen. |
| Failure to ensure a resident's urinary catheter drainage bag was covered with a privacy bag at all times. |
| Failure to ensure recommendations for a re-evaluation following a Level I PASRR evaluation were requested in a timely manner. |
| Failure to ensure a resident's interim care plan was completed within 48 hours of admission. |
| Failure to ensure a resident's podiatry foot care services were rendered in a timely manner. |
| Failure to ensure a resident's catheter bag was positioned appropriately below the bladder. |
| Failure to ensure a resident alleging physical mistreatment was immediately reported to the State Agency prior to making a determination of credibility. |
| Failure to ensure food items were served at appropriate hot temperatures. |
| Failure to ensure resident equipment was maintained in safe operating conditions. |
| Name | Title | Context |
|---|---|---|
| Giovanna Griffin | Administrator | Contacted during inspection and named in findings related to infection control and resident care. |
| Savonna Ormond | Director of Nursing Services (DNS) | Contacted during inspection and named in findings related to infection control and resident care. |
| Nicholas Tomczyk | Nurse Consultant | Report submitted by. |
| Karen Gworek | Supervising Nurse Consultant | Signed complaint investigation notice. |
| Judith Birtwistle | Supervising Nurse Consultant | Signed important notices and correspondence related to the inspection. |
| Description | Severity |
|---|---|
| Failure to ensure staff wore appropriate Personal Protective Equipment while providing care to a resident on contact and droplet precautions and failure to handle soiled linen in accordance with facility policy. | SS=D |
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Interviewed regarding infection control practices and PPE use during care of Resident #2 |
| NA #1 | Nurse Aide | Observed providing care without appropriate PPE including isolation gown and eye protection |
| Description |
|---|
| Failure to ensure staff wore appropriate PPE and handle soiled linen according to facility policy during care of a resident on contact and droplet precautions. |
| Name | Title | Context |
|---|---|---|
| Giovanna Griffin | Administrator | Named as personnel contacted and recipient of the notice letter. |
| Kathleen Plaskon | Survey Team Leader | Conducted the inspection and submitted the report. |
| Karen Gworek | Supervising Nurse Consultant | Signed the notice letter and involved in complaint investigation. |
| Description |
|---|
| Failure to ensure Resident #11's urinary catheter drainage bag was covered/not visible. |
| Failure to ensure a physician order was present that reflected the wishes of the resident or resident representative for Advanced Directives for Residents #11, #79, and #179. |
| Failure to ensure an allegation of physical mistreatment was reported to the State Agency prior to making the determination whether the allegation was credible. |
| Failure to ensure recommendations for a re-evaluation for PASRR were requested in a timely manner for Resident #52. |
| Failure to ensure the Interim Care Plan was completed within 48 hours of admission for Resident #79. |
| Failure to provide podiatry services in a timely manner for Resident #30. |
| Failure to ensure the urinary tubing and drainage bag was below the level of the bladder for Resident #11. |
| Name | Title | Context |
|---|---|---|
| Judith Birtwistle | Supervising Nurse Consultant | Signed the plan of correction notice letter |
| Giovanna Griffin | Administrator | Named in relation to violations and plan of correction |
| MD #1 | Physician | Referenced in findings related to physician orders and advanced directives |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding urinary catheter care and code status |
| DNS | Director of Nursing Services | Interviewed regarding code status and care plans |
| NA #1 | Nurse Aide | Interviewed regarding alleged mistreatment incident |
| SW #1 | Social Worker | Interviewed regarding PASRR and mistreatment allegations |
| RN #4 | Registered Nurse | Interviewed regarding podiatry services and resident care |
| Description |
|---|
| Violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies |
| Name | Title | Context |
|---|---|---|
| Judy Birtwistle | Supervisor | Approval for issuance of license granted by |
| Description |
|---|
| Failure to ensure Resident #11's urinary drainage bag was covered and dignity maintained during dining. |
| Failure to ensure physician orders reflected residents' advanced directives and code status for Residents #11, #79, and #179. |
| Failure to maintain Resident #11's bedroom walls and floor mats in good repair. |
| Failure to report an allegation of physical mistreatment of Resident #30 to the State Agency. |
| Failure to ensure recommendations for re-evaluation of Resident #52 were requested in a timely manner. |
| Failure to complete Interim Care Plan within 48 hours for Resident #79. |
| Failure to provide timely podiatry services to Resident #30. |
| Failure to ensure Resident #11's catheter bag was positioned below the bladder for drainage. |
| Failure to ensure food items served to Resident #29 were at hot and appetizing temperatures. |
| Failure to maintain electrical and resident care equipment in safe operating condition. |
| Name | Title | Context |
|---|---|---|
| Judith Birtwistle | Supervising Nurse Consultant | Signed approval for issuance of license and authored the important notice letter. |
| Giovanna Griffin | Administrator | Named as facility administrator and recipient of the notice letter. |
| Name | Title | Context |
|---|---|---|
| Heather Nazario | RN, NC | Report submitted by and signature on desk audit review |
| Giovanna Griffin | Administrator | Personnel contacted during inspection |
| Description |
|---|
| Failure to ensure Resident #1's rights to privacy and confidentiality were not violated, including unauthorized taking and sharing of pictures. |
| Failure to ensure Resident #1's movement was not restrained while seated in the wheelchair without proper authorization. |
| Failure to report the incident of mistreatment involving Resident #1 to the Administrator or Director of Nursing immediately. |
| Failure to initiate Cardio-Pulmonary Resuscitation (CPR) timely when Resident #1 was found unresponsive and pulseless. |
| Failure to ensure licensed nursing staff were actively certified in Cardiopulmonary Resuscitation (CPR). |
| Failure to ensure physician's orders were signed at appropriate time intervals by attending physicians or APRNs. |
| Failure to ensure yearly performance evaluations were completed for nurse aides. |
| Failure to provide documentation of the Governing Body meetings and members. |
| Failure to review and update the Facility Assessment as necessary and at least annually. |
| Name | Title | Context |
|---|---|---|
| Karen Gworek | Supervising Nurse Consultant | Signed the violation letter and correspondence related to complaint investigation. |
| Giovanna Griffin | Administrator | Named as recipient of the report and involved in interviews regarding findings. |
| LPN #1 | Licensed Practical Nurse | Identified in unauthorized restraint incident, terminated after investigation. |
| Nurse Aide (NA) #1 | Involved in unauthorized taking of pictures of Resident #1 and other incidents. | |
| Nurse Aide (NA) #2 | Witnessed restraint incident and reported to supervisors. | |
| Nurse Aide (NA) #3 | Observed providing care to Resident #1 during critical incident. | |
| Nurse Aide (NA) #4 | Involved in incontinent care deficiencies. | |
| Nurse Aide (NA) #5 | Reviewed for performance evaluations. | |
| RN #1 | Registered Nurse | Identified performing CPR and medication administration during Resident #1's critical event. |
| RN #2 | Registered Nurse | Reported incident and interviewed regarding Resident #1's restraint. |
| Director of Nursing | Involved in notification and oversight of incidents and corrective actions. | |
| Administrator | Compliance monitor and involved in interviews and corrective action plans. |
| Description |
|---|
| Failure to ensure Resident #1's rights to privacy and confidentiality were not violated. |
| Failure to ensure Resident #1's movement was not restrained while seated in the wheelchair. |
| Failure to report the incident of mistreatment to the Administrator or Director of Nursing immediately. |
| Failure to initiate Cardio-Pulmonary Resuscitation (CPR) when Resident #1 was unresponsive and pulseless. |
| Failure to provide documentation of the Governing Body meetings and members. |
| Failure to review and update the Facility Assessment as necessary and at least annually. |
| Failure to ensure licensed nursing staff were actively certified in CPR. |
| Failure to ensure yearly performance evaluations were completed for nurse aides. |
| Name | Title | Context |
|---|---|---|
| Giovanna Griffin | Administrator | Named in relation to complaint investigation and findings |
| Savonna Ormond | Acting Director of Nursing | Named in relation to complaint investigation and findings |
| Karen Gworek | Supervising Nurse Consultant | Author of important notice and correspondence related to violations |
| Licensed Practical Nurse #1 | Named in findings related to physical restraint and CPR incident | |
| Nurse Aide #1 | Named in findings related to physical restraint and privacy violations | |
| Nurse Aide #2 | Named in findings related to physical restraint and incident reporting | |
| Nurse Aide #3 | Named in findings related to resident care and supervision | |
| Nurse Aide #4 | Named in findings related to resident care and supervision | |
| Nurse Aide #5 | Named in findings related to employee evaluations | |
| Registered Nurse #1 | Named in findings related to CPR and resident care | |
| Registered Nurse #2 | Named in findings related to CPR and incident reporting |
| Description |
|---|
| Failure to notify resident representative timely about Resident #2's hospitalization and COVID-19 status. |
| Failure to appropriately screen authorized entrants for COVID-19 symptoms as per facility policy. |
| Name | Title | Context |
|---|---|---|
| Karen Gworek | Supervising Nurse Consultant | Named as the Supervising Nurse Consultant in the amended violation letter. |
| Cher Michaud | Supervising Nurse Consultant | Named as the Supervising Nurse Consultant in the original violation letter. |
| Description | Severity |
|---|---|
| Failure to promptly notify resident representative of discharge to hospital during COVID-19 pandemic. | SS=D |
| Failure to establish and maintain an infection prevention and control program to prevent transmission of communicable diseases including COVID-19. | SS=D |
| Name | Title | Context |
|---|---|---|
| Person #1 | Interviewed regarding notification of resident discharge and communication failures | |
| Social Service #1 | Social Service | Interviewed regarding facility protocol for updating phone numbers of resident representatives |
| Director of Nurses | DNS | Interviewed regarding attempts to notify resident representative and facility policy |
| Assistant Director of Nurses | ADNS | Interviewed regarding communication attempts and facility protocol |
| Administrator | Interviewed regarding COVID-19 screening policy and monitoring implementation of plan of correction | |
| Receptionist #1 | Interviewed regarding screening of authorized persons entering facility | |
| EMS #1 and EMS #2 | Observed entering and exiting facility; interviewed regarding screening |
| Description |
|---|
| Failure to appropriately screen authorized entrants to the facility during the COVID-19 pandemic. |
| Failure to notify resident representative timely about Resident #2's hospitalization and COVID-19 status. |
| Screening form and policy did not include all symptoms listed in facility policy for COVID-19 screening. |
| Name | Title | Context |
|---|---|---|
| Terrance Brennan | Administrator | Contacted during inspection and named in findings related to facility policies and communication. |
| Christine Regan | Director of Nursing Services (DNS) | Contacted during inspection and named in findings related to screening and notification failures. |
| Laura Trombley Norton | Nurse Consultant | Report submitted by her. |
| Karen Gworek | Supervising Nurse Consultant | Signed the amended violation letter. |
| Cher Michaud | Supervising Nurse Consultant | Signed the original violation letter. |
| Description | Severity |
|---|---|
| Failure to establish and maintain an infection prevention and control program that includes appropriate cohorting and isolation of residents with COVID-19 symptoms or positive tests. | SS=D |
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