Deficiencies (last 6 years)
Deficiencies (over 6 years)
13.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
141% worse than Connecticut average
Connecticut average: 5.6 deficiencies/yearDeficiencies per year
32
24
16
8
0
Occupancy
Latest occupancy rate
93% occupied
Based on a December 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Renewal
Census: 28
Capacity: 30
Deficiencies: 0
Date: 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
Deficiencies: 1
Date: Sep 12, 2024
Visit Reason
The inspection was conducted to investigate the facility's compliance with Leave of Absence (LOA) procedures after an incident where a resident signed out on an LOA without proper authorization or verification of LOA privileges.
Findings
The facility failed to ensure the approved LOA list was checked prior to allowing a resident to sign out on a Leave of Absence. A resident left the facility without orders for LOA, and the security guard did not verify LOA privileges before allowing the resident to leave. The resident was later found safe and returned to the facility.
Deficiencies (1)
Failed to ensure the approved LOA list was checked prior to allowing a resident to sign out on a Leave of Absence.
Report Facts
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Security Guard #1 | Did not check the LOA book before signing out Resident #1 | |
| DNS | Interviewed regarding LOA orders and verification procedures |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 12, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure the approved Leave of Absence (LOA) list was checked prior to allowing a resident to sign out on a Leave of Absence.
Complaint Details
The complaint investigation found that Resident #1 left the facility without proper LOA authorization. The issue was substantiated with findings that the security guard failed to verify LOA status and no orders for LOA were present despite the resident requiring such privileges.
Findings
The facility failed to verify Leave of Absence privileges before allowing Resident #1 to leave the facility, resulting in the resident signing out without proper authorization. Interviews revealed that the security guard did not check the LOA book or contact nursing staff prior to allowing the resident to leave.
Deficiencies (1)
F 0684: The facility failed to ensure the approved Leave of Absence list was checked prior to allowing Resident #1 to sign out on a Leave of Absence. The security guard did not verify LOA privileges or contact nursing staff before permitting the resident to leave.
Report Facts
Residents affected: 3
Inspection Report
Routine
Deficiencies: 8
Date: Jun 6, 2024
Visit Reason
Routine state inspection survey conducted to assess compliance with regulatory requirements related to resident care, medication administration, staff competencies, food safety, and immunization policies.
Findings
The facility was found deficient in multiple areas including failure to provide dignified dining assistance, incomplete care plans regarding assistive devices, inaccurate transcription and implementation of physician orders, lack of timely physician order signatures, incomplete annual competency trainings for staff, improper food labeling and storage practices, and failure to properly assess and document resident immunization status for pneumococcal and COVID-19 vaccines.
Deficiencies (8)
F 0550: The facility failed to provide a dignified dining experience by not having the nurse aide sit while feeding Resident #8, contrary to facility expectations.
F 0656: The facility failed to include the use of assistive devices such as slings in the comprehensive care plans for Residents #17 and #26, leading to incomplete care documentation.
F 0684: The facility failed to ensure physician's orders for Residents #2 and #5 were transcribed and implemented accurately, including failure to complete ordered orthostatic blood pressure monitoring.
F 0711: The facility failed to ensure physician's orders for Resident #22 were signed and dated in a timely manner as required by regulations.
F 0726: The facility failed to ensure annual competency trainings were completed for licensed nurses and CNAs, with many staff lacking documented competencies for 2022, 2023, and 2024.
F 0812: The facility failed to properly label, date, and discard expired or undated food items and allowed bare hand contact with prepared food during service.
F 0883: The facility failed to offer and/or assess pneumococcal vaccination status upon admission for Resident #26 and failed to document refusal or consent properly.
F 0887: The facility failed to offer and/or assess COVID-19 vaccination status upon admission for Residents #2 and #26 and failed to document refusals or consents appropriately.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 2
Residents affected: 1
Staff members: 24
Staff members with competencies: 6
Food items: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| APRN #2 | Psychiatric Nurse Practitioner | Named in medication order and orthostatic blood pressure monitoring deficiencies |
| NA #1 | Nurse Aide | Named in dignified dining deficiency for feeding Resident #8 |
| DNS | Director of Nursing Services | Interviewed regarding care plan expectations and competency training deficiencies |
| Staff Development Nurse | LPN | Responsible for staff competency training and identified gaps in training records |
| Food Service Manager | Interviewed regarding food labeling, storage, and hygiene deficiencies | |
| Infection Preventionist Nurse | RN | Named in immunization assessment and documentation deficiencies |
Inspection Report
Renewal
Census: 28
Capacity: 30
Deficiencies: 0
Date: 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).
Complaint Details
Complaint Investigation # CT36480 was referenced, but no substantiation status or further details were provided in the report.
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.
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
Annual Inspection
Deficiencies: 8
Date: Jun 6, 2024
Visit Reason
The inspection was conducted as a comprehensive annual survey to assess compliance with federal regulations regarding resident care, medication administration, staff competencies, food safety, and immunization practices at the nursing home.
Findings
The facility was found deficient in multiple areas including failure to provide dignified dining assistance, incomplete care plans regarding assistive devices, inaccurate transcription and implementation of physician orders, lack of timely physician order signatures, incomplete staff competency training, improper food labeling and storage practices, and failure to properly assess and document pneumococcal and COVID-19 vaccinations for residents.
Deficiencies (8)
Failure to provide a dignified dining experience by not having nursing aides seated while feeding residents.
Failure to include use of assistive devices such as slings in comprehensive care plans with appropriate physician orders.
Failure to ensure physician's orders were transcribed and implemented accurately, including missed orthostatic blood pressure monitoring.
Failure to ensure physician's orders were signed and dated in a timely manner.
Failure to ensure licensed staff and CNAs received annual competency trainings.
Failure to ensure food items were properly dated, labeled, and expired foods discarded; improper hygienic practices during food handling.
Failure to offer and/or assess pneumococcal vaccination upon admission and failure to document refusals.
Failure to offer and/or assess COVID-19 vaccination upon admission and failure to document refusals.
Report Facts
Residents affected: 8
Residents affected: 2
Residents affected: 5
Residents affected: 1
Staff members: 24
Staff members with competencies: 6
Food items: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| APRN #2 | Psychiatric Nurse Practitioner | Named in medication order transcription and orthostatic blood pressure monitoring deficiency |
| LPN #2 | Charge Nurse | Named in medication order transcription deficiency |
| LPN #1 | Staff Development Nurse | Named in staff competency training deficiency |
| RN #2 | Infection Preventionist Nurse | Named in immunization assessment and documentation deficiency |
| Administrator | Interviewed regarding staff competencies and training | |
| DNS | Director of Nursing Services | Interviewed regarding care plan expectations, medication orders, and staff competencies |
| NA #1 | Nursing Assistant | Named in dignified dining assistance deficiency |
| Therapy Director | Named in assistive device care plan deficiency | |
| Food Service Manager | Named in food safety and labeling deficiency |
Inspection Report
Renewal
Census: 28
Capacity: 30
Deficiencies: 0
Date: 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
Date: 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)
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
Deficiencies: 6
Date: Mar 17, 2022
Visit Reason
The inspection was conducted based on complaints and concerns raised regarding resident rights, advanced directives, care planning, medication management, and dining services at the facility.
Complaint Details
The complaint investigation was triggered by concerns including failure to address resident grievances about hygiene, incomplete advanced directives documentation, failure to complete discharge assessments, inadequate care planning for pressure ulcers, delayed response to pharmacy recommendations, and issues with meal service and menu substitutions.
Findings
The facility was found deficient in multiple areas including failure to address resident grievances regarding hygiene issues, incomplete advanced directives documentation for several residents, failure to complete and submit discharge assessments, incomplete care plans for pressure ulcer management, delayed response to pharmacy recommendations, and failure to provide meal items as stated on the menu or notify residents of substitutions.
Deficiencies (6)
Failed to address a resident's hygiene concern reported in resident council meetings for three consecutive months.
Failed to establish advanced directives related to code status and life sustaining treatments with newly admitted and readmitted residents.
Failed to complete and submit a discharge MDS assessment for a discharged resident.
Failed to develop and implement a complete care plan that includes specific instructions for use of a low air loss mattress and Roho cushion for a resident with a stage 4 pressure ulcer.
Failed to respond timely to pharmacist recommendations regarding unnecessary medications.
Failed to provide meal items as stated on the meal ticket and failed to notify a resident when menu items were substituted.
Report Facts
Days after admission for physician order: 43
Pressure ulcer measurement: 11
Pressure ulcer measurement: 8
Pressure ulcer measurement: 2
Pressure ulcer measurement: 6
Pressure ulcer measurement: 5.5
Pressure ulcer measurement: 0.8
Date of pharmacist medication review: Jan 14, 2022
Date of physician order discontinuing heparin: Mar 2, 2022
Date of physician order discontinuing zinc: Mar 16, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Nursing Supervisor | Identified responsibility for code status forms and admission procedures; interviewed regarding advanced directives and care planning. |
| TRD | Therapeutic Recreation Director | Reported resident hygiene concerns to housekeeping and nursing; interviewed about resident council meetings. |
| Director of Housekeeping | Interviewed regarding response to resident hygiene complaints. | |
| SW #1 | Social Worker | Interviewed regarding responsibilities for advanced directives and follow-up with residents and conservators. |
| DNS | Director of Nursing Services | Interviewed regarding policies and procedures for advanced directives, medication reviews, and care planning. |
| APRN #1 | Advanced Practice Registered Nurse | Interviewed regarding medication management and response to pharmacist recommendations. |
| Kitchen Manager | Interviewed regarding meal preparation, menu substitutions, and communication with residents. | |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding advanced directives documentation and resident care. |
| NA #1 | Nursing Assistant | Interviewed regarding care for Resident #9 and knowledge of special mattress use. |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Mar 17, 2022
Visit Reason
The inspection was conducted to investigate complaints related to resident rights, advanced directives, assessment accuracy, care planning, medication management, and dietary services at the nursing facility.
Complaint Details
The complaint investigation included issues of resident rights violations, failure to establish advanced directives, incomplete assessments, inadequate care planning, delayed medication regimen reviews, and dietary service deficiencies.
Findings
The facility failed to address a resident's grievance about bathroom hygiene for three months, did not establish or document advanced directives for several residents, failed to complete a discharge MDS assessment timely, lacked comprehensive care planning for pressure ulcer management, delayed response to pharmacist medication recommendations, and did not provide meals as per the menu or notify residents of substitutions.
Deficiencies (6)
F 0565: The facility failed to address a resident's complaint about a soiled shared bathroom for three consecutive months despite reporting in resident council meetings.
F 0578: The facility failed to establish and document advanced directives related to code status and life sustaining treatments for newly admitted and readmitted residents.
F 0641: The facility failed to complete and submit a discharge MDS assessment for a discharged resident in a timely manner.
F 0656: The facility failed to develop a comprehensive care plan including specific instructions for a low air loss mattress and Roho cushion for a resident with a stage 4 pressure ulcer.
F 0756: The facility failed to respond timely to pharmacist recommendations regarding unnecessary medications for a resident.
F 0803: The facility failed to provide meal items as stated on the meal ticket and did not notify the resident when substitutions were made.
Report Facts
Days after admission for physician order: 43
Pressure ulcer size: 11
Pressure ulcer size: 8
Pressure ulcer size: 2
Pressure ulcer size: 6
Pressure ulcer size: 5.5
Pressure ulcer size: 0.8
Medication regimen review date: Jan 14, 2022
Medication discontinuation date heparin: Mar 2, 2022
Medication discontinuation date zinc: Mar 16, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Nursing Supervisor | Interviewed regarding advanced directives and care planning for residents |
| TRD | Therapeutic Recreation Director | Reported resident bathroom complaints and interviewed about resident council processes |
| Director of Housekeeping | Interviewed about bathroom cleaning and response to resident complaints | |
| SW #1 | Social Worker | Interviewed about advanced directives follow-up and resident care |
| DNS | Director of Nursing Services | Interviewed about advanced directives, medication reviews, and care planning |
| APRN #1 | Advanced Practice Registered Nurse | Interviewed about medication discontinuation and resident care |
| Kitchen Manager | Interviewed about dietary ticket discrepancies and meal substitutions | |
| LPN #1 | Licensed Practical Nurse | Interviewed about resident code status and medical record documentation |
| NA #1 | Nursing Assistant | Interviewed about care plan and mattress settings for resident |
Inspection Report
Plan of Correction
Census: 27
Capacity: 30
Deficiencies: 2
Date: 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.
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.
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.
Deficiencies (2)
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
Complaint Investigation
Census: 27
Capacity: 30
Deficiencies: 0
Date: Jan 12, 2022
Visit Reason
The inspection was conducted as a complaint investigation related to Complaint Investigation #31503 and a reportable event.
Complaint Details
The visit was triggered by Complaint Investigation #31503. Violations were identified, but no specific deficiencies or citations are detailed in the report. Narrative report/additional information was attached.
Findings
The tour of the facility found no infection control or safety concerns, and residents appeared well groomed. Staffing was reviewed and found to meet minimum State of Connecticut requirements.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Richard Howe | BSN, RN, NC | Report submitted by and signed nurse involved in the inspection. |
| Maureen Porto | RN DNS | Personnel contacted during the inspection. |
| Jay Katz | Admin | Personnel contacted during the inspection. |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Aug 15, 2019
Visit Reason
The inspection was conducted to investigate complaints related to failure in accurately identifying residents' advanced directives, timely reporting of abuse allegations, failure to notify residents and representatives about hospitalizations and bed hold policies, failure to notify the state agency of changes in mental status or diagnosis, and failure to revise care plans according to changes in resident care needs.
Complaint Details
The complaint investigation included review of allegations related to inaccurate advanced directives documentation for Resident #11, failure to timely report abuse involving Resident #18, failure to notify residents and representatives about hospitalizations and bed hold policies for Residents #13, #27, and #28, failure to notify the state agency of changes in mental status for Resident #4, and failure to revise care plans for Resident #18 after a change in care needs. The facility was found deficient in all these areas.
Findings
The facility failed to ensure accurate documentation of Resident #11's advanced directives, timely reporting of abuse allegations involving Resident #18, notification of hospitalizations and bed hold policies for multiple residents, notification to the state agency for changes in mental status for Resident #4, and revision of the care plan for Resident #18 following a change in care needs. Several policy and procedural deficiencies were identified, including lack of timely communication with physicians and state agencies, and failure to update care plans and notifications as required.
Deficiencies (6)
Failed to ensure Resident #11's wishes for Advanced Directives were accurately identified in the clinical record.
Failed to timely report an allegation of abuse involving Resident #18 to the state agency.
Failed to provide written notification regarding hospitalizations to Residents #13, #27, and #28 and their representatives or ombudsman in a timely manner.
Failed to notify Residents #13, #27, and #28 or their representatives in writing about the facility's bed hold policy when hospitalized.
Failed to notify the state-designated agency of a change in mental status or diagnosis for Resident #4.
Failed to revise the care plan for Resident #18 to reflect changes in care needs after an abuse allegation.
Report Facts
Residents reviewed for advanced directives: 12
Residents reviewed for abuse: 1
Residents reviewed for hospitalization notification: 4
Residents reviewed for bed hold notification: 3
Residents reviewed for PASRR notification: 2
Residents reviewed for care plan revision: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| SW #1 | Social Worker | Named in advanced directive documentation and notification failure for Resident #11. |
| DNS | Director of Nurses | Named in abuse reporting failure and notification delays for Resident #18. |
| LPN #1 | Licensed Practical Nurse | Named in PASRR notification failure for Resident #4. |
| RN #1 | Registered Nurse | Named in care plan revision failure for Resident #18. |
| Administrator | Interviewed regarding notification policies and reporting delays. |
Inspection Report
Plan of Correction
Deficiencies: 6
Date: 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)
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
Date: 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.
Deficiencies (6)
Failure to ensure a resident'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.
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.
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.
Failure to notify the state-designated agency with a change in mental status or diagnosis for PASRR.
Failure to revise the plan of care related to a change in Resident care needs.
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
Complaint Investigation
Deficiencies: 6
Date: Aug 15, 2019
Visit Reason
The inspection was conducted to investigate complaints related to advanced directives, timely reporting of abuse allegations, hospitalization notifications, bed hold policies, PASRR notifications, and care plan revisions for residents at the facility.
Complaint Details
The complaint investigation involved Resident #11's advanced directives documentation, Resident #18's abuse allegation and reporting, hospitalization notifications for Residents #13, #27, and #28, bed hold policy notifications, PASRR notification for Resident #4, and care plan revision for Resident #18. The abuse allegation was substantiated with findings of delayed reporting and incomplete care plan updates.
Findings
The facility failed to accurately identify and document Resident #11's advanced directives, failed to timely report an allegation of abuse involving Resident #18, failed to provide written notifications of hospitalizations and bed hold policies to residents and representatives, failed to notify the state agency of changes in mental status for Resident #4, and failed to revise the care plan for Resident #18 to reflect updated care needs.
Deficiencies (6)
F 0578: The facility failed to ensure Resident #11's advanced directives were accurately identified and documented in the clinical record.
F 0609: The facility failed to timely report an allegation of abuse involving Resident #18 to the state agency.
F 0623: The facility failed to provide written notification of hospitalizations to Residents #13, #27, and #28 and their representatives or ombudsman in a timely manner.
F 0625: The facility failed to notify Residents #13, #27, and #28 and their representatives in writing about the facility's bed hold policy upon hospitalization.
F 0644: The facility failed to notify the state-designated agency of a change in mental status or diagnosis for Resident #4 as required by PASRR.
F 0657: The facility failed to revise the care plan for Resident #18 to reflect updated care needs related to abuse allegations and care interventions.
Report Facts
Residents reviewed for advanced directives: 12
Residents reviewed for abuse: 1
Residents reviewed for hospitalization: 4
Residents reviewed for PASRR: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| SW #1 | Social Worker | Named in advanced directive documentation and failure to notify physician. |
| DNS | Director of Nurses | Named in abuse allegation reporting and interview regarding reporting timelines. |
| LPN #1 | Licensed Practical Nurse | Named in PASRR notification interview. |
| RN #1 | Registered Nurse | Named in care plan revision responsibility for Resident #18. |
Inspection Report
Renewal
Census: 28
Capacity: 30
Deficiencies: 6
Date: 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)
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
Date: 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)
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
Date: 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)
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 |
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