Nathaniel Witherell, The

In the surveyor’s words

From the most serious findings on record at Nathaniel Witherell, The, in the surveyor’s own words.

• Actual harm, isolatedF689Mar 9, 2022

  Based on review of the clinical record, facility documentation, facility policy, and interviews for 2 of 3 residents (Resident #8 and 371) reviewed for accidents, for 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 the resident was seated, which resulted in the wheelchair sliding and bumping the resident's leg causing a displaced distal femur fracture. The findings include: 1. […]

• No harm, potential for more than minimal, widespreadF880Jun 17, 2026

  Based on observations, review of clinical records, review of facility policy, review of facility documentation, and interviews, the facility failed to review the infection prevention control program policies and procedures at least annually; the facility failed to provide documentation of infection surveillance data collection and analysis of infection trends within the facility reports that were completed on a routine basis; the facility failed to provide documentation of environmental/infection control rounds; the facility failed to ensure appropriate disinfectant solution was used when cleaning areas and surfaces within the facility consistently by the housekeeping staff; the facility failed to ensure biohazards were emptied when filled and two sampled resident (Resident #3, Resident… […]

• No harm, potential for more than minimal, widespreadF880Aug 6, 2024

  Based on observations, clinical record reviews, facility documentation review, and interviews for 4 of 4 residents (Resident #11, #86, #117 and #137) reviewed for infection control, the facility failed to ensure that infection control practices related to glucometer cleaning and disinfection in between resident and the facility failed to ensure personal protective equipment (PPE) carts were available outside every resident room who required the use of PPE, evidence of infection surveillance, evidence of annual review of the Intravenous and Infection Control Policy books, evidence facility water management plan and for 1 of 3 residents evaluated for pressure ulcers (Resident #24), the facility failed to ensure staff used appropriate personal protective equipment (PPE) when performing… […]

• No harm, potential for more than minimal, patternF603Jun 17, 2026

  Based on observations, review of clinical records, review of facility policy/procedures and interviews for 3 of 5 sampled residents (Resident #70, Resident #74 and Resident #127) reviewed for involuntary seclusion, the facility failed to ensure that nursing units not designated as secure/specialized care units allowed residents the freedom to independently exit the nursing units. The findings include: Observations on all days of the survey 6/9, 6/10, 6/15, 6/16 and 6/17/26 identified that all six nursing units in the facility were secured and required a numerical code to exit the unit. The third-floor nursing unit (capacity of 40) was identified as the secured dementia unit and had specific criteria in place for admission and care on the unit. […]

• No harm, potential for more than minimal, patternF755Jun 17, 2026

  Based on review of facility documentation, review of facility policy/procedures and interviews for 3 of 6 medication carts reviewed for medication storage and labeling, the facility failed to ensure that controlled medications were reconciled (assurance of the medication count being correct) with each shift change, failed to ensure controlled medications were kept under double lock, and failed to implement a system for controlled substance reconciliation to ensure accurate reconciliation on controlled substances in the facility. […]