Deficiencies (last 7 years)
Deficiencies (over 7 years)
10.9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
95% worse than Connecticut average
Connecticut average: 5.6 deficiencies/yearDeficiencies per year
24
18
12
6
0
Occupancy
Latest occupancy rate
23% occupied
Based on a October 2025 inspection.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 3
Date: Oct 6, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding inadequate supervision of a resident with known wandering behaviors, which resulted in the resident leaving the secured unit and sustaining a fall outside the building.
Complaint Details
The complaint investigation substantiated that Resident #1, with a history of dementia and wandering, was able to leave the secured unit unnoticed due to inadequate supervision and a non-functioning exit door alarm, resulting in a fall outside the building with injuries. The facility was found to have environmental hazards in the courtyard and failed to prevent elopement.
Findings
The facility failed to ensure adequate supervision for Resident #1, who had dementia and wandering behaviors, resulting in the resident leaving the secured unit unnoticed and falling outside the building with injuries. Additionally, the courtyard adjacent to the secured unit contained multiple environmental hazards and the exit door alarm was not functioning at the time of the incident.
Deficiencies (3)
Failed to ensure adequate supervision for a resident with known wandering behaviors to prevent elopement and injury.
The courtyard adjacent to the secured unit was not free from hazards, including uneven pavement, loose rocks, unsecured stone wall with sharp edges, and unsecured double gate allowing egress.
Exit door alarm was not functioning at the time Resident #1 exited the facility, failing to alert staff.
Report Facts
Census: 46
Residents at risk for elopement: 6
Size of hematoma: 6
Size of hematoma: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Charge Nurse | Notified RN/supervisor of Resident #1's fall and reported exit door alarm was not sounding |
| RN #1 | Supervisor | Notified by LPN #1 about Resident #1's fall outside the building |
| NA #1 | Nurse's Aide | Found Resident #1 outside the exit door and reported last seeing resident 2 hours prior |
| ADNS | Assistant Director of Nursing Services/Unit Manager | Provided information on Resident #1's wandering behaviors and environmental hazards |
| DON | Director of Nursing | Interviewed regarding exit door alarm and facility policies |
| Administrator | Facility Administrator | Interviewed regarding exit door alarm functionality and environmental hazards |
| APRN | Advanced Practice Registered Nurse | Evaluated Resident #1 after fall and ordered hospital transfer |
| Maintenance Supervisor | Maintenance Supervisor | Interviewed regarding exit door alarm testing and environmental conditions |
Inspection Report
Monitoring
Census: 170
Capacity: 199
Deficiencies: 0
Date: 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
Date: 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)
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
Date: 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.
Complaint Details
Complaint investigation referenced with complaint numbers 36954 and 11473; substantiation status not stated.
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.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael Latino | Personnel contacted during the inspection | |
| Tanya Niro | Personnel contacted during the inspection |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 19, 2025
Visit Reason
The inspection was conducted following complaints regarding failure to administer ordered treatments and medication to Resident #26 and concerns about accident hazards related to Resident #10's transport in a shower chair.
Complaint Details
Resident #26 filed a complaint about not receiving dressing changes and eye drops as ordered on 5/11/25. The complaint was substantiated as a medication error involving an agency nurse (LPN #4) who did not administer the treatments. Resident #10 experienced a fall from a shower chair during transport over a threshold, resulting in a head injury and persistent pain. Interviews revealed inadequate training and unclear policies regarding shower chair use.
Findings
The facility failed to administer artificial tears and wound treatment as ordered for Resident #26, resulting in a medication error. Additionally, the facility failed to ensure Resident #10 was free from accidents during transport in a shower chair, leading to a fall and head injury. The facility lacked proper education and competency training on shower chair use.
Deficiencies (2)
Failure to administer treatment/medication as ordered to Resident #26, including artificial tears and wound dressing.
Failure to ensure Resident #10 was free from accidents when transported in a shower chair, resulting in a fall and head injury.
Report Facts
Weight: 213
Weight capacity: 450
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #4 | Licensed Practical Nurse | Agency nurse who failed to administer ordered treatments to Resident #26 |
| RN #4 | Registered Nurse | Identified incomplete treatment administration to Resident #26 on third shift |
| DNS | Director of Nursing Services | Processed the medication error incident involving Resident #26 and LPN #4 |
| NA #6 | Nursing Assistant | Pushed Resident #10 in shower chair when fall occurred |
| NA #7 | Nursing Assistant | Provided information about shower chair types and usage |
| RN #5 | Unit Manager | Uncertain about shower chair assignment and therapy assessments |
| NA #1 | Nursing Assistant | Discussed training on shower chair use |
| OT #1 | Assistant Director of Rehabilitation | Provided information on therapy education regarding shower chairs |
| RN #7 | Staff Development Nurse | Discussed training and competency requirements for shower chair use |
| NA #8 | Nursing Assistant | Described staff requirements for transporting residents in shower chairs |
Inspection Report
Routine
Deficiencies: 14
Date: May 19, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, infection control, medication administration, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to document and honor advance directives, inadequate secured unit placement documentation, late transmission of MDS assessments, incomplete care plans, improper medication administration, inadequate pressure ulcer care, unsecured medication carts, unavailable menu items, incomplete infection control environmental rounds, and failure to ensure pneumococcal, influenza, and COVID-19 vaccinations were offered and administered as required.
Deficiencies (14)
Failed to ensure physician's order indicated resident's wishes related to cardiopulmonary code status and treatments.
Failed to assess, care plan, and obtain consents for residents residing on a secured unit and demonstrate it was the least restrictive setting.
Failed to transmit Minimum Data Set (MDS) assessments to CMS within 14 days of completion date.
Failed to hold interdisciplinary care plan meeting and develop comprehensive care plan within required timeframe.
Failed to review and revise care plan to reflect resident's ADL status and skin/pressure issues.
Failed to provide care consistent with professional standards for medication administration; resident self-administered medications without order or observation.
Failed to administer treatment and medication as ordered for skin conditions and wounds.
Failed to provide appropriate pressure ulcer care and documentation consistent with professional standards.
Failed to ensure resident was free from accidents when transported in a shower chair; incident of fall due to improper transport.
Failed to ensure medication carts were locked when not in use or out of nurse's sight.
Failed to ensure menu choice items were available and substitutions offered when items were out of stock.
Failed to provide documentation that environmental rounds were conducted quarterly as required.
Failed to ensure pneumococcal and influenza vaccines were assessed, offered, and administered to residents as required.
Failed to ensure COVID-19 booster vaccine was administered as requested and offered on admission.
Report Facts
Deficiencies cited: 14
MDS late transmission days: 7
MDS late transmission days: 14
MDS late transmission days: 13
MDS late transmission days: 9
MDS late transmission days: 7
Pressure ulcer size: 2
Pressure ulcer size: 0.8
Pressure ulcer size: 0.3
Resident weight: 213
Fall risk score: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #7 | Licensed Practical Nurse | Named in finding related to missing physician orders for code status |
| RN #5 | Unit Manager | Named in findings related to care plan deficiencies and wound care |
| RN #3 | Registered Nurse | Named in medication administration deficiency |
| LPN #4 | Licensed Practical Nurse | Named in medication/treatment omission for Resident #26 |
| RN #6 | Infection Preventionist Nurse | Named in vaccine administration deficiencies and infection control rounds |
| RN #15 | Night Shift Nursing Supervisor | Named in medication cart security deficiency |
| NA #6 | Nursing Assistant | Named in fall incident involving shower chair transport |
| RN #8 | Nursing Supervisor | Named in wound care communication deficiency |
| MD #2 | Wound Physician | Named in wound care assessment and treatment deficiency |
| RN #9 | Nurse | Named in wound care notification deficiency |
| RN #7 | Staff Development Nurse | Named in shower chair use training deficiency |
| NA #7 | Nursing Assistant | Named in shower chair use and fall incident |
| RN #1 | Noble Unit Manager, MDS Coordinator | Named in late MDS transmission deficiency |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Apr 8, 2025
Visit Reason
The inspection was conducted following a complaint and reportable event concerning Resident #1 who sustained multiple fractures and subsequently died after a fall out of bed on 2025-04-04. The investigation focused on the facility's compliance with professional standards of care related to fall prevention and post-fall assessment.
Complaint Details
The complaint investigation centered on Resident #1's fall on 2025-04-04, which resulted in multiple fractures and death. The investigation found that staff moved the resident before RN assessment, contrary to protocol. The resident had a history of falls and was on hospice. The facility's fall prevention policies were reviewed, and interviews with staff revealed inconsistent assistance and communication failures.
Findings
The facility failed to ensure that care and services met professional standards for Resident #1, who fell out of bed and sustained multiple fractures leading to death. Staff moved the resident prior to a Registered Nurse assessment, contrary to policy. The facility's fall risk assessments and care plans were in place but interventions were insufficient to prevent the fall. Interviews revealed inconsistent assistance levels and failure to follow protocols after the fall.
Deficiencies (2)
Failed to ensure care and services met professional standards for Resident #1 who fell out of bed and sustained multiple fractures.
Failed to ensure a timely assessment pertaining to bed mobility during care, resulting in multiple fractures and death of Resident #1.
Report Facts
Date of fall: Apr 4, 2025
Number of medications contributing to fall risk: 3
Number of predisposing conditions: 3
Number of previous falls without injury: 2
Time of fall: 1055
Time of death: 1715
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA #1 | Nursing Assistant | Performed personal care and attempted to prevent Resident #1's fall; moved Resident #1 prior to RN assessment |
| RN #1 | Nursing Supervisor | Assessed Resident #1 after fall, directed staff not to move resident, notified APRN, and ordered transfer to ED |
| LPN #1 | Licensed Practical Nurse | Assisted NA #1 in moving Resident #1 prior to RN assessment and did not notify RN #1 of the movement |
| DNS | Director of Nursing Services | Unaware that Resident #1 was moved prior to RN assessment; investigated fall and identified no facility failure |
| APRN #1 | Advanced Practice Registered Nurse | Notified of fall, ordered transfer of Resident #1 to ED, and stated residents with suspected fractures should not be moved until emergency services arrive |
| MD #2 | Physician | Reviewed medical records and noted fractures were unusual without trauma or underlying conditions |
| OTA #1 | Occupational Therapy Assistant | Reported last evaluation of Resident #1's ADLs on 8/15/24 and described assistance levels |
| Rehab Director | Rehabilitation Director | Provided information on therapy screening policies and Resident #1's functional status |
| LPN #2 | Licensed Practical Nurse | Instructed NA #1 to change Resident #1's brief prior to ambulance transport |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jan 6, 2025
Visit Reason
The inspection was conducted following complaints of failure to update residents' care plans after physical altercations among residents, specifically involving Residents #4, #5, #6, and #7.
Complaint Details
The complaint investigation was substantiated with findings that the facility did not update care plans for residents involved in physical altercations, despite incidents occurring on 8/28/24 and 10/22/24. The Assistant Director of Nurses and Director of Nurses confirmed the failures during interviews.
Findings
The facility failed to update care plans for several residents after incidents of physical altercations, despite documented behavioral issues and injuries. The care plans for Residents #5, #6, and #7 were not updated to include interventions to prevent recurrence of incidents, contrary to facility policy.
Deficiencies (2)
Failure to update Resident #5's care plan following an altercation on 8/28/24 to protect the resident and prevent recurrence.
Failure to update care plans for Residents #6 and #7 following an altercation on 10/22/24 to protect the residents and prevent recurrence.
Report Facts
Residents reviewed for abuse: 6
Residents affected: 4
Injury measurement: 5
Duration of medication prescribed: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nurses (ADNS) | Interviewed on 1/6/25 regarding Resident #5 and Resident #4 altercation and care plan updates. | |
| RN #1 | Registered Nurse | Interviewed on 1/2/25 regarding care plan updates following 8/28/24 incident. |
| Director of Nurses (DNS) | Interviewed on 1/13/25 regarding failure to update care plans for Residents #6 and #7 after 10/22/24 incident. |
Inspection Report
Monitoring
Census: 178
Capacity: 199
Deficiencies: 0
Date: 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.
Complaint Details
The inspection references complaint investigations #41493, #41950, and #42300, but no substantiation status or findings related to these complaints are provided.
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.
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
Date: 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
Complaint Investigation
Deficiencies: 1
Date: Jul 17, 2024
Visit Reason
The inspection was conducted due to an allegation of staff to resident abuse involving Resident #1 during a transfer on 6/24/2024.
Complaint Details
The complaint involved an allegation of staff to resident abuse without injury on 6/24/2024. The allegation was investigated, and the assessment found no injuries, but documentation was incomplete. The complaint was substantiated by the finding of failure to document the assessment.
Findings
The facility failed to ensure the clinical record was complete and accurate by not documenting an assessment after the abuse allegation. The nursing supervisor performed an assessment noting no injury or pain, but documentation was missing.
Deficiencies (1)
Failure to document assessment of resident after allegation of abuse.
Report Facts
Date of abuse allegation: Jun 24, 2024
Date of incident report: Jun 27, 2024
Date of facility summary: Jun 28, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #2 | Nursing Supervisor | Performed assessment after abuse allegation but did not document it |
| RN #1 | Could not recall if assessment was documented | |
| NA #1 | Nursing Assistant | Alleged to have been rude and rough during transfer |
| NA #2 | Nursing Assistant | Reported NA #1's behavior during transfer |
| Acting DON, ADNS | Director of Nursing, Assistant Director of Nursing Services | Provided policy information and confirmed documentation requirements |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Dec 12, 2023
Visit Reason
The inspection was conducted due to complaints regarding the facility's failure to follow physician orders and facility policy for mechanical lift transfers, resulting in a resident falling twice from the lift.
Complaint Details
The investigation was complaint-driven, focusing on allegations that the facility failed to follow physician orders and facility policy for mechanical lift transfers, resulting in Resident #1 falling twice. The complaint was substantiated with findings of neglect and failure to provide adequate staff assistance and education.
Findings
The facility neglected to utilize two staff members during mechanical lift transfers as ordered, resulting in Resident #1 falling twice, including one fall that led to unresponsiveness and hospital transfer. The facility also failed to update the resident's care plan timely and did not ensure all staff were re-educated or audited for compliance with mechanical lift policies.
Deficiencies (3)
Failure to utilize two staff members during mechanical lift transfers as ordered, resulting in resident falls.
Failure to update the resident's care plan timely to reflect transfer status and falls.
Failure to ensure adequate supervision and accident prevention during mechanical lift transfers.
Report Facts
Residents affected: 1
Staff required for mechanical lift transfers: 2
Incident dates: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA #1 | Nursing Assistant | Transferred Resident #1 alone during mechanical lift transfers, incorrectly applied lift pad |
| NA #3 | Nursing Assistant | Was requested to assist by NA #1 but was not present during transfer |
| RN #3 | Registered Nurse | Responsible for developing and revising Resident #1's care plan, admitted oversight in updating care plan |
| RN #1 | Registered Nurse | Called to Resident #1's room when unresponsive and initiated CPR |
| DNS | Director of Nursing Services | Interviewed regarding staff education and policy adherence failures |
| Medical Director | Medical Director | Interviewed regarding cardiac arrest relation to fall |
Inspection Report
Renewal
Census: 186
Capacity: 199
Deficiencies: 0
Date: 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
Routine
Deficiencies: 17
Date: Aug 8, 2023
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to ensure urinary catheter bag coverage, inaccurate resident assessments, incomplete care plans, inadequate pressure ulcer prevention and treatment, failure to complete ordered lab work, lack of proper IV medication competency documentation, incomplete pain assessments, failure to monitor psychotropic medication effects, inadequate dietary sanitation and food labeling, incomplete nurse aide training, and failure to post nurse staffing information visibly.
Deficiencies (17)
Failed to ensure urinary catheter collection bag was covered appropriately.
Failed to ensure accurate coding of PASRR Level II status in resident assessments.
Failed to develop baseline care plan to prevent pressure ulcers on admission.
Failed to develop and implement a comprehensive care plan addressing all resident needs.
Failed to ensure RN assessment on admission and proper co-signing of LPN assessments.
Failed to provide necessary assistance with activities of daily living for a resident.
Failed to complete ordered bloodwork for a resident.
Failed to implement interventions to prevent development and worsening of pressure ulcers.
Failed to perform weekly weights per physician order and timely dietician assessment for weight loss.
Failed to obtain physician order for placement and care of midline catheter.
Failed to provide documentation of staff competency for IV push medications and annual IV training.
Failed to complete annual performance evaluations for nurse aides.
Failed to post daily nurse staffing information in an area visible to residents.
Failed to monitor target behaviors, orthostatic blood pressures, and complete baseline AIMS for resident on antipsychotic medication.
Dietary department was not maintained in a clean, sanitary manner; food items were not consistently labeled or stored properly.
Emergency 3-day water supply storage area was not maintained, clean, or free from disrepair.
Failed to provide required dementia training for nurse aides.
Report Facts
Weight loss: 13.2
Weight loss percentage: 5.7
Pressure ulcer wound size: 4.9
Pressure ulcer wound size: 3
Pressure ulcer wound size: 2
Medication dosage: 25
Medication dosage: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #2 | Unit Manager | Responsible for care plan development and admission assessments |
| RN #1 | Nurse | Identified failure to complete ordered lab work |
| LPN #1 | Licensed Practical Nurse | Completed admission assessments without RN co-signature |
| LPN #2 | Assistant Manager | Completed admission MDS with incorrect PASRR coding |
| DNS | Director of Nursing Services | Provided multiple interviews regarding deficiencies and responsibilities |
| MD #1 | Wound Specialist | Observed wound care and provided expert opinion on pressure ulcers |
| NA #1 | Nursing Assistant | Provided information on resident mobility and care needs |
| Dietician | Responsible for assessing resident weights and nutrition | |
| LPN #3 | Licensed Practical Nurse | Interviewed regarding lack of physician order for midline catheter |
| LPN #4 | Licensed Practical Nurse | Interviewed regarding midline catheter care and orders |
| IV Educator | Pharmacy Educator | Interviewed regarding IV push medication training and competency |
| DNS | Director of Nursing Services | Interviewed regarding nurse staffing posting and midline catheter orders |
| RN #5 | Unit Manager | Responsible for monitoring psychotropic medication interventions (not interviewed) |
| Dietary Manager | Interviewed regarding dietary sanitation and maintenance issues | |
| Staff Development Coordinator | Interviewed regarding dementia training for nurse aides |
Inspection Report
Follow-Up
Census: 150
Capacity: 199
Deficiencies: 0
Date: 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
Date: 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.
Deficiencies (5)
Failed to ensure narcotic count was done according to professional standards, resulting in a discrepancy of Diazepam tablets for Resident #141.
Failed to administer Insulin within its expiration for Resident #67.
Failed to administer Diazepam 5mg on 5/25/21 at 9:00 PM according to physician's order for Resident #141.
Failed to ensure air conditioner in food preparation and storage area was clean and lacked a cleaning schedule policy.
Failed to follow infection control guidelines related to COVID-19; staff member was observed eating unmasked in resident rooms.
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
Date: 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
Date: 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)
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
Complaint Investigation
Deficiencies: 5
Date: May 27, 2021
Visit Reason
The inspection was conducted based on complaints regarding medication administration errors, narcotic count discrepancies, expired insulin administration, food safety concerns, and infection control practices related to COVID-19 at Avery Nursing Home.
Complaint Details
The visit was complaint-related, triggered by concerns about medication administration errors, narcotic discrepancies, expired medication use, food safety, and infection control violations. The complaint was substantiated with findings of minimal harm or potential for harm affecting a few residents.
Findings
The facility failed to ensure proper narcotic counts, resulting in a discrepancy with Diazepam administration for Resident #141. Insulin was administered beyond its expiration date for Resident #67. The facility also failed to maintain and clean an air conditioning unit in the kitchen and did not follow infection control guidelines related to COVID-19, including staff eating in resident rooms.
Deficiencies (5)
Failed to ensure the narcotic count was done according to professional standards, resulting in a discrepancy of Diazepam tablets for Resident #141.
Failed to administer insulin within its expiration date for Resident #67.
Failed to administer Diazepam 5mg according to physician's order for Resident #141.
Failed to ensure an air conditioner in the food preparation and storage area was clean and lacked a cleaning policy.
Failed to follow infection control guidelines related to COVID-19, including staff eating in resident rooms.
Report Facts
Deficiencies cited: 5
Date of narcotic count discrepancy: May 26, 2021
Date of survey completion: May 27, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Observed narcotic count and interviewed regarding narcotic discrepancy and infection control. |
| LPN #2 | Licensed Practical Nurse | Worked 3:00 PM - 11:00 PM shift on 5/25/21; involved in narcotic count and medication administration error. |
| LPN #3 | Licensed Practical Nurse | Worked 11:00 PM - 7:00 AM shift on 5/25/21; involved in narcotic count and narcotic discrepancy. |
| RN #3 | RN Supervisor | Notified of narcotic discrepancy. |
| LPN #1 | Licensed Practical Nurse | Identified expired insulin vial during medication cart review. |
| RN #4 | Unit Manager | Interviewed regarding insulin expiration policy. |
| LPN #4 | Licensed Practical Nurse | Administered expired insulin for 15 of 23 days. |
| Pharmacy Consultant #1 | Pharmacy Consultant | Interviewed regarding insulin efficacy after expiration. |
| Director of Food Service | Director of Food Service | Interviewed regarding air conditioner cleaning and maintenance. |
| NA #1 | Nursing Assistant | Observed eating lunch in resident room, violating infection control policies. |
| RN #2 | Infection Control Nurse | Interviewed regarding infection control practices and staff compliance. |
Inspection Report
Abbreviated Survey
Census: 133
Capacity: 199
Deficiencies: 1
Date: 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.
Deficiencies (1)
Failure to notify the physician of a significant change in condition for Resident #1 in a timely manner.
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
Date: 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)
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
Date: 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)
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
Date: 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
Date: 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
Date: 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
Date: 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
Date: 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
Date: 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.
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.
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.
Deficiencies (1)
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
Date: 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.
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.
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.
Deficiencies (2)
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
Date: 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)
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
Date: 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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