Witherell Overall Rating Drops to 1 Star after Inspections Reveal 16 Deficiencies Including Abuse

Greenwich’s town-owned nursing home, the Nathaniel Witherell, was recently cited for 16 deficiencies by a State Dept of Health inspection, according to Medicare.Gov. The site was updated on July 27, and the most recent inspection was March 9.

As a result, the facility’s Overall rating, which last year declined from 5 stars to 3, has now dropped to 1 star.

The ratings page features a “red hand” icon, with the warning: “Nursing home has been cited for resident harm or potential harm for abuse or neglect.”

The Overall rating is based on 3 sources: Health Inspections, Staffing, and Quality Measures.

The Nathaniel Witherell’s Health Inspection rating was 1 star.

For both Staffing and Quality Measures, the facility earned 4 stars.

Resident Care Plans

Per Medicare.gov, state inspectors conduct yearly health and safety inspections of nursing homes for compliance with Medicare and Medicaid regulations. A nursing home may also be inspected based on a complaint submitted by a resident or other individual, or based on a facility’s self-reported incident.

Among the deficiencies outlined in the report is a failure to revise a care plan for Resident #39 after the resident fell three times – once while attempting to sit in a lounge chair, once falling and hitting his/her head and being sent to the hospital, and once while ambulating out of the day room and sustaining a skin tear to the right knee.

After the second fall, the resident was sent to the hospital, and returned to the facility later in the evening with a cut on the back of his/her head.

Bingo Incident

The facility’s policy for Elder Abuse, Neglect and Prevention directs that all residents be safe from harm at all times, but a resident was hit in the face by another resident during afternoon Bingo in January.

Per the inspection report, at Bingo, Resident #39 became agitated, swinging his/her arms out at anyone and hit Resident #128 in the face.

Review of the care plan following the incident, “failed to reflect Resident #128 was the victim of physical abuse with interventions to protect the resident from possible future incidents and/or psychosocial needs.”

Nurse Aid Verbal Abuse

Inspection report detailed how a Nurse Aid, identified as NA#1, was verbally abusive to residents.

The facility is required to “honor the resident’s right to a dignified existence, self-determination, communication, and to exercise his or her rights.”

“In a written statement dated 9/13/21 NA #3 identified NA #1 was not speaking respectfully to some of the residents, especially residents that NA #1 thought were hard to take care of. NA #3 indicated whenever NA #1 did not want to work with a resident, NA #1 behaved very nasty towards them and the family members would ask the nurse to remove NA #1 from caring for their loved ones.”

Per the report: “The Facility Reported Incident form dated 9/15/21 identified Resident #97’s family reported that a private aide observed NA #1 being loud and verbally abusive to Resident #97.”

More recently, per the report: “Interview with the Director of Nursing (DON) on 2/28/22 at 12:10 PM identified the allegation of abuse was substantiated, even though nobody witnessed any abuse or wanted to report any mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .”

Per the report, on March 1, an interview with the Assistant Director of Nursing identified the care plan should have been revised with interventions to protect the resident from future incidents of abuse.

The report indicates Nurse Aid #1 went on to resign.

Damaged Paint

Residents have a right to a safe, clean, comfortable and homelike environment, but another deficiency outlined numerous incidents of damaged, chipped or peeling paint in the facility, including bedroom walls and bathroom doors.

Advance Directives: Code Status and Resuscitation Policy

The facility is required to provide basic life support, including CPR, prior to the arrival of emergency medical personnel, subject to physician orders and the resident’s advance directives.

The advance directives include wishes for DNR’s (Do Not Resuscitate) and ACLS (Advanced cardiac life support).

Resident or family wishes for code status were not documented for Resident #54 or Resident #122.

Resident #54. “The Pre-Admission assessment dated [DATE] identified the resident’s code status at current hospital and nursing home was no code, Do Not Resuscitate (DNR), and no ACLS (Advanced cardiac life support). Nurse’s notes failed to reflect Resident #54’s representative was educated and able to make Resident #54’s wishes known regarding code status. Review of physician’s notes and social worker notes dated [DATE] – [DATE] failed to reflect Resident #54’s wishes for a code status.”

Per the report: “The DNS (Director of Nursing Services) indicated she was not aware the charge nurses and supervisors were not using a code status form and not having the resident or representative and the physician sign the code status form making their wishes known within the 48 hours of admission or readmission as she would expect them to do.”

Loose Pills, Unclean and Unsecured Medication Carts

The report documented instances of loose pills in medication carts and carts that weren’t clean or sanitized.

The facility is required to ensure drugs be labeled and stored in locked compartments.

Medication carts are required to be secured.

Observation of medication carts on the first, second, third and fourth floor indicated “a moderate amount of loose pills of assorted sizes and colors and blister pack back covers located at the bottom of the first and second drawer.”

“Observation on the Garden Level Rehabilitation unit on 3/1/22 at 1:08 PM, at 1:20 PM with the DNS, and 2:11 PM with the Unit Manager identified in the Spa Room (century tub room with a resident bathroom on the side and door unlocked) was an unlocked medication cart that contained a cup full of 14 unused 1 ML U-100 syringes. The left second drawer contained…” (open bottles of medication). (See page 26 of 31)

The report found that for 4 of 6 medication carts, the facility failed to maintain medication carts in a clean and sanitary manner, and failed to ensure a medication cart was secured and in a designated area.

Flu and Pneumonia Vaccinations

The facility is required to develop and implement policies and procedures for flu and pneumonia vaccinations, but the inspection report outlines five instances where Pneumococcal 23 vaccinations had not been offered and/or administered.

Resident’s Weight Loss

The facility is required to provide enough food/fluids to maintain a resident’s health.

Another statement of deficiencies cited the facility’s failure to notify a resident’s doctor and family of the resident’s 40 lb weight loss.

The weekly weight sheet dated 2/25/22 identified Resident #162 weighed 128 lbs., a total weight loss of 41.6 lbs. weight loss since admission on 11/10/21. “Observation and interview with Resident #162 on 2/27/22 at 9:45 AM identified the resident appeared thin, and frail seated in the bed with the meal tray on the overbed table.”

“The facility failed to ensure the physician and family were notified of a weight loss,” the report said.

Preventing Accidents

The facility is required to ensure it is free from accident hazards and provide adequate supervision to prevent accidents.

In the case of Resident #8, the facility “failed to use the appropriate size sling during a mechanical lift transfer which resulted in the resident falling out of the sling onto the floor during a mechanical lift transfer and sustaining a [CONDITION(S)] that required 8 staples to close.”

For Resident #371, who was being transported in a vehicle, the facility failed to adequately secure the wheelchair, which resulted in the wheelchair sliding and bumping the resident’s leg causing a displaced distal femur fracture.

Cleanliness and Storage in Kitchen Area

The facility is required to store, prepare, distribute and serve food in accordance with professional standards, but the facility failed to ensure the kitchen was maintained in a clean and sanitary manner, and failed to ensure food items were covered and dated according to policy.

The report details numerous spillage, smears and brown buildup in various areas in the kitchen/dry storage room/walk in freezer.

There were instances of food without covers, and in one instance, “A steel container containing tuna salad without a date.”

A walk in refrigerator had cuts of sealed raw meat on a tray improperly stored.

“Entire front on the outside of all refrigerators, coolers freezers, walk ins with white smearing top to bottom and concentrated smearing around door handles.”

Also, “Can opener and surrounding base with moderate amount congealed brown buildup.”

Witherell Response to Health Inspection Reports

Neither Board of Directors Chair Larry Simon nor First Selectman Fred Camillo responded to requests for comment.

Sheilah Smith, Co-Chair of the Family Council and a long time resident of Greenwich, took senior management to task.

“Nathaniel Witherell, Greenwich’s once prized skilled nursing facility, has just received Medicare’s lowest rating – 1-star.  Just 2-1/2 years ago it was rated 5 stars. Last year, it was rated 3 stars. What caused this dramatic fall?” she asked.

Ms Smith noted that none of the violations cited by the CT Department of Public Health were related to Covid-19. 

“How could Nathaniel Witherall’s Executive Team and the Board have let this happen in our affluent town to our Town-operated facility?” she asked.

“Although the overall rating of Nathaniel Witherall has dropped to one star, luckily the quality of care is 4 stars,” she said. “This is because 95% of the Town-employed nurses and certified nursing assistants are exceptional, and continue to work hard, above and beyond duty, despite the many challenges of a significantly reduced staff, quality of food reductions and infectious disease control problems.”

Ms Smith noted that last year, when the facility dropped to 3 stars, Witherell officials expressed public confidence that it would regain the 5-star rating. 

“Instead, the budget was reduced further and facility and health conditions deteriorated dramatically.
After requests by the Family Council, the Witherell Board of Directors, finally, at its meeting on July 25, 2022 briefly discussed and downplayed the CT Dept of Health survey results, saying everything had been corrected.”

“There was no discussion at all of the implication of the CT Dept of Health survey on the federal government Medicare rating and how a one-star rating would impact Witherell’s ability to attract new long term residents and short term rehab patients,” she said.

“Family of present residents did not select a one-star facility for their family members.  Who would?”

Smith said the Family Council urges Board leadership and senior management to be accountable, and hold an emergency meeting to develop an action plan for restoring Witherell’s 5-star rating. 

“The Town of Greenwich, its citizens, Witherell residents and front line staff deserve better than this,” she said.  

Greenwich First Selectman Fred Camillo said on Wednesday that the downgrade was extremely disappointing and concerning.

“I have reached out and spoken with both John Mastronardi and Larry Simon, and they share that disappointment and concern, yet are determined to address each and every violation,” Camillo said.

“We also know that many reputable privately run facilities in the country do receive ratings of one from time to time and bounce back, and the great strides that have been made in the last two years at our facility show me that we should expect that here too,” Camillo added.

On Thursday, Bill Drake, a BET member who is liaison to the Witherell said, “This CMS review ought to be part of the public discussions required under the budget condition: ‘The budgeted annual contribution of $500,000 from the General Fund to TNW shall be subject to release upon appropriate public discussions on potential actions with respect to RFP 7568 on the part of the Witherell board, the Board of Selectmen and the BET to be held no later than December 31, 2022.‘”

Witherell Executive Director John Mastronardi issued a statement Tuesday through his PR firm saying, “While we were extremely pleased that our Quality and Staffing Measures were excellent as ranked by the Centers for Medicare and Medicaid, we were disappointed that our survey results slipped.”

He said a plan of correction was immediately put into action that addresses the issues that the Centers for Medicare & Medicaid Services (CMS) cited.

“We are rebuilding our nurse training and education program, and providing ongoing refresher training, including core nursing principles, accurate documentation, standards of care, effective communication, policies and procedures,” Mastronardi added. “Then, we will evaluate and report on the results at our quarterly Quality Assurance and Performance Improvement Committee meeting. We have full confidence that our former top tier ranking will be reinstated as a result.”

Mr. Mastronardi said the exceptional, collaborative compassionate senior care, delivered in state-of-the-art facility tailored to residents’ unique needs and preferences remains unchanged. He said staff retention rates remain high, at 7% compared to an average for nursing homes nationally of 46%, as reported by AARP. Finally he said the facility retains excellent national recognition by U.S. News & World Report for quality and safety.

While Mr. Simon did not respond to a request for comment, eight months ago, in November 2021, when the star rating dropped from 5 to 3, he said the fate of the Witherell was in the First Selectman’s hands, but that he was optimistic because many efficiencies had been found.

“I think we have found a formula to make money and be a five star facility,” Mr. Simon said in November. “If you go to a one or two star facility it’s really depressing, but there are a lot of facilities like that. You make more money by having lower costs.”

As for the RFP for Management Services for The Nathaniel Witherell, Mr. Simon said a recommendation had been sent to Mr. Camillo based on responses to the RFP.

“The motivation for the RFP came from a lot of people on the RTM who said it cost the town too much, but if we’re making money, and more money than any of the respondents (to the RFP) would give us, there’s no interest in getting rid of the Witherell.”

On Tuesday, State Rep Steve Meskers put the situation in a larger context, questioning why the Witherell should be expected to make a profit. He compared its operation to other town departments.

“Greenwich has the only municipally owned nursing home in the state of Connecticut. Over time, other municipalities have made the decision to exit the business,” he said. “Primarily they were looking at it as a costly endeavor. It’s a question the community has to ask itself.”

“We dedicate a significant amount of resources to our public education, and to our police and firemen and our emergency medical people. Is there a willingness to spend money to dedicate to people in the last stages of life?” Meskers asked.

“The fact that the nursing home had cost the town money in the past has been used as an excuse as to why we should disassociate or separate ourselves from this activity,” Meskers added. “I’ve never been involved in a dialogue where we spoke that way about our schools our police or a fireman. There was never a question as to whether or not those services made money or if they broke even. Every service in town has a cost and a benefit so the real question is the whether or not the town and its taxpayers are supportive of NW a town owned facility that cares for people at the end of their life.”

See also:

Dissecting the Loss of the Nathaniel Witherell’s 5-Star Rating

November 30, 2022

Note: This story was updated Wednesday, Aug 3 to include comments from First Selectman Fred Camillo.

This story was updated Thursday, Aug 4 with a comment from BET member Bill Drake who is a liaison to the Witherell.