Inspection Reports for
Whispering Pines Rehabilitation and Nursing Center

Violation #1 was identified as corrected as of 03/21/2025, and the Director of Nursing was notified of the corrections on 03/21/2025 at 2:46 PM.

The facility failed to ensure medication orders were transcribed accurately, resulting in Resident #2 receiving duplicate doses of Lamotrigine on 1/25 and 1/26/2025. This was due to a transcription error and lack of a medication order transcription policy. The facility provided education to staff and notified the resident's neurologist and medical director.

The complaint investigation found that the facility refused to re-admit Resident #1 after a psychiatric evaluation cleared the resident, citing concerns about repeated inappropriate behavior towards staff. The facility did not discuss discharge with the Inter-Disciplinary Team and did not have a policy for emergency discharges.

The facility failed to allow Resident #1 to return after hospitalization following inappropriate behavior towards staff, resulting in the resident being admitted to a new long-term care facility. The facility did not initiate a consultative process with the hospital and lacked a specific policy for emergency discharges.

The visit was related to complaints #40383 and #42329. The letter references multiple investigations but does not explicitly state substantiation status.

The report details violations of Connecticut state regulations identified during the visit, including a specific incident involving Resident #1 and inappropriate behavior leading to transfer to the Emergency Department and subsequent denial of readmission by the facility. The facility lacked a specific policy for emergency discharges.

The facility failed to timely report a change in condition for Resident #1 with a fractured pinky finger and failed to ensure Resident #5 remained free from injury during a Hoyer lift transfer, resulting in bruising. The facility conducted investigations and implemented corrective actions including increased supervision and staff education.

Violations numbered 1 through 11 were identified as corrected as of 7/2/24. The DNS was notified by telephone on 7/18/24 that all violations were corrected.

The facility was found deficient in multiple areas including failure to notify physicians of missed resident weights, incomplete care plans for behavioral issues, inadequate podiatry services, failure to assess and manage bowel and bladder continence, failure to monitor significant weight changes timely, improper oxygen administration, failure to monitor psychotropic medication behaviors, improper medication refrigerator temperature control, and inadequate infection prevention in the laundry area.

The audit found that Violation #1 was corrected as of 5/7/24, and the Administrator was notified via telephone that all violations were corrected.

The complaint investigation found that the facility did not follow physician orders for urine testing, including ordering a urine copper test in error instead of urinalysis with culture and sensitivity, resulting in delayed diagnosis and treatment of a urinary tract infection in Resident #1.

The facility failed to ensure timely and correct urinary lab testing for Resident #1, who developed a urinary tract infection. Errors included ordering the wrong urine test and delays in collecting the correct specimen, despite physician orders and documented interventions.

The facility failed to ensure that Resident #1 had blood work completed according to physician orders and failed to notify the physician and responsible party when the resident refused laboratory blood draws. Documentation of notification and completion of ordered laboratory tests was missing.

The complaint investigation involved three residents. Resident #1 had an injury of unknown origin that was not reported within two hours as required. Resident #1 also had a delay in nurse notification following a pain complaint. Resident #2 was found to have fallen from a wheelchair due to lack of leg rests, which were not in place at the time of the incident despite prior orders and care plans.

The facility failed to report an injury of unknown origin within the required timeframe, failed to ensure nursing staff were notified following a resident's complaint of pain which was later diagnosed as a fracture, and failed to provide leg rests for a resident requiring assistance with locomotion in a wheelchair, resulting in a fall. Interviews and record reviews confirmed these deficiencies.

The complaint involved Resident #1 who exited the facility through a door left propped open by a maintenance worker during sprinkler pipe repairs. Resident #1 was placed on one-to-one supervision immediately after the incident. The door was secured and sounders were added. Staff education was conducted and ongoing. The complaint was substantiated with corrective actions implemented and no further incidents reported.

The facility failed to ensure an exterior door was secured, allowing Resident #1, identified as a high risk for wandering and elopement, to leave the building unattended. Immediate corrective actions included securing the door, placing the resident on one-to-one supervision, educating staff, and adding sounders to doors. The deficiency was corrected by 5/16/23 with no further incidents.

The complaint investigation was related to Resident #1 who required assistance with toileting. The investigation found that staff denied Resident #1 access to the bathroom and did not provide timely assistance, resulting in unmet toileting needs. The incident was investigated and found to be unsubstantiated based on staff interviews and resident condition. Resident #1 has since been discharged with no untoward effects.

Deficiencies and/or violations were identified during the visit related to failure to provide timely assistance to a resident requiring toileting help, as documented through clinical record review, interviews, and facility documentation.

Complaint investigation #32695 was conducted following allegations related to infection control practices, resident care, and mistreatment. The complaint was investigated with no substantiated violations found at the time of inspection.

The inspection found no violations of the General Statutes of Connecticut or regulations of Connecticut State Agencies at the time of the inspection. However, detailed findings related to infection control, resident care, and facility policies were documented in the attached narrative report.

The visit was complaint-related under ACTS Reference Number CT00030477. Deficiencies were cited as a result of this survey.

The facility was found deficient in infection prevention and control practices, specifically failing to ensure staff wore appropriate Personal Protective Equipment (PPE) while providing care to a resident on contact and droplet precautions and improperly handling soiled linen contrary to facility policy.

Complaint investigation #30477 was conducted. The report does not explicitly state the substantiation status.

The facility failed to ensure staff wore appropriate Personal Protective Equipment (PPE) while providing care to a resident on contact and droplet precautions and failed to handle soiled linen according to facility policy. Specific observations included a nurse aide not wearing a protective isolation gown and improper handling of soiled linen.

The report identifies multiple violations of Connecticut State Agencies regulations related to resident care, including failure to ensure privacy for urinary catheter drainage bags, lack of physician orders reflecting residents' wishes for advanced directives, failure to report allegations of physical mistreatment, failure to ensure timely recommendations for PASRR evaluations, incomplete interim care plans, and failure to provide podiatry services in a timely manner.

The visit was complaint-related, triggered by allegations including failure to maintain resident dignity and privacy, lack of proper advanced directive documentation, alleged physical mistreatment not reported timely, failure to follow PASARR recommendations, incomplete interim care planning, inadequate foot care services, and improper catheter care.

The facility was found deficient in multiple areas including failure to ensure urinary catheter privacy and proper positioning, lack of valid physician orders for residents' code status, failure to timely report alleged physical mistreatment to the State Agency, failure to request timely PASARR re-evaluation, incomplete interim care plans within 48 hours of admission, failure to provide timely podiatry services, and failure to maintain catheter drainage bags below bladder level with privacy.

Violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified during the inspection. A violation letter dated 3/3/22 was attached. A desk audit was also completed.

The inspection identified multiple violations of Connecticut State Agencies regulations related to resident care, documentation, environment, and facility policies. Deficiencies included failure to ensure privacy for urinary catheter drainage bags, incomplete advanced directives and code status documentation, unsafe environmental conditions, failure to provide timely podiatry services, and failure to maintain food temperatures and equipment safety. Plans of correction were submitted addressing these issues.

The visit was complaint-related, investigating allegations including unauthorized use of physical restraints, privacy violations, failure to report abuse, failure to initiate CPR, and other deficiencies. The complaint numbers referenced are CT# 30163 and #30221. The facility contested some alleged deficiencies through the IDR process.

The investigation found multiple violations including failure to ensure resident rights to privacy and confidentiality, unauthorized use of physical restraints, failure to report incidents of mistreatment, failure to initiate cardiopulmonary resuscitation (CPR) timely, failure to ensure physician orders were signed timely, and failure to maintain proper staff certifications and performance evaluations. Several staff members were terminated or no longer employed as a result of the findings.

Complaint investigation #30163 and #30221 related to allegations of unauthorized use of physical restraints, failure to report abuse, failure to initiate CPR, and other mistreatment issues.

The investigation found multiple deficiencies including failure to protect resident rights and privacy, improper use of physical restraints, failure to report incidents of abuse, failure to initiate CPR timely, inadequate staff training and supervision, and failure to maintain proper documentation and performance evaluations.

Complaint #CT27850 triggered the investigation. The complaint involved concerns about communication failures related to Resident #2's hospitalization and COVID-19 status, and inadequate COVID-19 screening procedures for entrants during the pandemic.

The investigation identified failures in the facility's notification and communication protocols regarding a resident's change in condition and discharge to the hospital. The facility also failed to appropriately screen authorized entrants for COVID-19 symptoms according to their policy during the pandemic.

The facility failed to ensure a resident representative was promptly notified of a discharge during the COVID-19 pandemic and failed to appropriately screen an authorized entrant to the facility during the pandemic. Deficiencies were identified related to notification of changes and infection prevention and control.

Complaint #CT27850 was investigated. Violations were substantiated as noted in the violation letter dated July 26, 2020, and amended on April 27, 2021.

Findings were identified during the inspection including issues related to COVID-19 screening, notification of change in condition, and communication with resident representatives. Staffing met minimum regulatory requirements.

Complaint investigations CT27349 and CT27350 were reviewed as part of the COVID-19 focused survey. The facility was found to have failed in proper infection control practices related to COVID-19, including cohorting and testing of residents.

The facility failed to appropriately cohort residents with known or suspected COVID-19 infection, resulting in symptomatic residents being housed with asymptomatic roommates without barriers. Testing and isolation practices did not follow facility policy or CDC guidelines, contributing to potential transmission of COVID-19 within the facility.