Inspection Report Summary
The most recent inspection on December 31, 2025, found no deficiencies. Earlier inspections showed a mixed record with several citations related mainly to documentation issues such as advanced directives, care planning, and timely communication with pharmacy and hospital recommendations. Complaint investigations included a substantiated case in early 2022 involving follow-up on hospital discharge instructions and medication administration, while other complaints were unsubstantiated or lacked detailed findings. Enforcement actions such as fines or license suspensions were not listed in the available reports. The trend suggests improvement over time, with the most recent inspection showing compliance after prior issues were addressed.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
6.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
16% worse than Connecticut average
Connecticut average: 5.6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
93% occupied
Based on a December 2025 inspection.
Census over time
Inspection Report
Renewal
Census: 28
Capacity: 30
Deficiencies: 0
Dec 31, 2025
Visit Reason
The inspection was conducted as a licensing inspection with a renewal purpose 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.
Report Facts
Licensed Bed Capacity: 30
Census: 28
Inspection Report
Renewal
Census: 28
Capacity: 30
Deficiencies: 0
Jun 6, 2024
Visit Reason
The inspection visit was conducted as a licensing inspection including a renewal and was related to a complaint investigation (Complaint Investigation # CT36480).
Findings
The report indicates that violations of the General Statutes of Connecticut and/or regulations were identified during the inspection. However, no citation number or detailed narrative report is attached in the provided pages.
Complaint Details
Complaint Investigation # CT36480 was referenced, but no substantiation status or further details were provided in the report.
Report Facts
Licensed Bed Capacity: 30
Census: 28
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jay Katz | Personnel contacted during the inspection. | |
| Tara McCarten | Personnel contacted during the inspection. |
Inspection Report
Renewal
Census: 28
Capacity: 30
Deficiencies: 0
Mar 17, 2022
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. The report includes verification of CRF grant, Shift Coach, and Full Time Infection Prevention and Control Specialist.
Report Facts
Licensed Bed/Bassinet Capacity: 30
Census: 28
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jay Katz | Administrator | Personnel contacted during inspection |
Inspection Report
Renewal
Census: 28
Capacity: 30
Deficiencies: 9
Mar 17, 2022
Visit Reason
Unannounced visits were made to Leeway, Inc for the purpose of conducting a licensing and certification survey, concluding on March 17, 2022.
Findings
Violations of the Regulations of Connecticut State Agencies and/or General Statutes were identified during the visits, including failures in responding to resident grievances, incomplete advance directives documentation, failure to submit discharge assessments, inadequate care planning for pressure ulcers, untimely pharmacy recommendation responses, and dietary service deficiencies.
Deficiencies (9)
| Description |
|---|
| Facility failed to respond to a grievance reported by Resident #18 for three consecutive months. |
| Resident #5 did not have a completed code status (advanced directives) form in clinical record. |
| Resident #9's clinical record failed to indicate completed Advanced Directives. |
| Resident #641's advanced directives were not addressed or followed up appropriately. |
| Facility failed to complete and submit a discharge MDS assessment for Resident #2. |
| Resident #9 was placed on a low air loss mattress but care plan and physician orders did not reflect this. |
| Facility failed to respond to pharmacy recommendations in a timely manner for Resident #29. |
| Facility failed to provide meal items as stated on the meal ticket and failed to notify Resident #9 when a menu item was substituted. |
| Facility failed to ensure posted menus were dated, conspicuous, and legible for residents. |
Report Facts
Licensed Bed Capacity: 30
Census: 28
Inspection Dates: 4
Plan of Correction Submission Deadline: Apr 14, 2022
Stage 4 Pressure Ulcer Size: 11 cm x 8 cm x 2 cm
Weekly Pressure Ulcer Tracking Size: 6 cm x 5.5 cm x 0.8 cm
Heparin Dosage: 5000
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jay Katz | Administrator | Personnel contacted during inspection and recipient of the notice letter. |
| Sandra Vermont-Hollis | Supervising Nurse Consultant | Signed the notice letter regarding violations and plan of correction. |
| RN #1 | Nurse involved in interviews and clinical record reviews related to code status and advance directives. | |
| Social Worker #1 | Interviewed regarding advance directives follow-up. | |
| APRN #1 | Advanced Practice Registered Nurse | Identified in medication review and advance directives follow-up. |
| Cook #1 | Interviewed regarding meal service and substitutions. |
Inspection Report
Complaint Investigation
Census: 27
Capacity: 30
Deficiencies: 0
Jan 12, 2022
Visit Reason
The inspection was conducted as a complaint investigation referenced by Complaint Investigation # CT 31503 and was identified as a reportable event.
Findings
The tour of the facility found no infection control or safety concerns, and residents appeared well groomed. Staffing was reviewed for the period 12/29/2021 through 01/19/2022 and found to meet minimum State of Connecticut requirements.
Complaint Details
Complaint Investigation # CT 31503 was conducted. Violations of the General Statutes of Connecticut and/or regulations were identified, but no specific deficiencies or severity levels were detailed in this report.
Report Facts
Licensed Bed/Bassinet Capacity: 30
Census: 27
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maureen Porto | RN DNS | Personnel contacted during inspection |
| Jay Katz | Admin | Personnel contacted during inspection |
| Richard Howe | BSN, RN, NC | Report submitted by |
Inspection Report
Plan of Correction
Census: 27
Capacity: 30
Deficiencies: 2
Jan 12, 2022
Visit Reason
The visit was conducted as a reportable event related to a complaint investigation (CT 31503) involving violations of Connecticut State regulations identified during the inspection.
Findings
The inspection found no infection control or safety concerns, and staffing met state requirements. However, a violation related to Resident #1's care and follow-up on hospital discharge recommendations was identified, with deficiencies in communication and policy regarding prescriber directions.
Complaint Details
The visit was complaint-related under investigation number CT 31503. The complaint involved concerns about Resident #1's opioid abuse history and the facility's handling of hospital discharge instructions and medication administration. The complaint was substantiated with identified violations.
Deficiencies (2)
| Description |
|---|
| Failure to provide documentation that hospital recommendations for follow-up with SCRC and Buprenorphine administration were acknowledged, communicated, and implemented. |
| Lack of policy regarding facility notification and following prescriber direction. |
Report Facts
Licensed Bed Capacity: 30
Census: 27
Plan of Correction Submission Deadline: Feb 5, 2022
Audit Period: 6
Audit Period: 6
Hospital Discharge Date: Jan 8, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maureen Porto | RN DNS | Personnel contacted during inspection. |
| Jay Katz | Administrator | Personnel contacted during inspection and recipient of the notice letter. |
| Richard Howe | BSN, RNC | Report submitted by this nurse; conducted review and inspection. |
| Maureen Golas Markure | SNC Supervising Nurse Consultant | Signed the notice letter regarding violations and plan of correction. |
Inspection Report
Plan of Correction
Deficiencies: 6
Aug 15, 2019
Visit Reason
Unannounced visits were made to Leeway, Inc. on August 15, 2019, by representatives of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting a licensure and certification investigation.
Findings
The facility was found to have multiple violations related to failure to ensure accurate advanced directives, failure to report allegations of abuse in a timely manner, failure to notify regarding hospitalizations and bed hold policies, failure to notify the state-designated agency of changes in mental status, and failure to revise care plans related to changes in resident care needs. The facility was required to submit a plan of correction addressing these issues.
Deficiencies (6)
| Description |
|---|
| Failure to ensure Resident #11's wishes for Advanced Directives were accurately identified in the clinical record. |
| Failure to report an allegation of abuse to the state agency in a timely manner for Resident #18. |
| Failure to ensure written notification regarding hospitalizations was provided to Residents and their Representatives for Residents #13, #27, and #28. |
| Failure to ensure written notification regarding the facility bed hold policy was provided when Residents were hospitalized. |
| Failure to notify the state-designated agency with a change in mental status or diagnosis for Resident #4. |
| Failure to revise the plan of care related to a change in Resident #18's care needs. |
Report Facts
Residents reviewed for advanced directives: 12
Residents reviewed for abuse: 1
Residents reviewed for hospitalization notification: 4
Completion date for plan of correction: Sep 25, 2019
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cher Michaud | Supervising Nurse Consultant | Signed the letter regarding the plan of correction and oversight of deficiencies. |
| Jay Katz | Administrator | Administrator of Leeway, Inc., named in the report and plan of correction. |
| SW #1 | Social Worker | Interviewed regarding advanced directive and abuse reporting findings. |
| DNS | Director of Nurses | Interviewed regarding abuse reporting and care plan revisions. |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding resident evaluations and PASRR process. |
| RN #1 | Registered Nurse | Responsible for revising care plans for Resident #18. |
Inspection Report
Annual Inspection
Deficiencies: 6
Aug 15, 2019
Visit Reason
Unannounced visits were made to the facility on August 12, 13, 14, and 15, 2019 by representatives of the Facility Licensing & Investigations Section for the purpose of conducting a licensure inspection and certification survey.
Findings
The facility was found deficient in multiple areas including failure to accurately identify and document residents' advanced directives, failure to timely report allegations of abuse, failure to provide written notification of hospitalizations and bed hold policies to residents and representatives, failure to notify the state-designated agency of changes in mental status for PASRR, and failure to revise care plans to reflect changes in resident care needs.
Severity Breakdown
SS=D: 4
SS=B: 2
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to ensure a resident's wishes for Advanced Directives were accurately identified in the clinical record. | SS=D |
| Failure to report an allegation of abuse to the state agency in a timely manner. | SS=D |
| Failure to ensure written notification regarding a hospitalization was provided to the Resident and the Resident's Representative, and/or failed to ensure notification of hospitalizations was sent to the ombudsman in a timely manner. | SS=B |
| Failure to ensure written notification regarding the facility bed hold policy was provided to the Resident and/or the Resident's Representative when the Resident was hospitalized. | SS=B |
| Failure to notify the state-designated agency with a change in mental status or diagnosis for PASRR. | SS=D |
| Failure to revise the plan of care related to a change in Resident care needs. | SS=D |
Report Facts
Residents reviewed for advanced directives: 12
Residents reviewed for abuse: 1
Residents reviewed for hospitalization notification: 3
Residents reviewed for bed hold policy notification: 3
Residents reviewed for PASRR: 2
Residents reviewed for care plan revision: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| SW #1 | Social Worker | Involved in advanced directive meeting and failed to notify physician and nursing staff of changes. |
| DNS | Director of Nurses | Identified delay in abuse reporting and lack of timely notification of hospitalizations and bed hold policies. |
| RN #1 | Registered Nurse | Responsible for revising care plan for Resident #18 but failed to do so. |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding PASRR process and mental status diagnosis updates. |
Inspection Report
Renewal
Census: 28
Capacity: 30
Deficiencies: 6
Aug 14, 2019
Visit Reason
The inspection was a licensure renewal inspection conducted over multiple days in August 2019 to assess compliance with Connecticut state regulations and statutes for the facility.
Findings
Violations of Connecticut General Statutes and regulations were identified during the inspection, with a detailed violation letter dated August 30, 2019. The facility was required to submit a plan of correction by September 9, 2019. A subsequent desk audit on October 11, 2019, found that violations numbered 1 through 6 were corrected and no violations were identified at that time.
Deficiencies (6)
| Description |
|---|
| Failure to report an allegation of abuse in a timely manner related to Resident #18. |
| Failure to ensure written notification regarding hospitalization was provided to residents and representatives in a timely manner for Residents #13, #27, and #28. |
| Failure to ensure Resident #11's wishes for Advanced Directives were accurately identified in the clinical record. |
| Failure to revise the plan of care related to a change in Resident #18's care needs. |
| Failure to notify the state-designated agency with a change in mental status or diagnosis for Resident #4. |
| Failure to provide written notice of the bed hold policy to residents and conservators upon hospital discharge. |
Report Facts
Licensed Bed Capacity: 30
Census: 28
Inspection Dates: 4
Plan of Correction Submission Deadline: Sep 9, 2019
Desk Audit Date: Oct 11, 2019
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Daugherty | Administrator's Assistant | Personnel contacted during the inspection. |
| Jay Katz | Administrator | Named in relation to the Incompliance phone call and inspection correspondence. |
| Cher Michaud | Supervising Nurse Consultant | Signed the important notice letter regarding violations and plan of correction. |
| P. Henrietta Simmons | DPH Nurse Consultant | Submitted the desk audit report on October 11, 2019. |
Inspection Report
Renewal
Census: 29
Capacity: 30
Deficiencies: 5
Sep 25, 2018
Visit Reason
The inspection was an unannounced renewal licensure inspection and certification survey conducted by the Department of Public Health to assess compliance with Connecticut state regulations.
Findings
The facility was found to have violations related to resident supervision, medication administration, nursing staff licensing, and documentation. A plan of correction was required to address these deficiencies.
Deficiencies (5)
| Description |
|---|
| Failure to provide adequate supervision to prevent elopement of Resident #11. |
| Failure to ensure physician's orders were followed for medication administration for Resident #19. |
| Failure to notify the state agency of Resident #11's elopement. |
| Failure to ensure a Registered Nurse hired as a Consultant had a current and active professional license. |
| Failure to provide documentation that the facility was licensed or notified the Department of a change in status. |
Report Facts
Licensed Bed Capacity: 30
Census: 29
Inspection Dates: Inspection occurred on 9/19, 9/20, 9/24, and 9/25 of 2018.
Plan of Correction Submission Deadline: Plan of correction to be submitted by November 1, 2018.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Heather Aaron | Administrator | Named as personnel contacted during inspection and in plan of correction response. |
| Charlene Francois | Director of Nurses | Named as personnel contacted during inspection and in plan of correction response. |
| Jay Katz | Executive Director | Signed plan of correction letter responding to inspection findings. |
| Kelly Mueller | Certified Nurse Consultant | Signed desk audit review confirming corrections. |
| Connie Greene | Supervising Nurse Consultant | Signed complaint investigation letter. |
Inspection Report
Follow-Up
Census: 30
Capacity: 40
Deficiencies: 5
Oct 24, 2017
Visit Reason
Unannounced visits were made on October 24, 25, and 26, 2017 for the purpose of conducting an investigation and a certification inspection, including a review of the plan of correction for a prior violation letter dated 1/30/2017.
Findings
Violations of the General Statutes of Connecticut and regulations were identified during the inspection, including failure to follow up on a resident's applied income concern, failure to ensure survey results were accessible to residents, failure to issue a 30-day discharge notice, failure to post accurate staffing information, and failure to store refrigerated food properly. A subsequent desk audit on December 27, 2017 found the facility in compliance with no violations identified.
Deficiencies (5)
| Description |
|---|
| Facility failed to follow up on a resident's concern regarding applied income in accordance with facility policy. |
| Facility failed to ensure survey results, certification, complaint investigations, and plan of corrections were readily accessible to all residents. |
| Facility failed to issue a 30-day discharge notice prior to resident's discharge. |
| Facility failed to post accurate nursing home licensed and unlicensed staff information reflecting resident census and staffing hours. |
| Facility failed to store refrigerated food in accordance with professional standards and facility policy, including unlabeled and undated items. |
Report Facts
Licensed Bed: 40
Census: 30
Inspection Dates: 2017-10-24 to 2017-10-26
Desk Audit Date: Dec 27, 2017
Licensed Bed: 30
Census: 29
Inspection Date: Mar 13, 2017
Licensed Bed: 30
Census: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Heather Aaron | Administrator | Named in relation to findings and inspections |
| Kerry Augur | Director of Nursing (DNS) | Named in relation to findings and inspections |
| J. Overbye | RN, MSN, DPH Nurse Consultant | Report submitted by for desk audit |
| Sandra Vermont-Hollis | RN, DNS | Report submitted by for prior revisit inspection |
| Danuta Brugos | Report submitted by for main inspection |
Report
Sep 12, 2024
File
complaint-inspection_2024-09-12.pdf
Report
Jun 6, 2024
File
health-inspection_2024-06-06.pdf
Report
Mar 17, 2022
File
health-inspection_2022-03-17.pdf
Report
Aug 15, 2019
File
health-inspection_2019-08-15.pdf
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