Inspection Report Summary
The most recent inspection on July 14, 2025, found that all previously identified violations had been corrected. Earlier inspections showed a pattern of deficiencies primarily related to medication administration, infection control, and documentation, including issues with narcotic counts, expired insulin use, and COVID-19 precautions. A notable complaint investigation in 2019 involved an alleged abuse incident that was not substantiated, though the facility was cited for incomplete clinical records. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s record indicates improvement over time, with recent inspections showing correction of prior deficiencies and compliance with state regulations.
Deficiencies (last 7 years)
Deficiencies (over 7 years)
3.9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
30% better than Connecticut average
Connecticut average: 5.6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
85% occupied
Based on a July 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Monitoring
Census: 170
Capacity: 199
Deficiencies: 0
Jul 14, 2025
Visit Reason
The visit was a desk audit conducted on 7/11/25 and 7/14/25 to review the implementation of the Plan of Correction for a prior violation letter dated 7/7/25.
Findings
All previously identified violations listed in the violation letter dated 7/7/25 were found to be corrected as of 6/2/25. The administrator was notified by telephone on 7/14/25 that all violations were corrected.
Report Facts
Violation numbers corrected: 31
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Latina | Administrator | Notified by telephone on 7/14/25 that all violations were corrected. |
Inspection Report
Follow-Up
Census: 169
Capacity: 199
Deficiencies: 1
May 29, 2025
Visit Reason
The visit was conducted to review the implementation of the plan of correction for the Violation Letter dated May 2, 2025.
Findings
Staffing met the minimum requirement for the State of Connecticut Public Health Code for the 2 week period reviewed. Violations #1a and #2a were reviewed and corrected as of 5/20/25. The facility was approved for removal of the posted citation.
Deficiencies (1)
| Description |
|---|
| Violations #1a and #2a were reviewed and corrected as of 5/20/25 |
Report Facts
Census: 169
Total licensed capacity: 199
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Lantina | Administrator | Personnel contacted during inspection |
Inspection Report
Renewal
Census: 169
Capacity: 199
Deficiencies: 0
May 19, 2025
Visit Reason
The inspection was conducted as a licensing renewal inspection and also included a complaint investigation related to complaint numbers 36954 and 11473.
Findings
Violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection, as noted in an attached violation letter.
Complaint Details
Complaint investigation referenced with complaint numbers 36954 and 11473; substantiation status not stated.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Latino | Personnel contacted during the inspection | |
| Tanya Niro | Personnel contacted during the inspection |
Inspection Report
Monitoring
Census: 178
Capacity: 199
Deficiencies: 0
Jan 2, 2025
Visit Reason
The inspection was conducted as a licensing inspection with a strike monitoring purpose, including follow-up on complaint investigations numbered 41493, 41950, and 42300.
Findings
Violations of the General Statutes of Connecticut and/or regulations were not identified at the time of this inspection. A citation was not issued as a result of this inspection.
Complaint Details
The inspection references complaint investigations #41493, #41950, and #42300, but no substantiation status or findings related to these complaints are provided.
Report Facts
Licensed Bed Capacity: 199
Census: 178
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Latina | Personnel contacted during the inspection | |
| Kristina Robinshaw | Survey Team Leader | Survey team leader conducting the inspection |
| Margaret McKinney | Supervisor | Supervisor overseeing the inspection |
Inspection Report
Plan of Correction
Census: 170
Capacity: 199
Deficiencies: 0
Sep 4, 2024
Visit Reason
A desk audit was conducted on 2024-09-04 to review the implementation of the Plan of Correction for a violation letter dated 2024-07-30.
Findings
Violation #1 was identified as corrected as of 2024-08-04. The Administrator was notified via telephone on 2024-09-04 at 12:13 PM that all violations were corrected.
Report Facts
Licensed Bed Capacity: 199
Census: 170
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Reba Stoddard | NC | Reported as the person submitting the report and conducting the desk audit |
Inspection Report
Renewal
Census: 186
Capacity: 199
Deficiencies: 0
Aug 9, 2023
Visit Reason
The inspection was conducted as a renewal licensing inspection for the facility.
Findings
No violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection.
Inspection Report
Follow-Up
Census: 150
Capacity: 199
Deficiencies: 0
Jul 23, 2021
Visit Reason
A desk audit review was conducted on 7/23/21 and 7/28/21 to review the plan of correction for previous violation letters dated 6/3/21 and 5/26/21, verifying correction of identified violations.
Findings
The review found that violations identified in prior letters had been corrected. No new violations were identified during this desk audit inspection.
Report Facts
Licensed Bed Capacity: 199
Census: 150
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maria Taylor | RN, NC | Signed the licensing inspection narrative report for the desk audit review |
| Bonnie Ganim | DNS | Personnel contacted during inspection |
| Bill Thompson | Administrator | Personnel contacted during inspection and author of plan of correction letters |
Inspection Report
Annual Inspection
Census: 143
Capacity: 199
Deficiencies: 5
May 27, 2021
Visit Reason
A Recertification survey was conducted on 5/20, 5/24, 5/25, 5/26 and 5/27 at Avery Nursing Home to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities.
Findings
The facility was found deficient in several areas including narcotic medication administration and counting, expired insulin administration, food service sanitation, and infection control practices related to COVID-19. Deficiencies included a narcotic count discrepancy, failure to administer Diazepam as ordered, use of expired insulin, unclean air conditioning in the kitchen, and staff eating unmasked in resident rooms.
Severity Breakdown
SS=D: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure narcotic count was done according to professional standards, resulting in a discrepancy of Diazepam tablets for Resident #141. | SS=D |
| Failed to administer Insulin within its expiration for Resident #67. | SS=D |
| Failed to administer Diazepam 5mg on 5/25/21 at 9:00 PM according to physician's order for Resident #141. | SS=D |
| Failed to ensure air conditioner in food preparation and storage area was clean and lacked a cleaning schedule policy. | SS=D |
| Failed to follow infection control guidelines related to COVID-19; staff member was observed eating unmasked in resident rooms. | SS=D |
Report Facts
Deficiencies cited: 5
Total Capacity: 199
Census: 143
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Observed narcotic count and interviewed regarding narcotic discrepancy and medication administration |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding narcotic administration and discrepancy for Resident #141 |
| LPN #3 | Licensed Practical Nurse | Interviewed regarding narcotic count discrepancy and medication administration |
| RN #3 | RN Supervisor | Notified of narcotic discrepancy |
| DNS | Director of Nursing Services | Interviewed regarding narcotic count procedures and medication administration expectations |
| LPN #1 | Licensed Practical Nurse | Identified expired insulin vial during medication cart review |
| RN #4 | Unit Manager | Interviewed regarding medication expiration expectations |
| LPN #4 | Licensed Practical Nurse | Interviewed regarding expired insulin administration |
| Director of Food Service | Interviewed regarding air conditioner cleaning and maintenance in kitchen | |
| NA #1 | Nurse Aide | Observed eating unmasked in resident rooms and interviewed regarding infection control violation |
| RN #2 | Infection Control Nurse | Interviewed regarding infection control policies and staff break room usage |
Inspection Report
Renewal
Census: 143
Capacity: 199
Deficiencies: 0
May 27, 2021
Visit Reason
The inspection was conducted as a renewal licensing inspection for Avery Nursing Home.
Findings
Violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified during the inspection. Certification files were reviewed and visitation compliance was verified.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Bonnie Ganim | DHS | Personnel contacted during the inspection |
| Bill Thompson | Adm | Personnel contacted during the inspection |
Inspection Report
Plan of Correction
Deficiencies: 5
May 27, 2021
Visit Reason
The document is a plan of correction submitted by Avery Nursing Home in response to the results of unannounced visits conducted at the facility on May 27, 2021, addressing alleged violations.
Findings
The facility was found to have multiple violations including narcotic count discrepancies, failure to administer insulin and diazepam according to physician orders, lack of cleaning policy for an air conditioner in the food preparation area, and failure to follow infection control guidelines related to COVID-19. The facility has submitted corrective actions and requests this plan of correction serve as evidence of compliance.
Deficiencies (5)
| Description |
|---|
| Failure to ensure narcotic count was done according to professional standards, resulting in a discrepancy with Diazepam tablets. |
| Failure to ensure insulin was administered according to professional standards and within expiration dates. |
| Failure to administer Diazepam as ordered by physician. |
| Failure to ensure air conditioner in food preparation and storage area was clean and lack of cleaning policy for the unit. |
| Failure to follow infection control guidelines related to COVID-19, including staff being unmasked in resident rooms during meals. |
Report Facts
Date of inspection visit: May 27, 2021
Completion date for plan of correction: Jul 8, 2021
Resident ID: 141
Resident ID: 67
Resident ID: 171
Resident ID: 62
Resident ID: 68
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| William Thompson | Administrator | Signed the plan of correction and mentioned in relation to facility compliance |
Inspection Report
Abbreviated Survey
Census: 133
Capacity: 199
Deficiencies: 1
Feb 23, 2021
Visit Reason
A COVID-19 Focused Survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including infection prevention and control practices to prevent COVID-19 transmission.
Findings
The facility failed to notify the physician promptly of a significant change in condition for one resident, resulting in delayed medical intervention. The facility lacked a physician notification policy at the time of the incident.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to notify the physician of a significant change in condition for Resident #1 in a timely manner. | SS=D |
Report Facts
Weight loss: 34.3
Census: 133
Total Capacity: 199
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Primary nurse for Resident #1 who failed to notify physician of change in condition |
| APRN #1 | Advanced Practice Registered Nurse | Provided progress notes and was not notified timely of resident's condition change |
| Medical Director | Interviewed regarding expectations for physician notification | |
| Director of Nurses | DON | Identified lack of physician notification policy and standard practice expectations |
Inspection Report
Plan of Correction
Deficiencies: 1
Feb 23, 2021
Visit Reason
An unannounced visit was made to Avery Nursing Home by the Department of Public Health for the purpose of conducting an inspection.
Findings
The facility failed to notify the physician of a significant change in condition for Resident #1, who had dementia and experienced functional decline. The facility lacked a physician notification policy and did not report the change in condition timely.
Deficiencies (1)
| Description |
|---|
| Failure to notify the physician of a change in condition for Resident #1. |
Report Facts
Weight loss: 34.3
Fluid intake: 30
Plan of correction submission deadline: Mar 19, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Barbara Cass | Branch Chief | Author of the notice letter from Healthcare Quality and Safety Branch. |
| William Thompson | Administrator | Administrator of Avery Nursing Home who responded with plan of correction. |
| Advanced Practice Registered Nurse #1 | Wrote progress notes and was interviewed regarding Resident #1's condition. | |
| Licensed Practical Nurse #1 | Wrote nurse notes and failed to notify physician of Resident #1's change in condition. | |
| Medical Director | Interviewed regarding expectations for physician notification. | |
| Director of Nurses | DON | Interviewed about notification policy and identified policy deficiencies. |
Inspection Report
Plan of Correction
Deficiencies: 2
Nov 3, 2020
Visit Reason
Unannounced visits were made to Avery Nursing Home to conduct an inspection by the Facility Licensing and Investigations Section of the Department of Public Health.
Findings
The facility failed to ensure appropriate infection control practices to prevent and control the spread of COVID-19, including improper use and storage of PPE, lack of fit testing for N95 masks, and failure to place exposed residents on droplet precautions. Additionally, the facility lacked documentation of physician testing and did not have a policy for storage of PPE taken home by employees.
Deficiencies (2)
| Description |
|---|
| Failure to ensure appropriate infection control practices to prevent and control the spread of infection, including improper PPE use and storage, and failure to place exposed residents on droplet precautions. |
| Failure to ensure appropriate infection control practices related to wound care physician visits and documentation of testing. |
Report Facts
Positive COVID-19 residents: 5
Positive staff members: 8
Date of inspection visit: Nov 3, 2020
Plan of correction completion date: Nov 28, 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cher Michaud | Supervising Nurse Consultant | Author of the notice letter regarding violations and plan of correction |
| William Thompson | Administrator | Facility administrator addressed in the notice and author of plan of correction letter |
| Director of Nurses | Director of Nurses (DON) | Interviewed multiple times regarding infection control practices and COVID-19 cases |
| RN #1 | Registered Nurse | Observed and interviewed regarding PPE use and fit testing |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Tested positive for COVID-19 and involved in exposure incidents |
| Nurse Aide #1 | Nurse Aide | Tested positive for COVID-19 and involved in exposure incidents |
| Assistant Director of Nurses | Assistant Director of Nurses (ADON) | Interviewed regarding wound care physician visits |
Inspection Report
Abbreviated Survey
Census: 139
Capacity: 199
Deficiencies: 0
May 20, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted to determine compliance with 42 CFR §483.80 Infection Control regulations for Long Term Care Facilities.
Findings
The facility has implemented CMS and CDC recommended practices related to COVID-19. No deficiencies were cited as a result of this survey.
Report Facts
Capacity: 199
Census: 139
Inspection Report
Routine
Census: 158
Capacity: 199
Deficiencies: 0
Apr 28, 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 no deficiencies related to infection prevention and control practices for COVID-19 at Avery Nursing Home.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Apr 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
No deficiencies were cited as a result of this COVID-19 focused survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Apr 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
No deficiencies were cited as a result of this COVID-19 focused survey.
Inspection Report
Census: 184
Capacity: 199
Deficiencies: 0
Nov 27, 2019
Visit Reason
A desk audit review was conducted on 11/27/19 for the purpose of reviewing the Plan of Correction (POC) from the Violation letters dated 11/21/2019 and 10/2/19.
Findings
All violations identified in the previous violation letters were corrected. No new violations of the General Statutes of Connecticut or regulations of Connecticut State Agencies were identified at the time of this inspection.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Liptak | Assistant Director of Nurses | Personnel contacted during the inspection. |
| Terri D. McNeil | RNC | Report submitted by and signed the Licensing Inspection Narrative Report. |
Inspection Report
Plan of Correction
Deficiencies: 1
Sep 25, 2019
Visit Reason
An unannounced visit was made to Avery Nursing Home on 09/25/19 by a representative of the Facility Licensing & Investigations Section for the purpose of conducting an investigation.
Findings
The facility was found not to have met the requirement to be free from abuse, neglect, and exploitation as evidenced by an incident involving Resident #1 and RN #1. The facility submitted a plan of correction and has achieved substantial compliance with all requirements as of the completion dates specified.
Complaint Details
The visit was complaint-related, investigating allegations of abuse involving Resident #1 and RN #1. The facility was unable to substantiate the incident as abuse because RN #1 only redirected the resident's hands to prevent choking and denied hitting the resident. RN #1 was sent home immediately and has not worked since the incident on 8/15/19.
Deficiencies (1)
| Description |
|---|
| Resident #1 was not free from abuse, neglect, and exploitation as RN #1 was observed striking and shoving the resident and attempting to choke her. |
Report Facts
Date of survey completion: Sep 25, 2019
Date of plan of correction completion: Nov 6, 2019
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| William Thompson | Administrator | Signed the plan of correction letter |
| Jacqueline Ruot | Supervising Nurse Consultant, Health Services Fire Safety & Construction Unit Supervisor | Recipient of the plan of correction letter |
Inspection Report
Complaint Investigation
Deficiencies: 2
Sep 25, 2019
Visit Reason
An unannounced visit was made to Avery Nursing Home on September 25, 2019 by a representative of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting an investigation related to allegations of abuse and failure to ensure clinical record completeness.
Findings
The facility was found to have failed to ensure a resident was free from abuse and failed to ensure the clinical record was complete. Specific findings included an incident involving a resident with dementia and behavior disturbance where a staff member was observed striking the resident, and incomplete documentation of assessments and clinical records related to the resident's injury and condition.
Complaint Details
The investigation was complaint-related, focusing on allegations of abuse involving Resident #1. The facility was unable to substantiate the incident as abuse because RN #1 only redirected the resident's hands and denied hitting the resident. RN #1 was sent home immediately and has not worked since the incident on 8/15/19.
Deficiencies (2)
| Description |
|---|
| Failure to ensure the resident was free from abuse, including an incident where RN #1 was observed striking Resident #1 in the shoulder and attempting to remove a beverage thickener container while the resident grabbed her stethoscope. |
| Failure to ensure the clinical record was complete, including missing RN assessments and incomplete documentation of an injury of unknown origin. |
Report Facts
Dates of key events: Aug 15, 2019
Dates of assessments: Aug 12, 2019
Dates of plan completion: Oct 12, 2019
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Susan Newton | Supervising Nurse Consultant | Author of the amended notice letter and contact for questions regarding deficiencies |
| William Thompson | Administrator | Administrator of Avery Nursing Home addressed in the letter |
Inspection Report
Plan of Correction
Deficiencies: 9
Mar 14, 2019
Visit Reason
The document is a plan of correction submitted by Avery Nursing Home in response to an unannounced visit conducted on March 14, 2019, addressing alleged violations found during the inspection.
Findings
The facility acknowledged multiple violations related to mail delivery, environmental maintenance, resident hospitalization notifications, pressure ulcer risk assessments, medication administration, supervision to prevent falls, nutritional assessments, and medication labeling. The plan of correction outlines steps taken to achieve substantial compliance with all requirements by April 25, 2019.
Deficiencies (9)
| Description |
|---|
| Failure to ensure ongoing mail delivery on Saturdays. |
| No facility policy for mail delivery. |
| Failure to notify Ombudsman of resident transfers to hospital. |
| Failure to develop baseline care plan for pressure ulcer risk. |
| Failure to assess and document pressure ulcer wounds weekly. |
| Failure to ensure licensed staff present during nebulizer treatment and medication administration errors. |
| Failure to provide appropriate supervision to prevent falls. |
| Failure to ensure timely nutritional assessments and weight change notifications. |
| Pharmacy failed to ensure correct medication labeling and administration. |
Report Facts
Date of inspection visit: Mar 14, 2019
Plan of correction completion date: Apr 25, 2019
Resident ID: 176
Resident ID: 31
Resident ID: 74
Resident ID: 29
Resident ID: 134
Resident ID: 168
Resident ID: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| William Thompson | Administrator | Signed the plan of correction letter |
Inspection Report
Follow-Up
Census: 171
Capacity: 199
Deficiencies: 0
Sep 14, 2018
Visit Reason
The visit was a desk audit conducted on September 14, 2018, for the purpose of reviewing the plan of correction for a violation letter dated August 2, 2018, and to verify compliance.
Findings
The review of facility policies, procedures, documentation of in-services to staff, and audits showed that violation #1 a through b was identified as being corrected. No violations were identified at the time of this desk audit, and the facility was found to be in compliance.
Report Facts
Licensed Bed: 199
Census: 171
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| William Thompson | Administrator | Personnel contacted during the inspection and informed of compliance status |
| P. Henrietta Simmons | Nurse Consultant | Report submitted by |
| Bonnie Ganim | DNS | Informed of compliance status during phone call |
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