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 (over 6 years)
9.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
75% worse than Connecticut average
Connecticut average: 5.6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
80% occupied
Based on a April 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 72
Capacity: 90
Deficiencies: 0
Date: Apr 3, 2025
Visit Reason
The inspection visit was conducted as part of Complaint Investigation #43519.
Complaint Details
Complaint Investigation #43519 was the reason for the visit. 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.
Report Facts
Licensed Bed Capacity: 90
Census: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Helen Byron | Administrator | Personnel contacted during the inspection |
| Savonna Ormond | DNS | Personnel contacted during the inspection |
Inspection Report
Follow-Up
Census: 76
Capacity: 90
Deficiencies: 1
Date: Mar 28, 2025
Visit Reason
The visit was a desk audit completed to review the implementation of a Plan of Correction for a prior violation letter dated 03/14/2025.
Findings
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.
Deficiencies (1)
Violation #1 identified in prior inspection
Report Facts
Licensed Bed Capacity: 90
Census: 76
Employees mentioned
| 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 |
Inspection Report
Census: 84
Capacity: 90
Deficiencies: 0
Date: Mar 6, 2025
Visit Reason
The inspection was conducted as a Desk Audit on 3/6/25 to review compliance and related documentation.
Findings
No violations of the General Statutes of Connecticut or regulations were identified at the time of this inspection. A narrative report/additional information was attached.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Helen Byron | Administrator | Notified via telephone that the violation was corrected. |
| Cesar Castillo | Survey Team Leader | Submitted the report. |
Inspection Report
Complaint Investigation
Census: 77
Capacity: 90
Deficiencies: 0
Date: Jan 8, 2025
Visit Reason
The inspection visit was conducted as a complaint investigation related to Complaint Investigations #40383 and #42329.
Complaint Details
The visit was triggered by complaints #40383 and #42329. Violations were substantiated as indicated by the identification of regulatory violations during the inspection.
Findings
Violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection, as referenced in an attached violation letter dated 2025-01-17.
Employees mentioned
| 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. |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jan 8, 2025
Visit Reason
An unannounced visit was made to Whispering Pines Rehabilitation and Nursing Center on January 8, 2025, by a representative of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting multiple investigations.
Complaint Details
The visit was related to complaints #40383 and #42329. The letter references multiple investigations but does not explicitly state substantiation status.
Findings
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.
Deficiencies (1)
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.
Report Facts
Date corrective measure effective: Feb 14, 2025
Random audit frequency: 4
Random audit frequency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Karen Gworek | Supervising Nurse Consultant | Author of the notice letter regarding violations and plan of correction instructions |
Inspection Report
Follow-Up
Census: 84
Capacity: 90
Deficiencies: 1
Date: Jul 18, 2024
Visit Reason
A desk audit was conducted to review the implementation of the Plan of Correction for the Violation letter dated 6/6/24.
Findings
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.
Deficiencies (1)
Violations #1-11 identified in prior inspection
Report Facts
Licensed Bed Capacity: 90
Census: 84
Violations corrected: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Savonna Ormond | DNS | Personnel contacted during inspection |
Inspection Report
Renewal
Census: 79
Capacity: 90
Deficiencies: 0
Date: May 16, 2024
Visit Reason
The inspection was conducted as a renewal licensing inspection and included a complaint investigation related to multiple complaint tracking numbers.
Complaint Details
Complaint investigation involved CT# 37036, CT# 37026, CT# 38806, and CT# 38792.
Findings
The report indicates that violations of the General Statutes of Connecticut and/or regulations were identified during the inspection. Specific details of the violations are referenced in attached violation letters and narrative reports.
Report Facts
Licensed Bed Capacity: 90
Census: 79
Inspection Report
Monitoring
Census: 80
Capacity: 90
Deficiencies: 1
Date: May 7, 2024
Visit Reason
A desk audit was conducted to review the implementation of the Plan of Correction for a previous violation letter dated 4/17/24.
Findings
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.
Deficiencies (1)
Violation #1 identified in previous inspection
Report Facts
Licensed Bed Capacity: 90
Census: 80
Employees mentioned
| 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 |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 90
Deficiencies: 1
Date: Jan 23, 2023
Visit Reason
An unannounced visit was made to Whispering Pines Rehabilitation and Nursing Center on January 23, 2023, for the purpose of conducting a complaint investigation.
Complaint Details
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.
Findings
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.
Deficiencies (1)
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.
Report Facts
Licensed Bed: 90
Census: 86
Plan of Correction Date: Feb 20, 2023
Employees mentioned
| 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 |
Inspection Report
Complaint Investigation
Census: 69
Capacity: 90
Deficiencies: 9
Date: Aug 16, 2022
Visit Reason
The inspection was conducted as a complaint investigation (Complaint #32695) following allegations related to infection control and other regulatory compliance issues at Whispering Pines Rehabilitation and Nursing Center.
Complaint Details
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.
Findings
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.
Deficiencies (9)
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.
Report Facts
Licensed Bed Capacity: 90
Census: 69
Complaint Number: 32695
Dates of Onsite Inspection: August 16 and August 23, 2022 (inspection dates).
Employees mentioned
| 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. |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 90
Deficiencies: 1
Date: May 12, 2022
Visit Reason
A Complaint Investigation Survey was conducted at Whispering Pines Health Care Center on May 12 and 13, 2022 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities.
Complaint Details
The visit was complaint-related under ACTS Reference Number CT00030477. Deficiencies were cited as a result of this survey.
Findings
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.
Deficiencies (1)
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.
Report Facts
Capacity: 90
Census: 76
Duration of COVID-19 quarantine precautions: 14
Employees mentioned
| 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 |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 90
Deficiencies: 1
Date: May 12, 2022
Visit Reason
Unannounced visits were made on May 12 and 13, 2022, to conduct a complaint investigation at Whispering Pines Rehabilitation and Nursing Center.
Complaint Details
Complaint investigation #30477 was conducted. The report does not explicitly state the substantiation status.
Findings
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.
Deficiencies (1)
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.
Report Facts
Licensed Bed Capacity: 90
Census: 76
Dates of onsite inspection: Inspection occurred on May 12 and 13, 2022.
COVID-19 Quarantine Duration: 14
Employees mentioned
| 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. |
Inspection Report
Plan of Correction
Deficiencies: 7
Date: Jan 28, 2022
Visit Reason
Unannounced visits were made to Whispering Pines Rehabilitation And Nursing Center concluding on January 28, 2022, for the purpose of conducting a recertification survey to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities.
Findings
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.
Deficiencies (7)
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.
Report Facts
Residents reviewed: 7
Plan of Correction Completion Date: Mar 11, 2022
Urinary catheter drainage bag volume: 200
Employees mentioned
| 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 |
Inspection Report
Renewal
Census: 73
Capacity: 90
Deficiencies: 1
Date: Jan 28, 2022
Visit Reason
The inspection was conducted as a renewal licensing inspection for Whispering Pines Rehab & Nursing in East Haven, CT.
Findings
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.
Deficiencies (1)
Violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies
Report Facts
Licensed Bed/Bassinet Capacity: 90
Census: 73
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Judy Birtwistle | Supervisor | Approval for issuance of license granted by |
Inspection Report
Renewal
Census: 73
Capacity: 90
Deficiencies: 10
Date: Jan 24, 2022
Visit Reason
Unannounced visits were conducted at Whispering Pines Rehabilitation And Nursing Center to perform a recertification survey to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, as part of the renewal licensing inspection.
Findings
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.
Deficiencies (10)
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.
Report Facts
Licensed Bed Capacity: 90
Census: 73
Inspection Dates: 5
Plan of Correction Completion Date: 2022
Employees mentioned
| 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. |
Inspection Report
Monitoring
Census: 75
Capacity: 90
Deficiencies: 0
Date: Jul 29, 2021
Visit Reason
A desk audit review was conducted on 7/29/21 by a representative of the FLIS for the purpose of reviewing the plan of correction for the violation letter dated 6/24/21.
Findings
The review of information identified that violations 1-9 have been corrected. No new violations were identified at the time of this inspection.
Report Facts
Licensed Bed: 90
Census: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Heather Nazario | RN, NC | Report submitted by and signature on desk audit review |
| Giovanna Griffin | Administrator | Personnel contacted during inspection |
Inspection Report
Complaint Investigation
Deficiencies: 9
Date: Jun 21, 2021
Visit Reason
Unannounced visits were made to Whispering Pines Rehabilitation and Nursing Center on June 21, 2021, by representatives of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting multiple investigations related to complaints and allegations.
Complaint Details
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.
Findings
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.
Deficiencies (9)
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.
Report Facts
Dates of falls: Resident #1 had actual falls on 4/25, 4/26, and 4/28/21.
Date of incident report: Facility Reported Incidents form dated 5/10/21 at 10:30 AM identified a nurse aide reported Resident #1 tied in wheelchair.
Date of incident: Incident occurred on 5/9/21 involving Resident #1 tied with sheet in wheelchair.
Date of termination: LPN #1 was terminated after investigation concluded.
Date of compliance monitor: Compliance dates for various plans of correction range from 6/11/21 to 7/12/21.
Number of residents reviewed: 6
Number of nurse aides reviewed: 5
Number of owners identified: 3
Employees mentioned
| 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. |
Inspection Report
Monitoring
Census: 64
Capacity: 90
Deficiencies: 8
Date: Jun 9, 2021
Visit Reason
The visit was a complaint investigation related to allegations of mistreatment and failure to ensure resident rights and safety, including unauthorized use of physical restraints and failure to initiate CPR.
Complaint Details
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.
Findings
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.
Deficiencies (8)
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.
Report Facts
Licensed Bed Capacity: 90
Census: 64
Dates of Onsite Inspection: 6/9/21, 6/10/21, 6/16/21, 6/21/21
Compliance Dates: Multiple compliance monitor dates including 6/11/21, 7/12/21
Employees mentioned
| 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 |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jul 13, 2020
Visit Reason
An unannounced visit was made to Whispering Pines Rehabilitation and Nursing Center to conduct an investigation and inspection following a complaint (#CT27850). The purpose was to assess compliance with state regulations and investigate alleged violations.
Complaint Details
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.
Findings
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.
Deficiencies (2)
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.
Report Facts
Plan of correction submission deadline: Aug 5, 2020
Date of inspection visit conclusion: Jul 13, 2020
Date of original violation letter: Jul 26, 2020
Completion date for plan of correction: Aug 5, 2020
Employees mentioned
| 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. |
Inspection Report
Abbreviated Survey
Census: 64
Capacity: 90
Deficiencies: 2
Date: Jul 13, 2020
Visit Reason
A COVID-19 focused survey and investigation were conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including infection prevention and control practices to prevent the development and transmission of COVID-19.
Findings
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.
Deficiencies (2)
Failure to promptly notify resident representative of discharge to hospital during COVID-19 pandemic.
Failure to establish and maintain an infection prevention and control program to prevent transmission of communicable diseases including COVID-19.
Report Facts
Capacity: 90
Census: 64
Employees mentioned
| 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 |
Inspection Report
Monitoring
Census: 64
Capacity: 90
Deficiencies: 3
Date: Jul 13, 2020
Visit Reason
The visit was conducted as a survey monitoring visit during the COVID-19 pandemic to assess compliance with regulations and infection control measures.
Complaint Details
Complaint #CT27850 was investigated. Violations were substantiated as noted in the violation letter dated July 26, 2020, and amended on April 27, 2021.
Findings
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.
Deficiencies (3)
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.
Report Facts
Licensed Bed Capacity: 90
Census: 64
Inspection Date: Jul 13, 2020
Plan of Correction Submission Deadline: Aug 5, 2020
Employees mentioned
| 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. |
Inspection Report
Abbreviated Survey
Census: 58
Capacity: 90
Deficiencies: 0
Date: May 20, 2020
Visit Reason
A COVID-19 Focused Survey was conducted 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 survey found the facility compliant with infection prevention and control requirements related to COVID-19. No deficiencies were cited as a result of this survey.
Report Facts
Capacity: 90
Census: 58
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: May 7, 2020
Visit Reason
A COVID-19 Focused Survey was conducted 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 survey found that the facility was in compliance with the infection prevention and control requirements related to COVID-19. No deficiencies were cited as a result of this survey.
Inspection Report
Complaint Investigation
Census: 64
Capacity: 90
Deficiencies: 1
Date: Apr 16, 2020
Visit Reason
A COVID-19 focused survey and multiple complaint investigations were conducted to determine compliance with infection prevention and control requirements related to COVID-19 at Whispering Pines Rehabilitation and Nursing Center.
Complaint Details
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.
Findings
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.
Deficiencies (1)
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.
Report Facts
Total beds: 90
Occupied beds: 64
COVID-19 positive residents: 2
COVID-19 positive residents: 4
COVID-19 positive residents: 1
Residents reviewed for infection control: 8
Symptomatic residents sharing rooms with asymptomatic roommates: 7
Private beds available: 4
Empty beds available: 26
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